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BMJ Case Rep. 2015; 2015: bcr2015212437.
Published online 2015 September 21. doi:  10.1136/bcr-2015-212437
PMCID: PMC4577631

Acute dural venous thrombosis

Description

An 18-year-old female student presented with a 7-day history of worsening frontal headache and 1 day history of vomiting. The patient described marked photophobia, but no fever or history of seizure. She was taking a combined oral contraceptive and had no other medical history. Physical examination showed no focal neurology, but funduscopy revealed bilateral papilloedema. On admission, a non-contrast CT of the head showed a hyperdense thrombus, triangle sign (figure 1) and prominence of the superior sagittal, straight, right transverse and sigmoid sinuses—highly suggestive of acute cerebral dural sinus thrombosis. Contrast CT demonstrated a δ sign, contrast outlining a filling defect due to a thrombus (figure 2). MR venogram (MRV) (figure 3) confirmed diagnosis and demonstrated little cerebral oedema, and no bleed or haemorrhagic infarction. The patient was treated with heparin and discharged on warfarin. Review after 4 months showed healthy discs with no papilloedema; the warfarin was stopped due to recurrent epistaxis and repeat MRI/MRV showed good re-canalisation (figure 4).

Figure 1
Non-contrast CT scan demonstrating the triangle sign.
Figure 2
Contrast CT scan demonstrating the δ sign.
Figure 3
MR venogram demonstrating a filling defect of the superior sagittal vein.
Figure 4
Repeat MR venogram demonstrating recanalisation of the superior sagittal vein.

Dural venous thrombosis represents 0.5–1% of all strokes and has an incidence of around 5 per million people per year.1 Presenting symptoms include: headache, papilloedema, cranial nerve palsies, unilateral motor weakness and speech disturbances.1 Non-contrast CT scans are often normal but may demonstrate a triangle sign (figure 1). Contrast CT may show a δ sign, a contrast filling defect in the superior sagittal vein (figure 2).2 MRV remains the gold standard imaging technique of dural sinus thrombosis.2 The mainstay of treatment is anticoagulation.1 The ISCVT study demonstrated a 8.3% mortality and 79% of patients make a full recovery.3

Learning points

  • Acute dural venous thrombosis represents around 0.5–1% of all strokes.
  • Non-contrast CT scan may be normal but contrast CT scan classically shows a δ sign: a contrast filling defect in the superior sagittal vein.
  • Always enquire about the use of an oral contraceptive in a young woman presenting with an acute onset headache.

Footnotes

Twitter: Follow Maam Mamun at @anis_mamun

Contributors: MM was jointly involved in the immediate and follow-up care of the patient as well as the review of this manuscript for submission.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Saposnik G, Barinagarrementeria F, Brown RD Jr et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:1158–92. doi:10.1161/STR.0b013e31820a8364 [PubMed]
2. Justich E, Lammer J, Fritsch G et al. CT diagnosis of thrombosis of dural sinuses in childhood. Eur J Radiol 1984;4:294–5. [PubMed]
3. Miranda B, Ferro JM, Canhão P et al. , ISCVT Investigators. Venous thromboembolic events after cerebral vein thrombosis. Stroke 2010;41:1901–6. doi:10.1161/STROKEAHA.110.581223 [PubMed]

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