MR T2 or FLAIR
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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.
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Conflict of interest information for the CME Advisory Committee members can be found on the following website: https://cme.ufl.edu/disclosure/.
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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.
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CA0610-MR T2 or FLAIR
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CA0610-MR T2 or FLAIR
Case ReportExam
Prior Study
Acute to subacute thrombosis of multiple dural sinuses is evident including the transverse sinuses on both sides, and the straight sinus. Acute venous thrombosis is evident in both of the internal cerebral veins (ICV), the vein of Galen and the right basal vein of Rosenthal. There is edema in the dorsal right thalamus, but whether this is vasogenic edema or cytogenic edema (venous stroke) is indeterminate. There is also reduced CT density wihtin the superior vermis, but whether this is from prior radiation therapy (with leukomalacia) or whether it is related to retrograde propagation of clot from the vein of Galen into the superior vermian vein complex is indeterminate.
CTperfusion
There is deep central vein thrombosis producing venous congestion in the the subependymal venous system (i.e. caudate, thalamostriate, and deep medullary parenchymal vein), greater on the right than the left.
Thrombosis of the straight sinus is evident on the CTA, which is included with the CT perfusion data set, but there is no CT perfusion evidence of collateral flow in the dural sinus wall.
CTV neck
There is thrombosis (likely chronic) of the right cervical internal jugular vein and the right sigmoid/transverse sinuses.
CTV head
There is thrombosis of multiple dural sinuses including the right transverse/sigmoid sinuses and the adjacent right internal jugular vein plus thrombosis of the straight sinus.
There is either thrombosis or at least delayed filling of the deep central veins, the vein of Galen, and the right basal vein of Rosenthal on CTA of the head. However, there is thrombus in these veins on the CT head consistent with hyperacute CVT.
There is re-routing of venous egress through the left superior sylvian venous complex/sphenoparietal sinus/cavernous sinus and through the left lateral tentorial venous confluence.
Post contrast head CT
There is evidence of edema in the dorsal right thalamus which is part of the right ICV venous egress territory. Whether this edema is vasogenic edema alone related to venous congestion or includes cytogenic edema from venous infarction is indeterminate. However, the partial rise in right thalamic venocapillary pool density makes completed infarction unlikely; correlate with MR diffusion sequences.
Intraluminal clot is evident in the vein of Galen/straight sinus junction (empty delta sign), as well as in the right channel of the torcula and proximal right transverse sinus. There is subependymal venous congestion more prominent on the right than left.
There is persistent CVT in the right transverse/sigmoid sinuses and right basal vein of Rosenthal with evidence of thickening (collateralized) dural sinus walls.
MR T1-w post contrast only
Persistent intraluminal thrombosis remains in the vein of Galen/straight sinus junction, straight sinus, right channel of the torcula and all of the transverse sinus. There is partially recanalized clot in the mesial segment of the left transverse sinus. There is expansion and enhancement of the dural sinus walls in the straight sinus and right transverse sinus and in the right lateral tentorial venous confluence, which are then re-routed through the dural wall collateral into the left patent transverse sinus. There is edema in the dorsal thalamus, as seen on prior exams. Whether this represent vasogenic alone or includes post ischemic cytogenic edema is indeterminate. There is evidence of deep medullary and subependymal venous congestion bilaterally.
Findings
MR FLAIR
There is positive FLAIR (from either slow flow or residual thrombus) in the apex of the straight sinus and in the left channel of the torcular herophile consistent with the presence of thrombus.
Most of the thrombosed dural sinuses, as seen on CTV, exhibit absent signal (apparent flow void) or nonspecific mixed signal, despite being actually occluded.
The remainder of the MR flair exam is within normal limits, including no evidence of vasogenic edema in the centronuclear structures.
Impression
There is no subependymal edema to confirm early hydrocephus.
There is no parenchymal edema in the centronuclear structures.
