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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
MR susceptibility sequence
Prior Study
CT HeadThere 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.
CTV of the head
There is extensive dural sinus thrombosis, which also involves a short segment of the major cortical veins (the segment adjacent to the dural sinus) bilaterally. Venous egress has been re-routed into the superior sylvian vein complex and the supra to infratentorial connections with the superior vermian vein complex and through the lateral anastomotic vein complex. The former exits through the cavernous sinus into the pharyngeal vein plexus and the lateral through the petrosal veins and perimedullary veins.
CT analysis of the venocapillary pool
No significantly reduced venocapillary CT density was noted to confirm site of venous stroke. However, there is minimally reduced contrast density in the right thalamus consistent with vasogenic edema related to venous congestion. There is thrombosis of the right deep central veins, while the left deep central veins and left septal vein are patent. There is evidence of persistent intraluminal thrombus (empty delta sign) within most of the major dural sinuses.
MR noncontrast T1-w exam
Hyperacute (isodense) thrombus is evident throughout most of the major dural sinuses (SSS, torcula, transverse sinuses, and the straight sinus). There is evidence of at least moderately advance congestion within the deep medullary vein complex and parenchymal edema in the centronuclear structures on the right.
MR diffusion
Diffusion is positive on both the DWI and ADC maps confirming evidence of post ischemic injury in right basal ganglia, right caudate and right thalamus (i.e. “venous stroke’).
MR T2/flair
There is evidence of significant focal vasogenic edema in the dorsal thalamus and minimal basal ganglia edema, plus evidence of deep medullary vein congestion in the right centrum semiovale, the right basal ganglia, the right caudate nucleus, and more prominently in the right thalamus. These are features of significant venous congestion in the right deep venous system. There is retroglobal edema on the right along with bilateral optic hydrops, as well as, limited right lateral venticulomegaly (early hydrocephalus) indicating there is CVT related elevated CSF pressure.
