Back to Venous Case 01 - Hyperacute Stroke

Case210d

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Case Notes

History

29 year old female presenting acutely with dysarthria, apahsia, facial droop. Patient was in an automobile accident 3 weeks earlier. Patient is not on birth control meds.

Exam

Prior Study

CT Head
There is widespread acute thrombosis within the superior sagittal sinus, the torcular herophile, the straight sinus, and both transverse sinuses. There may be partial thrombosis within the high cervical jugular veins.
There is acute thrombus in the lateral surface vertex cortical veins adjacent to the superior sagital sinus, and in the right basal vein of Rosenthal, and in the right ICV, and in the vein of Galen. There is focal vasogenic edema in the right dorsal thalamus and caudate with local mass effect consistent with significant right deep central venous egress obstruction (vasogenic edema). Whether cytogenic edema is present from venous infarction is indeterminate.There is early optic hydrops and right temporal ventriculomegaly consistent with early effects of CVT induced raised intracranial pressure.
 
CT Perfusion
CT perfusion features of dural sinus thrombosis with dural wall collateralization affecting  the SSS, the torcula, and the left transverse sinus. The right transverse sinus is apparently thrombosed without dural wall collateralization.There is significant venous congestion within the right subependymal venous plexus, as a result of venous egress block in the right ICV, vein of Galen and straight sinus.There is re-routing of the venous egress through the left superior sylvian vein complex into the cavernous sinus and from supra to infratentorial vein connections through the superior vermian vein and lateral anastomotic mesencephalic vein connections.
 
CTA/CTV/MRV of the neck: No imaging of the neck was obtained.

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Case210d

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.

​There is thrombotic occlusion of a transverse sinuses with secondary thickening of the dural sinus wall.

​There is thrombotic occlusion of a sigmoid sinus with secondary thickening of the dural sinus wall.

​There is thrombotic occlusion of an internal jugular veins.

​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).

Major Cortical Vein Thromboses

​There is thrombotic occlusion of an anterior frontal (frontopolar) vein.

​There is thrombotic occlusion of a vein of Trolard.

​There is thrombotic occlusion of a vein of Labbe’.

​There is thrombotic occlusion of  the superior sylvian vein complex.

​There is thrombotic occlusion of a petrosal vein.

​There is thrombotic occlusion of either the superior or inferior vermic vein(s).

Major Central Vein Thromboses

​There is thrombotic occlusion of a thalamostriate/septal vein(s).

​There is thrombotic occlusion of one or more of the internal cerebral veins (ICV) or vein of Galen.

​There is thrombotic occlusion of the vein of Galen/straight sinus apex/straight sinus.

​There is thrombotic occlusion of a basal vein of Rosenthal (BVR).

​There is thrombotic occlusion of deep central subependymal veins.

Minor Cerebral Venous Thromboses

​There is thrombotic occlusion of the lesser middle or posterior frontal vein(s).

​There is thrombotic occlusion of the lesser posterior parietal or occipital vein(s). 

​There is thrombotic occlusion any of the cerebellar cortical vein(s) or the lateral cerebellar venous confluence adjacent to the transverse sinus.

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).

​There is evidence of pial venous re-routing into the vertex venous lacunae (vertex pial/dural anastomoses).

​There is evidence of pial venous re-routing into the mesial &/or lateral tentorial venous confluences (ventral pial/dural anastomoses).

​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.

Other

​Other findings are present more consistent with a different cause for symptoms than venous stroke.