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Case: Superior Sagittal Sinus Thrombosison CT, CTV

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One of the most difficult calls to make in the

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emergency department for neuroimaging is the presence

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of a venous thrombosis on a non-contrast CT scan.

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Quite often, the presentation is either something

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like a severe headache or papilledema, and you're

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in the position of trying to make a judgment

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about whether or not the sinuses are too dense.

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It's a little bit easier when you have a symmetric

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sinus, like the transverse sinus, where you can compare

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one side to the other and assess the density of the

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sinus to make a judgment as to whether there's a clot.

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However, with a patient who has a question of a

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superior sagittal sinus thrombosis, it is a little bit

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more difficult, and that density that you're comparing,

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you should either compare with the transverse sinus,

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or when you compare the posterior to the anterior,

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you may make a judgment about whether it's too bright.

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In this situation, as we look from posterior

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to anterior, there is a gradient where

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the sinus anteriorly is more dense than

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that posteriorly, but it's not dramatic.

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And this is a situation where sometimes

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the clinical assessment will rule.

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Again, looking at the thin-section images may help you.

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In this case, when you window,

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you may wonder about some areas where the

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sinus is more dense internally than other

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areas of lower density in the sagittal sinus.

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This patient went on to get a CT venogram.

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And if we go directly to the MIP image of the CT venogram,

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we can see that there is a filling defect

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in the superior sagittal sinus in this individual.

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The CT venogram MIP may not be as useful as doing the

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high-resolution, thin-section reconstructions yourself.

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When you do that, you can window it a little bit

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more nicely, and you see this very large clot that

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is present all the way into the anteriormost portion

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of the superior sagittal sinus in this individual.

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If I show this to you in the raw data and

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window it, you can see that the patient has

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a clot here in the center of the sinus, which

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is a filling defect outlined by contrast.

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So this individual has evidence of

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superior sagittal sinus thrombosis.

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Nonetheless, as you can see, there aren't areas

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of abnormal density within the brain tissue.

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I would probably prefer to go with an MRI scan to

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look for it on FLAIR or diffusion-weighted imaging.

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But in this case, the patient had sinus thrombosis

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without infarction noted on CT, CT venography.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Vascular

Neuroradiology

Emergency

CTV

CT

Brain

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