Bleeding or clotting: an intracranial dilemma
Jonathan Dallimore,1 Rahul Bhatnagar2
1

Intensive Care Unit, Capital
& Coast District Health Board,
Wellington, New Zealand
2
Academic Respiratory Unit,
University of Bristol, Bristol, UK
Correspondence to
Dr Rahul Bhatnagar,
​rahul.​bhatnagar@b​ ristol.​ac.u​ k

Description

We present a complex diagnosis of a 25-year-old
woman with a background of ulcerative colitis
(UC) at risk of both intracranial haemorrhage and
thrombosis.
The patient presented to the emergency department having collapsed at work, obtaining a head
injury while falling to the floor and suffering an

Accepted 9 December 2017

Figure 1 (A) Axial unenhanced CT brain image showing
abnormal hyperdense sagittal sinus anteriorly (arrow;
compared with the normal low-density portion of the
sinus posteriorly) and patchy haemorrhagic change in
the right frontal lobe (arrow) with subtle low density
in the frontal lobe due to developing oedema/venous
infarction related to the venous thrombosis. (B) Coronal
unenhanced CT brain image showing an abnormally
dense cortical vein above the right frontal lobe (arrow),
in keeping with cortical vein thrombosis (associated with
the sagittal sinus thrombosis).

8 min seizure in the immediate aftermath. The
patient had an acute flare of her UC 2 weeks previously, and her medical history included a deep
vein thrombosis following a long-haul flight and
a pulmonary embolism while taking contraceptive
pill/oral contraceptives.
The patient denied a headache preceding her
collapse, although she admitted her head had
‘felt fuzzy’ during the previous 2 days. CT of
the head was performed (figure 1A,B), revealing
patchy haemorrhagic changes in the right frontal
lobe. Abnormal hyperdensity of the superior
sagittal sinus and of a cortical vein was also
noted; the patient underwent MRI of the head
and CT venography, confirming intracranial
thrombosis with substantial surrounding oedema
(figures 2 and 3). The patient was consequently
given a heparin infusion.
Although a head injury can cause intracranial haemorrhage, our patient had multiple risk
factors for thrombosis (UC with recent flare,
previous deep vein thrombosis and pulmonary
embolism)1 2 which, combined with an unusual
pattern of intracranial haemorrhage on CT,

Figure 3 Coronal (A) and sagittal (B) CT venogram
of the brain demonstrating the occlusive thrombus in
the sagittal venous sinus. A typical ‘empty delta sign’ is
present on the coronal image (A); the sagittal image (B)
shows a patent posterior portion of the sagittal sinus
with occluded sinus more anteriorly.

Learning points
►► Ulcerative colitis is an independent risk factor

To cite: Dallimore J,
Bhatnagar R. BMJ Case
Rep Published Online First:
[please include Day Month
Year]. doi:10.1136/bcr-2017222781

Figure 2 Axial T2 MRI of the brain showing loss of
normal flow void in the sagittal sinus anteriorly (arrow)
and substantial oedema/swelling in the right frontal
lobe with occasional small low-signal parenchymal foci
consistent with the known minor patchy haemorrhagic
change.

for venous thrombosis with a lifetime incidence
of around 6%.
►► Venous infarction secondary to cerebral
venous thrombosis appears as intracranial
haemorrhage on imaging in 30%–40% of
cerebral venous thrombosis.
►► Plain CT head images provide a diagnosis of
cerebral venous thrombosis in approximately
30% of cases; in the event of a normal CT head,
diagnostic suspicion must guide appropriate
further imaging such as CT/magnetic resonance
venography.

Dallimore J, Bhatnagar R. BMJ Case Rep 2018. doi:10.1136/bcr-2017-222781

1

BMJ Case Reports: first published as 10.1136/bcr-2017-222781 on 8 February 2018. Downloaded from http://casereports.bmj.com/ on 18 April 2024 by guest. Protected by copyright.

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triggered consideration of the alternative diagnosis of intracranial thrombosis, in which associated haemorrhage is a feature
in 30%–40% of cases.
Contributors JD drafted the case and revised it critically for important intellectual
content. RB reviewed the drafted manuscript, revised it critically for important
intellectual content and obtained patient consent.
Competing interests None declared.
Patient consent Obtained.

Provenance and peer review Not commissioned; externally peer reviewed.
© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article)
2018. All rights reserved. No commercial use is permitted unless otherwise expressly
granted.

References

1 Miehsler W, Reinisch W, Valic E, et al. Is inflammatory bowel disease an independent
and disease specific risk factor for thromboembolism? Gut 2004;53:542–8.
2 Wasay M, Bakshi R, Bobustuc G, et al. Cerebral venous thrombosis: analysis of a
multicenter cohort from the United States. J Stroke Cerebrovasc Dis 2008;17:49–54.

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Dallimore J, Bhatnagar R. BMJ Case Rep 2018. doi:10.1136/bcr-2017-222781

BMJ Case Reports: first published as 10.1136/bcr-2017-222781 on 8 February 2018. Downloaded from http://casereports.bmj.com/ on 18 April 2024 by guest. Protected by copyright.

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