Clinical Case Report Medicine ®

Cerebral venous thrombosis presented with

symmetrical crescent-shaped intracranial
hemorrhage in alcoholic liver disease
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Case reports
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Lingjia Xu, MMa, Guoping Fu, MMa,*

Abstract
Rationale: Cerebral venous thrombosis (CVT) is a relatively uncommon but fatal disease. It can be caused by a variety of
hereditary or acquired thrombotic diseases. Initial presentation with intracranial hemorrhage (ICH) in CVT is rare but can further
complicate the therapeutic measures and prognosis. Cases of CVT presented with ICH in patients with alcoholic liver disease
(ALD) have not been described in the literature, and it might be related with hemostatic abnormalities in ALD patients.
Patient concerns: We report 2 cases of men admitted to our hospital who were diagnosed with CVT but initially presented
with symmetrical crescent-shaped ICH; both of them were ALD patients.
Diagnoses: Cerebral imaging revealed extended CVT in both cases. The first case was a 64-year-old man with ALD deteriorated
with unconsciousness and convulsions; computed tomography showed symmetrical crescent-shaped ICH in the right temporal
lobe, and magnetic resonance venography revealed CVT. Another 50-year-old man with ALD complained about dizziness and
weakness of his right limbs; computed tomography revealed symmetrical crescent-shaped ICH in bilateral parietal and occipital
lobes, and magnetic resonance venography revealed CVT.
Interventions: The first patient was referred to the endovascular thrombectomy. Both of them were treated with anticoagulation
treatment.
Outcomes: Favorable outcomes were observed in both patients.
Lessons: Symmetrical or multiple crescent-shaped ICH requires a high suspicion in the diagnosis of CVT; even with hemorrhage,
it is still important to initiate anticoagulation therapy promptly. The crescent-shaped ICH might be a new sign for CVT, and further
studies are needed in the underlying mechanisms of ALD and potential thrombophilia.
Abbreviations: ALD = alcoholic liver disease, CT = computed tomography, CVT = cerebral venous thrombosis, ICH = intracranial
hemorrhage, MRV = magnetic resonance venography, SSS = superior sagittal sinus.
Keywords: alcoholic liver disease, case reports, cerebral venous thrombosis, intracranial hemorrhage, magnetic resonance
venography

1. Introduction Initial presentation with intracerebral hemorrhage (ICH) in

Cerebral venous thrombosis (CVT) is a rare but serious cerebro-
vascular disease with high lethiferous and disable ratio.[1] It is
more common in young people, especially females. The etiology
of CVT is complex; it can be caused by a variety of medical
conditions and the majors are genetic or acquired coagulation
dysfunction diseases, such as infection, tumor, brain trauma,
pregnancy, oral contraceptives, thrombophilia, and so on.[2]
CVT patients is rare but can further complicate the treatment
and prognosis.[3]
Alcoholic liver disease (ALD) is one of the most prevalent
chronic liver diseases and the leading cause of cirrhosis after
viral hepatitis or nonalcoholic fatty liver disease; ALD is typ-
ically diagnosed by a patient’s medical history, physical exam-
ination, imaging, laboratory tests, and liver biopsy is the gold
standard for diagnosing ALD.[4] Patients suffering from liver

The study was supported by grants from the Health Commission of Zhejiang * Correspondence: Guoping Fu, Department of Neurology, Shaoxing Second
Province (2024KY492). Hospital, The Second Affiliated Hospital of Shaoxing University Medical College,
The authors have no conflicts of interest to disclose. Shaoxing 312000, Zhejiang, China (e-mail: sxeysjnk@163.com).

All data generated or analyzed during this study are included in this published
article [and its supplementary information files].
Written informed consents were obtained from the patients for the publication of
any potentially identifiable images or data included in this article.
Supplemental Digital Content is available for this article.
a
Department of Neurology, Shaoxing Second Hospital, The Second
Affiliated Hospital of Shaoxing University Medical College, Shaoxing,
Zhejiang, China.
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
How to cite this article: Xu L, Fu G. Cerebral venous thrombosis presented with
symmetrical crescent-shaped intracranial hemorrhage in alcoholic liver disease:
Case reports. Medicine 2024;103:10(e37441).
Received: 29 November 2023 / Accepted: 9 February 2024
http://dx.doi.org/10.1097/MD.0000000000037441

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 Xu and Fu • Medicine (2024) 103:10Medicine

illness experience decreased absorption of vitamin K, which
leads to the synthesis and depletion of various coagulation com-
ponents, ultimately causing an imbalance between coagulation
and anticoagulation function.[5]
Here we report 2 patients with CVT presented with sym-
metrical crescent-shaped ICH, and both have the underlying
diseases of ALD, whether the thrombophilia mediated by ALD
leads to CVT, is the focus of discussion and future research
direction. Timely computed tomography (CT) or magnetic reso-
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102 mm Hg, respectively. The real-time head CT found no obvi-
ous abnormalities. On laboratory examination, the D-dimer
concentration increased (619 ng/mL, normal < 500 ng/mL),
and the result of liver function test reported elevated alanine
aminotransferase (120 U/L, normal < 40 U/L), aspartate ami-
notransferase (66 U/L, normal < 35 U/L), and r-glutamyl trans-
ferase (144 U/L, normal < 45 U/L). Other blood tests including
blood routine test, thyroid and kidney function, rheumatism
index, and tumor-related markers were all within the normal

nance venogram (MRV) examination has a pivotal position for range. Urapidil hydrochloride injection and pantoprazole were
better diagnosis and clinical treatment to improve the prognosis applied emergently. Ten hours after admission, the patient sud-
of patients. denly lost consciousness with limb convulsions for about 5
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minutes. He became delirious, failed to respond when calling

2. Case reports
2.1. Case 1
A 64-year-old man who had a history of ALD (used to drink
White wine 200 mL per day for about 40 years, equivalent to
166.4 g of pure alcohol per day), cirrhosis, and hypertension but
had not received regular treatment, no family history of genetic
diseases or traumatic history, went to our hospital’s emergency
department for treatment after experiencing dizziness, nausea,
vomiting, tinnitus, and drowsiness for 5 days without a fever
or convulsions. The physical examination found the patient
was conscious, well-oriented, had normal pulse with regular
rhythm, and normal muscle strength, but the patient’s sys-
tolic and diastolic blood pressure measurements were 225 and
and to cooperate in examination of muscle strength, and bilat-
eral Babinski sign was negative. Urgent reexamination of the
head CT showed symmetrical crescent-shaped ICH in the right
temporal lobe (Fig. 1A). Since the hematoma shape was not in
line with the general arterial hemorrhage, magnetic resonance
imaging and MRV were performed and then revealed throm-
bosis of the superior sagittal sinus (SSS), right transverse sinus,
and sigmoid sinus with corresponding hemorrhagic cerebral
infarction (Fig. 1B–E). Emergent interventional thrombectomy
was administrated. The patient was transferred to the inten-
sive care unit after the surgery with continuous anticoagulation
therapy and 1 week later, he was transferred to a rehabilitation
institution with a modified Rankin Scale score of 3. He recov-
ered well after the surgery with no significant sequela moni-
tored in 2-month follow-up, his CT scan revealed hemorrhage

Figure 1. Case 1. (A and B) Non-contrast brain computed tomography (CT) scan and T1 hyperintensity of magnetic resonance imaging (MRI) suggest sym-
metrical crescent-shaped intracranial hemorrhage in the right temporal and occipital lobes (White box). (C) Fluid-attenuated inversion recovery (FLAIR) imaging
shows juxtacortical edema surrounding the hemorrhage. (D) Diffusion weighted imaging (DWI) shows massive cerebral infarction throughout the right temporal
and occipital lobes. (E) Magnetic resonance venography (MRV) imaging shows cerebral venous sinus thrombosis of the superior sagittal sinus, right transverse
sinus, and sigmoid sinus (arrows). (F) CT examination obtained at 2-month follow-up.

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absorption and an ancient infarction in the right temporal lobe
(Fig. 1F and Figure S1, Supplemental Digital Content, http://
links.lww.com/MD/L845 which indicates the timeline).
2.2. Case 2
A 50-year-old man who was also an alcoholic (yellow rice
wine ingestion for over 30 years, with a daily consumption of
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CVT impedes venous blood drainage, leading to increased venous
pressure and subsequent brain tissue edema[7]; simultaneously,
metabolites build up and interfere with neurovascular oxygen-
ation, destroying the walls of capillaries and veins; this compro-
mises the blood-brain barrier, causing blood to leak through and
causing hemorrhagic transformation of cerebral venous infarc-
tion[8]; on the other hand, due to the absence of valve in cortical
veins and smooth muscle in tunica media, the increased venous
pressure during CVT leads to gradual dilation and even rupture

1000 ml, equivalent to 128 g of pure alcohol per day) and diag-
of these veins, making blood extravasation to the brain paren-
nosed ALD presented to our emergency room with a sudden
chyma and eventually hemorrhage in multiple brain lobes.[9]
onset of dizziness accompanied by blurred vision, gradually pro-
After viral hepatitis and nonalcoholic fatty liver disease, ALD
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gressive right limbs fatigue after getting up in the morning. He

is a kind of chronic liver disease and the primary cause of cirrho-
had no other diseases and drug use history, no family history, no
sis.[10] A further potential cause of thromboembolism is liver dys-
genetic diseases, or traumatic history. During admission phys-
function; studies have reported that various types of liver diseases
ical examination reported the patient was conscious, and had
are associated with an increased risk of developing thrombosis[11];
normal body temperature, respiratory rate, blood pressure, but
nevertheless, the mechanisms underlying how liver dysfunction
right limbs hemiplegia (grade 1 of muscle strength), and positive
leads to hypercoagulable states and how they translate into
right Babinski sign. His electrocardiography showed a pulse of
thrombotic events remain to be fully understood. In the issue of
47 beats per minute indicating sinus bradycardia. The result of
ALD, in addition to potentiating the growth of Gram-negative
testing for the coagulation profile solely revealed a high con-
bacteria in the intestine and increasing intestinal permeability,
centration of D-dimer (1846 ng/mL). Residual blood test exclu-
alcohol consumption can damage liver cells by encouraging the
sively showed abnormal liver function with elevated alanine
accumulation of acetaldehyde and other reactive oxygen species
aminotransferase, aspartate aminotransferase, and r-glutamyl
in the liver, which may cause oxidative stress, metabolism disor-
transferase (156, 78, and 256 U/L). Others including blood
ders, and liver cell death. This ultimately raises the level of endo-
routine test, thyroid and kidney function, rheumatism index,
toxin in peripheral blood and causes inflammation, necrosis, and
and tumor-related markers reported no obvious abnormalities.
fibrosis in the liver.[10,12] Proteases involved in the fibrinolytic sys-
His abdominal CT showed cirrhosis with liver lobar imbalance
tem, anticoagulation factors, and coagulation factors are all syn-
and widened portal vein (Fig. 2). Brain CT showed bilateral
thesized in large quantities in the liver. Due to variable degrees of
parietal and occipital lobes hemorrhage in consistent with the
injury or disruption, liver cells’ capacity to produce coagulation
symmetrical crescent-shape (Fig. 3A and B). The brain magnetic
and anticoagulation factors declines in ALD, leading to abnor-
resonance imaging found corresponding multifocal cerebral
malities of coagulation and anticoagulation mechanisms. In this
infarction with hemorrhagic transformation, MRV found SSS
context, patients with severe ALD may have both a higher risk of
thrombosis (Fig. 3C–E). Anticoagulant therapy with daltepa-
developing hemorrhage and thrombosis.[13]
rin sodium, dehydration cranial pressure therapies with glyc-
CVT with concomitant ALD has not been reported yet; in the
erol fructose and mannitol were applied, together with gastric
present report, both patients had ALD and a high D-dimer con-
mucosal protective agent, intravenous fluids, and rehabilitation
centration without other coagulation indicators of abnormali-
at bedside. The patient’s condition improved after anticoagula-
ties were detected. Whether the CVT represents a major threat
tion treatment in 1-month follow-up, and the CT showed hem-
of hemostatic abnormalities among ALD patients requires fur-
orrhage absorption (Fig. 3F and Figure S2, Supplemental Digital
ther exploration with more cases. Common cerebral hemato-
Content, http://links.lww.com/MD/L846 which indicates the
mas are often single, round, and oval-shaped, in line with the
timeline).
distribution of cerebral arterial blood vessels, while ICH with
diverse forms like the shape of cashew nuts, carob is often
detected in CVT with hemorrhagic transformation.[7,14] In our
3. Discussion
cases, the crescent-shaped juxtacortical hemorrhages may be
CVT is a relatively uncommon but fatal disease. Therefore, early related to the orientation of the subcortical vein along the arcu-
diagnosis and prompt management are critical, and knowledge ate fiber. The superficial and deep systems of the brain’s venous
of its radiological features and potential pathology are essential drainage merge into the subcortical veins and SSS in the cor-
to help it. ICH occurs in 30% to 40% of patients with CVT; tex,[15] and when the SSS is blocked by thrombus, the pressure
CVT initially presented with ICH predicts a poorer prognosis and of the subcortical veins increases and it is easy to rupture and
might be the leading cause of death in CVT patients,[6] however, it lead to juxtacortical hemorrhages. Clinically, the symmetrical
remains elusive about the specific pathophysiology. On one hand, crescent-shaped ICH in the aforementioned images, whether

Figure 2. Abdominal CT revealed cirrhosis, liver lobar imbalance, and widened portal vein in Case 2. CT = computed tomography.

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Figure 3. Case 2. (A and B) The brain CT scan shows symmetrical crescent-shaped intracranial hemorrhage in bilateral parietal and occipital lobes (White
boxes). (C and D) DWI and FLAIR show corresponding multifocal cerebral infarction with hemorrhagic transformation. (E) MRV suggests superior sagittal sinus
thrombosis (arrow). (F) CT examination obtained at 1-month follow-up. CT = computed tomography, DWI = diffusion weighted imaging, FLAIR = fluid-attenuated
inversion recovery, MRV = magnetic resonance venography.
or not it is in the same hemisphere, requires a high degree of
suspicion when diagnosing CVT, and it is highly recommended
to perform MRV examination to confirm the diagnosis earlier
and improve the prognosis. Moreover, additional research is
required to address the possibility of thrombophilia and ALD.
4. Conclusions
The symmetrical or multifocal crescent-shaped ICH in the
aforementioned images raises serious doubts about the diag-
nosis of CVT, and it is highly recommended to perform MRV
examination to confirm the diagnosis earlier and improve the
prognosis. Prompt anticoagulation is crucial and advantageous
for patients.
Author contributions
Conceptualization: Lingjia Xu.
Data curation: Lingjia Xu.
Investigation: Lingjia Xu, Guoping Fu.
Supervision: Guoping Fu.
Validation: Guoping Fu.
Writing – original draft: Lingjia Xu.
Writing – review & editing: Lingjia Xu, Guoping Fu.
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