Hyperacute Venous Stroke III - Clinical Case Summary
Hyperacute Venous Stroke III - Clinical Case Summary
Hyperacute Venous Stroke III - Clinical Case Summary
SummaryHistory
30 year old female who is one week post partum and presents with severe headache and some nonspecific change in vision.
Exams performed
Noncontrast CT head; MRV of the head; MR diffusion; MR T2-w turbo spine echo plus MR flair; MR susceptibility
Prior available imaging reports
Noncontrast CT Head
1. There is thrombosis of the right vein of Trolard. There is hemorrhagic conversion of the thrombosed vein of Trolard producing local mass effects. There are small volume subarachnoid blood products evident within vertex sulci bilaterally and in both the suprasellar and prepontine cisterns.
CT Perfusion No imaging available
CTV/MRV of the Neck No imaging available
MRV of the Head
1. There is mesial segmental occlusion of the right vein of Trolard. Focal displacement of cortical veins in the right parietal vertex is related to the parenchymal hematoma associated with the vein of Trolard thrombosis.
Anomolous, hypoplastic frontal SSS segmental hypoplasia is evident as an anatomic variant.
Post contrast head CT (venocapillary pool analysis) No imaging available
T1-W Sequence No imaging available
MR Diffusion
1. Focal right vertex hemorrhage matching the course of the right vein of Trolard obscurs any evidence of MR diffusion positivity to confirm venous stroke.
MR FLAIR plus T2-W Sequences
1. Subtle FLAIR signal abnormality is evident within the thrombosed segment of the vein of Labbe'.
Focal hematoma is evident adjacent to the right Trolard vein thrombosis. The hematoma, plus the surrounding edema, produces some local mass effect, but no appreciable brain herniation.
2. There is a dilated collateral pial vein adjacent to the posterior and lateral margin of the hematoma, which is secondary evidence of CVT.
MR susceptibility (SWI)
1. SWI confirms the presence of thrombus within the mesial segment of the right vein of Trolard.
2. SWI confirms the presence of local pial venous collaterals.
3. SWI confirms the hemorrhagic conversion of the right vein of Trolard CVT.
1. There is thrombosis of the right vein of Trolard. There is hemorrhagic conversion of the thrombosed vein of Trolard producing local mass effects. There are small volume subarachnoid blood products evident within vertex sulci bilaterally and in both the suprasellar and prepontine cisterns.
CT Perfusion No imaging available
CTV/MRV of the Neck No imaging available
MRV of the Head
1. There is mesial segmental occlusion of the right vein of Trolard. Focal displacement of cortical veins in the right parietal vertex is related to the parenchymal hematoma associated with the vein of Trolard thrombosis.
Anomolous, hypoplastic frontal SSS segmental hypoplasia is evident as an anatomic variant.
Post contrast head CT (venocapillary pool analysis) No imaging available
T1-W Sequence No imaging available
MR Diffusion
1. Focal right vertex hemorrhage matching the course of the right vein of Trolard obscurs any evidence of MR diffusion positivity to confirm venous stroke.
MR FLAIR plus T2-W Sequences
1. Subtle FLAIR signal abnormality is evident within the thrombosed segment of the vein of Labbe'.
Focal hematoma is evident adjacent to the right Trolard vein thrombosis. The hematoma, plus the surrounding edema, produces some local mass effect, but no appreciable brain herniation.
2. There is a dilated collateral pial vein adjacent to the posterior and lateral margin of the hematoma, which is secondary evidence of CVT.
MR susceptibility (SWI)
1. SWI confirms the presence of thrombus within the mesial segment of the right vein of Trolard.
2. SWI confirms the presence of local pial venous collaterals.
3. SWI confirms the hemorrhagic conversion of the right vein of Trolard CVT.
Overall impression
1. Acute thrombosis of the right vein of Trolard thrombosis with focal small volume right parietal vertex hematoma, plus other scattered subarachnoid blood bilaterally.
2. Anomalous hypoplasia of the anterior (frontal) aspect of the superior sagittal sinus.
2. Anomalous hypoplasia of the anterior (frontal) aspect of the superior sagittal sinus.
Lessons to be learned
1. Cortical vein CVT is prone to hemorrhagic conversion. In this case, there is a focal superficial hematoma located immediately beneath the thrombosed right vein of Trolard. There is also evidence of recent, small volume, subarachnoid hemorrhages within vertex sulci bilaterally and in the ventral cisterns. It is important to recognize SAH on noncontrast exams (i.e. noncontrast CT, noncontrast T1-w MR, MR flair) in order to not overcall cortical vein CVT on post contrast CT or MR nor on MR susceptibility sequences, since both venous CVT and SAH cause similar blooming artifacts.
2. Cortical vein hemorrhagic conversion, as in this case, often parallels the thrombosed vein; both appear as a "cord" sign.
3. The presence of a hemorrhage often masks the presence of the thrombosed vein. Thus, supposedly "idiopathic" brain hemorrhages may, in some cases, actually be secondary to cortical vein CVT. This is especially true, when hemorrhagic CVT involves the minor (unnamed) cortical veins.
2. Cortical vein hemorrhagic conversion, as in this case, often parallels the thrombosed vein; both appear as a "cord" sign.
3. The presence of a hemorrhage often masks the presence of the thrombosed vein. Thus, supposedly "idiopathic" brain hemorrhages may, in some cases, actually be secondary to cortical vein CVT. This is especially true, when hemorrhagic CVT involves the minor (unnamed) cortical veins.
Recommendations
Watch the included summary video for this instructional case.