A 61-year-old man with factor V Leiden thrombophilia presented with hemorrhage and transverse sinus thrombosis (figure, A). Four years later, he developed worsening aphasia, new hemorrhage, and hemispheric edema (figure, B). Susceptibility-weighted imaging (SWI) showed bright signal in the straight sinus (figure, C). A dural arteriovenous fistula (DAVF) was diagnosed (figure, D). The brain edema improved (figure, E) and SWI sinus hyperintensity resolved after endovascular disconnection of the fistula (figure, F).
(A) CT shows hemorrhage. (B) MRI fluid-attenuated inversion recovery (FLAIR) images 4 years later demonstrate progressive edema. (C) Susceptibility-weighted imaging shows hyperintense straight sinus. (D) Catheter angiography confirms a dural arteriovenous fistula (DAVF). (E) Improved brain edema on FLAIR and (F) resolved sinus hyperintensity on SWI post-treatment (white arrows, straight sinus; black arrow, DAVF).
Sinovenous thrombosis is a risk factor for DAVF.1 SWI that demonstrates hyperintensity within a venous sinus (from an arteriovenous shunt and oxygenated, high-flow blood) suggests the diagnosis.2
AUTHOR CONTRIBUTIONS
Vivek B. Kalra performed a literature review and drafted the manuscript text. Ajay Malhotra conceived of the study, performed a literature review, and assisted in writing the final manuscript text. Charles C. Matouk conceived of the study, performed a literature review, and assisted in writing the final manuscript text.
STUDY FUNDING
C.C.M. received support from Yale University, jointly from the School of Medicine and Department of Neurosurgery, and the Brain Tumor Gift Fund.
DISCLOSURE
The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
ACKNOWLEDGMENT
The authors thank the members of the Yale–New Haven Hospital Neurovascular & Stroke Programs for discussions and critical review of the manuscript.
- © 2013 American Academy of Neurology
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