Wk 4, Case 1 - Review

Patient History

Patient presents to the emergency department with sudden onset severe, worst headache of life (“thunderclap”) headache.

Findings

PROCEDURE: CT ANGIO HEAD WO AND W CONTRAST, CT ANGIO NECK WO AND W CONTRAST

COMPARISON: None

1. Axial CT head images were obtained from the skull base to the vertex without intravenous contrast.

2. 0.625 mm axial CT images were obtained through the head and neck following the uneventful administration of intravenous contrast. Sagittal and coronal reformatted images were performed. MIP and volume rendered images were also post processed at a separate workstation to further define anatomy and potential pathology.

CT HEAD:

No acute intracranial hemorrhage. Gray-white differentiation is preserved.

The ventricular system is normal in size and morphology. No abnormal extra-axial fluid collections or midline shift of structures. Patent basal cisterns.

Non depressed or displaced calvarial fracture.

Orbits are unremarkable. Visualized paranasal sinuses and mastoid air cells are well-aerated.

CTA NECK:

There is classic aortic branching without significant ostial stenosis. There is normal course and caliber of the common carotid arteries. Internal and external carotid arteries are within normal limits. The vertebral arteries originate from the subclavian arteries without significant ostial stenosis. There is normal course and caliber of the cervical vertebral arteries.

CTA HEAD:

The distal internal carotid arteries are unremarkable. Normal distal vertebral and basilar arteries. There are multifocal areas of mild to moderate A2/A3 ACA, left M2 MCA, and left P2/P3 PCA stenoses or vasoconstriction.

No evidence of aneurysm or malformation.

Conclusion

1. No acute intracranial hemorrhage, mass effect, or midline shift.

2. Multifocal areas of segmental vasoconstriction of the ACAs, MCAs, and PCAs consistent with reversible cerebral vasoconstriction syndrome (RCVS).