Neuroradiology (1995) 37:447-448
9 Springer-Verlag 1995

E Y. W a n g
W. C. S h e n

Received: 17 January 1994
Accepted: 23 March 1994
P. Y. Wang ( ~ )
Section of Neurology, Department of
Internal Medicine, Taichung Veterans
General Hospital, Chung-Kang Road,
Taichung, Taiwan 40705, ROC
W. C. Shen
Department of Radiology, Taichung
Veterans General Hospital, Taichung,
Taiwan 40705, ROC

MRI in internal cerebral vein thrombosis:
case note

Abstract A 40-year-old man developed general malaise, dizziness and
progressive headache 1 week after
a c u t e h a e m o r r h a g i c conjunctivitis.
Bizarre behaviour, confusion and
a d v e r s i v e s e i z u r e s o c c u r r e d later.
MRI showed haemorrhagic infarct
in t h e b i l a t e r a l b a s a l g a n g l i a a n d
t h a l a m u s a n d a b n o r m a l signal d e n sity in t h e i n t e r n a l c e r e b r a l veins.
Bilateral carotid angiography
s h o w e d n o filling o f s u p e r i o r s a g i t t a l

Introduction
I n t e r n a l c e r e b r a l v e i n t h r o m b o s i s is r a r e l y r e p o r t e d , esp e c i a l l y in adults. W e r e p o r t t h e M R I f i n d i n g s in a m a n
a g e d 40 years.

Case report
A 40-year-old robust man developed acute haemorrhagic conjunctivitis on 16 July 1992, which improved gradually on treatment.
General malaise, dizziness and progressive headache developed
1 week later. Bizarre behaviour and confusion developed on 28
July, and three adversive seizures occurred on 1 August. The patient looked apathetic, was disoriented to time and place with impaired recent memory and poor calculation. There were positive
frontal lobe signs, right hemianopia, gegenhalten in all limbs,
clumsiness of the right limbs with motor perseveration and
generalised hyperreflexia with fexor plantar reflexes. There was
sensory extinction over the right limbs. Lumbar puncture on
4 August disclosed a mildly elevated protein level only. Routine
laboratory examinations were all within normal limits except an
elevated fibrinogen level. E E G on 7 August showed diffuse slow
waves with frontal prominence. Somatosensory evoked potentials
from the median nerve were normal.
CT on 1 August showed faint high attenuation in the left thalamus. On August 7 MRI showed symmetrical low signal lesions in

sinus a n d i n t e r n a l c e r e b r a l veins.
With MRI, cerebral venous thrombosis can be suspected and diagnosed earlier than before, obviating
any invasive investigation.
K e y words S t r o k e 9 Sinus
t h r o m b o s i s 9I n t e r n a l c e r e b r a l v e i n s

the basal ganglia and thalamus, and high signal in the left parietal
lobe on Tl-weighted images (Fig. i a). On T2-weighted images, the
lesions gave low signal intensity at their centre, with high signal
peripherally (Fig. 1 b). After intravenous Gd-DTPA, rather symmetrical ring enhancement in the thalamus and focal enhancement
in the left basal ganglia were seen (Fig. i c). High signal was seen in
the internal cerebral veins on sagittal Tl-weighted images
(Fig. 1 d), and the superior sagittal sinus, straight sinus and internal
cerebral veins showed contrast enhancement (Fig. le). Bilateral
carotid angiography on 11 August showed no filling of the superior
sagittal sinus and internal cerebral veins, with numerous collateral
veins draining anteriorly (Fig. 2).
Subcutaneous heparin 5,000 units was given twice daily for
i week. The symptoms and signs gradually resolved and the patient
was discharged on 20 August. MRI on 25 September showed resolution of brain oedema and partial resorption of the haematomas
in the basal ganglia, thalamus, and parietal lobe. EEG the same
day was normal. The patient was able to work as before from October.

Discussion
T h r o m b o s i s o f t h e d e e p c e r e b r a l v e i n s is r a r e l y r e p o r t ed. T h e m a j o r i t y o f cases a r e s e e n in c h i l d r e n [1], alt h o u g h t h e r e a r e i s o l a t e d case r e p o r t s in a d u l t s [2, 3].
O c c l u s i o n l e a d s to h a e m o r r h a g i c i n f a r c t s d e e p in t h e

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Fig.1 a Tl-weighted MRI disclosed symmetrical low signal le-

sions in the basal ganglia and thalamus. High signal was seen in the
internal cerebral veins, b The lesions in the basal ganglia and thalamus gave low signal centrally, with a periphery of high signal, on
T2-weighted images, c Rather symmetrical ring contrast enhancement in the thalamus and focal enhancement in the left basal
ganglia was seen. The internal cerebral veins and straight sinus also
enhanced, d High signal in the internal cerebral veins and low
signal in the superior sagittal sinus (arrow) were clearly seen on
sagittal Tl-weighted images, e The superior sagittal sinus, straight
sinus and internal cerebral veins also enhanced
Fig.2 Lateral venous phase of left carotid angiogram showed no
filling of superior sagittal sinus and internal cerebral veins, with
numerous collateral veins

cerebral hemispheres, s o m e t i m e s with intraventricular
h a e m o r r h a g e . M o r t a l i t y is p r o b a b l y high b e c a u s e the
condition is o f t e n o v e r l o o k e d . T h e diagnosis m a y be
suggested by C T [3], and c o n f i r m e d by cerebral angiography.
M R I clearly s h o w e d the h a e m o r r h a g i c infarcts in the
basal ganglia and thalamus. T h e high signal f r o m the
internal cerebral veins, and m a r k e d contrast e n h a n c e m e n t of the superior sagittal sinus, straight sinus, and
internal cerebral veins suggested t h r o m b o s i s of the internal cerebral veins and stagnant slow flow in the sinuses. These abnormalities led us to p e r f o r m confirmat o r y angiography. Thus, with M R I cerebral v e n o u s
t h r o m b o s i s can be suspected and d i a g n o s e d earlier t h a n
before, obviating any invasive investigation.

References
1. Smith RR, Sanford RA (1984) Disorders
of the deep cerebral veins. In: Kapp JR
Schmidek HH (eds) The cerebral venous
system and its disorders. Grune and
Stratton, Orlando, pp 547-555

2. Yoshii N, Seiki Y, Samejima H, Shibata
K, Awazu S (1978) Occlusion of the deep
cerebral veins. Neuroradiology 16: 287288

3. Wang PY (1992) Intracranial sinus
thrombosis in early pregnancy: report of
two cases. Acta Neurol Sin 1:278-283