Cerebral Dural Sinus Thrombosis A Case Report Faik Budak, M.D. Okan Bölükbaşi, M.D. Ali Demirci, M.D. † Mehmet Özmenoğlu, M.D. and Baki Komsuoglu, M.D. ‡ TRABZON,TURKEY - ABSTRACT Cerebral dural sinus thrombosis is an uncommon syndrome that a patient presents with severe headache, which may be associated with complex physical and neurologic findings. The authors present a thirty-two-year-old woman with severe headache, focal motor seizures, and subsequent hemiparesis when she was ten weeks pregnant, diagnosed as having a dural sinus thrombosis by magnetic resonance imaging and magnetic resonance angiography. In this report, the application of magnetic resonance techniques, including angiography to diagnose and monitor therapy for dural sinus thrombosis, is presented. From the Departments of *Neurology, † Radiology, and ‡ Cardiology, KTU, Faculty of Medicine, Farabi Hospital, Trabzon, Turkey. 541 Downloaded from ang.sagepub.com at UNIV OF MASSACHUSETTS on March 16, 2015 Introduction Thrombosis of a dural sinus is most commonly seen in association with pregnancy, the puerperium, the use of oral contraceptives, tumors, trauma, hematologic disorders, and rheologic dehydration.l2 Magnetic resonance imaging (MRI) combines the capability for direct imaging of the clotted blood in the vessels causes like with noninvasiveness.3 The case of a thirty-two-year-old woman with dural sinus thrombosis (DST) and with diagnosis and follow-up made by MRI and magnetic resonance angiography (MRA) is presented. Case Report A thirty-two-year-old woman presented with severe frontal headache associated with focal motor seizures and nausea. On the day of ad- mission, she was ten weeks pregnant. Examination revealed a 37°C temperature, mild confusion, a stiff neck, normal fundi, a left hemiparesis, left extensor plantar response, and left brisk deep tendon reflexes. Computed tomography (CT) showed a minimal hyperdense focus on the right parietal lobe. A lumbar puncture revealed an opening pressure of 52 cm cerebrospinal fluid, 416 red blood cells. Protein was 62 mg/dL, and glucose was 76 mg/dL. Coagulation tests, including fibrin, D. Dimer, prothrombin time, and partial thromboplastin time were all within normal limits. MRI showed a hyperintense thrombus completely filling the superior sagittal sinus (SSS), right transverse sinus, and the jugular vein on sagittal and axial Tl-weighted images (Figure 1). A hyperintense millimetric focus was detected as a cortical hemorrhagic infarction area on CT. Two-dimensional time-of-flight (TOF) and three-dimensional phase contrast MRA con- Figure 1. T1-weighted (TR/TE 450/20 ms) sagittal magnetic resonance image shows a hyperintense thrombus completely filling superior sagittal sinus. 542 Downloaded from ang.sagepub.com at UNIV OF MASSACHUSETTS on March 16, 2015 firmed the spin-echo MR images, showing an absence of dural sinus flow on the right side. Dural sinuses of the left side showed &dquo;signal void,&dquo; indicating patent lumina (Figure 2). Second MR and MRA examination, performed two weeks later, showed that the hyperintense appearance of the SSS detected on the previous MRI was resolved this time; however, the flow void could not be detected definitely. But the hyperintensity of the right sigmoid, transverse sinuses, and jugular vein had not disappeared. On third MR examination performed six weeks later, the thrombus in the right transverse sinus had resolved. The sigmoid sinus and jugular vein had thrombi but were partly reopened. Two-dimensional TOF MRA showed recanalized right-side dural sinuses with some residual thrombi and dilatations (Figure 3). She made complete recovery and was discharged home on a phenytoin regimen. Discussion The diagnosis of DST is often clinically unsuspected because the symptoms resulting from increased intracranial pressure, such as headache and emesis, are nonspecific. Other common symptoms include mild paresis, lethargy, change in the level of consciousness, and dis- turbance of vision.4 CT signs include cord and the delta signs, demonstration of dilatated collateral veins, increased tentorial contrast enhancement, small ventricles, and hemorrhagic infarction or lowdensity areas not confined to a single arterial territory. 5,6 These signs are inconstant, are less specific, and can be overlooked.4~~ Our patient demonstrated a hemorrhagic infarction of the right parietal lobe. The superiority of MRI over CT in detection of DST is well known .2,4 MRI offers major advantages for evaluating these patients because Figure 2. Magnetic resonance angiography shows an absence of dural sinus flow on the right side. 543 Downloaded from ang.sagepub.com at UNIV OF MASSACHUSETTS on March 16, 2015 Figure 3. Magnetic resonance angiography shows recanalized right-side dural sinuses with some residual thrombi and dilatations. of its sensitivity to blood flow, its high intrinsic contrast, and its noninvasiveness. The thrombus is isointense with brain on Tl-weighted images8 in the case of an acute thrombosis. Thrombosis in the subacute and chronic stages shows an increased signal as compared with that of brain on both Tl- and T2-weighted images because of the formation of methemoglobin.9 Subacute thrombus demonstrates a hyperintense signal characteristic on Tl-weighted images and slightly later on T2-weighted images related to methemoglobin formation on the clot. In this case, the noncontrast axial Tl-weighted MRI demonstrated hyperintensity to brain within the superior sagittal sinus, right transverse sinus, and the jugular vein, suggesting methemo- Angiography has been for a long a time the single direct diagnostic modality.l° However, this invasive procedure may not be ordered without a specific indication. As for CT, the use of iodinated contrast medium is potentially dangerous in these patients.4 It can produce dehydration that may aggravate a hypercoagulable state. MRA provides conclusive visualization for flow in the dural sinuses in place of reliance on a flow-related enhancement effect in imaging sequences.ll The combined MRI and MRA study provides a noninvasive technique without ionizing radiation, allowing direct visualization and accurate delineation of the thrombus. globin. However, T2-weighted noncontrast images showed an abnormal high signal in the superior sagittal sinus, right transverse sinus, and the jugular vein, which was inconsistent with early blood denaturation product. Conclusion We believe that application of MRI techniques including MRA will become the test of choice 544 Downloaded from ang.sagepub.com at UNIV OF MASSACHUSETTS on March 16, 2015 for diagnosing and monitor therapy for dural sinus thrombosis. Faik Budak, M.D. KTÜ Tip Fakültesi, Nöroloji ABD TR 61080 Trabzon, Turkey References 7. Synder TC, Sachdev SH: MRI of cerebral dural sinus thrombosis. J Comput Assist Tomogr 10 :889- 1. McMurdo SK, Zawadzki MB, Bradley WG, et al: Dural sinus thrombosis, study using intermediate field strength MR imaging. Radiology 161:83-86, 1986. 2. Padayachee TS, Bingham JB, Graves MJ, et al: Dural sinus thrombosis. Neuroradiology 33:165-167, 1991. 891, 1986. 8. Gomori JM, Grossman RI, Goldberg HI, et al: Intracranial hematomas: Imaging by high field MR. Radiology 157:87-93, 1985. 3. Hulcelle PJ, Dooms GC, Mathurin P, et al: MRI assessment of unsuspected dural sinus thrombosis. Neuroradiology 31:217-221, 1989. 4. Harris TM, Smith RR, Koch KJ: Gadolinium-DTPA enhanced MR imaging of septic dural sinus thrombosis. J Comput Assist Tomogr 13:682-684, 1989. 9. Bradley WG, Schmidt P: Effect of methemoglobin formation on the MR appearance of subarachnoid hem- orrhage. Radiology 156:99-103, 1985. 10. Barnes BD, Brandt-Zawadzki M, Menzer W: Digital subtraction angiography in the diagnosis of superior sagittal sinus thrombosis. Neurology 33:508- 5. Panke TS: Cerebral dural sinus thrombosis. Ann Emerg Med 20:813-816, 1991. 6. Buananno FS, Moody DM, Ball MR, et al: Computed cranial tomographic findings in cerebral sinovenous occlusion. J Comput Assist Tomogr 2:281-290, 1978. 510, 1983. 11. Rippe DJ, Boyko OB, Spritzer CE, et al: Demonstration of dural sinus occlusion by the use of MR angiography. Am J Neuroradiol 11:119-201, 1990. 545 Downloaded from ang.sagepub.com at UNIV OF MASSACHUSETTS on March 16, 2015