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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2021; 79(10): 938-939
DOI: 10.1590/0004-282X-ANP-2021-0115
Articles

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
Cesar Castello Branco LOPES 
1   Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
,
Vinicius Trindade Gomes da SILVA 
2   Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurocirurgia, São Paulo SP, Brazil.
,
José Erasmo Dal Col LUCIO 
2   Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurocirurgia, São Paulo SP, Brazil.
,
Renata Harumi Gobbato YAMASHITA 
2   Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurocirurgia, São Paulo SP, Brazil.
,
Luiz Roberto COMERLATTI 
1   Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
,
Leandro Tavares LUCATO 
3   Universidade de São Paulo, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brazil.
,
Fernando FREUA 
1   Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
4   Beneficiência Portuguesa de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
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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]).

Zoom Image
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).
Zoom Image
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.


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Conflict of interest:

There is no conflict of interest to declare.

Authors’ contributions:

CCBL, LRC, FF: contributed to patient neurological evaluation and data acquisition; VTGS, JEDCL, RHGY: contributed to patient neurosurgical evaluation and data acquisition; LTL: contributed to interpretation and discussion of neuroimaging findings. All authors contributed to the study conception and design, and all authors contributed in writing the main manuscript, which was critically reviewed by all.


  • 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
  • 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.20210115202101150401

Address for correspondence

Cesar Castello Branco Lopes

Publication History

Received: 30 March 2021

Accepted: 06 May 2021

Article published online:
07 June 2023

© 2021. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • 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
  • 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.20210115202101150401

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