Case PresentationCase PresentationNeuroradiology BlockNeuroradiology Block

A.A. SwartbooiSwartbooi

Diag RadDiag Rad

UFSUFS

Patient InformationPatient Information16 yr old female patient 16 yr old female patient

Day 4 post partumDay 4 post partum

Referred from Manapo Hospital Referred from Manapo Hospital – Presented with persistant convulsionsPresented with persistant convulsions– Severe headacheSevere headache– N & VN & V– Treated for EclampsiaTreated for Eclampsia

No response to RXNo response to RX

Admitted 12 June at Universitas Neurology for Admitted 12 June at Universitas Neurology for further managementfurther management

Clinical PresentationClinical PresentationPatient acutely illPatient acutely ill

Vitals normalVitals normal

JACCOL NADJACCOL NAD

DisorientatedDisorientated

No Neck StiffnessNo Neck Stiffness

Left hemiplegiaLeft hemiplegia

CVS, RESP, GIT Exam – NADCVS, RESP, GIT Exam – NAD

Lab ResultsLab ResultsU&EU&E NN

FBCFBC HB 12.2HB 12.2

Platelets 291Platelets 291

WCC NWCC N

HIV HIV (-)(-)

VirologyVirology NAD (Herpes, Syphillis)NAD (Herpes, Syphillis)

ImagingImagingComputed TomographyComputed Tomography

ImagingImagingComputed TomographyComputed Tomography

ImagingImagingComputed TomographyComputed Tomography

ImagingImagingComputed TomographyComputed Tomography

ImagingImagingComputed TomographyComputed Tomography

ImagingImagingComputed TomographyComputed Tomography– Oedema (R) Temporoparietal lobeOedema (R) Temporoparietal lobe– No HaemorrhageNo Haemorrhage– No Venous sinus ThrombosisNo Venous sinus Thrombosis– Patient basal cisternaePatient basal cisternae

Lumbar Puncture doneLumbar Puncture done– NADNAD

ImagingImagingMagnetic Resonance ImagingMagnetic Resonance Imaging

ImagingImaging

ImagingImagingMagnetic Resonance ImagingMagnetic Resonance Imaging

ImagingImagingMagnetic Resonance ImagingMagnetic Resonance Imaging

ImagingImagingMagnetic Resonance ImagingMagnetic Resonance Imaging

ImagingImagingMagnetic Resonance ImagingMagnetic Resonance Imaging

ImagingImagingMRIMRI– High Signal intensity right occipital lobe and right High Signal intensity right occipital lobe and right

temporal lobetemporal lobe– No other cerebral parenchymal abnormalitiesNo other cerebral parenchymal abnormalities– No SSS ThrombosisNo SSS Thrombosis– Right transverse and Sigmoid sinuses normalRight transverse and Sigmoid sinuses normal– Left tranverse and Sigmoid sinuses not visualizedLeft tranverse and Sigmoid sinuses not visualized– No secondary signs of thrombosis notedNo secondary signs of thrombosis noted– Lesion of low signal on T1 and of high signal intensity on Lesion of low signal on T1 and of high signal intensity on

T2 and FLAIR sequences in the splenium of corpus T2 and FLAIR sequences in the splenium of corpus callosumcallosum

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– CausesCauses

Diverse, with over 100 causes identifiedDiverse, with over 100 causes identified

TraumaTrauma

Tumors Tumors

InfectionsInfections

Dehydration Dehydration

Behcet diseaseBehcet disease

Coagulopathies related to systemic diseaseCoagulopathies related to systemic disease

Congenital coagulation disordersCongenital coagulation disorders

PregnancyPregnancy

Post-partum periodPost-partum period

Use of oral contraceptivesUse of oral contraceptives

Cause unknown in 20-25 % of casesCause unknown in 20-25 % of cases

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– CT FindingsCT Findings

Noncontrast CT scan, the classic finding is the delta sign, which is Noncontrast CT scan, the classic finding is the delta sign, which is observed as a dense triangle (from hyperdense thrombus) within observed as a dense triangle (from hyperdense thrombus) within the superior sagittal sinusthe superior sagittal sinus

On contrast-enhanced CT scan, the reverse delta sign (ie, empty On contrast-enhanced CT scan, the reverse delta sign (ie, empty triangle sign) can be observed in the superior sagittal sinus from triangle sign) can be observed in the superior sagittal sinus from enhancement of the dural leaves surrounding the comparatively enhancement of the dural leaves surrounding the comparatively less dense thrombosed sinus. less dense thrombosed sinus.

The presence of both the delta and reverse delta signs increases The presence of both the delta and reverse delta signs increases the likelihood of the diagnosis.the likelihood of the diagnosis.

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

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– CT FindingsCT Findings

infarctions in a nonarterial distribution in the white matter and/or infarctions in a nonarterial distribution in the white matter and/or cortical white matter junction, often associated with hemorrhage, cortical white matter junction, often associated with hemorrhage, should suggest the possible diagnosis of venous thrombosisshould suggest the possible diagnosis of venous thrombosis

Bilateral cerebral involvement can occur, including the superior Bilateral cerebral involvement can occur, including the superior cerebral white matter of the convexities from superior sagittal cerebral white matter of the convexities from superior sagittal sinus thrombosis, or the basal ganglia and thalami from internal sinus thrombosis, or the basal ganglia and thalami from internal cerebral vein thrombosis in which the internal cerebral veins cerebral vein thrombosis in which the internal cerebral veins appear hyperdense in the noncontrast scanappear hyperdense in the noncontrast scan

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– Indirect CT FindingsIndirect CT Findings

Focal cerebral cortical ischemia with gyral enhancementFocal cerebral cortical ischemia with gyral enhancement

Small ventricles compressed by cerebral edemaSmall ventricles compressed by cerebral edema

Intense tentorial enhancementIntense tentorial enhancement

Occasionally the transcerebral medullary cortical veins can be Occasionally the transcerebral medullary cortical veins can be observedobserved

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– CT LimitationsCT Limitations

Characteristic CT scan appearances and signs strongly suggest Characteristic CT scan appearances and signs strongly suggest cerebral venous thrombosis, but CT scans are seldom conclusively cerebral venous thrombosis, but CT scans are seldom conclusively diagnosticdiagnostic

Because of the subtlety of the findings, the prospective diagnosis Because of the subtlety of the findings, the prospective diagnosis of venous thrombosis may not be made unless a high index of of venous thrombosis may not be made unless a high index of suspicion is maintained during interpretation of the CT studysuspicion is maintained during interpretation of the CT study

A false-positive delta sign may occur in a trauma setting because A false-positive delta sign may occur in a trauma setting because of an adjacent subdural hematomaof an adjacent subdural hematoma

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– MRI FindingsMRI Findings

In most patients, MRI brain scan with MRV is recommended to In most patients, MRI brain scan with MRV is recommended to establish the CT diagnosisestablish the CT diagnosis

Parenchymal regions of T2-hyperintense signal abnormality in the Parenchymal regions of T2-hyperintense signal abnormality in the distribution of the draining sinus is often observeddistribution of the draining sinus is often observed

Frequent parenchymal MRI finding is thalamic edemaFrequent parenchymal MRI finding is thalamic edema

Restricted diffusion may or may not be seen in cerebral venous Restricted diffusion may or may not be seen in cerebral venous thrombosisthrombosis

Dilated venous collaterals, such as transcortical medullary veins, Dilated venous collaterals, such as transcortical medullary veins, provide indirect evidence of venous thrombosisprovide indirect evidence of venous thrombosis

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– MRI FindingsMRI Findings

The diagnosis usually can be made without intravenous contrast, The diagnosis usually can be made without intravenous contrast, although contrast enhancement can aid in confirming the diagnosisalthough contrast enhancement can aid in confirming the diagnosis

A thrombus can be directly visualized within a vesselA thrombus can be directly visualized within a vessel

Secondary venous infarctions and foci of hemorrhage can be seen Secondary venous infarctions and foci of hemorrhage can be seen with gradient-echo imageswith gradient-echo images

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– MRI LimitationsMRI Limitations

Hypoplasia or severe attenuation of a transverse sinus, which are Hypoplasia or severe attenuation of a transverse sinus, which are normal anatomic variants, may simulate venous sinus thrombosisnormal anatomic variants, may simulate venous sinus thrombosis

In-plane flow-induced signal loss in 2D TOF MRV also can mimic In-plane flow-induced signal loss in 2D TOF MRV also can mimic intravenous thrombusintravenous thrombus

Prominent arachnoid granulations may simulate thrombusProminent arachnoid granulations may simulate thrombus

DiscussionDiscussion– Hyperintense signal in the thrombosed superior sagittal Hyperintense signal in the thrombosed superior sagittal

sinussinus– MRV – TOF revealed absence of a signal in the superior sagittal sinusMRV – TOF revealed absence of a signal in the superior sagittal sinus

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– Angiography FindingsAngiography Findings

CCerebral catheter arteriography and venography was used erebral catheter arteriography and venography was used before the advent of MRI to confirm the diagnosisbefore the advent of MRI to confirm the diagnosis

Classic findingsClassic findings– Filling defects from thrombus within the venous sinusFilling defects from thrombus within the venous sinus– Occlusion of a draining sinusOcclusion of a draining sinus

DiscussionDiscussionVenous Sinus ThrombosisVenous Sinus Thrombosis– Angiography FindingsAngiography Findings

Secondary indirect angiographic findings are as follows:Secondary indirect angiographic findings are as follows:– Decreased focal venous circulation around a thrombosed Decreased focal venous circulation around a thrombosed

venous sinusvenous sinus– Visualization of collateral circulationVisualization of collateral circulation– Narrowing of arteries in the involved regionNarrowing of arteries in the involved region– Prolonged contrast blush in the brain parenchymaProlonged contrast blush in the brain parenchyma– Tortuous vessels in the capillary and venous phasesTortuous vessels in the capillary and venous phases– Collateral flow in dilated anastomotic vesselsCollateral flow in dilated anastomotic vessels

DiscussionDiscussion

– Large part of the superior Large part of the superior sagittal sinus and some sagittal sinus and some cortical veins do not fill cortical veins do not fill with contrast materialwith contrast material

DiscussionDiscussionDiagnosisDiagnosis

– No Venous Sinus Thrombosis No Venous Sinus Thrombosis Absent / Hypoplastic Left Transverse Venous SinusAbsent / Hypoplastic Left Transverse Venous Sinus

– Posterior Reversible Encephalopathy SyndromePosterior Reversible Encephalopathy Syndrome

DiscussionDiscussionPRESPRES– Classically characterized as symmetric parietooccipital Classically characterized as symmetric parietooccipital

edema but may occur in other distributions with varying edema but may occur in other distributions with varying imaging appearancesimaging appearances

– Usually reversible neurologic syndrome with a variety of Usually reversible neurologic syndrome with a variety of presenting symptoms ranging from headache, altered presenting symptoms ranging from headache, altered mental status, seizures, and vision loss to loss of mental status, seizures, and vision loss to loss of consciousnessconsciousness

DiscussionDiscussionPRESPRES– CausesCauses

HypertensionHypertension

Eclampsia and preeclampsiaEclampsia and preeclampsia

Immunosuppressive medications such as cyclosporineImmunosuppressive medications such as cyclosporine

Various antineoplastic agentsVarious antineoplastic agents

Severe hypercalcemiaSevere hypercalcemia

Thrombocytopenic syndromesThrombocytopenic syndromes

Henoch-Schönlein purpuraHenoch-Schönlein purpura

Hemolytic uremic syndromeHemolytic uremic syndrome

Amyloid angiopathyAmyloid angiopathy

Systemic lupus erythematosusSystemic lupus erythematosus

Various causes of renal failureVarious causes of renal failure

DiscussionDiscussionPRESPRES– Mechanism is not entirely understood but is thought to Mechanism is not entirely understood but is thought to

be related to a hyperperfusion state, with blood–brain be related to a hyperperfusion state, with blood–brain barrier breakthrough, extravasation of fluid potentially barrier breakthrough, extravasation of fluid potentially containing blood or macromolecules, and resulting containing blood or macromolecules, and resulting cortical or subcortical edema cortical or subcortical edema

– It has also been proposed that vasospasm may It has also been proposed that vasospasm may precipitate the reversible edema, leading to cytotoxic precipitate the reversible edema, leading to cytotoxic edema if left untreatededema if left untreated

DiscussionDiscussionPRESPRES– Typical imaging findings of PRES are most apparent as Typical imaging findings of PRES are most apparent as

hyperintensity on FLAIR images in the parietooccipital hyperintensity on FLAIR images in the parietooccipital and posterior frontal cortical and subcortical white and posterior frontal cortical and subcortical white mattermatter

– Less commonly, the brainstem, basal ganglia, and Less commonly, the brainstem, basal ganglia, and cerebellum are involvedcerebellum are involved

DiscussionDiscussionPRESPRES– Blood pressure may even be normal in some cases of Blood pressure may even be normal in some cases of

PRESPRESChemotherapyChemotherapy

Immunosuppressive therapyImmunosuppressive therapy

SepsisSepsis

– Insult from raised blood pressure could persist for days Insult from raised blood pressure could persist for days after the onset of symptomsafter the onset of symptoms

– Radiologists should be aware that PRES may Radiologists should be aware that PRES may occasionally present with minimal or no detectable occasionally present with minimal or no detectable parietooccipital edemaparietooccipital edema

ImagingImagingIncidental FindingIncidental Finding– Lesion in the Splenium of the Corpus CallosumLesion in the Splenium of the Corpus Callosum

ImagingImagingIncidental FindingIncidental Finding– Lesion in the Splenium of the Corpus CallosumLesion in the Splenium of the Corpus Callosum

DiscussionDiscussionCorpus Callosum LesionsCorpus Callosum Lesions– Often reversible changes due to:Often reversible changes due to:

Vasogenic edema following a seizureVasogenic edema following a seizure

Withdrawal of an antiepileptic drugWithdrawal of an antiepileptic drug

Reversible demyyelination due to Antiepileptic drug toxicityReversible demyyelination due to Antiepileptic drug toxicity

TraumaTrauma

Infarct Infarct

High altitude cerebral oedemaHigh altitude cerebral oedema

Neoplasm Neoplasm

Adrenoleukodystrophy and other leukodystrophiesAdrenoleukodystrophy and other leukodystrophies

AIDS dementia complexAIDS dementia complex

Marchiafava–Bignami diseaseMarchiafava–Bignami disease

Childhood-onset anorexia nervosaChildhood-onset anorexia nervosa

Multiple sclerosisMultiple sclerosis

– Non-specefic end point of different disease processes leading Non-specefic end point of different disease processes leading to vasogenic oedemato vasogenic oedema

Patient OutcomePatient OutcomeClinical dx – Transverse sinus ThrombosisClinical dx – Transverse sinus Thrombosis

Treated as follows:Treated as follows:– Therapeutic LPTherapeutic LP– DiamoxDiamox– Tramal and DolorolTramal and Dolorol– EpilimEpilim– ClexaneClexane– WarfarinWarfarin

Recovered remarkably regaining full power and Recovered remarkably regaining full power and higher functionshigher functions

Discharged 23 JulyDischarged 23 July– Stable conditionStable condition– No Neurological deficitNo Neurological deficit

ReferencesReferencesIntracranial MR Venography in Children: Normal Intracranial MR Venography in Children: Normal

Anatomy and Variations; Anatomy and Variations; AJNR 2004 25: 1557-1562AJNR 2004 25: 1557-1562Thrombosis of the Cerebral Veins and Sinuses;NEJM Thrombosis of the Cerebral Veins and Sinuses;NEJM

352;17 2005352;17 2005Posterior Reversible Encephalopathy Syndrome: Posterior Reversible Encephalopathy Syndrome:

Incidence of Atypical Regions of Involvement and Incidence of Atypical Regions of Involvement and

Imaging Findings;Imaging Findings; AJR 2007; 189:904–912 AJR 2007; 189:904–912Focal lesion in the splenium of the corpus callosum in Focal lesion in the splenium of the corpus callosum in

epileptic patients: Antiepileptic drug toxicity? AJNR epileptic patients: Antiepileptic drug toxicity? AJNR

Neuroradiol. 1999;20:125–9Neuroradiol. 1999;20:125–9