Case Images
Case Notes
History
54 year old male with history of epilepsy who presented with a 2 week history of progressive loss of coordination and balance. On admission the patient was aphasic but without focal findings. Patient is on long term Dilantin therapy.Exam
Post contrast head CT for analysis of the venocapillary pool
Purpose
To identify any site of reduced CT density in any area of the venocapillary pool to confirm site of significant oligemia.
To determine if there is opacification of the dural sinuses indicating patency. Note: luminal thrombosis is only confirmed when the dural sinus is viewed in cross-section. Thus, nearly always need to apply multiplanar reformations. Also note, the sites of luminal thrombosis are often segmental in different sites within different sinuses. These segmental dural thrombosis are bridged by dural sinus wall and venous lacunae collaterals. Hence, the next purpose #3.
To identify evidence of opacification of the dural sinus wall plus lack of luminal opacification to dural wall collateralization. Dural wall collateral typically enlarges the overall size of the dural sinus.
To determine the state of venous egress (i.e. pattern of how the blood gets out of the head) has been altered, or even reversed in direction.
To identify pial venous collateral veins, which usually increase size, characteristic serpiginous appearance, and altered filling pattern (they drain toward unexpected major vein sites). Flow direction is often reversed (vein gets larger at its’s source rather than when it approaches a dural sinus.
Identify sites of intraluminal thrombus, which will correspond to the vein course.
Idenitfy sites of hemorrhagic conversion, which usually eminate from the junction of the vein thrombus with the pial venous collateral (corresponding to the site of venous reperfusion).
Purpose
To identify any site of reduced CT density in any area of the venocapillary pool to confirm site of significant oligemia.
To determine if there is opacification of the dural sinuses indicating patency. Note: luminal thrombosis is only confirmed when the dural sinus is viewed in cross-section. Thus, nearly always need to apply multiplanar reformations. Also note, the sites of luminal thrombosis are often segmental in different sites within different sinuses. These segmental dural thrombosis are bridged by dural sinus wall and venous lacunae collaterals. Hence, the next purpose #3.
To identify evidence of opacification of the dural sinus wall plus lack of luminal opacification to dural wall collateralization. Dural wall collateral typically enlarges the overall size of the dural sinus.
To determine the state of venous egress (i.e. pattern of how the blood gets out of the head) has been altered, or even reversed in direction.
To identify pial venous collateral veins, which usually increase size, characteristic serpiginous appearance, and altered filling pattern (they drain toward unexpected major vein sites). Flow direction is often reversed (vein gets larger at its’s source rather than when it approaches a dural sinus.
Identify sites of intraluminal thrombus, which will correspond to the vein course.
Idenitfy sites of hemorrhagic conversion, which usually eminate from the junction of the vein thrombus with the pial venous collateral (corresponding to the site of venous reperfusion).
Prior Study
CT headAcute to subacute thrombosis of multiple dural sinuses is evident including the transverse sinuses on both sides, and the straight sinus. Acute venous thrombosis is evident in both of the internal cerebral veins (ICV), the vein of Galen and the right basal vein of Rosenthal. There is edema in the dorsal right thalamus, but whether this is vasogenic edema or cytogenic edema (venous stroke) is indeterminate. There is also reduced CT density wihtin the superior vermis, but whether this is from prior radiation therapy (with leukomalacia) or whether it is related to retrograde propagation of clot from the vein of Galen into the superior vermian vein complex is indeterminate. Patient has known von-Hippel Lindau syndrome and has had prior treatment of a hemanioblastoma leaving moderately advanced cerebellar atrophy.
CT perfusion
There is deep central vein thrombosis producing venous congestion in the the subependymal venous system (i.e. caudate, thalamostriate, and deep medullary parenchymal vein), greater on the right than the left.
Thrombosis of the straight sinus is evident on the CTA, which is included with the CT perfusion data set, but there is no CT perfusion evidence of collateral flow in the dural sinus wall.
CTA of the neck
There is thrombosis (likely chronic) of the right cervical internal jugular vein and the right sigmoid/transverse sinuses.
CTA of the head
There is thrombosis of multiple dural sinuses including the right transverse/sigmoid sinuses and the adjacent right internal jugular vein plus thrombosis of the straight sinus.
There is either thrombosis or at least delayed filling of the deep central veins, the vein of Galen, and the right basal vein of Rosenthal on CTA of the head. However, there is thrombus in these veins on the CT head consistent with hyperacute CVT. There is re-routing of venous egress through the left superior sylvian venous complex/sphenoparietal sinus/cavernous sinus and through the left lateral tentorial venous confluence.
