British Journal of Neurosurgery, February 2015; 29(1): 5253

2014 The Neurosurgical Foundation

ISSN: 0268-8697 print / ISSN 1360-046X online
DOI: 10.3109/02688697.2014.954987

NEUROSURGICAL IMAGE

Deep cerebral venous thrombosis during pregnancy

Abdullah Hamid Feroze, Aditya Mantha & Omar Choudhri

Br J Neurosurg Downloaded from informahealthcare.com by Chinese University of Hong Kong on 04/10/15

For personal use only.

Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA

Introduction

injury to the thalamus, basal ganglia, and subcortical white

matter.1 However, with early diagnosis and appropriate management, excellent neurologic recovery remains possible.

The rarest form of cerebral venous thromboses, thrombosis of the deep venous system, is often fatal given potential

Fig. 1. Magnetic resonance (MR) imaging in deep cerebral venous thrombosis. (A) MR venography reconstruction demonstrating filling of only
the superficial cerebral venous system including the superior sagittal sinus and the transverse sigmoid sinus. There is no demonstration of the
deep venous system given thrombosis. (B) Axial gradient echo image demonstrating thrombosed internal cerebral veins (arrowheads) and the
straight sinus (arrow). (C) Axial T2 image showing increased signal in bilateral thalami and basal ganglia secondary to venous engorgement with
associated edema. (D) Coronal FLAIR image showing edema in bilateral thalami, caudate nuclei, and putamen secondary to deep cerebral venous
thrombosis.
Correspondence: Dr. Omar Choudhri, Department of Neurosurgery, Stanford University School of Medicine, Edwards Building R201, 300 Pasteur Drive,
Stanford, CA 94305, USA. Tel: 1 (610) 202-7144. Fax: 1 (650) 723-7813. E-mail: ochoudhri@stanford.edu
Received for publication 3 March 2014; accepted 4 August 2014

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Cerebral venous thrombosis during pregnancy

Br J Neurosurg Downloaded from informahealthcare.com by Chinese University of Hong Kong on 04/10/15

For personal use only.

Case history
A 27-year-old pregnant woman at 10-week gestation presented with a 3-day history of headaches, vomiting, and
altered mental status, alert and oriented only to name and
location upon admission. Examination demonstrated 3/5
strength bilaterally in the lower extremities with the corresponding hyperactive (3) patellar and Achilles reflexes.
Imaging demonstrated significant edema of the bilateral
basal ganglia and thalami in addition to engorgement of the
central veins (Fig. 1).
Given concern for cerebral venous thrombosis involving the straight sinus in the setting of pregnancy-induced
hypercoagulability, the patient was initiated on a heparin
drip. Electroencephalography demonstrated no evidence
of epileptiform activity. She was stabilized with 3% normal
saline prior to transitioning to low molecular weight heparin, and ultimately discharged without evidence of residual
neurologic deficits.

Discussion
In contrast to dural venous sinus thromboses, pathology of
the deep cerebral vasculature is often associated with faster
progression to profound deficits and poorer prognosis, particularly when the internal cerebral veins are involved.2,3
Associated signs and symptoms are typically nonspecific.4
Thalami are usually bilaterally edematous with potential
superimposed venous infarction, but may also present in a
unilateral or asymmetric fashion.3 Anticoagulation is considered the treatment of choice, even in the presence of

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hemorrhage.5 Albeit rare, full neurologic recovery is possible,

as documented herein.6
Twenty to thirty percentage of cerebral venous thromboses remain idiopathic in nature.4 In our case, hypercoagulability workup was negative for antiphospholipid antibody,
Factor V Leiden, prothrombin 20210A, and antithrombin
III syndromes. Levels of activated protein C resistance and
Protein S levels were elevated but were difficult to interpret
in the setting of pregnancy.
Declarations of interest: The authors report no declarations of interest. The authors alone are responsible for the
content and writing of the paper.

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