MR T2 or FLAIR
Claim CME CreditPOINT OF CARE INFORMATION
This CME activity consists of the student reviewing the video of the professor reviewing the case as well as the associated DICOM image set related to the case in question.
Learning Objectives
As a result of participation in this activity, participants should be able to:
- Provide improved patient care.
- Greater knowledge of the imaging characteristics of the patient's disease.
- Understand a better approach to interpretation of studies.
Faculty Disclosure
Mehmet Albayram, MD, Ivan Davis, MD, Mariam Hanna, MD, Anthony Mancuso, MD, Ronald Quisling, MD, Dhanashree Rajderkar, MD, Priya Sharma, MD, Roberta Slater, MD and Joann Stamm, MBA have disclosed that they have no relevant financial relationships. No one else is a position to control content have any financial relationship to disclose.
CME Advisory Committee Disclosure:
Conflict of interest information for the CME Advisory Committee members can be found on the following website: https://cme.ufl.edu/disclosure/.
Continuing Medical Education Credit
Accreditation: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit: The University of Florida College of Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CA0601-MR T2 or FLAIR
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CA0601-MR T2 or FLAIR
Case ReportExam
Prior Study
CT head
Acute thrombus has progressed and is now evident in most of the superior sagittal sinus (SSS), the straight sinus, the torcular herophile, the right transverse sinus and the initial segment of the left transverse sinus.
The hydrocephalus seen on initial imaging has resolved.
CT perfusion NO CT perfusion imaging is available
CTV of the neck NO neck CTV imaging was available
MRV of the head
There are progressive dural CVT changes (compared to the initial MRV) with widespread dural sinus thromboses (SSS, torcula, and both transverse sinuses). The lateral aspect of the left transverse sinus wall is opacified but drains not through its' lumen to the sigmoid sinus, but rather into dural emissary channels. There is no apparent cortical vein thrombosis. The major veins are all patent; the vertex veins interconnect across the midline through the vertex venous lacunae. The pial/dural anastomoses combine with expanded dural wall venous plexes, and opened emissary venous channels to provide the dominant means of cerebral venous egress in this case, where there is thrombosis of both sigmoid sinuses.
Post contrast head CT No post contrast CT was available
Pre and post contrast T1-w MR
Multiple dural sinus thromboses remain, as above, without additional cortical vein thromboses. Reasonably functional collateral venous drainage is present utilizing expansion of the dural wall venous plexes, the left lateral tentorial venous confluence connected to the superior sylvian venous plexus egress route. The major venous egress routes for the deep central and subependymal veins appear through supra to infratentoral connections through the superior vermic vein and LAM collaterals ultimately draining into the petrosal veins.
There is minimal evidence of persistently raised CSF pressure. There are expected post operative changes in the right mastoid area.
MR diffusion
The MR diffusion is now negative with no positive signal in the left superior vermis to confirm a completed stroke in this area.
Findings
MR FLAIR
The previous FLAIR positive features of acute bacterial meningitis have resolved after therapy.
There is now positive intraluminal FLAIR signal within the previously patent right transverse sinus and most of the SSS. Other previously thrombosed dural sinuses remain FLAIR positive (left transverse sinus and torcula). There is no FLAIR positivity to indicate parenchymal vasogenic edema nor hemorrhage.
There is postitive FLAIR signal in the right otomastoid region (site of prior infection & surgical mastoidectomy)
There is no persistent transependymal fluid migration to confirm elevated ventricular pressure; there is some persistent optic hydrops.
Impression
2. There is resolution of the prior evidence of active meningitis; There is resolution of the subependymal edema; there is no parenchymal vasogenic edema.
3. Optic hydrops is the only evidence that the dural sinus thrombosis has raised intracranial CSF pressure.
4. There is an incidental small left vertex arachnoid cyst (evident on the initial exam), which remains unchanged.
Recommendations
Proceed to the summary video and case report to view all of the imaging findings in this case plus the "Lessons to be learned" from this specific instructional case.
