Unilateral Manifestation of Deep Cerebral Vein Thrombosis Joel M. Stein, MD, PhD Bryan Pukenas, MD Suyash Mohan, MD Division of Neuroradiology Department of Radiology Hospital of the University of Pennsylvania ASNR 2016 EE-19

Disclosures Joel M. Stein, MD, PHD: No disclosures Bryan Pukenas, MD: No disclosures Suyash Mohan, MD: No disclosures

Purpose Deep cerebral vein thrombosis (DCVT) typically results in bilateral involvement of the thalami and other deep grey nuclei. We present a case of DCVT with striking left-sided involvement that prompted an initial diagnosis of neoplasm. Neuroradiologists should be aware of the rare unilateral presentation of DCVT so that appropriate imaging and intervention are initiated.

Case Report A 71 year-old woman with recently diagnosed acute myelogenous leukemia was brought to her local hospital after being found initially unresponsive at home, unable to move her right side, and with speech difficulty. Head CT and brain MRI showed a lesion involving the left thalamus and basal ganglia with hemorrhage, edema and mass effect. She received steroids and antiepileptics. Her mental status declined, requiring endotracheal intubation and ventricular drain placement.

Case Report - continued At our institution, the patient was found to be in status epilepticus, neutropenic, thrombocytopenic and febrile. She was covered with broad spectrum antibiotics, but bacterial and fungal blood cultures were negative. Repeat brain MRI demonstrated DCVT with left-sided hemorrhagic venous infarct. Venography confirmed this diagnosis. Successful mechanical thrombectomy was performed in the straight sinus and left transverse sinus. Despite these measures, the patient remained comatose throughout her hospitalization and died after withdrawal of care.

Imaging Findings - CT Axial sections from the initial head CT show expansile hypoattenuation in the left thalamus and basal ganglia extending to the corona radiata, hemorrhage in the left caudate head and density in the straight sinus and vein of Galen. (Advance slide for arrows)

* * * Imaging Findings - CT Axial sections from the initial head CT show expansile hypoattenuation in the left thalamus and basal ganglia extending to the corona radiata, hemorrhage in the left caudate head and density in the straight sinus and vein of Galen. (Advance slide for arrows)

Imaging Findings - MRI FLAIR T1 T1+C GRE Follow-up MRI shows increased left basal ganglia and thalamic hemorrhage with susceptibility on GRE, diffusion changes reflecting hemorrhage and cytotoxic edema in these regions and also involving the splenium, and surrounding vasogenic edema extending to left cerebral white matter. (Advance for arrows) DWI ADC

Imaging Findings - MRI FLAIR T1 T1+C GRE Follow-up MRI shows increased left basal ganglia and thalamic hemorrhage with susceptibility on GRE, diffusion changes reflecting hemorrhage and cytotoxic edema in these regions and also involving the splenium, and surrounding vasogenic edema extending to left cerebral white matter. (Advance for arrows) DWI ADC

Imaging Findings - MRI and CTV T1 bright clot in the left internal cerebral vein and basal veins along with a filling defect and corresponding susceptibility. CTV (far right) shows absence of left internal cerebral vein filling with partial filling of the other deep veins indicating frainage via collaterals. Hemorrhage in the ventricles is from shunt placement.

Imaging Findings - MRI and CTV T1 bright clot in the left internal cerebral vein and basal veins along with a filling defect and corresponding susceptibility. CTV (far right) shows absence of left internal cerebral vein filling with partial filling of the other deep veins indicating frainage via collaterals. Hemorrhage in the ventricles is from shunt placement.

Imaging Findings - Angio Conventional venography showed thrombosis of the straight sinus extending into the left transverse sinus. Improved reflux into the straight sinus is demonstrated after thrombectomy Initial Post thrombectomy Frontal views Lateral views

Summary DCVT is associated with multiple conditions that may have played a role in this case, including coagulopathy, malignancy, dehydration and infection. DCVT typically arises from propagation of more widespread dural sinus thrombosis. Due to shared straight sinus drainage, there is usually bilateral if variable involvement of the deep gray nuclei. DCVT has a poor prognosis and may persist or recur despite attempted thrombectomy.

Summary - continued Timely recognition of DCVT is important to initiate appropriate management and avoid unnecessary interventions. This case is rare for its striking asymmetry, and findings were initially thought to reflect neoplasm. Note that vasogenic edema and hemorrhage are the primary early manifestations of venous infarct. Involvement of multiple arterial territories is also a clue to the diagnosis of venous occlusion and infarction.

Summary - continued Look for dense clot within deep cerebral veins and dural sinuses on unenhanced CT and filling defects on CTV. Similarly, look for T1-hyperintense subacute thrombus or susceptibility on unenhanced MRI and filling defects on enhanced sequences. Look for loss of flow on MRV. In this case, 3D T1-weighted imaging was obtained as part of a protocol for surgical navigation due to the initial concern for neoplasm. In our experience, pre- and post- contrast 3D sequences may be quite useful and compliment other methods in depicting cerebral, dural or cavernous sinus thrombosis.