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.