Image of the moment Ho Tin Wong,1 Chris Rowland-Hill,2 Rubesh Gooriah1 1 Department of Neurology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK 2 Department of Neuroradiology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK Correspondence to Dr Rubesh Gooriah, Department of Neurology, Hull and East Yorkshire Hospitals NHS Trust, Hull HU3 2JZ, UK; ​rubesh.​ gooriah@​hey.​nhs.​uk Accepted 25 April 2019 Case report A 25-year-old Indian woman presented to the emergency department with sudden onset of moderately severe holocranial headache. She was nauseated, but had no vomiting, neck stiffness or photophobia. She had been previously well and took the combined oral contraceptive pill. There was no family history of thrombosis. On examination, she was apyrexial with a Glasgow coma scale score of 15. There were no focal neurological signs. Routine blood tests were normal and her MRI scan of brain was initially reported as normal (figure 1). Her headache persisted and 2 days later she had a generalised tonic-clonic seizure. Repeat MRI scan of brain showed haemorrhage in the right temporal lobe (figure 2). Due to further convulsive seizures and persistently low level of consciousness, she was intubated and ventilated. Review of the initial MRI scan identified a thrombosed right vein of Labbé on T2 fluid-attenuated inversion recovery (FLAIR), with no associated parenchymal changes (figure 3). Her thrombophilia screen was negative. We attributed the thrombosis to combined oral contraceptive pill. We advised her to Figure 2 MR scan of brain (axial T2 FLAIR) showing a right temporal lobe haemorrhage. FLAIR, fluid-attenuated inversion recovery. stop the pill and to start levetiracetam and warfarin. She recovered completely during 6 days in hospital. She remained anticoagulated for nearly 6 months, after which an MR cerebral venogram showed persistent filling defect in the right vein of Labbé. We stopped her warfarin at this point, and stopped the levetiracetam a month later. Three months later she represented with a witnessed unprovoked generalised tonic-clonic seizure. CT scan of head showed encephalomalacia in the right temporal lobe (figure 4); repeat venogram showed no evidence of a recurrent venous thrombosis. She restarted levetiracetam © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ. To cite: Wong HT, Rowland-Hill C, Gooriah R. Pract Neurol Epub ahead of print: [please include Day Month Year]. doi:10.1136/ practneurol-2019-002286 Figure 1 MR scan of brain (axial FLAIR) was initially reported as normal. FLAIR, fluidattenuated inversion recovery. Figure 3 Close up of figure 1 showing thrombosed right vein of Labbé (arrow). Wong HT, et al. Pract Neurol 2019;0:1–2. doi:10.1136/practneurol-2019-002286 1 Pract Neurol: first published as 10.1136/practneurol-2019-002286 on 24 May 2019. Downloaded from http://pn.bmj.com/ on 24 July 2019 by guest. Protected by copyright. Vein of Labbé thrombosis: Don’t miss the dot! Image of the moment Contributors HTW wrote the original draft. CRH revised the manuscript and provided expert neuroradiology advise. RG reviewed the patient and revised the manuscript. Figure 4 Non-contrast CT scan of head showing right temporal lobe encephalomalacia. 500 mg twice daily and has since remained seizure free. Discussion The vein of Labbé, described by French surgeon Charles Labbé in the 19th century, is also known as the inferior anastomotic vein. It is one of the superficial cortical veins connecting the middle cerebral vein to 2 Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent for publication Obtained. Provenance and peer review Not commissioned. Externally peer reviewed by Joshua Klein, Boston, USA. References 1 Gold M. Isolated right vein of Labbe thrombosis. JAMA Neurol 2016;73:120–1. 2 Ramsawak L, Whittam D, Till D, et al. Isolated thrombosis of the vein of Labbe – clinical and imaging features. Journal of Acute Medicine 2016;6:73–5. Wong HT, et al. Pract Neurol 2019;0:1–2. doi:10.1136/practneurol-2019-002286 Pract Neurol: first published as 10.1136/practneurol-2019-002286 on 24 May 2019. Downloaded from http://pn.bmj.com/ on 24 July 2019 by guest. Protected by copyright. the transverse sinus, and drains the adjacent temporal lobe. Isolated thrombosis of the vein of Labbé is rare and usually presents with headaches or seizures. For reasons unknown, thrombosis of the left vein of Labbé occurs significantly more frequently than the right. Isolated right vein of Labbé thrombosis has only been described in a handful of cases.1 2 Although very rare, it is important to consider this in the differential diagnosis of a right temporal lobe haemorrhage, as failure to start appropriate treatment can have serious consequences. In our case, the initial T2 FLAIR showed an occluded vein of Labbé in the form of a hyperintense ‘dot’ over the right temporal cortex. Interestingly, there was no associated adjacent temporal lobe abnormality, which is unusual for vein of Labbé thrombosis. This early finding should alert both neurologists and radiologists to a possible thrombosis, to allow timely introduction of anticoagulation.