Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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May 9, 2024
Isolated Cortical Vein Thrombosis Mimicking Brain Neoplasm
- Background:
- A wide variety of non-neoplastic etiologies may closely resemble intracranial neoplasms on imaging. Vascular diseases have particular potential for misdiagnosis as brain tumors. The consequences of an incorrect imaging diagnosis of intracranial tumor leads to unnecessary surgical procedures. In our case, the T2* gradient-echo sequence plays a crucial role in reaching the diagnosis. Isolated cortical vein thrombosis can occur in a small subset of patients without dural venous sinus involvement.
- Clinical Presentation:
- Headache is the most common nonspecific presenting symptom.
- Patients may have seizures or focal neurologic motor or sensory symtoms based on the area affected.
- Isolated intracranial hypertension can occur.
- Key Diagnostic Features:
- Noncontrast CT can show linear hyperdensity along the thrombosed cortical vein.
- Adjacent cortex can show variable signal related to venous infarct with mild DWI restriction and may have microhemorrhages and edema.
- Convexity sulcal hemorrhage may be occasionally seen.
- Venogram shows filling defect in the convexity cortical veins.
- Differential Diagnosis:
- Normal variant hyperdense vessels on CT in patients with dehydration or hemoconcentration—they will lack parenchymal changes. Overall vascular density will be high and not limited to a focal region.
- Tumor mimic: T1/T2 signal changes in the cortex with edema can sometimes mimic the features of brain tumor. Hypointensity on T2* gradient-echo images of the thrombosed vein plays a crucial role in diagnosing cortical vein thrombosis. Moreover, neoplasms will show expansile infiltrative appearance of the cortex and adjacent white matter.
- Treatment:
- Heparin, tPA
- Endovascular thrombolysis in selected patients
- Antiepileptic
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