Bithalamic infarcts: embolism of the top of basilar artery or deep cerebral venous thrombosis?

Bithalamic infarcts are usually attributed to thromboembolism of the top of the basilar artery. However, in some cases, deep cerebral venous thrombosis and thrombosis of cerebral venous sinuses was proved to be the cause. The case of a 47-year-old female with ischemic thalamic and mesencephalic lesions is reported, that was attributed to thrombosis of internal cerebral veins. In cases of bithalamic infarcts, apart from the top of the basilar artery syndrome, deep cerebral venous thrombosis should be taken into consideration. Neuroimaging findings such as generalized cerebral edema, multiple infarcts or hemorrhages, hyperdense appearance of cerebral sinuses or veins and filling defects in the cerebral venous sinuses in contrast-CCT, can lead to the proper diagnosis.     

Trismus, pseudobulbar syndrome and cerebral deep venous thrombosis

We report a case of cerebral deep venous thrombosis that manifested clinically by a pseudobulbar syndrome with major trismus, abnormal movements and static cerebellar syndrome. To our knowledge, only three other cases of deep cerebral venous thrombosis associated with cerebellar or pseudobulbar syndrome have been published since 1985. The relatively good prognosis in our patient could be explained by the partially intact internal cerebral veins as well as use of early anticoagulant therapy. There was a spontaneous hyperdensity of the falx cerebri and the tentorium cerebelli on the brain CT scan, an aspect highly contributive to diagnosis. This hyperdensity of the falx cerebri was found in 19 out of 22 cases of deep venous thrombosis detailed in the literature.     

A case of bilateral cerebellar infarction in the distribution of the bilateral superior cerebellar artery]

We reported a case of bilateral cerebellar hemorrhagic infarction in the distribution of the bilateral superior cerebellar artery. A 58-year-old man suddenly developed dizziness and transient loss of consciousness. The neurological examination revealed left hearing disturbance, left sensory disturbance involving face, dysarthria and bilateral ataxia. This patient was considered to be classic clinical syndrome of right superior cerebellar artery. CT and MRI revealed hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery. The right posterior cerebral artery was filling through the right posterior communicating artery on the right carotid angiography taken 2 hours after the onset. Bilateral vertebral angiography on the 18th day demonstrated no occlusions in the basilar artery and the bilateral superior cerebellar artery. Hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery, sparing other territories as the present case, is extremely rare. In this case, cerebral embolism (top of the basilar syndrome) was suggested because of existence of atrial fibrillation and sudden onset.     

Vernet's Syndrome Associated with Internal Jugular Vein Thrombosis

Our objective is to present a case of Vernet's syndrome (cranial nerve (CN) IX, X, and XI palsy) associated with cerebral venous thrombosis (CVT) in an internal jugular vein. The patient presented with acutely developed dysphagia. The weakness of the left sternocleidomastoid and trapezius muscles was observed. The initial magnetic resonance imaging and computed tomography (CT) with contrast enhancement showed contrast-filling defect in the left internal jugular vein inside the jugular foramen. The magnetic resonance venography with contrast enhancement revealed a partial filling defect in the left sigmoid sinus and total occlusion of the left internal jugular vein. Under the diagnosis of CVT associated with CN IX, X palsy, anticoagulation therapy with low-molecular-weighted heparin was initiated. Despite the continued anticoagulation therapy for 3 months, neither the burden of thrombosis in the left sigmoid sinus and internal jugular vein on neck CT nor dysphagia symptoms improved. Clinicians need to be aware of internal jugular venous thrombosis as one of the differential diagnoses in Vernet's syndrome in patients in a hypercoagulable state. Further reporting of similar cases is needed to confirm the association between CVT and Vernet's syndrome.     

Interobserver agreement in the magnetic resonance location of cerebral vein and dural sinus thrombosis

The interobserver variation in the magnetic resonance (MR) location of cerebral vein and dural sinus thrombosis (CVT) has not been previously reported. Four independent observers rated a convenience sample of 40 MR/MR angiographies to assess whether or not each dural sinus and major cerebral veins were occluded. Interobserver reliability was measured using κ statistics. Interobserver agreement was comparable between the six pairs of raters. Agreement was excellent for thrombosis of the deep cerebral venous system ( κ  = 1.00), cerebellar veins ( κ  = 1.00), superior saggital sinus ( κ range: 0.82–1) and right jugular vein ( κ range: 0.84–0.95); good to excellent for the right transverse/sigmoid sinus ( κ range: 0.75–0.90) and the left jugular vein ( κ range: 0.65–0.85); moderate to excellent for the left lateral sinus ( κ range: 0.59–0.78) and the straight sinus ( κ range: 0.59–0.92); poor to good for the cortical veins ( κ range: 0.02–0.65). Agreement between observers varies with the location of CVT. It is good or excellent for most of the occluded sinus and veins, except for the cortical veins. This study suggests that information on the location of CVT can be reliably collected and used in multicentre studies.     

Vein of galen aneurysmal malformation with deep venous communication and subarachnoid hemorrhage

A previously healthy 2-year-old boy presented with the acute onset of left middle cerebral artery syndrome. Evaluation revealed subarachnoid hemorrhage and a vein of Galen aneurysmal malformation with angiographic reflux into the deep venous system. Analysis of the angioarchitecture of the lesion demonstrated the basis of the hemorrhage to be reflux into cortical veins. The case supports and underscores the clinical relevance of recent reports indicating that the venous drainage of a vein of Galen aneurysmal malformation may communicate with the normal deep venous system. Such a communication implies that endovascular or surgical obliteration of the venous side of a vein of Galen aneurysmal malformation may impair normal venous drainage, potentially resulting in a venous infract or hemorrhage.     

Neuropsychological disorders after bithalamic infarct caused by deep venous thrombosis

We report a case of deep cerebral venous thrombosis with bithalamic infarction that led to neuropsychological disorders including left side visuospatial neglect, aphasia and amnesia, as well as frontal and intellectual disorders. After a six month course, the patient showed only slight intellectual deficit and mild anterograde amnesia. Deep cerebral venous thrombosis is uncommon and prognosis is poor. Reports in the literature illustrate the neuropsychological disturbances they provoke but provide little analyzable data. The positive progress in our case demonstrates that bithalamic lesions of venous origin can have a good prognosis.     

Corpus callosum hematoma secondary to cerebral venous malformation presenting as alien hand syndrome

A 26-year-old right-handed female presented with alien hand syndrome (AHS) secondary to corpus callosum (CC) hematoma. The patient had abnormal feelings in the left upper limb and exhibited intermanual conflict. Imaging studies demonstrated acute hemorrhage in the genu and body of the CC secondary to cerebral venous malformation. Callosal hemorrhage is usually caused by head trauma or a ruptured arteriovenous that extends beyond the CC. We report what may be the first case of AHS caused by callosal hemorrhage due to venous malformation.     

颅内静脉窦血栓形成后昏迷患者预后相关因素研究

目的探讨影响颅内静脉窦血栓形成(CVST)后昏迷患者预后的相关因索。 方法对梧州市工人医院神经内科自2001年2月至2010年2月收治的以昏迷就诊或在入院6h内出现不同程度昏迷的30例CVST患者的临床资料进行回顾性分析。 结果随访0.5～10年,本组患者中12例无明显颅内压增高、脑深静脉血栓及相关脑血管意外,8例死亡,2例重残,8例遗留不同程度的偏瘫或智力语言障碍。CVST后昏迷患者伴有中枢神经系统感染、恶性肿瘤、脑深静脉血栓形成、癫痫及颅内出血等改变时患者预后差,其中恶性肿瘤患者重残或死亡率高达50％。 结论CVST后发生昏迷的患者预后差,病死率高,及早诊治并合理治疗有助于改善预后。     

Recovery from multiple brain infarcts complicating basilar artery dissection

A 38-year-old woman suffered a spontaneous basilar artery dissection leading to bilateral occipital, right thalamic and cerebellar infarction and a dorsal midbrain syndrome. Computerized tomography showed left cerebellar, right thalamic and bilateral occipital infarctions and selective angiography showed a narrowed segment in the basilar artery, absent filling of the right superior cerebellar artery and narrowing of the right posterior cerebral artery. She improved rapidly without specific therapy and made a near full recovery. Basilar artery dissection, while often fatal, may have a benign outcome and we review the literature in this regard.     

血管内局部溶栓治疗颅内静脉窦血栓

目的评价局部溶栓与机械碎栓治疗静脉窦血栓的影像学资料与治疗效果。方法对7例静脉窦血栓病人经股静脉穿刺,将微导管选择性插入已闭塞的静脉窦内。6例行静脉窦局部灌注尿激酶或基因重组组织型纤溶酶原激活剂,1例采用球囊机械碎栓术;3例伴脑皮质或深部静脉血栓者同时经颈动脉给予溶栓药。结果造影示6例已闭塞的静脉窦部分再通,1例无明显再通;3例侧支静脉回流增多。1例溶栓后原有脑内血肿增大,导致偏瘫加重;1例术后发生无症状出血性静脉梗死。随访10个月~3年,6例mRankin评分0~1分,1例mRankin评分2分。结论血管内局部溶栓治疗静脉窦血栓,静脉窦完全再通率低,但血管部分再通及侧支静脉回流增多,可改善病人的临床预后。     

Sturge-Weber syndrome: deep venous occlusion and the radiologic spectrum

Sturge-Weber syndrome is a neurocutaneous syndrome with a facial port-wine nevus and neurologic features, typically including seizures and hemiparesis. Glaucoma may also occur. MRI features include leptomeningeal angiomatosis, cortical and pial calcifications, and angiomatous change of the choroid plexus. We reviewed a subset of patients with Sturge-Weber syndrome with the rare finding of deep venous occlusion, and present such a case, unusual by comparison to previously reported cases of Sturge-Weber syndrome with deep venous occlusion. Six previously reported cases were reviewed. All cases presented with seizures; five of six had evidence of leptomeningeal angiomatosis; half had cerebral hemiatrophy. This report presents a unique case lacking clinical seizures, but with a port-wine stain and congenital glaucoma. This patient lacked the radiologic findings of leptomeningeal angiomatosis and hemicerebral atrophy, but demonstrated deep venous occlusion with frontal venous collaterals. There is a wide spectrum of findings in Sturge-Weber syndrome. The lack of seizures and angiomatosis in this case are likely "true-true" and related. The case illustrates the unusual finding of deep venous occlusion in Sturge-Weber syndrome occurring without leptomeningeal angiomatosis. Additionally, it demonstrates that although the initial evaluation is normal, patients may later manifest clinical characteristics of Sturge-Weber syndrome.     

Cerebral venous thrombosis in COVID-19-associated coagulopathy: A case report

COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was first reported in Wuhan, China in December 2019, and is ongoing pandemic. While a majority of patients with SARS-CoV-2 infection shows asymptomatic or mild disease, hospitalized patients can develop critical condition, such as pneumonia, sepsis, and respiratory failure. Some cases deteriorate into sever systemic disease and multiorgan failure. Many patients of severe COVID-19 show hypercoagulable state and complicate with venous thromboembolism and atrial thrombosis. We herein reported a case of COVID-19 who developed cerebral venous thrombosis (CVT) co-incidence with pulmonary thromboembolism (PTE). A 56-year-old Japanese man was presented with fever and malaise and diagnosed with COVID-19. He was treated with ciclesonide and azithromycin, but his respiratory condition deteriorated. Thus, systemic corticosteroids and favipiravir were initiated and these treatments resulted in afebrile state, improving malaise and respiratory failure. However, he suddenly developed severe headache and vomiting with increased concentration of D-dimer. Brain CT and MRI showed typical images of CVT in the left transvers sinus and CT pulmonary angiography showed PE. Administration of unfractionated heparin followed by edoxaban treatment reduced the levels of D-dimer and improved his clinical presentation and thrombosis. Monitoring coagulopathy is important in COVID-19 patients and in case of venous thromboembolism, including cerebral venous system, appropriate anticoagulant therapy should be initiated.     

Galen＇s静脉系统的三维CTA观察

目的应用三维CT血管造影（3D-CTA）对Galen＇s静脉系统的解剖结构和变异进行研究，评估其对松果体区手术的影响。方法选取60例正常成人头颅的3D—CTA影像学资料，对Galen＇s静脉、大脑内静脉、基底静脉、枕内静脉、小脑中央前静脉进行测量和分析。结果Galen＇s静脉直径为（4．7±1．5）mm；大脑内静脉直径为（2．56±0．37）mm，两侧大脑内静脉之间形状分为菱形（60％，36／60）、发夹形（35％，21／60）、或平行走行（5％，3／60）。基底静脉直径为（2．20±0．2）mm，汇入Galen＇s静脉48例（80％）；大脑内静脉12例（20％）；枕内静脉直径为（1．64±0．5）mm，汇入Galen＇s静脉48例（80％）、大脑内静脉6例（10％）、基底静脉6例（10％）；小脑中央前静脉直径（1．40±0．3）mm。结论Galen＇s静脉系统存在一定的变异。术前应用三维CTA详细地了解Galen＇s静脉系统的血管间隙、走行、直径等情况．对松果体区肿瘤采用个体化的手术有着重要的指导意义。     

Diagnosis of acute phase of venous infarction by diffusion-weighted image: case report and review of the literature]

Diffusion-weighted imaging (DWI) can diagnose early stage not only of the arterial infarction but also of venous infarction. We successfully diagnosed a case as acute venous infarction by DWI. The patient, an infant of one year and ten months, presented disturbance of consciousness and left hemiparesis two weeks after dehydration and infections. Computed tomographic scan revealed a cerebral hemorrhage in the right parietal lobe. Cerebral angiography revealed no contrast filling of the posterior side of superior sagittal sinus, straight sinus and transverse sinus. DWI demonstrated a large hyperintensity lesion around the hematoma, suggesting venous infarction in the early stage. We thought that venous infarction was caused by secondary extension of thrombus to cerebral cortical veins and deep cerebral veins. External decompression and postoperative hypothermia therapy were performed because of rapidly deteriorating intracranial hypertension. Intracranial hypertension was, however, uncontrollable. The patient died four days after the onset. Diagnosis of the venous infarction by DWI was discussed along with other recent reports. Diffusion hyperintensity was displayed in almost all subjects with acute venous infarction. DWI pattern of venous infarction is more heterogeneous than that of arterial one because pathway from venous obstruction to infarction is complicated.     

Cerebral panthrombophlebitis in a paucisymptomatic patient

In most cases, extensive cerebral venous thrombosis present themselves with a severe clinical outcome and poor prognosis. We present the case of a 59-years-old patient with a slight rather unrevealing symptoms but suffering from a cerebral thrombosis impacting on both superficial and deep venous system. The etiologic assessment revealed activated protein C resistance. Clinical evolution under systemic anticoagulation was prompt, with complete repermeabilization of the various venous structures.     

Cerebral air embolism due to disconnection of a central venous catheter

A case of cerebral air embolism complicating disconnection of a central venous catheter is presented. In the context of increasing use of central venous catheterization this case highlights the risk of cerebral air embolism associated with the use of central venous catheters. In this case there was no patent foramen ovale and air must have passed from the venous to the cerebral circulation through physiologic shunts in the lung. Possible means of entry of air with central venous catheters, pathogenetic mechanisms relating to cerebral air embolism, treatment and preventative measures are also discussed.     

Temporal Profile of CT and T2*-Weighted Gradient-Echo MRI in a Patient with Unilateral Thalamostriate Vein Thrombosis

Deep cerebral venous system thrombosis (DCVST) is an uncommon variety of thrombosis that accounts for 11% of cases of cerebral venous thrombosis. Thalamostriate vein (TSV) thrombosis is further rare among patients with DCVST. Although patients with cerebral venous thrombosis commonly have characteristic neurological deficits including headache, deterioration of consciousness, and seizures, patients with DCVST do not necessarily show such symptoms. Therefore, diagnose of DCVST is sometimes difficult. Here we report a case of TSV thrombosis with a unilateral basal ganglion lesion presenting with right-sided hemiparesis. A 61-year-old Japanese female was referred to our hospital. On neurological examination, she had no headache but presented with right facial paresis with dysarthria. Her right hemiparesis was present in the upper and lower extremities. We repeatedly performed brain computed tomography (CT) and T2*-weighted conventional gradient-echo (GRE) magnetic resonance imaging, and conclusively diagnosed as left TSV thrombosis. We firstly report a case of unilateral DCVST associated with TSV thrombosis in which a temporal profile of CT and T2*-weighted GRE images was obtained. Although DCVST is a rare clinical entity, physicians should be aware that repeated radiological observations can be useful for the diagnosis and early medical treatment for DCVST.     

Unruptured dural arteriovenous malformation of the transverse-sigmoid sinus presenting with focal symptoms and coma

We are presenting the case of a 63 year-old man with a dural arteriovenous malformation of the transverse sigmoid sinus who developed focal deficits followed by less localized symptoms such a disorientation, lethargy and eventually comatose status. Initial cerebral angiography showed retrograde filling of the cortical and deep cerebral venous system with marked delay in venous empting. Following embolization clinical symptoms completely cleared at the time that control angiography showed retrograde venous flow turning anterograde. Patient's symptoms recurred four months later when there was a relapse of retrograde cerebral venous drainage at the time he developed thrombosis of the superior longitudinal and right transverse sinuses. Sinus thrombosis and thrombosis of the central retinal artery were coincidental with hypercoagulability related to hyperhomocysteinemia. Since control angiography still showed persistence of the AV shunting radical excision of the involved dural sinuses was performed. The final outcome was excellent. The physiopathological mechanism responsible for neurological deficits in our patient most likely was ischemia of venous origin secondary to venous hypertension resulting from retrograde cerebral venous drainage. The clinical and angiographic presentation in few similar cases reported in the literature is reviewed.     

Intracranial hypertension related to cerebral venous thrombosis; and acute ischemic stroke with micro-infarcts associated with IgG4-related disease

ABSTRACT

IgG4-related systemic disease (IgG4-RD) is characterized by an inflammatory reaction rich in IgG4-positive plasma cells, affecting multiple organs. This report describes a case who was diagnosed with IgG4-RD, having cerebral venous thrombosis and a subsequent acute ischemic stroke of undetermined cause. A 47-year-old woman presented with headache, visual disturbance and eyelid swelling and two years later she was admitted with acute attacks of mild left lower limb sensory-motor monoparesis. Indirect immunohistochemistry assay showed elevated level of IgG4, labeling neurons of the central nervous system, suggesting an immunological process possibly affecting vascular structures. Our experience suggests that IgG4-RD may be considered in patients with ischemic stroke and cerebral venous system involvement.