Case 1
History:
36 year old female with non-specific headaches, nausea and vomiting
Findings:
Enhanced T1 weighted images showing irregular filling defect involving the left transverse sinus.
Diagnosis:
Transverse sinus thrombosis
Discussion:
Clinically, CVT presents with high variability. Most common symptoms included headaches (75-90%), seizure (40%) mental status change (22-39%), motor/sensory deficit ( 34%), papilledema (285), dysphasia (19%), cranial nerve palsies, and visual loss. Also the timing with regard to onset of symptoms is also variable. In 28% of cases symptoms were acute (<48hrs). 42% were sub acute in presentation (48hrs-30days). 30% were chronic >30 days. CT scan is often obtained as first line screening. Rarely an empty delta sign can be encountered representing the clot within the sinus. Venous infarct, in unusual location, often bilateral, sparing cortex, often with hemorrhagic transformation.
On MRI thrombus is acutely intense on T1 (during approximately the first 5 days) and hypointense on T2. Diffusion images may be normal. From 4 to 7days the thrombus is bright on T1. Both time of flight (TOF) and phase contrast (PC) MR venography have been used. TOF is sensitive to slow flow. Contrast MR Venography provides information directly on filling defects. Pitfall includes slow flow. TOF may be helpful; also dropping the VENC (velocity encoding) may be helpful.
The mainstay of treatment is anticoagulation. Heparin has been shown to be safe; hemorrhagic are usually not be a contraindication. However, there is still controversy about whether or not heparin is beneficial.
