Case Presentation Neuroradiology Block Swartbooi Diag Rad UFS

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

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

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

Imaging Computed Tomography

Imaging Computed Tomography

Imaging Computed Tomography

Imaging Computed Tomography

Imaging Computed Tomography

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

Magnetic Resonance Imaging

Imaging

Magnetic Resonance Imaging

Magnetic Resonance Imaging

Magnetic Resonance Imaging

Magnetic Resonance Imaging

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

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 20-25 % of cases

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Imaging Incidental Finding Lesion in the Splenium of the Corpus Callosum

Imaging Incidental Finding Lesion in the Splenium of the Corpus Callosum

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

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

References Intracranial MR Venography in Children: Normal Anatomy and Variations; AJNR 2004 25: 1557-1562 Thrombosis of the Cerebral Veins and Sinuses;NEJM 352;17 2005 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