Case Report
Atypical Clinical Picture Observed in Three Patients with Thrombosis of
the Cerebral Sinuses
Hristo G. LESIDRENSKI, Krasimir R. GENOV, Stratina S.STRATIEVA*
Affiliation of the authors:
Military Medical Academy, Clinic of nervous diseases, Sofia Bulgaria
Corresponding author:
Assoc. Prof. Krasimir R. GENOV, M.D., Ph. D.
Clinic of nervous diseases- Military Medical Academy, Sofia, Bulgaria
3 Georgi Sofiiski str., 1000 Sofia, Bulgaria
Tel: (+359-2) 922 59 14
E-mail:
K.Genov@abv.bg
Abstract
We present three cases of cerebral
venous sinuses thrombosis. Dissociation
between minor complaints from the
patients, almost negative neurological
status and major changes in the venous
phase of cerebral circulation evidenced
by MRI venography, CT venography
and Doppler sonography of the carotid
and vertebrobasilar systems is very
interesting.
Minimal
subjective
complaints
and
almost
negative
neurological status were the main
reasons for the disease to remain
undetected in the early periods in these
three patients. Thanks to modern
neuroimaging methods such as CT-
angiography, MRI- angio and veno
graphy, duplex scanning of the greater
and basilar cerebral vessels, the
diagnosis
becomes
possible.
The
prognosis of chronic venous thrombosis
is good if diagnosis and proper
treatment are administered in time.
Frequency is 3 to 4 cases per 1 million in
adult population and 7 cases per 1
million in children. Over the past decade
new resources of the neuroimaging
Balkan Military Medical Review
Oct - Dec 2012; 15(4): 282 - 288
techniques increased the possibility of
rapid and correct diagnosis and
therefore the administration of more
effective
treatment.
This
greatly
improves the prognosis for the disease
and for the patients. Approximately
80% of all patients have regression of
neurological symptoms and almost
complete recovery
Keywords: cerebral venous sinuses,
thrombosis,
progress
Introduction
We present three cases of venous
sinuses
thrombosis
of
the
brain.
Dissociation between minor complaints
from the patients, almost negative
neurological status and major changes in
the venous phase of cerebral circulation
evidenced by MRI venography, CT
venography and Doppler sonography of
the carotid and vertebrobasilar systems is
very interesting [1, 2].
Thrombosis of cerebral veins and
sinuses is a cerebrovascular disorder in
which clinical symptoms are very
dramatic, very non-specific and diverse,
thus making diagnosis difficult [3].
Patients present with headache, vomiting,
dizziness and their condition is often
mistaken with psychiatric disorders
(neurosis, hysteria, depression, etc.).
The incidence is 3 to 4 cases per 1
million in adult population and 7 cases per
1 million in children. Over the past decade,
the
development
of
neuroimaging
techniques increased the possibility of
rapid
and
correct
diagnosis
and
consequently more effective treatment [4-
6]. This greatly improves the prognosis for
these patients. Approximately 80% of all
patients have regression of neurological
symptoms and almost complete recovery
[7,8].
Possible risk factors for cerebral sinus
thrombosis are deficiency of natural
anticoagulants (Antitrombin III, Protein C,
Protein S, plasminogen); disfibrinogene
mia; primary antiphospholipid syndrome;
homocystinuria; severe liver disease;
nephrotic syndrome; malignant tumors;
severe DIC syndrome; systemic immune
diseases (SLE, Behcet, ulcerative colitis);
blood
disorders
-
polycythemia,
thrombocytosis, leukemia, hemoglobino
pathies; lymphomas; Wegener's granuloma
tosis; congenital heart defects (so called
"blue"); valvular diseases; congestive heart
failure syndrome; Budd-Chiari syndrome;
dural AVM; aneurysm of vena Galeni;
pulmonary diseases
- secondary
polycythemia, cor pulmonale, trauma,
postoperative conditions; lumbar puncture;
tumors, cachexia and dehydration with
different etiology; general and local (in
the zone of the head) infections; diabetes
mellitus.
Clinical cases
Patient № 1 (DP), male aged 48,
visits the emergency room complaining of
severe headache in the occipital and frontal
areas, repeating vomiting and loud
pulsating tinnitus. The beginning of the
complaints dates back about a year with
rare episodes of headache and feeling sick
while bending the head mainly in the
morning. The patient reported pain in the
front area of the head with pulsating
character and tinnitus.
Comorbidities:
-
arterial
hypertension II-III degree, chronic colitis,
hemorrhoids.
Past illnesses: - empyema in childhood,
treated surgically. Drug allergy to
penicillin.
Normal
somatic
status.
Neurologic status - light coordination
disorder, Cephalalgia.
Patient № 2 (IK), a male aged 58,
admitted in the clinic due to complaints of
283 Balkan Military Medical Review
Vol. 15, No 4, Oct –Dec 2012
numbness on the left side of the head and
pain in the neck while moving. The patient
had these symptoms for a year and a half.
Comorbidities: - diaphragmatic hernia,
gastritis. Past illnesses: - none reported.
Smoker - 20 cigarettes a day. No allergies
mentioned.
Normal
somatic
status.
Neurologic - Left facial hypoesthesia for
left
part
of
face.
Bradipsihia
Patient № 3 (GM), a male aged 32
is admitted in the clinic with complaints of
astringent headache predominantly with
frontal
localization,
dizziness
and
staggering. The complaint dated for eight
months.
Comorbidities:
-
arterial
hypertension I degree. Past conditions:
surgery on the occasion of recurrent
spontaneous pneumothorax. Drug allergy
to vaccines and antibiotics. Normal
somatic status. Neurologic status - light
discoordination syndrome, Cephalalgia.
The main paraclinic indicators are
presented in tables 1 and 2.
Table 1. Paraclinic data
Paraclinic
investigation
urine Glu Hb
Hct
Tbil INR APTT fibrinogen
antiphospholipi
d antibodies
№1 (D.P)
Keton 7.9
135 0.40-h 30
1.15 28.4
2.53
Norm
№2 (I.K)
Norm 5.4
152 0.43-h 12
1.09 29.7
2.20
Norm
№3 (G.M)
Norm 6.0
148 0.44- h 35
0.89 27.0
2.39
Norm
Table 2. Results of Doppler sonography of cerebral vessels
Duplex
scanning of the
highway and
basal
cerebral
arteries
№1 (D.P)
Thickened intima media complex in both bifurcatio carrotis. Blood flow in current vein of
Rozentau-in
upper limit
№2 (I.K)
Left common carotid, data of chronic thrombosis. Right common carotid artery- thickened
intima-media complex with formation of smooth atheromatous heterogeneous plaque in
bifurcation. The left vertebral artery, significantly reduced blood flow in the distal segment
of the artery (submandibular and reversing its direction)
№3 (G.M)
right vertebral artery- moderately increased vascular resistance
Other
indicators
are
the
norm
X-ray studies: Ro-graphy - pulmo et cor-
for the three patients - norm.
Patient № 1 (D.P)
CT of the brain- Data for asymmetry of
sinus sagittalis and sinus transversus which
are enlarged, more significantly on the left.
MRI study –High contrast signal in the
upper sagittal sinus, sinus rectus, in
confluent sinus and in both transverse
sinuses.
MRI venography: showed no signal in
these sinuses.
Lesidrenski H.et al: Atypical Clinical Picture Observed inThrombosis of the Cerebral Sinuses 284
Figure No 1
Figure No 2
Conclusion: MRI signs of sinus thrombosis
of visualized sinuses.
Patient № 2 (I.K)
CT of the cervical vessels: Evidence of
thrombosis of the common carotid on the
left. High-grade stenosis of the bifurcation
of truncus brachiocefalicus and the
bifurcation of the right common carotid
artery is present.
Figure No 3
Figure No 4
CT angiography - Data for thrombosis of
left arteria corrotis communis, and the
right vertebral artery. High-grade stenosis
of the bifurcation of truncus brachio
cephalicus and common carotid artery on
the right.
285 Balkan Military Medical Review
Vol. 15, No 4, Oct –Dec 2012
Patient № 3 (GM)
CT of the brain - Evidence of Dandy-
Walker variant. Partial thrombosis in right
sinus sigmoideus. Chronic pansinuitis.
Figure No 5
Figure No 6
Table 3.
CONSULTATION
Ear Nose Throat
Ophthalmology
Cardiology
№1 (D.P.)
Norm
Angiospasmus
retinae hypertonica
Hypertension II-IIIdr.,
treatment with Diroton
1/2 tabl.
№2( I.K.)
Rhino sinusitis
Norm
norm
№3(G.M.)
Pansinuitis
Norm
Hypertension I-II dr.,
treatment with Diroton
1/2 tabl
Treatment during the stay in the clinic:
Because of lack of neurological
symptoms,
moderate
anticoagulation
therapy was applied [9]. Symptomatic
treatment with Nootropil, antihypertensive
dugs and painkillers was administered.
Patients were discharged with defined
therapy in improved general condition and
recommendation for a control MRI in three
months.
Discussion
Thrombosis of the venous sinuses
of the brain is a dramatically and urgently
life-threatening
condition
requiring
Lesidrenski H.et al: Atypical Clinical Picture Observed inThrombosis of the Cerebral Sinuses 286
treatment in a specialized clinic with
possibility
of
intensive
care
and
resuscitation [9]. Disease severity and
outcome depend on the type and
localisation of the pathological process,
predisposing
factors
and
occurring
complications [8, 10]. It is a relatively rare
disease - about 3% of the thrombosies of
cerebral vessels are caused by brain
phlebothrombosis and thrombophlebitis
and they count less than 1% of all strokes.
It occurs more often in women. There are
discussions that the etiology might be
primary and acquired hypercoagulation
status. Important to pathogenesis are:
increased coagulation, viscosity of the
blood, slowing of the blood flow in the
venous system (compression of brain veins
and dural sinuses by adjacent processes),
stagnation in the small circle of blood
circulation, increased intracranial pressure
(increased venous and capillary pressure,
in turn, increases CSF production and ICP)
[11]. Modern methods of research (mainly
MRI venography) [12] and the early
involvement of anticoagulant therapy, even
when phlebothrombosis is associated with
CNS bleeding, guarantee a good outcome
and reduce mortality by 5-15%. In
permanently acting etiopathogenic factor
recovery is slow and often incomplete [13].
The shown cases of venous
thrombosis of the cerebral sinuses had
minimal
subjective
complaints
and
objective neurological disorders for a long
period before hospitalization. It is most
likely that in these cases cerebral venous
thrombosis was caused by chronic
obstruction of dural sinuses. This
obstruction allows compensation of
impaired venous flow by the development
of collateral vessels. Detailed studies of the
patients during their stay in the clinic
revealed neither changes in coagulation,
nor evidence of systemic immune and
blood disorders [14, 15]. Minimal
subjective complaints and almost negative
neurological status could have caused the
disease to remain undetected at its early
period and in these three patients. Thanks
to modern neuroimaging techniques such
as CT angiography and angio-MR
venography, duplex scanning of the greater
and basilar cerebral vessels, the diagnosis
becomes possible. The prognosis of
chronic venous thrombosis is good with
early diagnosis and administration of
proper treatment.
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Lesidrenski H.et al: Atypical Clinical Picture Observed inThrombosis of the Cerebral Sinuses 288
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