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
MR flair sequence
Purpose
Assess the FLAIR sequences for parenchymal edema in a recognizable venous egress zone(s).
Assess whether concurrent zones of edema are located on either side of a dural sinus, which is evidence that there is or has been thrombosis of that segment of the dural sinus.
Assess for positive FLAIR signal in the walls of recanalized cortical veins, the dural sinus walls, or the outer dura itself.
Assess for global or hemisheric swelling, since CVT can produce either pseudotumor type of brain swelling or hydrocephalus if extensive enough.
Assess for evidence of dilatation of the intraorbital veins, and optic hydrops (dilated CSF space around the optic nerves).
FLAIR is the best means of detecting early hydrocephalus, because it not only detects early ventriculomegaly, but also evidence of transepenymal fluid, effacement of sulci, increased protein in sulci. These feature help distinguish early CSF pressure elevation from chronic, incidental, ventriculomegaly.
Purpose
Assess the FLAIR sequences for parenchymal edema in a recognizable venous egress zone(s).
Assess whether concurrent zones of edema are located on either side of a dural sinus, which is evidence that there is or has been thrombosis of that segment of the dural sinus.
Assess for positive FLAIR signal in the walls of recanalized cortical veins, the dural sinus walls, or the outer dura itself.
Assess for global or hemisheric swelling, since CVT can produce either pseudotumor type of brain swelling or hydrocephalus if extensive enough.
Assess for evidence of dilatation of the intraorbital veins, and optic hydrops (dilated CSF space around the optic nerves).
FLAIR is the best means of detecting early hydrocephalus, because it not only detects early ventriculomegaly, but also evidence of transepenymal fluid, effacement of sulci, increased protein in sulci. These feature help distinguish early CSF pressure elevation from chronic, incidental, ventriculomegaly.
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
CTV of the head
There is evidence of partial recanalization of dural sinus thromboses, which include the parietal-occipital segments of the SSS, the torcular herophile, the initial segment of the transverse sinuses, and the straight sinus. Multiple effective routes of collateral venous egress are present, as listed above. There is also some antegrade venous blood flow after partial recanalization.
Delayed post contrast CT
Dural sinus thrombosis is evident affecting the distal SSS, the straight sinus, the torcula, and both mesial segments transverse sinuses proximal to the lateral tentorial venous confluences. There is moderate venous congestion in the deep central venous system. The venous congestion accounts for the size effacement of the upper third ventricle. There is no evidence of venous stroke nor hemorrhagic conversion.
Noncontrast T1-w MR
There is evidence of recent thrombus within the distal SSS, straight sinus, torcula, and initial transverse sinuses. The age of the thrombus is acute, since the clot evolution has not yet change into the met-hemoglobin phase (which would appear hyperintense). There is evidence of deep central venous congestion now affecting the deep medullary veins indicating at least moderate venous congestion. There is no hemorrhagic conversion nor acute hydrocephalus nor clear evidence of optic hydrops.
MR dwi MR diffusion is negative for venous stroke.