PMC3636547_01
Images from case 1. A 34-year-old woman with Von Hippel-Lindau syndrome developed dural sinus thrombosis 5 days after resection of right cerebellar hemangioblastoma. (a) MR scan shows right cerebellar hemangioblastoma (arrow) with adjacent edema that was successfully resected. (b) Noncontrast CT scan 5 days later shows dense clot sign (arrow) in torcular herophili. (c) Venogram through 3-F microcatheter shows acute thrombus filling and distending left transverse sinus (arrows). Six milligrams of tPA was injected into thrombus over a period of 1 hour. (d) Repeat venogram 1 day later shows improved flow and reduction in thrombus. Residual thrombus (arrows) was treated with a second dose (3 mg) of tPA. (e-h) Gadolinium-enhanced MR blood pool images before thrombolytic therapy (e, f) show absence of flow in straight and left transverse sinuses. (g, h) Images at 3-month follow-up show flow restored in left transverse and sigmoid sinus (arrows, g) and straight sinus (arrows, h).
nihms424780f1.jpg
PMC3636547_04_nihms424780f1.jpg
F1
Ultrasonography (US) and venography revealed thrombosis of the IVC, right iliac vein, and entire deep venous system of the left leg from the common iliac veins to the calf veins (Fig E1, available online at www.jvir.org).
PMC3636547_02
Images from case 1. A 34-year-old woman with Von Hippel-Lindau syndrome developed dural sinus thrombosis 5 days after resection of right cerebellar hemangioblastoma. (a) MR scan shows right cerebellar hemangioblastoma (arrow) with adjacent edema that was successfully resected. (b) Noncontrast CT scan 5 days later shows dense clot sign (arrow) in torcular herophili. (c) Venogram through 3-F microcatheter shows acute thrombus filling and distending left transverse sinus (arrows). Six milligrams of tPA was injected into thrombus over a period of 1 hour. (d) Repeat venogram 1 day later shows improved flow and reduction in thrombus. Residual thrombus (arrows) was treated with a second dose (3 mg) of tPA. (e-h) Gadolinium-enhanced MR blood pool images before thrombolytic therapy (e, f) show absence of flow in straight and left transverse sinuses. (g, h) Images at 3-month follow-up show flow restored in left transverse and sigmoid sinus (arrows, g) and straight sinus (arrows, h).
nihms424780f1.jpg
PMC3636547_04_nihms424780f1.jpg
F1
Ultrasonography (US) and venography revealed thrombosis of the IVC, right iliac vein, and entire deep venous system of the left leg from the common iliac veins to the calf veins (Fig E1, available online at www.jvir.org).
Images from case 2. A 57-year-old man presented with right-leg DVT and a CSF leak that required epidural blood patch. (a-c) Development and resolution of CSF hypotension/hypovolemia is documented on axial CT images through the midthalamus obtained several months before diagnosis (a), at time of diagnosis (b), and 1 week after blood patch (c). Signs of CSF hypovolemia include subdural effusions, possibly with hemorrhage (arrows, b), decreased size of lateral ventricles (asterisk, b), and sulcal effacement (normal sulci indicated by arrows, a and c). (d-f) DVT thrombolysis and regional anticoagulation were performed. Right-leg DVT involved calf veins and the popliteal and femoral vein, stopping at the junction with deep femoral vein (arrow, d). (e, f) After thrombolytic therapy, regional anticoagulation was continued for 1 week via infusion of unfractionated heparin into a retrograde 3-F catheter (arrows, e) with its tip in the distal peroneal vein (arrow, f) at a rate of 700 U/h. Anti-factor Xa levels determined by a catheter inserted via jugular vein access show a therapeutic level (0.4 IU/mL) in the proximal superficial femoral vein (e), whereas systemic levels drawn from the right atrium were subtherapeutic (0.1 IU/mL). Note the chronic phlebitic changes revealed in peroneal veins (absence of valves and presence of narrow and irregular luminal changes) after thrombolysis.
nihms424780f2.jpg
PMC3636547_06_nihms424780f2.jpg
F2
Two days after cryoablation of a renal cell cancer of the right kidney (Fig E2a, available online at www.jvir.org), an 82-year-old woman developed multiple pulmonary emboli. Within 24 hours of anticoagulation, the patient developed flank pain accompanied by a decrease in hemoglobin level from 9.6 to 6.6 g/dL as a result of a retroperitoneal and perinephric hemorrhage (Fig E2b, available online at www. jvir.org), prompting discontinuation of anticoagulation and placement of a removable IVC filter.
PMC3636547_03
PMC3636547_04
Images from case 1. A 34-year-old woman with Von Hippel-Lindau syndrome developed dural sinus thrombosis 5 days after resection of right cerebellar hemangioblastoma. (a) MR scan shows right cerebellar hemangioblastoma (arrow) with adjacent edema that was successfully resected. (b) Noncontrast CT scan 5 days later shows dense clot sign (arrow) in torcular herophili. (c) Venogram through 3-F microcatheter shows acute thrombus filling and distending left transverse sinus (arrows). Six milligrams of tPA was injected into thrombus over a period of 1 hour. (d) Repeat venogram 1 day later shows improved flow and reduction in thrombus. Residual thrombus (arrows) was treated with a second dose (3 mg) of tPA. (e-h) Gadolinium-enhanced MR blood pool images before thrombolytic therapy (e, f) show absence of flow in straight and left transverse sinuses. (g, h) Images at 3-month follow-up show flow restored in left transverse and sigmoid sinus (arrows, g) and straight sinus (arrows, h).
nihms424780f1.jpg
PMC3636547_04_nihms424780f1.jpg
F1
Ultrasonography (US) and venography revealed thrombosis of the IVC, right iliac vein, and entire deep venous system of the left leg from the common iliac veins to the calf veins (Fig E1, available online at www.jvir.org).
PMC3636547_05
PMC3636547_06
Images from case 2. A 57-year-old man presented with right-leg DVT and a CSF leak that required epidural blood patch. (a-c) Development and resolution of CSF hypotension/hypovolemia is documented on axial CT images through the midthalamus obtained several months before diagnosis (a), at time of diagnosis (b), and 1 week after blood patch (c). Signs of CSF hypovolemia include subdural effusions, possibly with hemorrhage (arrows, b), decreased size of lateral ventricles (asterisk, b), and sulcal effacement (normal sulci indicated by arrows, a and c). (d-f) DVT thrombolysis and regional anticoagulation were performed. Right-leg DVT involved calf veins and the popliteal and femoral vein, stopping at the junction with deep femoral vein (arrow, d). (e, f) After thrombolytic therapy, regional anticoagulation was continued for 1 week via infusion of unfractionated heparin into a retrograde 3-F catheter (arrows, e) with its tip in the distal peroneal vein (arrow, f) at a rate of 700 U/h. Anti-factor Xa levels determined by a catheter inserted via jugular vein access show a therapeutic level (0.4 IU/mL) in the proximal superficial femoral vein (e), whereas systemic levels drawn from the right atrium were subtherapeutic (0.1 IU/mL). Note the chronic phlebitic changes revealed in peroneal veins (absence of valves and presence of narrow and irregular luminal changes) after thrombolysis.
nihms424780f2.jpg
PMC3636547_06_nihms424780f2.jpg
F2
Two days after cryoablation of a renal cell cancer of the right kidney (Fig E2a, available online at www.jvir.org), an 82-year-old woman developed multiple pulmonary emboli. Within 24 hours of anticoagulation, the patient developed flank pain accompanied by a decrease in hemoglobin level from 9.6 to 6.6 g/dL as a result of a retroperitoneal and perinephric hemorrhage (Fig E2b, available online at www. jvir.org), prompting discontinuation of anticoagulation and placement of a removable IVC filter.
PMC3636547_07