Case Notes
History
53 year old female who presented with confusion, depressed level of consciousnes, fever, and right ear pain. On admission patient had right coalescent otomastoiditis. Her lumbar puncture grew out strep pneumococcus.Exam
Post contrast head CT for venocapillary pool analysis
Prior Study
CT headThere is evidence of aggressive right otomastoiditis with sigmoid plate dehiscence (coalescent otomastoiditis) producing a small volume, epidural abscess, which partiall compresses the adjacent dural sinus. Focal deformity of the sigmoid sinus is evident at the site of epidural abscess, however, the remaining lumen of the right sigmoid sinus and the internal jugular vein are patent. Intraluminal thrombus is present in the torcular herophile, the left transverse/sigmoid sinuses, extending into the high cervical left IJ.
CT perfusion NO CT perfusion is available
CTA of the neck
Thrombosis of the high cervical left internal jugular vein with collateral drainage into the other left neck veins. The right IJ is patent. No soft tissue abnormality is evident within the cervical soft tissues.
MRV of the head obtained 4 days after the CTA neck
Segmental thromboses are evident in multiple dural sinuses, especially in the posterior superior sagittal sinus (SSS), the torcular herophile, and the left transverse/sigmoid sinuses. The extent of dural CVT has increased since the prior initial post contrast temporal bone CT. There is evidence of venous re-routing utilizing pial/dural anastomotic connections (the venous lacunae over the vertex, and the lateral tentorial confluence on the left) draining into the expanded dural wall venous plexus. Persistent right sigmoid deformity remains because of the persistent small epidural abscess adjacent to the right sigmoid plate.