Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: An easily misdiagnosed cause of cerebral haemorrhage

Dural sinus thrombosis has protean clinical and radiological manifestations ranging from minimal effacement of sulci with no symptoms to severe haemorrhagic infarcts associated with focal deficits, coma and even death. An uncommon form of presentation is characterized by unilateral lobar haemorrhage associated with extensive oedema and parenchymal distortion. In an acute presentation, this might resemble haemorrhage into a tumour. In delayed presentations, the haematoma, being iso‐ or hypodense and showing peripheral ring‐like enhancement, can mimic aggressive tumours or infective processes. As this is an uncommon condition, misdiagnosis is common with the potential for mismanagement and adverse outcomes. We present five such consecutive cases that were initially misdiagnosed as other entities. Each of these cases on closer inspection show features observed on CT and MRI that should have suggested a diagnosis of dural venous sinus thrombosis. One of these cases progressed to not only extensively involve the superficial sinuses but also the deep veins, with a significant adverse outcome. The imaging features of this interesting variant of dural sinus thrombosis are reviewed. The haemodynamic basis for haemorrhage and anatomical basis for the lateralization of the lesions are discussed.     

Magnetic resonance imaging of central nervous system haemorrhage

The variable magnetic resonance imaging appearances of central nervous system haemorrhage, both intra- and extra-axial, are described. These will vary with the type of image contrast (T1 or T2 weighting), the nature of the imaging sequence (spin-echo or gradient-echo) and the time from onset of haemorrhage. Magnetic resonance imaging is a useful technique for imaging haemorrhage in the central nervous system as it yields temporal information about haematoma development, and it is the only non-invasive means of imaging intraspinal haemorrhage. It is, however, limited in the imaging of haematomas within 24 h of onset and in subarachnoid haemorrhage where computed tomography is the investigation of choice.     

Cerebral venous sinus thrombosis presenting as subdural haematoma

The authors report a 39-year-old woman who presented with intermittent, excruciating nuchal and occipital headache. Magnetic resonance imaging and magnetic resonance angiography scans showed bilateral subdural haematomas with veno-occlusive disease of the superficial and deep venous systems. There were bridging collaterals with scalp veins, bleeds from which could explain the subdural haematoma. There was acute on chronic veno-occlusive disease with an acute rise in intracranial pressure and a bleed from the vein of Galen.     

ORIGINAL ARTICLE: Retrospective audit of the investigation of patients with suspected acute subarachnoid haemorrhage

Introduction: Recommended investigational care (RIC) of emergency department (ED) patients with suspected subarachnoid haemorrhage comprises lumbar puncture (LP) to detect xanthochromia if the preceding CT scan is negative. Methods: Retrospective audit of the investigational care of 100 consecutive ED patients presenting with possible subarachnoid haemorrhage. Results: Of the 100 patients, 91 had negative CT, and 36 (39.6%) of these patients had an LP performed to detect xanthochromia (i.e. RIC). Fifty-five of 91 (60.4%) patients did not receive RIC. Of the 55 patients who did not receive RIC, 25 (45.5%) had a documented senior clinical decision not to perform an LP; 15 (27.3%) had no documented reason; five (9.1%) refused consent; two (3.6%) had an LP but no xanthochromia requested, one patient did not have an LP because of technical issues, six patients underwent CT angiography (CTA), and one patient underwent magnetic resonance angiography (MRA), in the absence of a LP, following a negative CT. Two patients underwent CTA following a negative xanthochromia result. Patients admitted to the emergency extended care unit had 6.85 times the odds of receiving RIC (95% CI 2.20–21.4). Conclusions: Fifty-five (55) of 91 (60%) ED patients did not receive RIC. Fifteen of the 55 did not have any documented justification for not performing an LP with xanthochromia testing. Admission to an emergency extended care unit was a predictor of receiving RIC. Inappropriate use of CTA and MRA was identified. These findings have important implications for patient safety. Multifaceted strategies are required to close this evidence–practice gap.     

Perimesencephalic subarachnoid haemorrhage: Negative angiography and favourable prognosis

The computed tomography (CT) scans of 110 consecutive patients who presented, over a 4.5-year period, following spontaneous subarachnoid haemorrhage (SAH), were reviewed. All 110 patients also had one or more 4-vessel digital subtraction cerebral angiograms. The CT scans were reviewed in each case without knowledge of the angiographic result. In nine patients (8%), SAH was confined to the perimesencephalic area, interpeduncular cistern and/or prepontine region at CT. All nine patients had at least two, and some as many as four, negative cerebral angiograms. Eighteen of the 110 patients (16%) ultimately had negative angiography. Hence, the patients with isolated perimesencephalic haemorrhage (PMH) accounted for 50% of the negative angiograms. There was a significant association between isolated PMH and negative angiography (X²= 50.1, P < 0.005). The specificity of PMH for negative angiography was 100% (95% confidence interval (CI) = 97–100%) and the sensitivity of PMH for a negative study was 50% (95% CI = 16–84%). Six of the 110 patients had basilar artery aneurysms demonstrated angiographically as the cause of their SAH but none of these six had isolated PMH at CT. All patients with isolated PMH were alive and well at follow up and none had suffered repeat SAH or vasospasm-related ischaemic cerebral injury. Perimesencephalic haemorrhage should be distinguished from SAH in general, because of the good prognosis associated with it and the doubtful need for repeat cerebral angiography after an intitial negative study.     

Spinal arachnoiditis as a consequence of aneurysm‐related subarachnoid haemorrhage

Only a few case reports currently exist regarding symptomatic spinal arachnoiditis following aneurysm‐related subarachnoid haemorrhage. We present three patients who developed symptomatic spinal arachnoiditis following spontaneous aneurysm rupture. Following initial aneurysm and subarachnoid haemorrhage management (including ventriculo‐peritoneal shunt placement), all three patients developed gradually worsening neurological abnormalities, and subsequent imaging demonstrated spinal arachnoiditis. Despite spinal decompression, all three patients experienced progressively worsening neurological decline.     

Onyx embolisation of cavernous sinus dural arteriovenous fistula via direct percutaneous transorbital puncture

The cavernous sinus dural arteriovenous fistulas of three patients were successfully embolised by using Onyx (Onyx Liquid Embolic System, MTI, Irvine, CA, USA) as the sole embolic agent, through direct percutaneous transorbital punctures of the cavernous sinuses. Our early experience suggests that this direct approach, coupled with the unique physical properties of Onyx, is a safe and effective alternative to treat cavernous sinus dural arteriovenous fistulas when the conventional transvenous routes are inaccessible.     

Cerebral amyloid angiopathy: Review of clinico‐radiological features and mimics

Cerebral amyloid angiopathy (CAA) is an important cause of lobar intracerebral haemorrhage (ICH) in the elderly, but has other clinico‐radiological manifestations. In the last two decades, certain magnetic resonance imaging (MRI) sequences, namely gradient‐recalled echo imaging and the newer and more sensitive susceptibility‐weighted imaging, have been utilised to detect susceptibility‐sensitive lesions such as cerebral microbleeds and cortical superficial siderosis. These can be utilised sensitively and specifically by the Modified Boston Criteria to make a diagnosis of CAA without the need for ‘gold‐standard’ histopathology from biopsy. However, recently, other promising MRI biomarkers of CAA have been described which may further increase precision of radiological diagnosis, namely chronic white matter ischaemia, cerebral microinfarcts and lobar lacunes, cortical atrophy, and increased dilated perivascular spaces in the centrum semiovale. However, the radiological manifestations of CAA, as well as their clinical correlates, may have other aetiologies and mimics. It is important for the radiologist to be aware of these clinico‐radiological features and mimics to accurately diagnose CAA. This is increasingly important in a patient demographic that has a high prevalence for use of antiplatelet and antithrombotic medications for other comorbidities which inherently carries an increased risk of ICH in patients with CAA.     

Chondrosarcoma of nose and paranasal sinus - a rare presentation

Chondrosarcoma, the most malignant cartilageneous tumor, constitute only 4% of non-epithelial tumours of the nasal cavity, paranasal sinuses and nasopharynx, making it one of the rarest malignancies. Here we present a case of Grade 1 chondrosarcoma involving nose, maxillary sinus, ethmoids and sphenoid sinus managed surgically by wide excision. 12 months follow-up reveled no recurrence or complication.     

MRI findings of cerebral cryptococcosis in immunocompetent patients

Worldwide, cerebral cryptococcal infections caused by cryptococcus neoformans are mostly found in immunocompromised patients, but less found in immunocompetent patients with fewer related imaging reports in literatures. This pictorial essay describes some important MR imaging features in arriving at diagnosis for cerebral cryptococcosis in immunocompetent patients by way of five illustrative cases with intact MRI data.     

Magnetic resonance image detection of coincidental sphenoid sinus aspergillosis and pituitary microadenoma: A potential surgical disaster

While localizing the microadenoma in a patient with Cushing's disease on magnetic resonance imaging (MRI), fungal granuloma of the sphenoid sinus was coincidentally detected. This helped in the proper management of sphenoidal disease before undergoing trans-sphenoidal removal of the microadenoma, thus averting the possible catastrophe of direct intracranial spread of aspergillus infection.     

Acute disseminated encephalomyelitis and multiple sclerosis: Magnetic resonance imaging differentiation

The study was undertaken to compare the MR imaging features of acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS) in a country with a high prevalence of ADEM. Magnetic resonance scans from 33 patients diagnosed clinically with MS (14 patients) or ADEM (19 patients) were reviewed concurrently by two radiologists blinded to the clinical diagnosis. The size, site, morphology and pattern of brain and spinal cord involvement were recorded and the MR imaging diagnosis was compared with the clinical diagnosis. The MR imaging findings matched with the clinical diagnosis in 11 of 14 patients with MS (sensitivity = 78.6%), and with the clinical diagnosis in 15 of 18 patients with ADEM (sensitivity = 78.9%). Three patients had non‐specific findings and in a further three patients discordant imaging features were present. One patient with imaging features typical of Balo’s concentric sclerosis was diagnosed clinically as suffering from ADEM. In a country with a high prevalence of ADEM, the majority of patients with ADEM and MS can be differentiated on MR imaging.     

Imaging the sphenoid sinus: Pictorial essay

This paper focuses on the spectrum of sphenoid sinus lesions that may be seen radiologically and the mapping of disease extent. Imaging plays a central role in the assessment of sphenoid sinus disease. Although primary sphenoid sinus disease is uncommon, this sinus is nevertheless affected secondarily by a variety of pathological processes.     

Isolated atrophy and fatty infiltration of supraspinatus: A rare finding

Isolated atrophy and fatty infiltration of supraspinatus is very rare. We report the case of a 53 year old male with isolated atrophy and complete fatty replacement of supraspinatus and discuss potential aetiologies.     

Metastatic choriocarcinoma: A rare cause of stroke in the young adult

A 20‐year old woman presented with acute right hemiplegia 10 weeks after intrauterine fetal death at 34‐weeks gestation (G1P0). A brain MRI showed a typical acute infarct in the left middle cerebral artery territory. A CT pulmonary angiography carried out 1 week later for sudden cardiopulmonary deterioration showed disseminated pulmonary metastases. The CT was extended to the abdomen and pelvis, which showed a uterine mass with bilateral theca lutein cysts. The radiological diagnosis of metastatic choriocarcinoma was made and was subsequently confirmed with the markedly increased serum β‐human chorionic gonadotrophin. A serum β‐human chorionic gonadotrophin is therefore considered worthwhile in any young female adult who presents with stroke.     

Benign osteoblastoma of maxillary sinus: A rare presentation

Benign osteoblastoma of paranasal sinuses is a rare tumor of the 2^nd decade of life with only few cases reported till date. It arises most commonly from the ethmoid sinus and present as an intra-nasal mass leading to broadening of the nasal bridge. Here we present a case of benign osteoblastoma in a 8 year old girl presenting with a large intranasal mass seen through nostril and leading to facial deformity.     

鼻咽癌放疗后海绵窦复发再程放疗临床回顾性分析

目的:探讨鼻咽癌放疗后海绵窦复发受侵再程放疗的临床特点及文献复习.方法:回顾分析2000-06- 2006-04我院诊断的鼻咽癌初次治疗后局部海绵窦复发受侵者55例.全部经CT和(或)MR诊断,部分鼻咽局部重新活检;分析海绵窦受侵的CT和MR诊断意义及再治疗的效果、毒副反应和并发症.结果:55例海绵窦受侵复发患者,CT检出13例,MR检出43例.全组主要的临床表现及体征是外展神经麻痹、颅骨破坏,伴发头痛及前组颅神经受损.再程治疗后、2、3和5年生存率分别为92.73％、78.18％、34.54％和9.09％.初治时有无颅底破坏对再次治疗后的生存率有一定影响,但1、2年生存率差异无统计学意义,3、5年以上生存率差异有统计学意义,P＜0.05.初治到复发间隔时间越短再次治疗后生存率越低,与间隔3年以内者比较,间隔＞3年者生存率有明显提高,P＜0.05.结论:MR较CT能更早期准确诊断鼻咽癌复发中海绵窦受侵,头痛和颅神经症状是海绵窦受侵的主要临床体征,放疗后海绵窦处复发再放疗有积极的治疗意义.     

Bulky scalp metastasis and superior sagittal sinus thrombosis from a cervical adenocarcinoma: an unusual case

Distant cutaneous metastases from cervical malignancies are uncommon, with scalp metastases being exceptional events. We present the case of a 53-year-old postmenopausal lady with adenocarcinoma of the uterine cervix that metastasized to the scalp with superior sagittal sinus thrombosis 8 months after diagnosis. In contrast to the seven prior cases of scalp metastases of cervical squamous cell carcinoma reported in published reports, ours is the first documentation of such an occurrence in cervical adenocarcinoma. Superior sagittal sinus thrombosis has not been reported with this tumour in the past.