Near complete resolution of bilateral thalamic venous infarct in the absence of superficial venous sinus thrombosis

Case Description

A 45-year-old woman presented to the emergency department with a headache and progressive deterioration in sensorium since 2 days. On examination, her vitals were stable. Blood investigations were normal. Her Glasgow Coma Scale was 9/15. Bilateral plantar response was extensor. Magnetic resonance (MR) imaging of the brain demonstrated hypointense signals on T1 weighted images, hyperintense signals on T2 [[[Figure 1]]a white arrow], and fluid-attenuated inversion recovery (FLAIR) [[[Figure 1]]b white arrow] weighted images in bilateral thalamus. On diffusion weighted imaging (DWI), both the thalamus demonstrated isointense to hyperintense signals [[[Figure 1]]c white arrow] with corresponding hypointense signals on apparent diffusion coefficient imaging (ADC) [[[Figure 1]]d white arrow]. On susceptibility weighted imaging (SWI), blooming was evident in right thalamus [[[Figure 1]]e black arrow] and along the course of vein of Galen and straight sinus [[[Figure 1]]e white arrow]. On MR venogram, the vein of Galen and straight sinus was occluded [[[Figure 1]]f black arrow]. Superficial venous systems were patent. The imaging was consistent with the diagnosis of bilateral thalamic hemorrhagic venous infarct following occlusion of deep venous system. Her medical history was remarkable for multiple attacks of diarrhea before the onset of headache. On receiving anticoagulation, she showed gradual improvement in neurological status with near-complete recovery by 3 months. Investigations for coagulation disorder revealed normal protein C, protein S and antithrombin III levels. MR imaging (MRI) done at 3 months showed near complete reversal of signal changes in both the thalamic on T2 and FLAIR imaging [[Figure 2]]a and [[Figure 2]]b. Few discrete bilateral thalamic signal intensity changes were seen on T2 weighted, FLAIR, and SWI imaging [[[Figure 2]]a, [[Figure 2]]b, [[Figure 2]]c white arrow].

Figure 1: Magnetic resonance imaging of the brain demonstrates signal intensity changes in bilateral thalamus - hyperintense signals on T2 (a white arrow) and fluid attenuated inversion recovery (b white arrow) weighted images. On diffusion weighted imaging, both the thalamus demonstrate isointense to hyperintense signals (c white arrow) with corresponding hypointense signals on apparent diffusion coefficient imaging (d white arrow). On susceptibility weighted imaging, blooming is evident in right thalamus (e black arrow) and along the course of vein of Galen and straight sinus (e white arrow). On Magnetic resonance venogram, the vein of Galen and straight sinus is seen occluded (f black arrow)

Figure 2: Magnetic resonance imaging at 3 months shows near complete reversal of signal changes in both the thalamic on T2 and fluid attenuated inversion recovery imaging (a and b). Few discrete bilateral thalamic signal intensity changes are seen on T2-weighted, fluid attenuated inversion recovery and susceptibility weighted imaging (a-c white arrow)

Financial support and sponsorship

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Publication History

Article published online:
09 September 2022

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