Mixed Bag for Thursday, June 4th, 2026

Contributed by SUNY Upstate Medical University
Rasika Baraskar, Katarina Hayes, Amin Khan, Saurabh Gupta, and Alka Gupta.

History

6-week-old full-term and immunized female with recently diagnosed milk protein allergy presenting with lethargy, recurrent emesis, poor oral intake, decreased urine output, bloody stools, and a new onset high pitched cry.

Images (Click any image to enlarge)

Lobular and expanded mass like area of hyper-echogenicity within the region of the left caudate nucleus. This area of hyper-echogenicity extends into the lateral ventricle and third ventricle.
Areas of increased DWI signal seen in the bilateral caudate nuclei, left thalamus, and left periventricular white matter adjacent to the left frontal and occipital horn.
Heterogenous signal and ectasia of the left transverse sinus with extension into the confluence of the sinuses seen on the T1 weighted images, along with asymmetrically decreased SWI signal.
Markedly decreased SWI signal within the bilateral ventricles and decreased signal within the bilateral subependymal & deep medullary veins (predominantly on the left).

Question

What is the most likely diagnosis?

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Correct answer

Deep medullary venous thrombosis with subsequent hemorrhage.

Discussion

Deep medullary venous thrombosis--an uncommon anatomical location for cerebral venous sinus thrombosis (CVST)--likely precipitated by dehydration. In this case, there is medullary venous thrombosis with subsequent hemorrhage of the left caudate region, bilateral thalami, left frontal and occipital horn of the left lateral ventricle with extension into third ventricles, as well as likely involvement of periventricular parenchyma. Thrombosed left transverse sinus, posterior superior sagittal sinus, inferior sagittal sinus, and posterior straight sinus with extension into the confluence of sinuses also noted.

Early neuroimaging and prompt anticoagulation are essential to improve outcomes and reduce long-term sequelae in infants with CVST. Patient will need a repeat MRI in 1-2 years to assess for improvement and estimate long term prognosis.

Differential diagnosis

Parechovirus: Neonatal infection with human parechovirus, particularly HPeV-3, is thought to occur through vertical or horizontal transmission and can cause sepsis-like illness, fever, irritability, poor feeding, seizures, and encephalopathy in young infants. CNS involvement may lead to white matter injury and long-term neurodevelopmental sequelae despite often minimal CSF pleocytosis.

Intraventricular hemorrhages (IVH): Neonatal IVH most commonly arises from rupture of fragile germinal matrix vessels in premature infants, often precipitated by fluctuations in cerebral blood flow and impaired autoregulation. Clinical presentation ranges from asymptomatic disease to apnea, hypotonia, seizures, bulging fontanelle, anemia, or acute neurologic deterioration in severe cases.

Parenchymal infarcts: Neonatal parenchymal infarcts are typically caused by arterial or venous thrombotic/ischemic injury related to hypoxia-ischemia, congenital heart disease, infection, trauma, or coagulation abnormalities. Affected neonates commonly present with focal seizures, lethargy, feeding difficulty, hypotonia, or subtle focal neurologic deficits.