Post contrast head CT
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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/.
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.
CA0616-Post contrast head CT
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CA0616-Post contrast head CT
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.
CT perfusion
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.
Findings
Post contrast head CT (venocapillary pool analysis)
There is partial reduction in CT density within the dorsal right thalamus in the site of thalamic edema; this could reflect either vasogenic or cytogenic edema or both. However, there is no absence of CT density within the right thalamus to confirm a completed infarction.
There is opacification of both septal veins and rostral portions of the ICV's suggesting there be some recanalization. There is opacification of the right subependymal veins. These are features of venous congestion rather than occlusion.
There is evidence of a filling defect (empty delta sign) in the vein of Galen/straight sinus junction. The lumen of the right transverse sinus remains unopacified, although there is some enhancement of the collateralized sinus venous plexus in the dural wall.
Hyperdensity (thrombus) without opacification remains in the right basal vein of Rosenthal.
Impression
2. 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.
