Presentation
Seizure episode.
Patient Data
There is evidence of acute intracerebral hemorrhage involving the right basal ganglia and intraventricular hemorrhage mainly seen in the third ventricle extending into the occipital horns bilaterally and anterior horn of the right lateral ventricle.
Areas of hypodensities in the basal ganglia and distended hyperdense internal cerebral veins are also seen.
No shift of midline structures or signs of space-occupying mass lesions could be seen.
Rest of the brain parenchyma appears homogeneous.
Brainstem and cerebellum appear normal.
CTA intracranial cerebral &...
CTA intracranial cerebral & neck arteries
Both internal carotid arteries and their bifurcation into anterior and middle cerebral arteries were visualized. They appear with smooth wall and normal caliber without evidence of occlusion or stenosis.
Both carotid and vertebral arteries were opacified and appear normal without evidence of narrowing or occlusion.
No evidence of gross aneurysm or arteriovenous malformation.
The vertebrobasilar arterial system appears also normal.
IMPRESSION :
Normal C.T Angiogram of the intracranial cerebral and neck arteries.
There is a large partly hemorrhagic infarct located in the thalami, basal ganglia and most of the corpus callosum with diffusion restriction "signal drop-in ADC map and signal drop-in SWI"
Intraventricular hemorrhage is seen again with mild ventricular dilatation.
Scattered acute lacunar infarcts involving centrum semiovale bilaterally is also seen.
Absent flow of the straight sinus, inferior sagittal sinus, vein of Galen, internal cerebral veins and proximal aspect of the left transverse sinus indicating thrombosis.
Preserved flow of the superior sagittal sinus, and sigmoid sinuses.
Compared to previous studies.
There is significant worsening of the previously described hemorrhagic venous infarctions, involving the basal ganglia bilaterally, periventricular white matter and the right parietal lobe.
Further worsening of the intraventricular hemorrhage and hydrocephalus is also noted.
Case Discussion
This is a 25-year-old lady presenting through the emergency room after developing confusion and irritability following seizure episode. Brain CT was requested and showed acute intracerebral hemorrhage involving the right basal ganglia with intraventricular extension involving mainly the third ventricle. The patient was admitted and CT angiogram of the neck and intracranial arteries turned back to be normal. The treating team requested MRV to rule out the possibility of venous thrombosis, and the study showed evidence of sinus thrombosis complicated by infarction and hemorrhage. Two days later the patient developed an episode of decreased level of consciousness, and CT of the brain was done, unfortunately depicting further worsening of the hemorrhage with dilatation of lateral and third ventricles.
Venous infarction should be thought of in the assessment of confluent infarct/hemorrhage in atypical areas or infracts crossing arterial territories "not corresponding to typical arterial territory" or with cortical sparing.
They occur most commonly secondary to venous thrombosis and frequently manifests with hemorrhage and/or infarction in up to 50% of cases. They can occur following trauma, dural AVF, and following ligation. Typical areas of venous infraction:
- parasagittal structures (sagittal sinus thrombosis)
- temporoparietal regions (transverse / sigmoid sinus thrombosis)
- deep structures