A 43-year-old woman with a history of ulcerative colitis had focal motor seizures followed by rapidly progressive right hemiparesis, seizures, vomiting, and a decreased level of consciousness during the next 4 days. On examination, the patient had right gaze deviation, global aphasia, and quadriparesis greater on the right than on the left. A computed tomography study of the brain showed a hypodense heterogeneous lesion in the right frontoparietal area with mass effect. The patient had progressed to a comatose state during the next 2 days when this magnetic resonance imaging study was obtained. The diffusion-weighted image (Figure, A) demonstrated increased signal intensity of the bilateral frontal, right posteroparietal, and left occipitoparietal lobes. The fluid-attenuated inversion recovery image (Figure, B) showed hypointense areas of hemorrhage surrounded by vasogenic edema in the same locations. The gradient-refocused echo sequence (Figure, C) confirmed hemorrhage in all 4 lesions seen as a hypointense signal. The cerebrospinal fluid showed a white blood cell count of 4/μL (56% of which were lymphocytes), normal protein and glucose levels, and negative bacterial cultures. Viral polymerase chain reaction results were also negative. The opening pressure was 25 cm H2O. A cerebral angiogram revealed thrombosis with occlusion of the superior sagittal sinus and cortical veins (Figure, D). The patient's neurological status did not improve with full anticoagulation1 for 5 days. Based on case series2 with reports of good outcome, the patient underwent local thrombolysis with intravenous recombinant tissue-type plasminogen activator for 48 hours, which resulted in incomplete recanalization of the superior sagittal sinus and cortical veins (Figure, E). The neurological status had gradually improved to increased motor function of the right upper extremity and mainly nonfluent aphasia during the next 2 weeks when she was discharged to a skilled nursing facility.
Wartenberg KE, Palestrant D. Cerebral Sinus Thrombosis. Arch Neurol. 2006;63(9):1332. doi:10.1001/archneur.63.9.1332