Case Post traumatic cerebral venous thrombosis

Transcription

1 Case Post traumatic cerebral venous thrombosis AMMOR H Section: Neuroradiology Published: 2015, Jan. 20 Patient: 16 year(s), male Authors' Institution Hôpital Moulay El Hassan Ben El. Mehdi. Laayoune. Rue Termidi Apt Fes, Morocco; ammor_hicham@hotmail.com Clinical History A 16-year-old boy was hospitalized because of one-week history of headache and repeated vomiting after having a head injury. Examination showed no abnormalities. Imaging Findings Unenhanced CT revealed that there was a hyperdense appearance like intracerebral hematoma on the right occipital region with an ipsilateral occipital fracture. An injection with contrast media followed, and objectified a thrombosis of the transverse sinus. There was also a small hyperdense region in the left frontal lobe, which was most likely a haemorrhagic venous infarction. This focal haemorrhage can be misinterpreted as traumatic parenchymal contusion, especially if extraaxial haemorrhage is reported instead of CVT, leading to a misdiagnosis of trauma as the cause of the blood products. Discussion

2 The first case of blunt head injury associated with Dural Sino thrombosis (DST) was described by Ecker In Since then, other trauma-induced DSTs have been reported [1]. The pathogenesis of DST has not been well established yet in head injury. Various hypotheses for the development of DST imply intramural haemorrhages caused by the rupture of small sinusoids, injury to the endothelial lining, extension of the thrombus from injured emissary veins and compression of the sinuses from intracranial oedema in the development of DST in closed head injury patients [2-6]. In addition, abnormalities in the clotting mechanism, disturbances in the blood flow, alteration in the coagulation after head injury, or lesion the capillary endothelium may induce thrombosis [5]. Clinically, DST manifests commonly by increased intracranial pressure signs such as nausea, vomiting and headache.the compensatory function of the venous collateral system is the main factor that determines the DST diagnosis and also affects prognosis [6]. In children, incomplete growth of venous collaterals may facilitate the diagnosis of DST. This explain the relatively high frequency in children. The confirmation of the diagnosis implies the demonstration of thrombus by neuroimaging [7-10]. CT may show the thrombus itself in case of acute thrombosis, or a high density in the affected sinus region. After injection of contrast media we may have a specific delta sign [11]. However, MRI in combination with MRA is more sensitive. If the diagnosis is still uncertain, DSA may be used and provides better details of the cerebral veins [8, 10, 12]. There is no consensus on the overall strategy concerning surgical, radiosurgical, or conservative therapy in DST [6, 10, 11, 13-15]. If there is any compression to the dural sinus by depressed fracture or hematoma, it should be removed [5, 15, 16]. If these pathologies are not present, the priority of treatment in the acute phase is to stabilize the patient's condition (hydration, anticonvulsants, craniectomy for decreasing intracranial pressure...). Anticoagulation therapy is the first choice although it remains controversial in traumatic cases [11, 13-15, 17]. However, since the patients have a haemorrhagic lesion related to head injury, anticoagulant therapy should be applied carefully with adequate monitoring for complications such as new bleeding. The mortality varies between 4.3 and 30%, and furthermore survival cases may have permanent neurological deficits [10, 18, 19]. In the monitored posttraumatic DST cases, better recovery has been observed in right-localized sinus thrombosis (generally the left hemisphere is dominant in the population). Final Diagnosis Post traumatic cerebral venous thrombosis Differential Diagnosis List Extra axial haemorrhage, Parenchymal contusions Figures

3 Figure 1 Chest CT Unenhanced CT revealed that there was a hyperdense appearance like extra axial hematoma on right occipital region Area of Interest: Neuroradiology brain; Imaging Technique: CT; cerebral CT: bone window: fracture in the right occipital bone Area of Interest: Neuroradiology brain;

4 Imaging Technique: CT; cerebral CT scan after injection of contrast media; axial view: thrombosis of the right transverse sinus Area of Interest: Neuroradiology brain; Imaging Technique: CT; Unenhanced cerebral CT scan: Small hyperdense region in left frontal lobe is most likely hemorrhagic venous infarction.

5 Area of Interest: Neuroradiology brain; Imaging Technique: CT; References [1] Dalgiç A1, Seçer M, Ergüngör F, Okay O, Akda R, Ciliz D (2008) Dural sinus thrombosis following head injury: report of two cases and review of the literature Turkish Neurosurgery Vol: 18, No: 1, [2] Muthukumar N (2005) Uncommon cause of sinus thrombosis following closed mild head injury in a child Childs Nerv Syst 21: [3] Ochagavia AR, Boque MC, Torre C, Alonso S, Sirvent JJ (1996) Dural venous sinus thrombosis due to cranial trauma Lancet 347:1564 [4] Owler BK, Besser M (2005) Extradural hematoma causing venous sinus obstruction and pseudotumor cerebri syndrome Childs Nerv Syst 21: [5] Tamimi A, Abu-Elrub M, Shudifat A, Saleh Q, Kharazi K, Tamimi I (2005) Superior sagittal sinus thrombosis associated with raised intracranial pressure in closed head injury with depressed skull fracture Pediatr Neurosurg 41: [6] Yuen HW, Gan BK, Seow WT, Tan HKK (2005) Dural sinus thrombosis after minor head injury in a child Ann Acad Med Singap 34: [7] Brors D, Schafers M, Schick B, Dazert S, Draf W, Kahle G (2001) Sigmoid and transverse sinus thrombosis after closed head injury presenting with unilateral hearing loss Neuroradiology 43: [8] Renowden S (2004) Cerebral venous sinus thrombosis Eur Radiol 14: [9] Satoh H, Kumano K, Ogami R, Nishi T, Onda J, Nishimura S, Kurisu K (2000) Sigmoid sinus thrombosis after mild closed head injury in an infant: Diagnosis by Magnetic resonance imaging in the acute phase Neurol Med Chir 40: [10] Stam J (2005) Thrombosis of the cerebral veins and sinuses N Engl J Med 352: [11] Stiefel D, Eich G, Sacher P (2000) Posttraumatic dural sinus thrombosis in children Eur J Pediatr Surg 10: [12] Cruz BA, Santos LA, Damasceno RP Ribeiro LS, Xavier GA Jr, Nunes SV, Campos GB, Crivellari H (2001) Dural sinus thrombosis in childhood systemic lupus erythematosus J Rheumatol 28: [13] Stam J (2003) The treatment of cerebral venous sinus thrombosis Adv Neurol 92: [14] Taha JM, Crone KR, Berger TS, Becket WW, Prenger EC (1993) Sigmoid sinus thrombosis after closed head injury in children Neurosurgery 32:

6 [15] Yokota H, Eguchi T, Nobayashi M, Nishioka T, Nishimura F, Nikaido Y (2006) Persistent intracranial hypertension caused by superior sagittal sinus stenosis following depressed skull fracture. Case report and review of the literature J Neurosurg 104: [16] Uzan M, Ciplak N, Dashti SG, Bozkus H, Erdincler P, Akman C (1998) Depressed skull fracture overlying superior sagittal sinus as a cause of benign intracranial hypertension: Case report J Neurosurg 88: [17] Ferrera PC, Pauze DR, Chan L (1998) Sagittal sinus thrombosis after closed head injury Am J Emerg Med 16: [18] De Bruijn SF, de Haan RJ, Stam J (2001) Clinical features and prognostic factors of cerebral venous sinus thrombosis in a prospective series of 59 patients for The Cerebral Venous Sinus Thrombosis Study Group J Neurol Neurosurg Psychiatry 70: [19] Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F (2004) ISCVT Investigators Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis Stroke 35: Citation AMMOR H (2015, Jan. 20) Post traumatic cerebral venous thrombosis {Online} URL: