Case Notes
History
53 year old female who presented with acute onset diplopia and imaging evidence of dural sinus thrombosis affecting the torcular herophile, the left mesial transverse sinus, and the parietal segment of the SSS. Patient had evidence of meningitis and right sigmoid region epidural abscess. Patient was treated medically and with a right mastoidectomy. This patient is being reimaged at 10 days after the initial imaging.Exam
MRV of the head
Purpose
Assess for evidence of dural sinus thrombosis and for collateralization of the dural sinus wall including evidence of transcranial emissary veins.
Assess for evidence of cortical vein thrombosis. In many cases of cortical vein thrombosis the diagnosis is made by absence of veins compared to the opposite side. Additionaly, cortical vein & dural sinus occlusion can be inferred by the appearance of the collateral veins and reversed filling pattern. This inability to easily perceive cortical vein thrombotic occlusion as an absence of a vein(s) accounts for its under-reporting.
Assess for re-routing of the venous egress through reversed flow through other pial veins or through the pial/dural interconnections (vertex venous lacunae, mesial and/or lateral tentorial confluences, and the cavernous sinus).
Assess for exaggerated cortical vein prominence that is usually the result of a dural AV fistula in conjunction with dural sinus occlusion. It is often difficult to determine whether the AV fistula is the result of the dural sinus thrombosis collateralization, or whether the AV fistula occurs first, but elevated venous filling pressure causes stasis of flow and secondary dural sinus thrombosis.
Purpose
Assess for evidence of dural sinus thrombosis and for collateralization of the dural sinus wall including evidence of transcranial emissary veins.
Assess for evidence of cortical vein thrombosis. In many cases of cortical vein thrombosis the diagnosis is made by absence of veins compared to the opposite side. Additionaly, cortical vein & dural sinus occlusion can be inferred by the appearance of the collateral veins and reversed filling pattern. This inability to easily perceive cortical vein thrombotic occlusion as an absence of a vein(s) accounts for its under-reporting.
Assess for re-routing of the venous egress through reversed flow through other pial veins or through the pial/dural interconnections (vertex venous lacunae, mesial and/or lateral tentorial confluences, and the cavernous sinus).
Assess for exaggerated cortical vein prominence that is usually the result of a dural AV fistula in conjunction with dural sinus occlusion. It is often difficult to determine whether the AV fistula is the result of the dural sinus thrombosis collateralization, or whether the AV fistula occurs first, but elevated venous filling pressure causes stasis of flow and secondary dural sinus thrombosis.
Prior Study
Initial imaging at the time of presentation demonstrated right coalescent mastoiditis, evidence of meningitis and dural sinus thrombosis affecting the torcula, left transverse sinus and the parietal segment of the SSS. There was a punctate area positive on both FLAIR and MR diffusion in the left superior vermic area (possible ischemic event). The right sigmoid sinus was partially compressed by a small epidural abscess, but was otherwise patent.CT head
Acute thrombus has progressed and is now evident in most of the superior sagittal sinus (SSS), the straight sinus, the torcular herophile, the right transverse sinus and the initial segment of the left transverse sinus.
The hydrocephalus seen on initial imaging has resolved.
NO CT perfusion imaging is available
NO neck imaging was available