Rare isolated basal vein of Rosenthal thrombosis causing thalamic haemorrhage during intensive-phase antituberculous therapy: a case report

Abstract

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that affects young adults. Involvement of the deep cerebral venous system, especially isolated thrombosis of the basal vein of Rosenthal, is exceptionally uncommon and carries a poor prognosis. Tuberculosis is a recognized, yet underappreciated prothrombotic condition predisposing to venous thromboembolism. A 23-year-old Sri Lankan male with extrapulmonary pleural tuberculosis, receiving intensive-phase antituberculous therapy (isoniazid, rifampicin, pyrazinamide, ethambutol-HRZE) for 14 days, presented with acute right upper and lower limb numbness. He had no hypertension or coagulopathy. Noncontrast computed tomography (NCCT) of the brain revealed a left-sided thalamic intracerebral haemorrhage. Computed tomography angiography excluded arterial pathology. However, subsequently CT venography confirmed isolated thrombosis of the left basal vein of Rosenthal. He received therapeutic anticoagulation with continued antituberculous therapy, with close neurological monitoring. He showed gradual clinical improvement without haemorrhagic progression. This case highlights a rare presentation of an isolated basal vein of Rosenthal thrombosis manifesting as thalamic intracerebral haemorrhage in the setting of active tuberculosis. In the absence of traditional risk factors such as hypertension or coagulopathy, this diagnosis may not be immediately considered in young patients. Tuberculosis-associated systemic inflammation and hypercoagulability likely contributed to thrombosis, while treatment-related inflammatory responses, including possible TB-IRIS, may have played an additional role. In addition, rifampicin containing regimens have been associated with an increased incidence of thromboembolic events in some studies. Clinicians must maintain high vigilance for cerebral venous thrombosis as a potential cause of haemorrhagic stroke in young patients presenting with atypical features, without traditional risk factors. Early recognition is essential, as timely anticoagulation remains the cornerstone of management despite the presence of intracranial bleeding. Isolated deep cerebral venous thrombosis should be considered in young adults with intracerebral haemorrhage, especially in the presence of prothrombotic conditions like tuberculosis. Prompt venography guides anticoagulation, improving outcomes.