A 38 year old female presented with a sudden onset, severe occipital headache with vomiting, dizziness and blurred vision. The patient had just finished steroid treatment for a chest infection and was on the combined oral contraceptive pill. The patient demonstrated no focal neurology with normal visual acuity/fundoscopy.An un-enhanced CT, performed 10 hours after the initial symptoms and a CT venogram was subsequently performed.These images are gven below.



What is the most likely diagnosis?


ANSWER

Deep venous sinus thrombosis

The un-enhanced CT(upper image) demonstrates increased attenuation within the straight sinus, vein of Galen.
Lower Image demonstrates the filling defects within the vein of Galen,straight sinus and superior sagittal sinus on a CT venogram sagittal reconstruction.

This patient was female, had just finished steroid treatment after a chest infection and was on the combined oral contraceptive pill, all risk factors for venous sinus thrombosis.
The appearance of venous sinus thrombosis on un-enhanced CT is high attenuation secondary to thrombus formation, with corresponding filling defects on CT venogram as demonstrated in this case.

A differential for hyper-attenuation of the un-enhanced venous sinuses is elevated levels of haematocrit (Eg:secondary to polycythaemia ). Children also have higher haematocrit levels and a lower brain density often causing a hyper-dense appearance of the sinuses.Another differential is partial volume effects due to the proximity of the cerebral venous sinuses to bony structures. For both of these differentials, there should not be a corresponding filling defect on a CT venogram.

The venous sinuses can be separated into the deep cerebral veins comprising the straight sinus, internal cerebral veins and the vein of Galen, and the cerebral venous sinuses comprising the sigmoid, transverse and superior sagittal sinuses. High attenuation in the deep cerebral veins on un-enhanced CT has been shown to be 100% sensitive and 99.4% specific for deep venous sinus thrombosis. 

73-year-old diabetic male patient who was admitted to our hospital with severe left flank pain and high fever. Physical examination revealed a left flank palpable mass.

Contrast-enhanced CT

What is the diagnosis?

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