Case - Venous Infarction Evaluated for Subacute Stroke
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This is an example of a venous infarction.
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These are images of a 59-year-old
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male who presented with a seizure.
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So we're talking about differentiating
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venous infarction from tumor
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from subacute arterial stroke.
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So seizure is unusual with arterial stroke.
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So let's take a look at these images.
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So I see this flair hyperintensity
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involving the temporal and occipital lobes.
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So I see this flair hyperintensity
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involving the temporal and occipital lobes.
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And extending up into the periventricular white
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matter, and that is a non-arterial distribution.
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So this would be MCA, this would be PCA.
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So I'm already thinking it's
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not going to be um, arterial.
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So could be tumor, could be
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something else, let's keep looking.
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And then I look at the pattern of enhancement,
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and it's really peripheral and it's gyriform.
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So gyriform enhancement is making
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me think more ischemic, we don't
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think it's arterial, so maybe venous.
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Rather than tumor.
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I'm going to show you on
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these coronal images again.
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You can see this is really
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peripheral gyriform enhancement.
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And then we're going to take a look at the SWI
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images.
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I.
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images.
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And you can see that there are multiple
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foci of hemorrhage throughout this that
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look like tiny little microhemorrhages.
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The constellation of findings is more
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suggestive of a venous infarction.
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Then we have MPRAGE images.
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We can try to look at the veins on the
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MPRAGE images, and what you'll see here
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is there are nice cortical veins going up
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to the superior sagittal sinus, but there
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should be a big vein along the temporal
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lobe going down into the transverse sinus.
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And we don't see that big vein, and this
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was likely due to vein of Labbé thrombosis.
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This patient also has some variant anatomy,
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where he's got a small left transverse sinus,
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which probably should have filled out better
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than this, and he's got a large occipital sinus.
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So the combination of very poor filling of the
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left transverse sinus, the absence of the vein
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of Labbé, and then these classic findings of
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gyriform enhancement, non-arterial distribution,
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hemorrhage, and presentation of seizure,
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suggested that this was venous sinus thrombosis.
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The patient was treated appropriately,
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and this is a follow-up flair image
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from several months later, and you can
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see that all that edema has resolved.
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There's um, some residual
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encephalomyelitis and gliosis, but
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the vast majority of it is resolved.
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That, again, is in keeping
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with a venous infarct.
Pamela W Schaefer, MD, FACR
Professor of Radiology, Vice Chair of Education
Massachusetts General Hospital
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