Venous Infarcts Mimicking Large Vessel Arterial Disease: Watershed Lesions in Deep Cerebral Venous Thrombosis

We read with interest the recent report by Washida et al on multiple deep white matter hyperintensities seen in diffusion-weighted imaging (DWI) in a patient with straight sinus thrombosis. We would like to report a similar instance of a 30-year-old female who presented to us with a 4-day history of headache, vomiting, and progressive drowsiness; on examination, she was drowsy and had left hemiparesis. Her initial magnetic resonance imaging demonstrated thalamic and basal ganglia signal changes and bilateral centrum semiovale punctate infarcts (Fig 1, A,B) that suggested possible deep cerebral venous sinus thrombosis and additional arterial pathology. Susceptibility-weighted imaging showed straight sinus blooming (Fig 1, C). Magnetic resonance angiography was normal and contrast-enhanced magnetic resonance venogram showed straight sinus thrombosis (Fig 1, D). She was treated with unfractionated heparin and had completely recovered within 2 weeks. Straight sinus thrombosis might result in watershed region ischemia due to venous hypertension and consequent infarct visible in DWI. Venous watershed infarcts, thus, might mimic large vessel disease especially when deep parenchymal lesions are absent and should be considered as one of the causes for centrum semiovale region watershed infarcts. Bilateral distribution (though asymmetrical) of lesions and normal magnetic resonance angiography should provide clue to consider venous etiology especially if headache constitutes a patient's prominent clinical symptom. In addition to DWI, which demonstrates white matter lesion, susceptibility-weighted imaging is a particularly useful sequence to image thrombus in straight sinus.