Dural Venous Sinus Thrombosis: A Rare Cause of Intracranial Hemorrhage

Abstract

Dural venous sinus thrombosis, a subset of cerebral venous thrombosis, is an important pathology due to its significant morbidity and mortality. This process has an annual incidence of three to five cases per million adults. Although copious predisposing factors exist, the core principles revolve around Virchow's triad: venous stasis, hypercoagulability, and vascular endothelial damage. There are various risk factors related to unfavorable outcomes, which include female sex, intracranial hemorrhage, infection, cancer, and more. Trauma tends to be a risk factor, particularly in pediatric populations, as in this patient's case. Initial diagnosis in the acute setting commonly involves non-contrast CT studies to exclude hemorrhage. In subacute or chronic settings, MRI can be utilized. Anticoagulation remains the mainstay of therapy for treatment, along with treating any underlying causes of thrombosis. We present a pediatric patient with extensive post-traumatic dural venous sinus thromboses with classic imaging findings as well as full resolution of clinical symptoms after this pathologic process was recognized and treated appropriately.

Keywords: dural vein; head trauma; mr venography; pediatric head injury; sinus thrombosis.

Figure 1. Volume-rendered sagittal view of the contrast-enhanced brain MRV.

Displays filling defects involving the internal cerebral vein (red arrow), a vein of Galen (orange arrow), inferior sagittal sinus (yellow arrow), straight sinus (green arrow), and torcular herophili (blue arrow). MRV: magnetic resonance venography

Figure 2. Volume-rendered axial view of the contrast-enhanced brain MRV.

Displays a notable filling defect involving the superior sagittal sinus (blue arrow). The right transverse sinus is not well visualized, which may be secondary to significant hypoplasia, aplasia, or thrombosis. MRV: magnetic resonance venography

Figure 3. Concurrent brain MRI (with and without contrast).

Axial views of T1-weighted (a), diffusion-weighted imaging (b), and apparent diffusion coefficient (c) sequences of the contrast-enhanced brain MRI display a T1 hypointense right thalamus (red arrow) with corresponding true restricted diffusion (blue arrows). This is consistent with a right thalamic infarct secondary to deep cerebral vein thrombosis.

Figure 4. Axial views of T2-weighted and susceptibility-weighted imaging sequences of the contrast-enhanced brain MRI.

Displays T2 hyperintensities within the right thalamocapsular region and left frontal lobe (red arrows) with corresponding susceptibility on susceptibility-weighted imaging (blue arrows). This is consistent with subacute hemorrhages/microhemorrhages given the clinical history. The left intraventricular hemorrhage (orange arrow) is also partially visualized.

Figure 5. Axial view of the non-contrast head CT.

Illustrates the "cord" sign within the inferior aspect of the superior sagittal sinus (blue arrow), indicative of thrombosis. Hyperdense blood products within the atrium of the left lateral ventricle are also partially visualized (red arrow).

Figure 6. Sagittal view of the non-contrast head CT.

Displays multifocal hyperdense venous contents compatible with DVST. The visualized occluded vessels include the following: internal cerebral vein (red arrow), a vein of Galen (orange arrow), inferior sagittal sinus (yellow arrow), straight sinus (green arrow), and torcular herophili (blue arrow).

Figure 7. Volume-rendered sagittal view of the contrast-enhanced brain MR venography completed at the patient’s one-month follow-up after hospital discharge.

Displays interval recanalization of the internal cerebral veins as well as partial recanalization of the vein of Galen, straight sinus, and torcula.