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2014-05-05-09 Answer to the case of the week #371 © Bronshtein 

Answer to the case of the week #371

June 12, 2014 - June 26, 2014

Moshe Bronshtein, MD.

Haifa, Rambam, Israel.


Case report

Following images and videos show a case of torcular Herophili thrombosis first time observed at 24 weeks of a low risk pregnancy with non-contributive history. Previous ultrasonographic examination in 15 weeks was normal.

Magnetic resonance imaging (MRI) at 31 weeks had confirmed the finding.

Later ultrasonographic scans showed decreasing size of the thrombosis. Postnatal adaptation of the newborn was normal and the lesion kept decreasing of its size. Now, six months after delivery the child is doing well, no signs of torcular Herophili thrombosis are present and neurological status of the child is normal.

By our opinion, the finding may be a result of dural sinus malformation with arteriovenous fistula (dural arteriovenous fistula). The presence of the fistula leads to overload and consequent dilatation of the dural sinus. Once the sinus is dilated, the flow of the blood entering the dilated space is actually slowed down which predisposes to the formation of the thrombus.
Images 1, 2, 3, 4, 5, 6: 24 weeks; transverse, coronal and sagittal scans of the fetus showing dilated torcular Herophili (depicted in red on the images 2, 4, and 6) due to the torcular Herophili thrombosis.




Videos 1, 2, 3, 4: 24 weeks; the videos 1, 2, and 3 show pulsatile flow next to the torcular Herophili thrombosis probably compatible with an arteriovenous shunt. The video 4 shows dilated jugular vessels of the fetus.



Video 5: 32 weeks; the video shows transverse scan of the torcular Herophili thrombosis - its size had decreased in size and so did the surrounding vessels.


Images 7, 8, 9, 10: MRI 31 weeks; transverse and sagittal scans of the fetal head showing the ectatic thrombotic torcular Herophili (asterisk). 



Image 11: Schematic showing the position of the thrombus within the torcular Herophili (asterisk).

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