The clinico-radiological spectrum of isolated cortical vein thrombosis Rahul Rathakrishnan ⇑ , Vijay K. Sharma, Teoh Hock Luen, Bernard P.L. Chan Division of Neurology, Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore article info Article history: Received 13 November 2009 Accepted 8 February 2011 Keywords: Anticoagulation Cortical vein thrombosis MRI Seizures abstract Isolated cortical vein thrombosis (ICVT) in the absence of sinus or great venous involvement is rare. Var- ious MRI sequences have been proposed for diagnostic accuracy, although follow-up data are limited. The optimal management strategy remains uncertain. Patients with ICVT treated between 2006 and 2008 were retrospectively studied. Diagnostic and follow-up neuroimaging were reviewed independently, and we evaluated their treatment and outcomes. Five patients (mean age 41 years; range, 25–54 years) were included. All presented with seizures. Focal neurological deficits were noted in one patient only. T2 / susceptibility-weighted MRI abnormalities were observed in all patients. T2-weighted parenchymal hyperintensities involving the cortical–subcortical regions around the ICVT had completely resolved on follow-up scans. Clinical outcomes were uniformly good, despite variable treatment strategies. We observed significant, yet reversible, parenchymal T2-weighted MRI lesions in our patients with ICVT. Fol- low-up clinical and radiological studies demonstrate recovery independent of treatment regimes. T2 / - weighted MRI was found to be a useful diagnostic tool and might improve diagnostic accuracy in care- fully selected patients with new-onset seizures. Ó 2011 Elsevier Ltd. All rights reserved. 1. Introduction Isolated cortical vein thrombosis (ICVT) accounts for less than 1% of patients with stroke and is reported as single cases or small series. 1–4 Clinical data are scant due to a lack of distinction in the literature between ICVT and the separate entity of deep venous or dural sinus thromboses with cortical venous involvement. 5–9 The presenting features of ICVT may be distinct to those of dural sinus or deep venous thromboses. Headache and impairment of consciousness are less prominent in ICVT, presumably due to the absence of intracranial hypertension. 2,9 Deep venous involvement carries a poorer prognosis largely due to the diagnostic delay, involvement of critical structures and poor collateral compensa- tory mechanisms. 9 There are also few data available regarding the follow-up find- ings in patients with ICVT. Hence, we describe the clinico-radiolog- ical features of patients diagnosed with ICVT and provide follow- up data. 2. Case report Patients diagnosed with ICVT at our tertiary institution between January 2006 and December 2008 were studied retrospectively. Those with concomitant sinus or deep venous involvement were excluded. Patients were tested for serological markers of autoim- mune disease (antinuclear antibody, antiextractable nuclear anti- gen antibody, antidouble stranded DNA antibody) and thrombophilia (homocysteine levels, lupus anticoagulant, anticar- diolipin immunoglobulin (Ig)G and IgM, activated protein C resis- tance, protein C, protein S and antithrombin III activity). We collated follow-up data for all patients. 3. Results Five patients (mean age 41 years; range 25–54 years; four males) were included. Salient clinical and radiological data are in- cluded in Table 1. Antithrombotic treatment regimes varied amongst the pa- tients. Patient 1 initially received low-molecular-weight heparin (LMWH). He declined oral anticoagulation and was placed on clopidogrel. Despite non-compliance to medication, he remained well at follow-up. Patient 2 was treated with intravenous unfractionated heparin and discharged with warfarin therapy. Patient 3 was not given antithrombotic therapy in view of an incidental quiescent right temporal arteriovenous malformation Patient 4 was treated with LMWH and then warfarin for 6 months. Patient 5 was placed on unfractionated heparin fol- lowed by warfarin. Although anticoagulation was subtherapeutic due to variable compliance during follow-up, he remained asymptomatic. Five months later, he presented with acute left-sided weakness. Diffusion-weighted MRI (DWI) revealed foci of restricted diffusion in the perfusion territory of the right middle cerebral artery. Neurovascular sonography demonstrated right carotid non-stenosing plaque. No thromboembolic source was seen on transthoracic echocardiography. Detailed thrombo- philia screening for mutations such as Factor V Leiden R506Q, MTHFR C677T and G20210A were negative. Anticoagulation was optimised and 12 months later, replaced with antiplatelet therapy. The clinical follow-up period was 9 months to 28 months. All patients remained neurologically well and seizure-free. Anticon- vulsants were withdrawn in all but one (patient 3) who remained on medication in view of a persistent structural abnormality on fol- low-up MRI. 4. Discussion We describe clinical and neuroimaging features of ICVT in patients of Asian descent. One of the main strengths of this ser- ies is the long follow-up, compared to other reports of ICVT. 1– 4,10–12 This allowed us to study the temporal evolution of the clinical and neuroimaging abnormalities. Despite the small sam- ple size and widely variable management strategies, the pa- tients’ clinical and radiological characteristics were quite consistent. We observed significant disparity between clinical and radio- logical findings in our patients with ICVT. Neurological examina- tion was normal in four of five patients. All patients presented ⇑ Corresponding author. Tel.: +65 67724126; fax: +65 68723566. E-mail address: rahulrathakrishnan@yahoo.com.sg (R. Rathakrishnan). 1408 Case Reports / Journal of Clinical Neuroscience 18 (2011) 1408–1411