“Cord Sign” in Deep Cerebral Venous Thrombosis

The Journal of Emergency Medicine, Vol. 42, No. 1, pp. 60 – 61, 2012 Copyright © 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter

doi:10.1016/j.jemermed.2009.09.027

Visual Diagnosis in Emergency Medicine “CORD SIGN” IN DEEP CEREBRAL VENOUS THROMBOSIS Sameer Vyas,

MD,*

Paramjeet Singh, MD,* Kumar Rahul, MBBS, DMRD,* Pratibha D. Singhi, and Niranjan Khandelwal, MD, DNB, FICR*

MD,†

*Department of Radiodiagnosis and †Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India Reprint Address: Sameer Vyas, Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India

CASE REPORT A 17-month-old girl presented to the emergency department (ED) with an altered sensorium and abnormal limb movements that had developed over the prior 6 h. She had a history of vomiting (non-bilious and non-projectile), lethargy, and poor feeding for the prior 7 days. Neurological examination showed exaggerated limb reflexes, however, tone and power were normal. A non-contrast head computed tomography (CT) scan (Figure 1) showed ill-defined hypodensities in both thalami, with hyperdensity in the internal cerebral vein, vein of Galen, and straight sinus, suggestive of deep cerebral venous thrombosis (DCVT). DCVT is rare, and presents with a wide clinical spectrum. Imaging modalities include CT scan, magnetic resonance imaging (the imaging modality of choice), and digital subtraction angiography (1,2). The head CT scan may be normal (20% of cases), or may show thrombosed veins as the “cord sign” (direct sign), as well as parenchymal involvement in the form of edema or infarction of the thalami or basal ganglia (indirect sign). The “cord sign” is seen as an increased density of the cerebral veins, and is caused by increased attenuation of the thrombotic material in the affected vessel (3). It is best seen within the first week of the disease. After 1 to 2 weeks, the thrombus becomes isodense, and then hypodense. Identification of the cord sign in the vein of Galen and straight sinus is difficult, as they normally appear hyperdense, but the internal cerebral veins are normally isodense with the brain and, hence, the

Figure 1. Plain computed tomography scan of the brain showing hyperdense internal cerebral veins (black arrows), the vein of Galen, and straight sinus (white arrows) with ill-defined hypodensity in both thalami.

hyperdense thrombus can be readily seen (1). As DCVT presents with non-specific neurological symptoms, and a non-contrast CT scan is usually the first diagnostic mo-

RECEIVED: 4 August 2009; ACCEPTED: 19 August 2009 60

“Cord Sign” in Deep Cerebral Venous Thrombosis

dality performed in the ED, the “cord sign” with parenchymal changes is helpful in the identification of this entity. REFERENCES 1. Lafitte F, Boukobza M, Guichard JP, Reizine D, Woimant F, Merland JJ. Deep cerebral venous thrombosis: imaging in eight cases. Neuroradiology 1999;41:410 – 8.

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