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Case 231

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58 years old, female, patient attended the emergency room reporting sudden discomfort and loss of strength in the lower limbs followed by a fall from her own height. She reports chronic arterial hypertension, dyslipidaemia and thrombophilia (deficiency of antithrombin III). She uses Losartan and aspirin. Physical exam: good general state, vigilant, oriented in time and space, afebrile, hypertensive (180;110mmHg), absence of meningeal signs, left hemiplegia with hyperreflexia and plantar reflex indifferent to the left. It was requested a computed tomography (CT) of the cranium without contrast, a magnetic resonance (MRI) and an angioresonance of the cranium.

Based on the clinical history and in the imaging studies presented, it is possible to conclude that the cause of the lesion was:

a) Systemic arterial hypertension

25%

b) Arteriovenous malformation

25%

c) Cerebral Venous Thrombosis

25%

d) Brain Tumor Bleeding

25%
   

Image analysis

Image 1: CT without contrast showing a hyperdense dense and irregular image in the convexity of the parietal and frontal right lobes (yellow arrows), indicative of haemorrhage.

 

Image 2: T1-weighted magnetic resonance (MRI) image of the cranium, sagittal plane, after the contrast, showing filling defect of the superior sagittal sinus compatible with venous thrombosis (area between the yellow arrows).

Images 3 e 4: Cranial angioressonance, venous phase, axial and sagittal plane, showing absence of the blood flow in the proximal and medium third of the superior sagittal sinus (yellow arrows).

Highlights

- The venous cerebral thrombosis (VCT) is a rare condition, representing less the 1% of the brain stroke;

- The main risk factors are the pro thrombotic conditions, smoking and the use of oral contraceptives;

- Around 40 to 70% of the cases are manifested spontaneously as thrombophilia;

- The VCT is only suspected by the TC when the intracranial venous haemorrhage is present, while the occlusion of the venous sinus is only visualized in the angioresoance;

- The treatment consists in the use of heparin even in the presence of the intracranial haemorrhage because it reduces morbidity and mortality by additional thrombotic event and as a bridge to oral anticoagulation.

References

- Stam, J. Thrombosis of cerebral vein and sinuses. NEJM 2005; 352(17):1791-1798.

- SAPOSNIK, G 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 (4):1158-1192.

- CRISTO, Paulo Pereira, CARVALHO Gustavo Martins de, eGOMES NETO Antonio Pereira. "Trombose de seios venosos cerebrais: estudo de 15 casos e revisão de literatura." Rev Assoc Med Bras 2010; 56 (3): 288-292.

- KASPER, FL. Capítulo 370 "Medicina interna de Harrison. 18ª edição." Porto Alegre-RS: Editora (2013).

- FERRO, José M. E CANHÃO Patricia. Etiology, clinical features, and diagnosis of cerebral venous thrombosis. Uptodate. Acesso em 28 de maio de 2016. Disponível em: http://www.uptodate.com/contents/etiology-clinical-features-and-diagnosis-of-cerebral-venous-thrombosis?source=see_link.

Authors

Caroline dos Reis, 6th year medical student at Faculdade de Medicina da UFMG.

E-mail: creis.caroline [at]gmail.com

Supervisor

Carolina Ferreira de Oliveira, adjunct professor of the Medical clinical departament of the Faculdade de Medicina da UFMG. Doctor at UTI-Pronto Socorro do Hospital das Clínicas da UFMG.

E-mail: ferreira_carolina[at]yahoo.com.br

Reviewers

Giovanna Vieira, Ana Carina Nunes,Daniele Araújo Pires, Cairo Mendes, Carla Faraco, Bárbara Queiroz.

Translated by

Ana Carina Breunig Nunes, 5th year studentent at Faculdade de Medicina da UFMG.

E-mail: anacbreunig[at]gmail.com

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