Case Notes
History
16 year old female presenting with a severe headache, nausea and vomiting. Patient had photophobia but had no focal complaints nor findings on exam. Patient was on birth control.Exam
CTV of the Head: Our CTV protocol includes a dynamic head CT performed after the 1st bolus of contrast only (there is no second bolus as in CTA). However, the CTV timing is timed according to detection of contrast in a major dural venous sinus (usually the vein of Galen/straight sinus or torcula). Usually, the brain arteries are concurrently visualized, which is helpful in excluding an arterial stroke located in a venous egress territory (especially the retrosylvian area). Post processing subtraction is used to avoid the effect of hyperdense thrombus simulating patency on CTV. CT perfusion can be generated from the CTV data set.
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.
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
Noncontrast head CTAcute thrombosis is evident within the posterior (parietal/occipital) segments of the superior sagittal sinus extending into the torcular herophile and the straight sinus. There is no apparent cortical or deep central vein CVT.
CT perfusion No CT perfusion is available
CTV of the neck NO CTV neck is available