Cerebral venous sinus thrombosis (CVST) is a rare disease. Early diagnosis and treatment are important, as CVST is potentially fatal. Pregnancy and puerperium are known risk factors for CVST. Here, we report the case of a patient who developed superior sagittal sinus thrombosis after a normal vaginal delivery. A 20-year-old woman presented with a headache and seizures two days after a normal vaginal delivery. Initially, brain computed tomography (CT) showed a subarachnoid hemorrhage in the right parietal lobe and sylvian fissure, together with mild cerebral edema. CT angiography revealed superior sagittal sinus thrombosis. Multiple micro-infarctions were seen on diffusion-weighted magnetic resonance images. An intravenous infusion of heparin and mannitol was administered immediately. Two days after treatment initiation, the patient showed sudden neurological deterioration, with left-sided hemiplegia. Brain CT showed moderate brain edema and hemorrhagic densities. Emergency decompressive craniectomy was performed, and heparin was re-administered on post-operative day (POD) 1. On POD 9, the patient's mental state improved from stupor to drowsy, but the left-sided hemiplegia persisted. CT angiography showed that the superior sinus thrombosis had decreased. Superior sagittal sinus thrombosis is an uncommon complication, with an unfavorable outcome, after delivery. Timely diagnosis and treatment are important for preventing neurological deterioration.
Angiography ; Brain ; Brain Edema ; Cerebral Infarction ; Decompressive Craniectomy ; Diagnosis ; Early Diagnosis ; Emergencies ; Female ; Headache ; Hemiplegia ; Heparin ; Humans ; Infusions, Intravenous ; Mannitol ; Parietal Lobe ; Postpartum Period* ; Pregnancy ; Rare Diseases ; Risk Factors ; Seizures ; Sinus Thrombosis, Intracranial ; Stupor ; Subarachnoid Hemorrhage ; Superior Sagittal Sinus* ; Thrombosis* ; Young Adult

PURPOSE: Cerebral venous thrombosis (CVT) is a rare cause of pediatric stroke. Our goal was to describe the clinical CVT features among pediatric patients presenting at a tertiary referral center. METHODS: Patient data was retrospectively collected from the charts of all pediatric patients (newborn to 18 years old) who were diagnosed with CVT at Seoul National University Children's Hospital between 2000 and 2016. Magnetic resonance imaging or venography was conducted for diagnostic confirmation. Modified Rankin Scale (mRS) was used to evaluate neurologic outcome. RESULTS: Twenty patients were diagnosed with CVT during the study period (16 male, 4 female). Median age was 4 years. The most common risk factor was systemic infection (6/20, 30.0%). Twelve patients initially presented with headache or vomiting (12/20, 60.0%). Seizure was in only 3 patients within 48 hours of symptom onset; however, as the clinical course progressed, seizure was the symptom that most frequently led to brain imaging (12/20, 60.0%). Thrombosis in the superior sagittal sinus was frequently associated with intracranial hemorrhage (4/11, 36.4%) and clinical seizure (9/11, 81.8%). Anticoagulation and/or antiplatelet agents were used in 16 patients (16/20, 80%). At the 3-month follow-up, 14 patients (14/20, 70%) had an mRS of 0 or 1, showing that most of these patients had no neurologic impairment. CONCLUSION: Seizure and signs of increased intracranial pressure are the most common manifestation of pediatric CVT. However, clinical features are diverse and include age at symptom onset and underlying risk factors. Despite diagnostic delay, neurologic outcome is favorable in most patients.
Follow-Up Studies ; Headache ; Humans ; Intracranial Hemorrhages ; Intracranial Pressure ; Korea* ; Magnetic Resonance Imaging ; Male ; Neuroimaging ; Pediatrics ; Phlebography ; Platelet Aggregation Inhibitors ; Retrospective Studies ; Risk Factors ; Seizures ; Seoul ; Stroke ; Superior Sagittal Sinus ; Tertiary Care Centers ; Thrombosis ; Venous Thrombosis* ; Vomiting

OBJECTIVE: Cerebral venous thrombosis (CVT) is a rare condition for which few clinical reviews have been conducted in Korea. Our aim was to investigate, risk factors, clinical presentations/courses, and outcomes of 22 patients treated for CVT at two centers. MATERIALS AND METHODS: A retrospective analysis was conducted, selecting 22 patients diagnosed with and treated for CVT at two patient care centers over a 10-year period (January 1, 2004 to August 31, 2015). Patient data, pathogenetic concerns (laboratory findings), risk factors, locations, symptoms, treatments, and clinical outcomes were reviewed. RESULTS: Mean patient age at diagnosis was 54.41 ± 16.19. Patients most often presented with headache (40%), followed by seizure (27%) and altered mental status (18%). Focal motor deficits (5%), visual symptoms (5%), and dysarthria (5%) were less common. Important predisposing factors in CVT included prothrombotic conditions (35%), infections (14%), hyperthyroidism (18%), trauma (14%), and malignancy (4%). By location, 9 patients (40%) experienced thrombosis of superior sagittal sinus predominantly, with involvement of transverse sinus in 20 (90%), sigmoid sinus in 12 (40%), and the deep venous system in 5 (23%). Treatment generally consisted of anticoagulants (63%) or antiplatelet (23%) drugs, but surgical decompression was considered if warranted (14%). Medical therapy in CVT yields good functional outcomes. CONCLUSION: Mean age of patients with CVT in our study exceeded that reported in Europe or in America and had difference in risk factors. Functional outcomes are good with use of antithrombotic medication, whether or not hemorrhagic infarction is evident.
Americas ; Anticoagulants ; Causality ; Colon, Sigmoid ; Decompression, Surgical ; Diagnosis ; Dysarthria ; Europe ; Headache ; Humans ; Hyperthyroidism ; Infarction ; Korea ; Patient Care ; Retrospective Studies ; Risk Factors ; Seizures ; Sinus Thrombosis, Intracranial ; Superior Sagittal Sinus ; Thrombosis ; Venous Thrombosis*

Patients with inflammatory bowel disease (IBD) have an elevated risk of venous thromboembolism compared with the general population. The most common sites of venous thromboembolism in IBD patients are the deep veins of the legs, the pulmonary system, and portal and mesenteric veins. However, cerebral venous thrombosis is rarely associated with IBD. This report describes a case of cerebral venous thrombosis in a patient with Crohn's disease. A 17-year-old girl, diagnosed 4 years earlier with Crohn's disease, presented with headache and vomiting. Magnetic resonance imaging of the brain with venography showed venous thrombosis in the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. The patient immediately started anticoagulation therapy with intravenous heparin infusion followed by daily oral rivaroxaban 10 mg. Follow-up imaging after 2 weeks showed resolution of the thrombosis, with recanalization of the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. She continued rivaroxaban therapy for 6 months, and remained well, without neurologic sequelae. A high level of concern for cerebral venous thrombosis may be important when treating active IBD patients, because anticoagulation treatment can prevent fatal complications.
Adolescent ; Brain ; Crohn Disease* ; Female ; Follow-Up Studies ; Headache ; Heparin ; Humans ; Inflammatory Bowel Diseases ; Jugular Veins ; Leg ; Magnetic Resonance Imaging ; Mesenteric Veins ; Phlebography ; Rivaroxaban ; Superior Sagittal Sinus ; Thrombosis ; Veins ; Venous Thromboembolism ; Venous Thrombosis* ; Vomiting

Superior sagittal sinus thrombosis is an uncommon disease, and 25% of cases are considered to be idiopathic. Hypercoagulability, local bloodstream stasis, and vessel wall abnormalities may contribute to the development of this condition. The thyrotoxic phase of Graves’ disease is associated with venous thrombosis caused by hypercoagulability, which is in turn induced by increased levels of homocysteine and factor VIII and decreased fibrinolytic activity. Here, we report the case of a 39-year-old male who presented with superior sagittal sinus thrombosis and concomitant hyperthyroidism.
Adult ; Factor VIII ; Graves Disease* ; Homocysteine ; Humans ; Hyperthyroidism ; Male ; Protein C Deficiency ; Superior Sagittal Sinus ; Thrombophilia ; Thrombosis ; Thyrotoxicosis ; Venous Thrombosis*

Cerebral venous sinus thrombosisis an uncommon entity and its clinical presentations are highly variable. We present the case of superior sagittal sinus thrombosis. Although it was medical refractory, successfully treated with mechanical thrombectomy using the Solitaire FR device. A 27-year-old man who presented with venous infarction accompanied by petechial hemorrhage secondary to the superior sagittal sinus (SSS) thrombosis. Due to rapid deterioration despite of anticoagulation therapy, the patient was taken for endovascular treatment. We deployed the Solitaire FR device (4×20 mm) in the anterior portion of the thrombosed SSS, and it was left for ten minutes before the retraction. Thus, we removed a small amount of thrombus. But the sinus remained occluded. We therefore performed the thrombectomy using the same methods using the Solitaire FR (6×20 mm). Thus, we were successful in removing larger clots. Our case highlights not only that the mechanical thrombectomy using the Solitaire FR is effective in achieving revascularization both rapidly and efficiently available, but also that it might be another option in patients with cerebral venous sinus thrombosis who concurrently had rapid clinical deterioration with devastating consequences.
Adult ; Hemorrhage ; Humans ; Infarction ; Sinus Thrombosis, Intracranial ; Superior Sagittal Sinus* ; Thrombectomy* ; Thrombosis*

PURPOSE: Knowledge of variations in the cerebral dural venous sinus anatomy seen on magnetic resonance (MR) venography is essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST). Very limited data is available on gender difference of the cerebral dural venous sinus anatomy variations. MATERIALS AND METHODS: A retrospective study was conducted to study the normal anatomy of the intracranial venous system and its normal variation, as depicted by 3D MR venography, in normal adults and any gender-related differences. RESULTS: A total of 1654 patients (582 men, 1072 women, age range 19 to 86 years, mean age: 37.98±13.83 years) were included in the study. Most common indication for MR venography was headache (75.4%). Hypoplastic left transverse sinus was the most common anatomical variation in 352 (21.3%) patients. Left transverse sinus was hypoplastic in more commonly in male in comparison to female (24.9% versus 19.3%, p = 0.009). Most common variation of superior sagittal sinus (SSS) was atresia of anterior one third SSS (15, 0.9%). Except hypoplastic left transverse sinus, rest of anatomical variations of the transverse and other sinuses were not significantly differ among both genders. CONCLUSION: Hypoplastic left transverse sinus is the most common anatomical variation and more common in male compared to female in the present study. Other anatomical variations of dural venous sinuses are not significantly differ among both genders.
Adult ; Female ; Headache ; Humans ; Male ; Phlebography* ; Retrospective Studies ; Sinus Thrombosis, Intracranial ; Superior Sagittal Sinus

We are reporting an unusual case of dural arteriovenous fistula (AVF) of the superior sagittal sinus (SSS) after tamoxifen treatment for breast cancer. A 30-year-old female arrived at the emergency room with a sudden headache and left sided weakness and sensory loss. In her past medical history, she was diagnosed with breast cancer 1 year prior, and subsequently underwent a breast conserving mastectomy with whole breast radiation and adjuvant chemotherapy with tamoxifen. At the time of admission, computed tomography showed a small acute intracerebral hemorrhage at the right parietal cortex, and magnetic resonance imaging showed that a dural AVF at the SSS with a prominent and tortuous venous enhancement along the centrum semiovale was present. Cerebral angiography showed that the dural AVF at the mid-portion of the SSS with meningeal arterial feeding vessels entering the wall of the SSS, then draining through the dilated cortical veins. Our patient had no signs of active malignancy or any abnormalities in her coagulation profile, so it can be concluded that the tamoxifen was the likely cause of the SSS thrombosis and dural AVF. The dural AVF was treated by an endovascular coil embolization for the arterialized segment of the SSS. The patient dramatically recovered favorably from left side motor and sensory deficit. The best clinical approach is to screen potential patients of tamoxifen hormonal therapy and educate them on the sign and symptoms of life threatening thromboembolic events while taking tamoxifen.
Adult ; Breast ; Breast Neoplasms* ; Central Nervous System Vascular Malformations* ; Cerebral Angiography ; Cerebral Hemorrhage ; Chemotherapy, Adjuvant ; Embolization, Therapeutic ; Emergency Service, Hospital ; Female ; Headache ; Humans ; Magnetic Resonance Imaging ; Mastectomy ; Rabeprazole ; Superior Sagittal Sinus* ; Tamoxifen* ; Thrombosis ; Veins

Cerebral venous thrombosis is an uncommon cause of cerebral infarction. A 31-year-old man complained of headache, weakness, and numbness of the left leg a day before being admitted to the hospital. After admission, brain computed tomography and brain magnetic resonance imaging revealed superior sagittal sinus thrombosis with cerebral infarction in the right hemisphere. He had no significant medical history. On the fourth hospital day, he suddenly collapsed and died. Medicolegal autopsy was performed 3 days later; medical malpractice was suspected. External examination revealed a few conjunctival petechiae. Internal examination revealed thrombi in the superior sagittal sinus and superficial cortical veins. Thrombi were noted in the pulmonary trunk and both pulmonary arteries. Upon dissection of the left leg, we found thrombi in the posterior tibial vein. A microscopic examination revealed vasculitis of the same cortical veins, and we therefore assumed that vasculitis of the cortical veins gave rise to thrombosis. In typical autopsy practice, an examination of the dura mater is often overlooked, but careful examination of this region should be performed in cases of cerebral infarction in young adults, such as this one.
Adult ; Autopsy ; Brain ; Cerebral Infarction ; Dura Mater ; Headache ; Humans ; Hypesthesia ; Intracranial Thrombosis ; Leg ; Magnetic Resonance Imaging ; Malpractice ; Pulmonary Artery ; Pulmonary Embolism* ; Purpura ; Superior Sagittal Sinus ; Thrombosis ; Vasculitis ; Veins ; Venous Thrombosis* ; Young Adult

The infantile skull is malleable, and its sutures are tightly adhering to the underlying dura and venous sinus. These characteristics, in association with the small amount of total blood volume, can result in a specific fatal type of skull fracture, which is unique to infancy. The authors report a case of this injury, and stress the need to pay attention to the possibility of massive bleeding during operation in infants. A 23-month-old female baby presented with semicomatose mentality after sustaining injuries by falling from a second-floor. Plain skull films showed bi-frontal skull fracture crossing the midline. Computed tomography revealed an acute subdural hematoma along the right convexity with severe brain edema. In the emergency operation, the scalp incision exposed massive bleeding from the fracture site. The bleeding was identified as arising from the lacerated and widely separated sagittal sinus beneath the fracture. The patient entered hypovolemic shock immediately after the scalp incision, and died from severe brain edema two days after the trauma and surgery. This case implies that special care should be paid during the operation of patients that have skull fracture overlying the venous sinus, especially when the fracture line is separated.
Blood Volume ; Brain Edema ; Brain Injuries ; Craniocerebral Trauma* ; Emergencies ; Female ; Hematoma, Subdural, Acute ; Hemorrhage ; Humans ; Infant ; Sagittal Sinus Thrombosis ; Scalp ; Shock ; Skull ; Skull Fractures* ; Sutures