Wk 1, Case 4 - Review

Patient History
Left sided weakness

Findings
CT HEAD WITHOUT CONTRAST (MRIO0002062): Focal loss of gray-white differentiation in the right paramedian frontal lobe at the vertex involving the superior frontal gyrus and right precentral gyrus to lesser extent. Diffusely increased attenuation is noted in the superior sagittal sinus as well as several proximal cortical veins suspicious for venous thrombosis.Mild prominence of the ventricles is noted. Otherwise brain parenchymal architecture appears to be within normal limits. Intracranial vascular calcifications are faintly present involving the petrocavernous ICAs. Remainder of gray-white differentiation is preserved.The included paranasal sinuses are predominantly clear. No mastoid effusions.No suspicious osseous abnormalities.

CT PERFUSION (MRIO0000128): Perfusion imaging is markedly suboptimal secondary to extensive motion artifact during the examination. Scanning was not performed to the top the vertex as well. The limited perfusion sequences do demonstrate increased mean transit time in the right paramedian frontal lobe corresponding to the area of loss of gray-white differentiation with decreased cerebral blood flow.

CTA HEAD (MRIO0000128):

Venous: Marked expansion of the superior sagittal sinus is noted with a large filling defect throughout the superior sagittal sinus. There is no extension into the transverse sinuses or the inferior aspect of the superior sagittal sinus. There appears to be thrombosis of several draining proximal cortical veins bilaterally including the right vein of Trolard with minimal reconstitution. The transverse sinuses as well as the sigmoid sinuses and jugular bulbs are patent. The distal internal jugular veins are patent. The paired internal cerebral veins are grossly patent as well as the vein of Galen and straight sinus.

Arterial: The petrocavernous and supraclinoid internal carotid artery segments are patent. The anterior, middle, and posterior cerebral arteries are patent without stenosis. The anterior communicating artery is present. Bilateral posterior communicating arteries are patent. The intracranial V4 segments and basilar artery are patent.No evidence of aneurysm or vascular malformation.

Impressions
1. Superior sagittal sinus thrombosis with additional thrombosis of several large draining proximal cortical veins including the right vein of Trolard. Evidence of venous infarct involving the right superior frontal gyrus without evidence of hemorrhagic conversion. Perfusion imaging was not performed at the vertex in the region of the infarct and is significantly degraded by motion but does demonstrate imaged at-risk ischemic tissue in the right paramedian frontal region.
2. Remainder of the major dural venous sinuses are patent without evidence of thrombosis.
3. No significant intracranial arterial stenosis or vascular cut off.
4. No significant stenosis of the cervical carotid or vertebral arteries.

Findings
Area of T2 FLAIR hyper signal abnormality involving the cortex and subcortical white matter in the right posterior frontal high convexity region with no restricted diffusion. There is associated foci of signal loss on SWI within the depth of the right central sulcus. There is also thickening of the signal loss within the superior sagittal and right greater than left superficial cortical veins of the high convexity. On MRV images filling defects are seen within the superficial/cortical veins right greater than the left and superior aspect of the superior sagittal sinus consistent with venous sinus thrombosis. Otherwise there is good contrast enhancement within the major intracranial venous sinuses including the inferior sagittal sinus, the internal cerebral veins, the straight sinus, transverse and sigmoid sinuses.

The remainder of the brain parenchyma is normal in signal intensity. There is mild diffuse prominence of the cerebral sulci with commensurate dilatation of the supratentorial ventricles. There is also mild dilatation of the fourth ventricle. The sellar region is grossly normal. The craniocervical junction is unremarkable. No other areas of intracranial or extracranial hemorrhage are seen. No territorial restricted diffusion to suggest acute or subacute infarction. The orbits are grossly normal. Trace mucosal thickening of the paranasal sinuses. Mastoid cells are clear.

Impressions
Signs of dural venous thrombosis within the superior aspect of the superior sagittal sinus and adjacent right greater than the left cortical veins with associated right posterior frontal parenchymal edema and subarachnoid hemorrhage along the right central sulcus. This may be on the basis of venous congestion as there does not appear to be cytotoxic edema based on ADC maps at this time.