Hyperacute Venous Stroke: CT Head

History

Recent neurologic changes, often not focal.

Exam

Non-contrast screening head CT

Purpose

1. Identify all areas of chronic post ischemic (or post traumatic/postoperative) damage, including encephalomalacia, subcortical leukomalacia, ischemic demyelination, shrunken gyri/ulegyria, since they will exhibit reduced flow on the CTV & CT perfusion;

2. Assess for acute edema in one or more recognizable venous egress zones, especially those affecting the major veins in both the supratentorial and infratentorial regions;

3. Assess for hyperdense venous thrombosis in the high cervical internal jugular veins or intracranial dural sinuses;

4. Assess for hyperdense venous thrombosis in any of the cortical veins;

5. Assess for hyperdense perivenous (SAH, subpial or parenchymal) hemorrhage in any of the cortical vein egress zones;

6. Search for aggressive sinusitis/otomastoiditis/parapharyngeal infection as a cause for cavernous sinus, or sphenoparietal sinus thrombosis, or cortical vein thrombosis;

7. Assess for early hydrocephalus, which can accompany widespread dural sinus thrombosis.

Prior Study

N/A

Findings

Observation: Evidence of a Dural Sinus Thrombosis or Co-Morbid Cause for Thrombosis

There is evidence of acute thrombosis of any dural sinus or the torcular herophile. [Yes/No]

There is evidence of acute thrombosis of the jugular fossa segment of the sigmoid sinus (possible “jugular fossa syndrome”). [Yes/No]

There is evidence of acute thrombosis of either high cervical internal jugular veins. [Yes/No]

There is evidence of a straight sinus thrombosis. [Yes/No]

There is evidence of aggressive otomastoid sinus disease, which could lead to internal jugular vein or sigmoid or transverse sinus thrombosis. [Yes/No]

There is evidence of cavernous sinus thrombosis. [Yes/No]

There is evidence of aggressive sphenoid sinus or retropharyngeal infectious disease, which could lead to cavernous sinus thrombosis. [Yes/No]

There is evidence of dilatation of the orbital veins (optic hydrops). [Yes/No]

Observation: Evidence of a Recognizable Cortical Vein Thrombosis or Co-Morbid Cause for Thrombosis

There is evidence of supratentorial cortical vein thrombosis or cytogenic edema corresponding to a recognizable cortical vein (i.e. a cerebral venous vector). [Yes/No]

There is evidence of infratentorial cortical vein thrombosis or cytogenic edema corresponding to a recognizable cortical vein (i.e. a posterior fossa venous vector). [Yes/No]

There is evidence of frontal or frontoethmoid sinusitis, which can cause frontal vein thrombophlebitis. [Yes/No]

There is evidence of deep central vein (ICV, septal vein, thalamostriate) or vein of Galen possibly including the straight sinus thrombosis. [Yes/No]

There is evidence of basal vein of Rosenthal thrombosis. [Yes/No]

There is evidence of invasive or allergic (AFS) nasopharyngeal fungal disease, which could lead to cavernous sinus thrombosis. [Yes/No]

There is evidence of post surgical vein sacrifice. [Yes/No]

There is evidence of focal mass effect (i.e. meningioma, depressed skull fracture, transcranial herniation) compressing either a dural sinus, or cortical vein(s), or both. [Yes/No]

Observation: Evidence of Secondary Effects of Venous Hypertension

There is evidence of recent intracranial parenchymal (intra axial) hemorrhage in a venous egress zone. [Yes/No]

There is evidence of recent intracranial subarachnoid/cisternal hemorrhage. [Yes/No]

There is evidence of subpial prepontine venous hemorrhage. [Yes/No]

There is evidence of early hydrocephalus. [Yes/No]

There is evidence of pseudotumor cerebri. [Yes/No]

Other

Other findings are present consistent with a disorder other than CVT. [Yes/No]

Impression

Hyperacute Stroke - Venous, Diagnostic: CT Head

Contact the emergency medical service to suggest the patient be admitted to the stroke service for CVT.
No recommendation is necessary.