Woman with left-side weakness

Abstract

Most acute intracranial hemorrhages present to the emergency department are due to severe hypertension, coagulopathies, aneurysm, or tumor. We describe a 41-year-old female presented with progressive left-side weakness for 6 h. Initial computed tomography of the brain showed acute hemorrhage at right temporo-parietal region. Subsequent brain magnetic resonance imaging confirmed right cerebral cortical venous thrombosis complicated by acute intraparenchymal hematoma. This report provides a rare etiology of acute intracranial hemorrhage in which early diagnosis and prompt anticoagulation are crucial for patient well-being.

A 41-year-old female presented to the emergency department (ED) complaining of new-onset progressive left-side weakness for 6 h, especially the upper limb, associated with mild headache and left leg numbness. On arrival, the patient walked into the ED with assistance. Neurological examination revealed reduced muscle power of 3/5 and 4/5 for left upper limb and left lower limb, respectively. Computed tomography (CT) of the brain was immediately arranged (Figure 1) and magnetic resonance imaging (MRI) of the brain was performed during admission (Figure 2).

Figure 1.

Brain CT showing acute hemorrhage at right parieto-temporal with midline shift to the left side.

Figure 2.

Brain MRI (SWAN) showing a thrombosed right cortical fronto-parietal vein.

Questions

1. What were the CT and MRI findings?

2. What was the diagnosis?

3. What is the clinical significance of this diagnosis to the emergency physician?

Answers

1. Head CT showed acute hemorrhage at right parieto-temporal with midline shift to the left (Figure 1). Brain MRI showed right cerebral cortical venous thrombosis (Figure 2).

2. The diagnosis was isolated cerebral vein thrombosis presenting with acute intracranial hemorrhage.

3. Early diagnosis and prompt anticoagulation are crucial for patient well-being. Acute cerebral venous thrombosis is an uncommon but serious condition that should be included in the differential diagnoses for spontaneous intracranial hemorrhage. Urgent MRI of the brain should be obtained in patients with risk factors for cerebral venous thrombosis if common etiologies yield non-significant findings.

Discussion

Cerebral venous thrombosis (CVT) is an uncommon neurovascular disease with wide-ranging clinical manifestations and illness course. The documented annual incidence was 1–12 cases per million and approximately 0.5%–3% of all types of cerebral vascular accidents. ¹ Isolated cortical vein thrombosis (ICVT), a subset of CVT, is reported to be extremely rare, representing approximately 6% of all CVT. ² The developmental variations in cortical vein anatomy, nonspecific clinical manifestations, and a lack of standard imaging protocol pose a diagnostic challenge to clinicians, especially in emergency settings. ³ The initial clinical presentations may be headache, seizure, or focal neurological deficits. MRI is the optimal diagnostic imaging modality. A T2-gradient echo or susceptibility-weighted magnetic resonance (MR) sequence is by far the most sensitive technique to detect cortical vein thrombosis. There is no definite consensus on the management of cortical venous thrombosis due to the rarity of its incidence; however, most patients have a good prognosis after anticoagulation. For severe CVT patients, intravascular thrombolysis treatment will then be an option. ⁴