What about cerebral venous sinus thrombosis? A series of three autopsy cases

Abstract

Cerebral venous sinus thrombosis (CVST) is an uncommon cerebrovascular disorder that gained massive media attention in 2021, when an association between COVID-19 and its vaccines was found in several reported cases, raising the suspicion of a causative relation that is still debated. Three cases of CVST unrelated to COVID-19 are reported in this article to highlight the difficulty in the early recognition and management of this condition, as it occurs in a variety of diseases with different clinical and pathological manifestations. When the diagnosis cannot be achieved in the clinical setting, the role of the pathologist becomes essential in the determination of the cause of death and in the identification of the etiology of CVST. During the autopsy, coordination between the physician and the forensic pathologist is crucial to correlate the clinical presentation with the pathological picture.

Keywords: Cerebral venous sinus thrombosis; Cerebral venous thrombosis; Dural sinus sampling; Stroke.

Fig. 1

Case 1 Superior Sagittal Sinus. In situ incision of the SSS with a longitudinal section of the vessel to expose the thrombus.

Fig. 2

Case 2 gross and histological specimens of the SSS and the brain parenchyma. a) Formalin fixed transverse and left sigmoidal sinuses showing signs of obstruction from thrombotic material - note the bluish discoloration. b) Cerebral venous infarction with red-to-purple hemorrhagic punctuations. c) Histological appearance of thrombus inside the SSS under light microscopy - note the contact with the vascular wall. (10x) d) Thrombus degree of re-organization with erythrocytes, fibrin deposits and PMN cells infiltrates, which allows to give an estimation on the age of the thrombus, approximately 8–10 days. (10x) e) Brain parenchyma showing signs of edema and vascular congestion with hemorrhagic foci (infiltrated erythrocytes). (10x) f) Right kidney section with ischemic areas affecting both the tubules and the glomeruli, characterized by the absence of nuclei and massive glomerular congestion. (10x). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

Case 3 gross examination of the brain and the formalin-fixed dura mater a) Brain congestion and edema, with flattened sulci and circumvolutions. b) Section of dura mater and the falx cerebri, the rectum and both transverse sinuses. c) Lateral left view of the SSS with thrombotic material emerging from the right transverse sinus. d) Incision of the left transverse sinus along its major axis with discovery of the thrombus.

Fig. 4

Case 3 histological specimens of the SSS thrombus. a) SSS thrombus microscopic structure with erythrocytes, fibrin deposits and PMN cells infiltrates - note the contact with the dural sinus wall with minimal PMN cells infiltrates. (20x) b) Degree of re-organization of the thrombus which allows to give an estimation on the age of the thrombus, approximately 8–10 days (compare with Fig. 2c) (20x).

Fig. 5

Case 3 histological examination of brain parenchyma and meninges. a) Edema, congestion with extensive hemorrhagic area. (10x) b) Thrombosis of the smaller branches of the meningeal vasculature, surrounded by intense lymphocytes cells infiltrates. (10x) c) Focus on the perivasal lymphocytes cells infiltrates that extends up to the vascular wall (10x).