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Imaging: Cortical Vein Thrombosis

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Imaging: Cortical Vein Thrombosis

  1. 1. IMAGE OF THE WEEK PROF.DR.G.SUNDARAMURTHY M2 UNIT P-VANJI NATHAN
  2. 2. CLINICAL HISTORY AND EXAMINATION  35 year old male patient, a chronic alcoholic presented to casualty with history of headache 1 week, sudden onset, gradual progression, associated with blurring of vision. An episode of vomiting X 1 day.  O/E Patient was conscious oriented, looked distressed and had R lateral rectus palsy (diplopia) on CNS examination.  Urgent imaging (CT-Brain) was done,
  3. 3. FOLLOWING THE ABNORMAL CT FINDINGS, MRI BRAIN WAS TAKEN
  4. 4. CT-BRAIN REPORT  CT BRAIN AXIAL SECTIONS SHOWING 1. HYPERDENSITY IN THE RIGHT FRONTAL REGION 2. HYPERDENSITY IN THE R TRANSVERSE SINUS 3. HYPODENSITY IN THE SUPERIOR SAGITTAL SINUS (?EMPTY DELTA SIGN)  SUGGESTIVE OF ?PARENCHYMAL HEMORRHAGE WITH CORTICAL VEIN THROMBOSIS ?CALCIFIED GRANULOMA.
  5. 5. 1 22 3
  6. 6. MRI BRAIN REPORT  MRI brain shows T1 hyperintense / non suppressible T2 hyperintensity in the right high parietal lobe. The lesion shows peripheral blooming in T2 gradient sequence suggestive of hemorrhage.  Absence of flow voids in mid sagittal and transverse sinus in FLAIR images suggestive of sinus thrombosis  T1 hyperintensity noted in superior sagittal sinus and right transverse sinus suggestive of thrombosis.  MR venography confirms the evidence of thrombosis in superior sagittal sinus and right transverse sinus.
  7. 7. T2 hyper intensity Gradient blooming T1 hyperintensity FLAIR FLOW VOID
  8. 8. CEREBRAL VEINS-VALVELESS,THIN EXTERNAL SUPERIOR MIDDLE SUPER FICIAL DEEP CAVERNOUS OR SPHENOPARIETAL SINUSSUPERIOR SAGITTAL SINUS BASAL VEIN INTERNAL-2 IN NUMBER- JOIN TO FORM GREAT CEREBRAL VEIN INFERIOR SUP.CER.VN OR CAV.SIN. BASAL VN RECEIVES
  9. 9. CT FINDINGS IN CVT  Dense clot sign - Areas of thrombosis in sinuses appearing as hyperdensities in unenhanced ct.  Cord sign - Dense cortical veins-uncommon direct sign of cvt in unenhanced ct.  Venous infarction is the most non specific indirect sign in unenhanced ct - presence of multiple isolated lesions, subcortical involvement, more than one arterial territory involved.  Empty delta sign - Filling defect with enhancing rim on enhanced ct.  Contrast enhancement secondary to venous stasis  Diffuse brain swelling with edema and decreased ventricular size might be present.  CT venogarhy allows direct visualisation of thrombus.
  10. 10. MRI FINDINGS IN CVT  Can confirmatively tell presence of CVT.  Venous thrombus may be directly visualised.  Patent dural sinuses are seen as flow void especially when the image is orthogonal to blood flow direction.  Thrombus manifest as absence of flow void-best seen in FLAIR and T2 weighted spin echo sequences.  T1 weighted - hyperintensity ; T2 weighted gradient echo-exaggerated signal loss.  MR venography - shows direct visualisation of thrombus.

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