Teaching NeuroImages: Congenital variant misdiagnosed as cerebral venous sinus thrombosis ~Clinical pitfall~

Summary

Terminology

Original

  • 23yo F
  • PMH
    • CVST (Cerebral venous sinus thrombosis) on warfarin
  • Ex
    • hypoplastic Rt transcerse sinus

A 23-year-old woman, with a history of cerebral venous sinus thrombosis (CVST) on warfarin, presented with acute septic hemarthrosis, requiring surgery. A cerebrovascular consultation was placed for anticoagulation recommendations. Brain magnetic resonance venography revealed a hypoplastic right transverse sinus (figure). Anticoagulation was discontinued. Given her history of headache and papilledema, acetazolamide was started due to clinical suspicion of idiopathic intracranial hypertension (IIH).

Figure

Figure

Figure
Various imaging modalities
(A, B) Magnetic resonance venography demonstrates a hypoplastic medial right transverse sinus and is likely a congenital variant. Lateral to the vein of Labbe the right transverse sinus and sigmoid sinus are small, but patent. Dominant left transverse sinus, superior sagittal sinus, internal cerebral veins, and straight sinus are all unremarkable in appearance. (C) Right fundus photograph demonstrates grade 2 papilledema using Frisen grading scale. (D) Left fundus photograph demonstrates grade 2 papilledema.

  • Uni hypoplasia/aplasia of trasverse sinus :
    • 20-39%
    • mimic CVST
  • transverse sinus stenosis in IIH

Unilateral hypoplasia/aplasia of the transverse sinus is a normal variant observed in 20%–39% of healthy people and can mimic CVST.1 Transverse sinus stenosis in IIH can also mimic CVST.2 Misdiagnosing these entities as CVST can lead to significant complications.

Refenreces

  1. Han K, Chao AC, Chang FC, et al. Diagnosis of transverse sinus hypoplasia in magnetic resonance venography: new insights based on magnetic resonance imaging in combined dataset of venous outflow impairment case–control studies: post hoc case–control study. Medicine 2016;95:e2862.
  2. Aldossary NM. Value of double-track sign in differentiating primary from thrombosed transverse sinus stenosis in patients presumed to have idiopathic intracranial hypertension. eNeurologicalSci 2018;10:22–25.