DOI: 10.12890/2026_006128
Superior sagittal sinus filling defect in metastatic lung cancer: tumour thrombus, bland thrombus or both?
Authors
harristahirchh@gmail.com
Keywords
Cerebral venous sinus thrombosis, superior sagittal sinus, tumour thrombus, arachnoid granulations, stroke mimics, neuroimaging, anticoagulationAbstract
Background: Cerebral venous sinus thrombosis is an uncommon but potentially life-threatening cause of stroke. In patients with active malignancy, dural venous sinus filling defects present a diagnostic challenge, as they may represent bland thrombosis, tumour thrombus or benign anatomic variants such as arachnoid granulations. Although anticoagulation is recommended for confirmed cerebral venous sinus thrombosis, guidance is limited when imaging findings are equivocal, or tumour involvement is suspected. Diagnostic misclassification may result in unnecessary anticoagulation or failure to treat thrombosis.
Case description: A 66-year-old woman with a history of subtotal colectomy complicated by chronic malabsorption and newly diagnosed metastatic lung cancer underwent brain magnetic resonance imaging for staging. Imaging revealed multiple intracranial metastases and a heterogeneous filling defect within the posterior superior sagittal sinus, with mild sinus expansion and internal flow voids, raising concern for cerebral venous sinus thrombosis or tumour thrombus. Anticoagulation was initiated despite the patient remaining neurologically intact. Subsequent computed tomography angiography and venography demonstrated preserved venous flow and findings consistent with arachnoid granulations rather than thrombosis or tumour invasion, allowing anticoagulation to be discontinued. The patient’s altered gastrointestinal anatomy was clinically relevant, as it would have limited the reliability of direct oral anticoagulant therapy.
Conclusions: This case demonstrates that magnetic resonance imaging alone may be insufficient to reliably differentiate cerebral venous sinus thrombosis, tumour thrombus and benign anatomic variants. In patients with active malignancy, confirmatory vascular imaging should be obtained before committing to prolonged anticoagulation. A structured, multimodal diagnostic approach can reduce misdirected therapy and unnecessary risk.
References
- Allroggen H, Abbott RJ. Cerebral venous sinus thrombosis. Postgrad Med J 2000;76:12–15. doi: 10.1136/pmj.76.891.12
- de Freitas GR, Bogousslavsky J. Risk factors of cerebral vein and sinus thrombosis. Front Neurol Neurosci 2008;23:23–54. doi: 10.1159/000111259
- Saposnik G, Bushnell C, Coutinho JM, Field TS, Furie KL, Galadanci N, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke 2024;55:e77–90. doi: 10.1161/STR.0000000000000456
- Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, et al. European Stroke Organization. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis – endorsed by the European Academy of Neurology. Eur J Neurol 2017;24:1203–1213. doi: 10.1111/ene.13381
- Karaosmanoglu AD, Onur MR, Uysal A, Akata D, Ozmen MN, Karcaaltincaba M. Tumor in the veins: an abdominal perspective with an emphasis on CT and MR imaging. Insights Imaging 2020;11:52. doi: 10.1186/s13244-020-00854-x
- Quencer KB, Friedman T, Sheth R, Oklu R. Tumor thrombus: incidence, imaging, prognosis and treatment. Cardiovasc Diagn Ther 2017;7:S165–S177. doi: 10.21037/cdt.2017.09.16
- Hübsch P, Schurawitzki H, Susani M, Theyer G, Traindl O, Pölzleitner D, et al. Color Doppler imaging of inferior vena cava: identification of tumor thrombus. J Ultrasound Med 1992;11:639–645. doi: 10.7863/jum.1992.11.12.639
- Idiculla PS, Gurala D, Palanisamy M, Vijayakumar R, Dhandapani S, Nagarajan E. Cerebral venous thrombosis: a comprehensive review. Eur Neurol 2020;83:369–379. doi: 10.1159/000509802
- Ferri N. Pharmacokinetics and pharmacodynamics of DOAC. In: Proietti R, Alturki A, Ferri N, Russo V, Jared Bunch T, editors. Indirect oral anticoagulants: from pharmacology to clinical practice. Cham: Springer International Publishing; 2021, p. 27–40.
- Byon W, Nepal S, Schuster AE, Shenker A, Frost CE. Regional gastrointestinal absorption of apixaban in healthy subjects. J Clin Pharmacol 2018;58:965–971. doi: 10.1002/jcph.1097
- Martin KA, Lee CR, Farrell TM, Moll S. Oral anticoagulant use after bariatric surgery: a literature review and clinical guidance. Am J Med 2017;130:517–524. doi: 10.1016/j.amjmed.2016.12.033
