Clinical diagnosis
Case 297
【Progress】
Two days later, her dysarthria did not recover completely, leaving a little difficulty on speaking clearly.
【Discussion】
Small bleeding and infarction in cortex of left temporal lobe was found in present case. Diffusion WIMRI and T2*MRI were useful to visualize small infarction and cortical bleeding, respectively. Two months later, FLAIRMRI visualized high signal intensity corresponded to small infarction. The characteristic of the present lesion is combination of cortical subdural hemorrhage with small infarction. The etiologies of subarachnoid hemorrhage are aneurysm rupture, trauma and others. Aneurysm rupture accounts for 85% of the subarachnoid hemorrhages (1). The others include trauma, cortical or sinusoid thrombosis, angioma of AV malformation, capillary and venous, and various arteriopathies, Moyamoya or severe atherosclerotic diseases (2-7). Of these, non-traumatic subarachnoid hemorrhage associated with small brain infarction is thought to occur only in cortical or sinusoid thrombosis (2-7). In the present case, FLAIRMRI at the onset depicted small vessels with high signal intensity at cortex and superficial brain surface adjacent to small infarction, indicative of thrombosed vessels. FLAIR is an initial of fluid attenuation inversion recovery whose sequences are heavy T2WI with cerebrospinal fluid nulling, providing excellent contrast between CSF and brain surface. Then, FLAIR is also known to be water suppression heavy T2WI. When thrombosed vein exists at cortical vein or sinusoids, FLAIR visualize it as high signal intensity. Although it is difficult to certify the existence of superficial thrombus on MRI, it is reported that FLAIR can visualize thrombosis of sigmoid sinus or transverse sinus as high signal intensity. Then, it is possible for FLAIR to have demonstrated thrombosis of small leptomeningeal veins as high signal intensity. It might be possible for FLAIR to visualize a responsible vessel in case of fresh brain infarction.
Most systemic veins have venous valves, whereas cerebral venous sinuses do not have ones. Then, in coagulopathic conditions such as contraceptive drugs, puerperium and pregnancy, brain venous sinus is one of the susceptible veins for thrombosis. Adult patients with sinus thrombosis are women with the incidence of 75% (8). The sinus thrombosis occurs spontaneously with the incidence of 25% (8-10).
In our case, she had no tendency of coagulation, implying unknown cause of cortex subarachnoid hemorrhage and infarction. She was a smoker and alcohol drinker that might cause in a situation of hydration and vessel constriction.
【Summary】
We present a fifty-year-old female with dysarthria. She realized to be unable to speak clearly at awaking in the morning. Diffusion WIMRI and T2*WI MRI showed a lesion with small cortical subarachnoid hemorrhage and infraction at left temporal lobe. Further, FLAIRMRI showed small vessels adjacent to the lesion and vessel at brain surface, indicative of small vessel thrombosis delay. We should keep in mind that non-traumatic cortical hemorrhage and infarction can occur in case of leptomeningeal or sinus thrombosis. Diffusion WI and T2*WI are useful to visualize fresh infarction and fresh hemorrhage, respectively, and FLAIR is useful to detect a responsible thrombosed vessel.
【References】
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2023.5.1