Bilateral thalamic bleed and cerebral venous sinus thrombosis in Japanese encephalitis.

Japanese encephalitis (JE) is a potentially serious form of viral encephalitis with varied clinicoradiological manifestations. We report the case of a 19-year-old girl admitted with headache, vomiting and altered sensorium in the absence of fever, whose cerebrospinal fluid analysis showed lymphocytic pleocytosis with significant protein content and positive serum IgM JE antibodies. MRI with venography revealed bilateral thalamic haemorrhage and cerebral venous sinus thrombosis. Although thalamic hypodensities are a well-described feature, thalamic haemorrhage and cerebral venous thrombosis are distinctly rare in JE. This report highlights the role of imaging in cases of encephalitis in general and JE in particular, in the early detection of uncommon manifestations that may complicate these diseases.

The spectrum of associated brain lesions in cerebral sinovenous thrombosis: relation to gestational age and outcome.

OBJECTIVE: To describe different patterns of associated brain lesions in preterm and full-term infants with cerebral sinovenous thrombosis (CSVT) and to assess whether these different patterns are related to gestational age at onset. DESIGN: Magnetic resonance scans of all neonates (six preterm, 24 full term) with suspected CSVT, collected over a 7-year period in two neonatal intensive care units, were evaluated to assess patterns of associated brain lesions. Comparisons between the two gestational age groups were made. RESULTS: CSVT was confirmed on magnetic resonance venography in 26 of 30 neonates (six preterm, 20≥36 weeks' gestational age). The straight (85%) and superior sagittal (65%) sinus were most often affected. Several sinuses were involved in 81% of infants. White matter damage affecting the entire periventricular white matter was seen in five of six preterm infants. Intraventricular haemorrhage (IVH) was common in both groups (4/6 preterm, 16/20 full term). Frontal punctate white matter lesions with restricted diffusion (15/20) and thalamic haemorrhage associated with IVH (11/20) were the most frequent lesions in full-term infants. Focal arterial infarction was present in four of 20 full-term infants. Six infants died in the neonatal period (four preterm, two full term). Follow-up MRIs at 3 months in all survivors showed evolution of the lesions with frontal atrophy in 13 of 20 (12 full term) and delayed myelination in seven of 20 (six full term). CONCLUSIONS: Preterm and full-term neonates show different patterns of associated brain lesions. Extensive white matter damage is the predominant pattern of injury in the preterm infant, while an IVH associated with a thalamic haemorrhage and punctate white matter lesions are more common in the full-term infant.

Acute dural sinus thrombosis following ingestion of an herbal tonic: case report.

OBJECTIVE: The use of herbals and health supplements is not without risk. This case report of a 17-year-old girl who presented with acute dural sinus thrombosis following herbal tonic ingestion illustrates the dangers of unsupervised ingestion of "health supplements." SUBJECT AND METHODS: A 17-year-old girl with normal menses and no prior medical history, procoagulant risk factors, or oral contraceptives use, presented following ingestion of herbal liquid for 2 days, with signs and symptoms of dural sinus thrombosis confirmed by CT scan. MRI and MRV showed bilateral transverse sinuses thrombosis. The patient had an extensive workup, and all procoagulant disorders or factors, including Behcet's disease, were ruled out. The temporal profile of the ingestion of herbal fluid may suggest association with the development of sinus thrombosis. CONCLUSION: Combinations of herbs in dietary or health supplements could potentiate their subclinical procoagulant effects, and this case highlights the need to report such serious central nervous system adverse effects associated with the ingestion of herbal preparations.

High-dose heparin plus warfarin administration in non-traumatic dural sinuses thrombosis. A clinical and neuroradiological study.

BACKGROUND: The management of intracranial dural sinuses thrombosis is still controversial and uncertain. The authors report the cases of 7 patients with non-traumatic thrombosis of the dural sinuses and describe the most important radiographic findings, the indication, effectiveness of antithrombotic therapy, and outcome. METHODS: A retrospective review was conducted of 7 cases of dural sinus thrombosis admitted, between 1994 and 1996, to our division. All patients underwent full anticoagulation therapy. Heparin was administered, using a dose of 25,000 units/day for two weeks; warfarin was given using a dose of 5 mg twice daily. Treatment course was followed by maintenance treatment with a single administration of 5 mg/day of warfarin. All patients were submitted to close titration and coagulation profile monitoring. RESULTS: In 4 cases Magnetic Resonance Imaging-Angiography (Angio-MRI) was performed for following up the recanalization of the sinuses, resulting a persistent no patency of the dural sinuses. Three patients underwent contrast-enhanced CT scan, demonstrated an "empty delta sign" in the sagittal sinus, confirming no recanalization. Nevertheless, six patients had have a good quality recovery, and one patient a moderate disability. DISCUSSION: Cerebral venous sinus thrombosis is an uncommon cause of cerebral infarction, and may be mistaken, unless specifically sought. The natural history of the disease is highly variable, with a mortality rates range from 10% to 20%. At present, in our opinion, the venous phase of Angio-MRI is the definitive examination, and a gold standard for diagnosis of dural sinus thrombosis. In our cases, antithrombotic therapy has been found to be a safe and effective treatment, despite contrast-CT scans and Angio-MRI showed no recanalization of the sinuses, in all patients.

Proton magnetic resonance spectroscopy in deep cerebral venous thrombosis.

A 63-year-old man developed a severe left frontal headache followed by an acute change of mentality 6 days later. Magnetic resonance imaging revealed bilateral thalamic ischemia. Angiography confirmed the occlusion of deep cerebral veins. Proton magnetic resonance spectroscopy (1H-MRS) of the thalami showed normal N-acetylaspartate (NAA) peak and the presence of lactate peak, indicating a relatively preserved neuronal viability. The patient improved during the follow-up period, and returned to work 45 days after the onset of the disease. With 1H-MRS, prognosis following venous infarctions may be feasible.

Cavernous sinus thrombosis: a report of eight consecutive comatose patients.

Septic thrombosis of the cavernous sinus is a severe and lethal condition if left untreated. The mortality is particularly high in those patients admitted in a comatose state. Eight patients treated successfully in Bulawayo, Zimbabwe in Mpilo Central Hospital over a period of three years are reported. In the discussion, emphasis is placed on the treatment of raised intracranial pressure in this particular group of patients and early treatment with appropriate antibiotics. Clinicians must be aware of this serious complication of infections around the face and must treat them early and aggressively.

Recovery from primary deep cerebral venous sinus thrombosis with recanalisation.

A 50-year-old woman with idiopathic deep cerebral sinus and vein thrombosis (DCVT) had cerebellar disturbance prior to impaired consciousness. CT and MRI revealed haemorrhagic infarction in the cerebellum and signal changes suggesting infarction in the thalamus and basal ganglia bilaterally. The straight sinus and internal cerebral vein (ICV) were dense on CT. On angiography, the vein of Galen (VG) and straight sinus were not seen. Following clinical recovery, CT and MRI became normal, and angiography showed recanalization of the VG and ICV. The relationship between cerebellar infarction and DCVT, and signal changes on CT and MRI are discussed.

Bithalamic hyperintensity on T2-weighted MR: vascular causes and evaluation with MR angiography.

PURPOSE: To determine whether MR angiography can be used to differentiate between the two vascular causes of bithalamic hyperintensity on T2-weighted MR images: "top of the basilar" artery occlusion and deep cerebral vein thrombosis. METHODS: A retrospective review identified six patients with bithalamic T2 hyperintensity of vascular causes. MR angiography was performed in four patients, MR angiography and conventional angiography in one patient, and conventional angiography in one patient. Data pertaining to clinical presentation and hospital course were collected. MR angiographic techniques were multislab overlapping three-dimensional time-of-flight, 2-D time-of-flight, and 2-D phase-contrast. RESULTS: Three cases of top of the basilar artery occlusion and three cases of deep cerebral vein thrombosis were recognized. In all cases, T2 hyperintensity in a vascular distribution suggested cerebral occlusive disease. Infarction involving the thalami and basal ganglia was present in two cases of deep cerebral vein thrombosis. Infarction of the thalami, mesodiencephalic region, and cerebellar hemispheres was present in two cases of basilar artery occlusion. Bithalamic infarction alone was seen in one case of deep cerebral vein thrombosis and one case of basilar artery occlusion. In the five cases in which MR angiography was used, this technique accurately distinguished the vessels involved (arterial or venous). CONCLUSION: MR angiography is a useful adjunct to MR imaging in the evaluation of bithalamic T2 hyperintensity. It does help distinguish between the two vascular causes: top of basilar artery occlusion and deep cerebral vein thrombosis.