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So now, we're going to talk about

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cortical vein thrombosis.

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Usually, the patients present with headache and seizures.

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If it involves a motor sensory strip,

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you can get hemiparesis or

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unilateral paresthesias.

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This is usually seen in young patients,

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and risk factors are hypercoagulable states,

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dehydration, trauma, intracranial hypotension,

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and infection, among others.

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On MR, the best way to diagnose cortical vein thrombosis

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are the gradient echo, or SWI images.

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As you can see here, this patient had had a CTA,

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and it was called normal.

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But when we got the MRI,

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You can see the susceptibility in a large cortical

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vein on the left because you have inflow,

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but you don't have outflow.

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You tend to have hemorrhage and edema.

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As you can see on the T2 weighted images,

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the hemorrhage is dark,

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deoxyhemoglobin, and then the edema is bright,

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and then there is early breakdown of

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the blood-brain barrier,

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so you tend to have gyriform enhancement.

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As you can see on this coronal image,

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diffusion can be elevated, restricted, or both,

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and the lesions tend to be usually very peripheral,

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like other enhancing masses that are more central.

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This is a case of cortical vein thrombosis.

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This is a head CT of a 48-year-old with B-cell

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acute lymphoblastic leukemia, on chemotherapy,

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and had sort of right-sided weakness

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and difficulty thinking.

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And this is a non-contrast head CT

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that shows hypodensity consistent with edema.

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And some hemorrhage in the left parietal lobe

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extending into the posterior frontal lobe.

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And it kind of looks like a hemorrhagic left MCA

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infarction, although if you look clearly,

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you can see it's extending kind of into the PCA.

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An ACA territory non-contrast CT.

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Was otherwise unremarkable, and so we got.

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An MRI,

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we got diffusion-weighted images

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and some FLAIR images,

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and you can.

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See on the diffusion images that there's

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some restricted diffusion.

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The dark signal is from the susceptibility

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from the hemorrhage.

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You can see that there's edema and swelling

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and effacement of sulci, and there's.

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Also a small lesion on the other.

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Side involving the right periwandic region where

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there isn't much restricted diffusion.

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It looks like it's going to

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be mostly vasogenic edema.

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So we've got two lesions, one on.

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The left, one on the right.

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And they were initially thought

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to be arterial infarctions.

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But again,

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this looks like it's spanning

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two vascular territories.

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And we're going to just show you the FLAIR

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in combination with the ADC map.

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And again,

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you can see some of this is restricted in the

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center. There's some peripheral edema.

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Again,

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that could be a subacute arterial infarction.

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but you always have to think.

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Like, could this be a venous infarction?

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So, on the MR study,

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we got an MRA of the circle of Willis.

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And you can see everything looks pretty normal.

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The MCAs, the ACAs, the internal carotid.

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Arteries,

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the posterior circulation, dominant left vert.

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PCAs look normal.

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There's kind of a fetal configuration

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of the right PCA.

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the right vert ends in a PICA.

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so that all looks pretty normal.

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I think we can spin it in the other direction,

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and you can see, again, the ICAs get a better.

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View on this rotation.

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And they look normal. So normal MRA of the head.

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So we went back and we looked at the

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gradient echo images, and these

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Are gradient echo images showing hemorrhage.

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We already knew there was hemorrhage on the non

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contrast CT. And you can see the susceptibility,

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as you'd expect on the gradient echo images.

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And as we get to the top of the brain, we can see.

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These cortical veins that have blooming, and.

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This is consistent with cortical venous sinus

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thrombosis. There's another cortical vein in here.

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And so we said, wow,

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we better get a better look at this.

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So we gave contrast on MR.

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And.

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You can see this is the MP-RAGE sequence.

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Basically, the veins enhance on the sequence.

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So it's good for looking for

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venous sinus thrombosis.

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And the superior sagittal sinus looks pretty normal.

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But then when you start looking

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at these veins coming into it,

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that actually may be part of the sinus, too.

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Where you saw susceptibility,

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you don't see enhancement.

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And you can see here a couple

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of other veins coming in,

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another vein coming in.

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So multiple cortical veins that have thrombosed.

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And there's some prominence of focal enhancement.

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In the region of the venous infarction.

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And it's probably just congested veins with.

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Breakdown of blood-brain barrier.

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You can sometimes get a little leptomeningeal

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enhancement as well. We then went to confirm this.

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Again, we got a CT venogram.

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So this is a delayed phase,

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the arteries aren't really enhancing much.

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And in the region of the superior sagittal sinus,

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the sinus is enhancing pretty well.

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And basically, we see what we.

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Saw on the gradient echo images.

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Where these cortical veins that

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come in are not enhancing.

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So here are two normal veins that come in,

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but here's another big enlarged vein.

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There's a vein right here.

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There's a vein here coming in.

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Again. This is another vein that might even.

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Be a small part of the sinus.

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So basically, this was an example of.

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Cortical vein thrombosis involving

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multiple cortical veins.