Hyperacute Venous Stroke: CTV-MRV Head
Hyperacute Venous Stroke: CTV-MRV Head
Search Pattern Assist ?History
Exam
CTV of the Head
Our CTV protocol includes a dynamic head CT performed after the 1st bolus of contrast only (there is no second bolus as in CTA). However, the CTV timing is timed according to detection of contrast in a major dural venous sinus (usually the vein of Galen/straight sinus or torcula). Usually, the brain arteries are concurrently visualized, which is helpful in excluding an arterial stroke located in a venous egress territory (especially the retrosylvian area). Post processing subtraction is used to avoid the effect of hyperdense thrombus simulating patency on CTV. CT perfusion can be generated from the CTV data set.
MRV of the Head
MRV can be performed in a number of ways. These include post contrast MP RAGE, Phase-contrast, and Time of Flight (usually 2D) MRV. All are reasonably helpful for dural sinus thrombosis, but frequently under-evaluate cortical vein thrombosis. The saturation band is placed in the neck for MRV, as opposed to the cranial vertex as it is in MRA of the head.
Purpose
2. Assess for evidence of cortical vein thrombosis. In many cases of cortical vein thrombosis the diagnosis is made by absence of veins compared to the opposite side. Additionaly, cortical vein & dural sinus occlusion can be inferred by the appearance of the collateral veins and reversed filling pattern. This inability to easily perceive cortical vein thrombotic occlusion as an absence of a vein(s) accounts for its under-reporting.
4. Assess for exaggerated cortical vein prominence that is usually the result of a dural AV fistula in conjunction with dural sinus occlusion. It is often difficult to determine whether the AV fistula is the result of the dural sinus thrombosis collateralization, or whether the AV fistula occurs first, but elevated venous filling pressure causes stasis of flow and secondary dural sinus thrombosis.
Prior Study
CT Perfusion
CTV/MRV Neck
Findings
Major Dural Sinus Thromboses
There is thrombotic occlusion of the superior sagittal sinus/torcular herophile/straight sinus with secondary thickening of the dural sinus wall. [Yes/No]
There is thrombotic occlusion of a transverse sinuses with secondary thickening of the dural sinus wall. [Yes/No]
There is thrombotic occlusion of a sigmoid sinus with secondary thickening of the dural sinus wall. [Yes/No]
There is thrombotic occlusion of an internal jugular veins.
[Yes/No]
There is thrombotic occlusion of the cavernous sinus possibly with dilatation of the afferent input (orbital veins, sphenoparietal sinus) or efferent output (pharyngeal venous plexus, inferior petrosal sinus, dorsal clival vein complex). [Yes/No]
Major Cortical Vein Thromboses
There is thrombotic occlusion of an anterior frontal (frontopolar) vein. [Yes/No]
There is thrombotic occlusion of a vein of Trolard. [Yes/No]
There is thrombotic occlusion of a vein of Labbe’. [Yes/No]
There is thrombotic occlusion of the superior sylvian vein complex. [Yes/No]
There is thrombotic occlusion of a petrosal vein. [Yes/No]
There is thrombotic occlusion of either the superior or inferior vermic vein(s). [Yes/No]
Major Central Vein Thromboses
There is thrombotic occlusion of a thalamostriate/septal vein(s). [Yes/No]
There is thrombotic occlusion of one or more of the internal cerebral veins (ICV) or vein of Galen. [Yes/No]
There is thrombotic occlusion of the vein of Galen/straight sinus apex/straight sinus. [Yes/No]
There is thrombotic occlusion of a basal vein of Rosenthal (BVR). [Yes/No]
There is thrombotic occlusion of deep central subependymal veins. [Yes/No]
Minor Cerebral Venous Thromboses
There is thrombotic occlusion of the lesser middle or posterior frontal vein(s). [Yes/No]
There is thrombotic occlusion of the lesser posterior parietal or occipital vein(s). [Yes/No]
There is thrombotic occlusion any of the cerebellar cortical vein(s) or the lateral cerebellar venous confluence adjacent to the transverse sinus. [Yes/No]
Evidence of Collateral Venous Drainage
There is evidence of re-routed collateral pial veins; serpiginous, peripherally enlarged cortical veins, which also drain in a reversed pattern into other pial vein collateral pathways (i.e. local veins, or supratentorial to infratentorial connections through the superior vermian vein complex or the lateral anastomotic/petrosal vein connection). [Yes/No]
There is evidence of pial venous re-routing into the vertex venous lacunae (vertex pial/dural anastomoses). [Yes/No]
There is evidence of pial venous re-routing into the mesial &/or lateral tentorial venous confluences (ventral pial/dural anastomoses). [Yes/No]
There is evidence of pial venous re-routing into sphenoparietal sinus to the cavernous sinus (central skull base pial/dural anastomosis) ending up in the retropharyngeal venous plexus. [Yes/No]
Other
Other findings are present more consistent with a different cause for symptoms than venous stroke. [Yes/No]
Impression
Hyperacute Stroke - Venous, Diagnostic: CTV-MRV Head
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Continue with venous thrombosis protocol CTV or MR with MRV as needed.
