Case Notes
History
56 year old male presented with acute onset right facial droop, right arm weakness, and both difficulty speaking and comprehending.Exam
MR Flair sequence
Prior Study
Noncontrast CT headFocal left retrosylvian vasogenic edema matching the vein of Labbe' venous egress territory. Whether there is cytogenic edema in this area representing venous stroke remains indeterminate. There is acute thrombus in multiple branches of the left vein of Labbe' without apparent concurrent left transverse sinus thrombosis.
There is no hemorrhagic conversion.
CT perfusion
There is a focal area of reduced brain perfusion in the left retrosylvian area corresponding to oligemia resulting from thrombosis of the left vein of Labbe' (evident on the noncontrast head CT). There is both collateral zone physiologic hyperemia in the collateral zone surrounding the retrosylvian oligemic area plus evidence of re-routing of venous egress into the left superior sylvian vein complex and left lateral tentorial venous confluence. This accounts for the increased blood volumn (increased CBV) in the cavernous sinus and left transverse sinus.
CTA neck including opacification of the major dural sinuses
The CTA of the neck was negative for venous thrombosis in the cervical area. The CTA of the neck included the head as well and demonstrated patent dural sinuses.
CTA of the head
CTA head evidence of re-routed venous egress into the lateral tentorial venous confluence. The cortical veins are not well seen on either sided, because of the timing of a CTA versus a CTV.
Post contrast head CT for venocapillary pool analysis
There is a 2 cm. focal area of virtually absent CT density in the venocapillary pool within the left retrosylvian area plus nonfilling of the vein of Labbe'; findings are consistent with venous stroke. There is no evidence of left transverse sinus thrombosis, nor evidence of arterial occlusion in the same area. The dominant routes for re-routing of the remain retrosylvian veins is into the cavernous sinus via left superior sylvian vein/sphenoparietal sinus route and into the left lateral tentorial venous confluence/left transverse sinus route. There is altered blood brain barrier with leak of contrast into the area of vasogenic edema (vein of Labbe' oligemic zone).
MR noncontrast T1-w sequence
There are focal changes in the left retrosylvian area consistent with thrombosis of the vein of Labbe' and evidence of focal tissue edema and cortical laminar necrosis (completed venous infarction). The area of ischemic penumbra surrounding the dense ischemic core exhibits features of dysautoregulation, including minimal contrast leak, plus venous congestion in both cortical and deep temporal parenchymal medullary veins.
MR diffusion sequences
Acute venous related, cortical infarction is evident in the left lateral retrosylvian regions. Most of the area of vasogenic edema (ischemic penumbra) evident on prior imaging is not MR diffusion positive.