LAUSR

Sir, isolated thromboses of cortical veins are rare and cerebellar vein thromboses are considered exceptional in scientific literature. We report the case of a 51-year-old Caucasian woman, hospitalized due to sudden onset of frontal stabbing headache followed by confusion and dizziness, and received diagnosis of acute venous thrombosis of inferior cerebellar vein with left lateral sinus hypoplasia and selective left superior semilunar lobule involvement. Her medical history was positive for migraine with visual aura, polycystic ovarian syndrome. She denied smoking or alcohol consumption; she did not take contraceptive pills. She worked as a nurse. Her familial history was negative for cardiovascular or cerebrovascular disorders. Her neurological examination resulted normal except for gait difficulty due to dizziness. She performed brain computer tomography without contrast, which shoved cerebellar hyperdensity (Fig. 1) and magnetic resonance angiography examination, which revealed hyperintensity at the cortico-subcortical junction in the left upper semilunar lobule at T2 fluidattenuated inversion recovery (Flair) (Fig. 2), suspect for bleeding. Consequently, she performed cerebral angiography which confirmed the presence of acute venous thrombosis of inferior cerebellar vein, associated with left lateral sinus hypoplasia, with left superior semilunar lobule involvement. Low molecular weight heparin (subcutaneous Enoxaparin 4000 bid) was initially introduced and then was switched to oral anticoagulant therapy (Warfarin) with indication to maintain INR range between 2 and 3. Thrombophilia and immunological blood tests were normal except for subclinical hypothyroidism with mild increased value of thyroid stimulating hormone and mild positivity of thyroid antithyroglobulin antibody and thyroid peroxidase antibodies, for which therapy with levothyroxine 25 mcg/die was introduced. Both headache and dizziness improved and neurological examination was normal at discharge. Cerebral sinus venous thrombosis (CSTV) is characterized by extreme variety of clinical presentation and etiology and represents an important cause of cerebral vascular accidents. Estimated incidence in the adult population is about 1.3–1.6/100,000, probably higher among Asian and Middle Eastern populations. In most cases, it affects adults between the ages of 20 and 50, while only 10% of people older than 65 years can develop CSTV. In most cases, superior sagittal, lateral, rectus, and cavernous sinuses can be involved. Isolated thromboses of cortical veins are rare and cerebellar vein thromboses are considered exceptional (3.9% in a study cohort performed on 230 patients in 2010) [1, 2]. Presentation is generally subacute with cerebellovestibular symptoms and intracranial hypertension. Most affected veins are sinus rectus, lateral sinuses, and superior petrous vein in association with cerebellar veins. Most important etiological factors are puerperium or protein C deficiency [2]. Brain computer tomography often shows abnormal but not specific patterns, such as cerebellar hyperdensity or hypodensity (“pseudotumor like pattern” or various degrees of hydrocephalus) while brain magnetic resonance or cerebral angiography are diagnostic [2]. Differential diagnosis includes arteriovenous f i s tu las—dura l ve ins , p ia l a r te r iovenous malformations, vasculitis of the various large cerebral nerves. Outcomes are variables from severe disability or exitus to complete remission [2]. We reported the case of a patient diagnosed for acute cerebellar venous thrombosis, without involvement of * Maria Sofia Cotelli [email protected]