Malignant cerebral venous thrombosis in a transgender patient: intraoperative aspect of vein of Trolard thrombosis

Trombose venosa cerebral maligna em um paciente transgênero: aspecto intraoperatório da trombose da veia de Trolard

A 53-year-old male-to-female transgender patient on cross-sex hormone replacement therapy (HRT) presented with a one-day history of sudden onset aphasia and hemiparesis, preceded by a one-week complaint of headache. CT scan showed a large frontoparietal hematoma and venous CT displayed extensive filling defects of the venous sinus drainage system (Figure 1). The patient was submitted to an urgent decompressive surgery. Intra-operatory aspect revealed thrombosis of the Trolard vein (Figure 2).

Figure 1.
Non-enhanced axial head CT (A and B) demonstrates intraparenchymal hemorrhages in the left cerebral hemisphere, especially in the parietal and occipital lobes. Note the hyperdensity in straight and sagittal sinuses (arrows in A); and in both Trolard veins (arrows in B), suggesting thrombosis of these structures. CT angiography (C), sagittal reformatted view, demonstrates absence of flow in straight and sagittal sinuses (arrows). Volume rendered image from head CT (D), inferior view, shows the hyperdense Trolard veins (arrows), suggesting bilateral thrombosis, and the hyperdense intraparenchymal hematomas in the left hemisphere. Volume rendered image from CT angiography (E), inferior view, demonstrates sagittal sinus thrombosis; notice the lack of flow in the corresponding location of both thrombosed Trolard veins (circles).

Figure 2.
Photographic record of intraoperative findings shows densification and opacification of the left cortical vein of Trolard, compatible with extensive thrombosis.

Venous thrombosis events are a known complication related to HRT, although it appears to be rare^1,2. Our case emphasizes an unconventional risk factor for cerebral venous thrombosis and provides an illustrative correlation between neuroimaging and intraoperative findings.

References

• ¹
  Ott J, Kaufmann U, Bentz EK, Huber JC, Tempfer CB. Incidence of thrombophilia and venous thrombosis in transsexuals under cross-sex hormone therapy. Fertil Steril. 2010 Mar;93(4):1267-72. https://doi.org/10.1016/j.fertnstert.2008.12.017
  » https://doi.org/https://doi.org/10.1016/j.fertnstert.2008.12.017
• ²
  Opaskar A, Scharf EL, Chilungu MW, Kelly AG. Transgender venous thrombosis. Neurol Clin Pract. 2017 Dec;7(6):531-3. https://doi.org/10.1212/CPJ.0000000000000401
  » https://doi.org/https://doi.org/10.1212/CPJ.0000000000000401

Publication Dates

• Publication in this collection
  20 Sept 2021
• Date of issue
  Oct 2021

History

• Received
  30 Mar 2021
• Reviewed
  29 Apr 2021
• Accepted
  06 May 2021