1. Case Presentation Neuroradiology Block
Swartbooi
Diag Rad
UFS

2. Patient Information 16 yr old female patient Day 4 post partum
Referred from Manapo Hospital
Presented with persistant convulsions
Severe headache
N & V
Treated for Eclampsia
No response to RX
Admitted 12 June at Universitas Neurology for further management

3. Clinical Presentation
Patient acutely ill
Vitals normal
JACCOL NAD
Disorientated
No Neck Stiffness
Left hemiplegia
CVS, RESP, GIT Exam – NAD

4. Lab Results U&E N FBC HB 12.2 Platelets 291 WCC N HIV (-)
Virology NAD (Herpes, Syphillis)

5. Imaging
Computed Tomography

6. Imaging
Computed Tomography

7. Imaging
Computed Tomography

8. Imaging
Computed Tomography

9. Imaging
Computed Tomography

10. Imaging Computed Tomography Oedema (R) Temporoparietal lobe
No Haemorrhage
No Venous sinus Thrombosis
Patient basal cisternae
Lumbar Puncture done
NAD

11. Magnetic Resonance Imaging

12. Imaging

13. Magnetic Resonance Imaging

14. Magnetic Resonance Imaging

15. Magnetic Resonance Imaging

16. Magnetic Resonance Imaging

17. Imaging
MRI
High Signal intensity right occipital lobe and right temporal lobe
No other cerebral parenchymal abnormalities
No SSS Thrombosis
Right transverse and Sigmoid sinuses normal
Left tranverse and Sigmoid sinuses not visualized
No secondary signs of thrombosis noted
Lesion of low signal on T1 and of high signal intensity on T2 and FLAIR sequences in the splenium of corpus callosum

18. Discussion Venous Sinus Thrombosis Causes
Diverse, with over 100 causes identified
Trauma
Tumors
Infections
Dehydration
Behcet disease
Coagulopathies related to systemic disease
Congenital coagulation disorders
Pregnancy
Post-partum period
Use of oral contraceptives
Cause unknown in % of cases

19. Discussion Venous Sinus Thrombosis CT Findings
Noncontrast CT scan, the classic finding is the delta sign, which is observed as a dense triangle (from hyperdense thrombus) within the superior sagittal sinus
On contrast-enhanced CT scan, the reverse delta sign (ie, empty triangle sign) can be observed in the superior sagittal sinus from enhancement of the dural leaves surrounding the comparatively less dense thrombosed sinus.
The presence of both the delta and reverse delta signs increases the likelihood of the diagnosis.

20. Axial non-contrast CT shows high density in the right transverse sinus, consistent with acute thrombus

21. Discussion Venous Sinus Thrombosis CT Findings
infarctions in a nonarterial distribution in the white matter and/or cortical white matter junction, often associated with hemorrhage, should suggest the possible diagnosis of venous thrombosis
Bilateral cerebral involvement can occur, including the superior cerebral white matter of the convexities from superior sagittal sinus thrombosis, or the basal ganglia and thalami from internal cerebral vein thrombosis in which the internal cerebral veins appear hyperdense in the noncontrast scan

22. Discussion Venous Sinus Thrombosis Indirect CT Findings
Focal cerebral cortical ischemia with gyral enhancement
Small ventricles compressed by cerebral edema
Intense tentorial enhancement
Occasionally the transcerebral medullary cortical veins can be observed

23. Discussion Venous Sinus Thrombosis CT Limitations
Characteristic CT scan appearances and signs strongly suggest cerebral venous thrombosis, but CT scans are seldom conclusively diagnostic
Because of the subtlety of the findings, the prospective diagnosis of venous thrombosis may not be made unless a high index of suspicion is maintained during interpretation of the CT study
A false-positive delta sign may occur in a trauma setting because of an adjacent subdural hematoma

24. Discussion Venous Sinus Thrombosis MRI Findings
In most patients, MRI brain scan with MRV is recommended to establish the CT diagnosis
Parenchymal regions of T2-hyperintense signal abnormality in the distribution of the draining sinus is often observed
Frequent parenchymal MRI finding is thalamic edema
Restricted diffusion may or may not be seen in cerebral venous thrombosis
Dilated venous collaterals, such as transcortical medullary veins, provide indirect evidence of venous thrombosis

25. Discussion Venous Sinus Thrombosis MRI Findings
The diagnosis usually can be made without intravenous contrast, although contrast enhancement can aid in confirming the diagnosis
A thrombus can be directly visualized within a vessel
Secondary venous infarctions and foci of hemorrhage can be seen with gradient-echo images

26. Discussion Venous Sinus Thrombosis MRI Limitations
Hypoplasia or severe attenuation of a transverse sinus, which are normal anatomic variants, may simulate venous sinus thrombosis
In-plane flow-induced signal loss in 2D TOF MRV also can mimic intravenous thrombus
Prominent arachnoid granulations may simulate thrombus

27. Discussion
Hyperintense signal in the thrombosed superior sagittal sinus
MRV – TOF revealed absence of a signal in the superior sagittal sinus

28. Discussion Venous Sinus Thrombosis Angiography Findings
Cerebral catheter arteriography and venography was used before the advent of MRI to confirm the diagnosis
Classic findings
Filling defects from thrombus within the venous sinus
Occlusion of a draining sinus

29. Discussion Venous Sinus Thrombosis Angiography Findings
Secondary indirect angiographic findings are as follows:
Decreased focal venous circulation around a thrombosed venous sinus
Visualization of collateral circulation
Narrowing of arteries in the involved region
Prolonged contrast blush in the brain parenchyma
Tortuous vessels in the capillary and venous phases
Collateral flow in dilated anastomotic vessels

30. Discussion
Large part of the superior sagittal sinus and some cortical veins do not fill with contrast material

31. Discussion Diagnosis No Venous Sinus Thrombosis
Absent / Hypoplastic Left Transverse Venous Sinus
Posterior Reversible Encephalopathy Syndrome

32. Discussion
PRES
Classically characterized as symmetric parietooccipital edema but may occur in other distributions with varying imaging appearances
Usually reversible neurologic syndrome with a variety of presenting symptoms ranging from headache, altered mental status, seizures, and vision loss to loss of consciousness

33. Discussion PRES Causes Hypertension Eclampsia and preeclampsia
Immunosuppressive medications such as cyclosporine
Various antineoplastic agents
Severe hypercalcemia
Thrombocytopenic syndromes
Henoch-Schönlein purpura
Hemolytic uremic syndrome
Amyloid angiopathy
Systemic lupus erythematosus
Various causes of renal failure

34. Discussion
PRES
Mechanism is not entirely understood but is thought to be related to a hyperperfusion state, with blood–brain barrier breakthrough, extravasation of fluid potentially containing blood or macromolecules, and resulting cortical or subcortical edema
It has also been proposed that vasospasm may precipitate the reversible edema, leading to cytotoxic edema if left untreated

35. Discussion
PRES
Typical imaging findings of PRES are most apparent as hyperintensity on FLAIR images in the parietooccipital and posterior frontal cortical and subcortical white matter
Less commonly, the brainstem, basal ganglia, and cerebellum are involved

36. Discussion
PRES
Blood pressure may even be normal in some cases of PRES
Chemotherapy
Immunosuppressive therapy
Sepsis
Insult from raised blood pressure could persist for days after the onset of symptoms
Radiologists should be aware that PRES may occasionally present with minimal or no detectable parietooccipital edema

37. Imaging Incidental Finding
Lesion in the Splenium of the Corpus Callosum

38. Imaging Incidental Finding
Lesion in the Splenium of the Corpus Callosum

39. Discussion Corpus Callosum Lesions Often reversible changes due to:
Vasogenic edema following a seizure
Withdrawal of an antiepileptic drug
Reversible demyyelination due to Antiepileptic drug toxicity
Trauma
Infarct
High altitude cerebral oedema
Neoplasm
Adrenoleukodystrophy and other leukodystrophies
AIDS dementia complex
Marchiafava–Bignami disease
Childhood-onset anorexia nervosa
Multiple sclerosis
Non-specefic end point of different disease processes leading to vasogenic oedema

40. Patient Outcome Clinical dx – Transverse sinus Thrombosis
Treated as follows:
Therapeutic LP
Diamox
Tramal and Dolorol
Epilim
Clexane
Warfarin
Recovered remarkably regaining full power and higher functions
Discharged 23 July
Stable condition
No Neurological deficit

41. References Intracranial MR Venography in Children: Normal
Anatomy and Variations; AJNR :
Thrombosis of the Cerebral Veins and Sinuses;NEJM
352;
Posterior Reversible Encephalopathy Syndrome:
Incidence of Atypical Regions of Involvement and
Imaging Findings; AJR 2007; 189:904–912
Focal lesion in the splenium of the corpus callosum in
epileptic patients: Antiepileptic drug toxicity? AJNR
Neuroradiol. 1999;20:125–9