IMAGE OF THE WEEK

PROF.DR.G.SUNDARAMURTHYM2 UNIT

P-VANJI NATHAN

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,

FOLLOWING THE ABNORMAL CT FINDINGS, MRI BRAIN WAS TAKEN

CT-BRAIN REPORT

CT BRAIN AXIAL SECTIONS SHOWING1. 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.

1

22 3

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.

T2 hyperintensity

Gradientblooming

T1hyperintensity

FLAIRFLOWVOID

CEREBRAL VEINS-VALVELESS,THIN

EXTERNAL

SUPERIOR MIDDLE

SUPERFICIAL

DEEP

CAVERNOUS OR

SPHENOPARIETALSINUSSUPERIOR

SAGITTAL SINUS

BASAL VEIN

INTERNAL-2 IN NUMBER- JOIN TO FORM GREAT CEREBRAL VEIN

INFERIOR

SUP.CER.VN OR CAV.SIN.

BASAL VN RECEIVES

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.

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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