Vol.:(0123456789) 1 3 Acta Neurologica Belgica https://doi.org/10.1007/s13760-018-0930-z NEURO-IMAGES Clinical and radiological findings of a rare case: reversible Parkinsonism in cerebral venous sinus thrombosis Deniz Alis 1  · Ceren Alis 2  · Ayse Deniz Elmali Yazici 3  · Yonca Senem Akdeniz 4  · Hulya Apaydin 2 Received: 28 February 2018 / Accepted: 17 April 2018 © Belgian Neurological Society 2018 Keywords CVST · DWI · MRI · MR venography · Parkinsonism Introduction A 46-year-old woman admitted to our emergency depart- ment with a 3 days history of a persistent headache, slurred speech, urinary and fecal incontinence. General physical examination and laboratory tests were normal. On neu- rologic examination, the patient had a masked face, brad- ykinesia, and resting tremors. Romberg test was positive. Magnetic resonance (MR) examination, including diffusion- weighted imaging (DWI), dynamic susceptibility contrast MR perfusion, contrast-enhanced angiography, 2D time of flight (TOF) MR venography sequences, was performed to exclude potential intracranial pathologies. MR venography examination revealed lack of flow in the left transverse sinus, sinus rectus, Galen vein and inferior sagittal sinus (Fig. 1). We detected hyper-intensity in both of the lentiform nuclei, caudate nuclei (more prominent on the right) and thalami on T2-weighted FLAIR sequences. Furthermore, diffusion restriction on DWI (Fig. 2) and decreased relative cerebral blood volume (rCBV) (Fig. 3) on MR perfusion imaging were also accompanied aforementioned signal abnormali- ties. The MR imaging findings were suggestive of cerebral venous sinus thrombosis (CVST), and intravenous heparin was started. The Parkinsonism symptoms and headache were resolved within a week. Discussion We report a case of reversible Parkinsonism due to CVST to present the clinical and MR imaging findings including 2D TOF MR venography, DWI, and perfusion-weighted imaging of this very rare entity. Parkinsonism is a syndrome presents with tremor, bradykinesia, rigidity, and postural instability. Many etiologic factors might lead to Parkinson- ism. Although the most frequent vascular etiologic factor of Parkinsonism are the ischemic or hemorrhagic stroke, in rare instances, CVST might also cause Parkinsonism [1]. To date, only three cases of CVST with Parkinsonism features have been described [2–4]. In all of these cases, Parkinson- ism and radiological abnormalities significantly regressed after anticoagulation treatment. Jenkins et al. demonstrated diffusion abnormalities in the lentiform nuclei, the right caudate and both thalami, and suggested these changes as a pathophysiological basis for the syndrome [4]. In CVST patients with Parkinsonism features, increase in interstitial and transcapillary pressure secondary to venous thrombosis is the main factor that causes cellular swelling, and cellular swelling in these patients is a reversible condition since there is no or little energy failure. Therefore, diffusion restriction in these patients might be also reversible, which is promi- nently different from stroke patients, in which cellular swell- ing is mainly caused by energy failure and irreversible; thus * Ceren Alis cerencivcik@gmail.com Deniz Alis drdenizalis@gmail.com Ayse Deniz Elmali Yazici denizelmali@yahoo.com Yonca Senem Akdeniz yonca.akdeniz@istanbul.edu.tr Hulya Apaydin hulyapay@istanbul.edu.tr 1 Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, 34098 Fatih/Istanbul, Turkey 2 Department of Neurology, Cerrahpasa Faculty of Medicine, Istanbul University, 34098 Fatih/Istanbul, Turkey 3 Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, 34098 Fatih/Istanbul, Turkey 4 Istanbul Faculty of Medicine, Emergency Medicine, Istanbul University, 34098 Fatih/Istanbul, Turkey