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RADIOLOGY OSBORN > VASCULAR MALFORMATIONS GALLERY > Flashcards

VASCULAR MALFORMATIONS GALLERY Flashcards

1
Q

What are the parts of the AVM

A

Graphic depicts AVM nidus with intranidal aneurysm , feeding artery (“pedicle”) aneurysm , and enlarged draining veins

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2
Q

Dx?

A

NECT scan (upper left) and CTA images in a patient with spontaneous cerebellar hemorrhage demonstrate an underlying AVM . Approximately 15% of AVMs are infratentorial

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3
Q

Describe the classic MRI findings of AVM

A

Axial T1WI in a 32-yearold man with headache shows a classic wedge-shaped left parietal AVM with multiple serpentine “flow voids” .

A few linear foci of T1 shortening represent thrombosed vessels within the nidus. T2WI in the same patient nicely demonstrates the wedge of “flow voids” . The broad base toward the cortex with apex pointing toward the lateral ventricle is a typical configuration for

brain AVMs.

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4
Q

FLAIR findings of AVM

A

FLAIR scan demonstrates minimal hyperintensity within and around the AVM , suggesting small foci of gliotic brain.. T1 C+ scan shows some linear and serpentine areas of enhancement that are mostly in draining veins.

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5
Q

What is your dx?

A

DSA of selective internal carotid angiogram in a patient with cerebral proliferative angiopathy shows

innumerable dilated vascular spaces with no dominant feeding arteries

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6
Q

Describe the parts of the DAVF

A

Graphic depicts dAVF with thrombosed transverse sinus with multiple tiny arteriovenous in the

dural wall . Lesion is mostly supplied by transosseous feeders from the external carotid artery

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7
Q

What is your dx?

A

Contrast-enhanced MRA source image shows dural sinus thrombosis , multiple enhancing vascular channels characteristic of posterior fossa dAVF. . MRA in the same patient shows innumerable tiny feeding arteries supplying a dAVF at the transverse-sigmoid sinus junction. The sinus has partially recanalized , and the distal sigmoid sinus and jugular bulb are partially opacified

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8
Q

What is your dx?

A

Autopsy case of direct CCF with dissection of the cavernous sinus (CS) and adjacent structures shows

that the right CS is enlarged by numerous dilated vascular channels

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9
Q

What is shown?

A

Clinical photograph of a patient with a CCF shows numerous enlarged scleral vessels . 7-17. CECT

scan shows classic findings of CCF. The right cavernous sinus is enlarged , and the ipsilateral superior

ophthalmic vein is more than 4 times the size of the left superior ophthalmic vein

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10
Q

Describe the MRI

A

T2WI shows typical MR findings of CCF with an enlarged right cavernous sinus containing numerous abnormal “flow voids” . Lateral DSA in a case of direct CCF in a 21-year-old woman with multiple skull base fractures shows that the ICA narrows before terminating in a large venous pouch . High-pressure venous reflux into the superior and inferior ophthalmic veins and the sphenoparietal sinus is present.

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11
Q

What is shown?

A

Pial AVF with slightly enlarged ACA branches connecting to a venous varix , dilated cortical

draining vein .

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12
Q

Describe the draining vessels of the AVF

A

Coronal T1 C+ scan shows a pial AVF in the posterior fossa. A small cerebellar artery connects

directly to a venous pouch , which in turn drains into a subependymal vein near the fourth

ventricle.

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13
Q

What is shown?

A

Graphic illustrates vein of Galen malformation. Enlarged choroid arteries drain directly into

dilated median prosencephalic vein (MPV) , falcine sinus . Torcular herophili (venous sinus

confluence) is massively enlarged.

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14
Q

What is the dx?

A

CECT scan in a newborn demonstrates a massive VGAM draining into an enlarged falcine sinus

, causing obstructive hydrocephalus

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15
Q

What is shown?

A

CECT, CTA depict classic DVA in the left cerebellar hemisphere

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16
Q

Where do the veins collect?

A

T1 C+ scan shows a classic DVA with enlarged WM veins and a collector vein draining into the anterior aspect of the superior sagittal sinus. SWI scan shows the DVA and collector vein as hypointense structures clearly different in configuration from the normal cortical veins. A focal hemorrhage adjacent to the left frontal horn is secondary to a small cavernous malformation. DVAs are often

histologically mixed lesions.

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17
Q

Describe the medullary veins

A

3D SSD demonstrates a classic DVA with enlarged medullary veins draining into the collector vein

. The appearance resembles a “Medusa head,” “upside-down willow tree” or “umbrella.”

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18
Q

What is shown?

A

T2WI shows classic “popcorn ball” appearance with locules of blood in different stages of evolution

surrounded by hemosiderin rim

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19
Q

What type of Cavernoma is shown?

A

Zabramski type 1 CCM is illustrated. (Left) T1WI shows that the lesion is hyperintense and surrounded by a hypointense hemosiderin rim .

(Right) T2* GRE scan shows “blooming” hypointensity both around and within the lesion. Microscopic section from the resected specimen in the same case shows a blood-filled cavity surrounded by thin endothelium-lined vascular channels

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20
Q

What type of Cavernoma is shown?

A

T2WI in a patient with multiple cerebral cavernous malformations shows a large left frontal lesion

with a fluid-fluid level . Multiple other hypointense lesions are present . 7-42B. T2* SWI shows

innumerable “blooming black dots” characteristic of Zabramski type 4 CCM (punctate microhemorrhages).

T2* scans are much more sensitive than FSE T2WI in depicting field inhomogeneities

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21
Q

What is shown?

A

Series of images demonstrates classic findings of pontine capillary telangiectasia. Axial T1WI is normal. Axial T2WI in the same patient likewise shows no abnormality.

FLAIR scan shows faint patchy hyperintensity in the pons. T2* GRE scan shows susceptibility effect with grayish hypointensity in the mid pons

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22
Q

What is your dx?

A

T1 C+ scan shows the brush-like faint enhancement that is characteristic of capillary telangiectasia. 7-47F. DTI fiber tracking is normal. The transverse pontine fibers cross undisturbed through the lesion

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23
Q

This figure is characteristic of?

A

(Top) Axial and (bottom) coronal T1 C+ scans show that the lesion enhances in a brush-like fashion. A prominent central draining vein is present . Imaging findings are characteristic of capillary telangiectasia

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24
Q
A

A patient with a history of whole brain radiation 5 years earlier for a WHO grade III anaplastic astrocytoma developed seizures. T2* GRE scan shows multiple “blooming” hypointensities.

T2* SWI scan in the same patient shows innumerable punctate microhemorrhages. Findings are

consistent with radiation-induced capillary telangiectasias

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25
Q

By convention, the extracranial ICA—which

normally has no named branches in the neck—is designated as the________

A

C1 (cervical) segment

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26
Q

C2 (PETROUS) ICA SEGMENT. The C2 (petrous) segment is contained within the carotid canal of the temporal bone

and is L-shaped (8-1). As it enters the skull at the exocranial opening of the carotid canal, the ICA lies just in front

of the______

A

internal jugular vein

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27
Q

What are the branches of C2

A

The vidian artery, also known as the artery of the pterygoid canal, anastomoses with branches of the external carotid artery (ECA). The caroticotympanic artery is a small ICA branch that supplies the middle ear

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28
Q

The _________is a short segment that lies just above the foramen lacerum and extends from the petrous apex to the cavernous sinus

A

C3 (lacerum) segment

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29
Q

What are the parts of the C4 segment

A

In order, these are (1) a short posterior ascending (vertical) segment, (2) the posterior genu, (3) a longer horizontal segment, (4) an anterior genu, and (5) an anterior vertical ascending (subclinoid) segment.

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30
Q

What are the branches of the C4 segment?

A

The meningohypophyseal trunk arises from the posterior genu, supplying the pituitary gland, tentorium, and clival dura.

The inferolateral trunk (ILT) arises from the lateral aspect of the intracavernous ICA and supplies cranial nerves and CS dura

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31
Q

The __________is a short interdural segment that lies between the proximal and distal dural rings of the CS. It terminates as the ICA exits the CS and enters the cranial cavity adjacent to the anterior clinoid process

A

C5 (clinoid) segment

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32
Q

The ________is the first ICA segment that lies wholly within the subarachnoid space

A

C6 (ophthalmic) segment

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33
Q

What are the branches of the C6 segment?

A

The ophthalmic artery (OA) arises from the anterosuperior aspect of the ICA, then passes anteriorly through the optic canal together with CN II. The OA has extensive anastomoses with ECA branches in and around the orbit and lacrimal gland.

The superior hypophyseal artery arises from the posterior aspect of the C6 ICA segment and supplies the anterior pituitary lobe (adenohypophysis) and infundibular

stalk as well as the optic chiasm.

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34
Q

________is the last ICA segment and extends from just below the PCoA origin to the terminal ICA bifurcation into the ACA and MCA. As it courses posterosuperiorly,

the ICA passes between the optic and oculomotor nerves

A

The C7 (communicating) segment

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35
Q

What are the branches of C7

A

The PCoA joins the anterior to the posterior circulation. A number of perforating arteries arise from the PCoA to supply the basal brain structures including the

hypothalamus.

The anterior choroidal artery (AChA) arises one or two millimeters above the PCoA and initially courses

posteromedially, then turns laterally in the suprasellar cistern to enter the choroidal fissure of the temporal horn.

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36
Q

What are the three ICA vascular anomalies?

A

Three important ICA vascular anomalies must be recognized on imaging studies: An aberrant ICA (AbICA), a

persistent stapedial artery, and an embryonic carotidbasilar anastomosis

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37
Q

A ____________is the most common COW

variant and occurs in one-quarter to onethird of all cases

A

hypoplastic or absent PCoA

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38
Q

The ___________also termed the horizontal or A1 segment, extends medially over the optic chiasm and nerves to the midline where it is joined to the contralateral ACA by the anterior communicating artery (ACoA).

A

first ACA segment,

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39
Q

Branches of the A1 segment

A

The medial lenticulostriate arteries pass superiorly through the anterior perforated substance to supply the medial basal ganglia.

The recurrent artery of Heubner arises from the distal A1 or proximal A2 ACA segment and curves

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40
Q

The _________segment courses superiorly in the interhemispheric fissure, extending from the A1-ACoA junction to the corpus callosum rostrum

A

A2 or vertical ACA

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41
Q

The A2 segment has two cortical branches, the _______ and ___________that supply the undersurface and inferomedial aspect

of the frontal lobe.

A

orbitofrontal and frontopolar arteries,

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42
Q

The A3 ACA segment curves anteriorly around the corpus callosum genu, then divides into the two terminal ACA branches, the_______ and ________

A

pericallosal and callosomarginal arteries

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43
Q

Two uncommon but important ACA anomalies:

A

An infraoptic A1 occurs when the horizontal segment passes below (not above) the optic nerve. An infraoptic A1 is associated with a highprevalence (40%) of aneurysms.

A single midline or azygous ACA is seen with the holoprosencephaly spectrum.

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44
Q

The most important branches of the M1 segment

A

The lateral lenticulostriate arteries supply the lateral putamen, caudate nucleus, and external capsule The anterior temporal artery supplies the tip of the temporal lobe.

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45
Q

The post-bifurcation MCA trunks turn posterosuperiorly in the sylvian fissure, following a gentle curve (the genu or “knee” of the MCA)

What segment?

A

M2 (INSULAR) SEGMENTS

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46
Q

The MCA branches loop at or near the top of the sylvian fissure, then course laterally under the parts (“opercula”) of the frontal, parietal, and temporal lobes that hang over and enclose the sylvian fissure.

It has 3 segments

A

M3 (OPERCULAR) SEGMENTS

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47
Q

Where is the P1 segment and what are its branches?

A

The P1 segment lies above the oculomotor nerve (CN III) and has perforating branches (the posterior thalamoperforating arteries) that course posterosuperiorly in the interpeduncular fossa to enter the undersurface of the midbrain.

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48
Q

Where is the P2 segment located?

A

The P2 segment extends from the P1-PCoA junction, running in the ambient

(perimesencephalic) cistern as it sweeps posterolaterally around the midbrain. The P2 segment lies above the

tentorium and the cisternal segment of the trochlear nerve (CN IV

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49
Q

What are the branches of P2

A

Two major cortical branches—the anterior and posterior temporal arteries—arise from the P2 PCA segment and pass laterally toward the inferior surface of the

temporal lobe

50
Q

________segment terminates within the calcarine fissure, where it divides into two

terminal PCA trunks

A

P4 (CALCARINE) SEGMENT. The P4

51
Q

Variant of the PCA

the proximal PCA arises from the internal carotid

artery instead of from the basilar bifurcation.

A

“fetal” origin of the PCA

52
Q

A rare but important PCA variant is an ____________________Here a single dominant thalamoperforating

artery arises from the P1 segment and supplies the rostral midbrain and bilateral medial thalami

A

artery of Percheron (AOP).

53
Q

The most specific but least sensitive sign is a hyperattenuating vessel filled with acute thrombus (8-33). A “dense

MCA” sign is seen in _______of cases with documented M1 occlusion

A

30%

54
Q

In CVD

Blurring and indistinctness of gray-white matter (GM-WM) interfaces can be seen in 50-70% of cases within the first

three hours following occlusion (8-37B). Loss of the insular cortex ___________ sign and decreased density of

the basal ganglia__________ sign are the most common findings

A

(“insular ribbon” sign)

(“disappearing basal ganglia” sign)

55
Q

CECT may show enhancing vessels if _____________via collaterals over the vascular watershed zone is present.

A

slow antegrade flow or retrograde filling

56
Q

_________depicts the effect of vessel occlusion on the brain parenchyma itself. It can also be used to predict potential benefit after thrombolysis.

A

Perfusion CT

57
Q

pCT has three major parameters:

A

Cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time

(MTT)

58
Q

The densely ischemic infarct core—the irreversibly injured brain—shows matched reduction in both_______

The infarct core is seen as a _________that contrasts with the normally perfused red/yellow

brain

A

CBV and CBF.

dark blue/purple or black area

59
Q

An ischemic penumbra with potentially salvageable tissue is seen as a “mismatch” between markedly reduced CBV

in the infarcted core and a surrounding area (penumbra) characterized by________

A

decreased CBF with normal CBV

60
Q

FLAIR-DWI “mismatch”(negative FLAIR, positive DWI) has been suggested as a quick indicator of_______ and ______

A

viable ischemic penumbra and eligibility

for thrombolysis.

61
Q

Intraarterial thrombus can sometimes be detected as ___________on T2* (GRE, SWI) studies

A

“blooming” hypointensity

62
Q

Signs of vessel occlusion on DSA

A

Frequent findings

include an abrupt vessel “cut-off”, “meniscus” sign, tapered or “rat-tail” narrowing, or

“tram-track” appearance with a trickle of contrast around the intraluminal thrombus

63
Q

UTZ findings of increase risk for stroke?

A

Carotid artery intima-media thickness as measured by Doppler US has been identified as a marker

for large artery disease, which in turn is correlated with increased stroke risk.

64
Q

findings of acute stroke in DWI

A

> 95% restriction within minutes

o Hyperintense on DWI

o Hypointense on ADC map

65
Q

What is shown?

A

Intracranial ICA, branches. The C2 (petrous) segment is long and L-shaped. C3 is a short segment between C2 and the cavernous ICA (C4) . C5 is the last extradural segment. Posterior , anterior genua of C4 are shown

66
Q

What is formed in this figure?

A

Lateral DSA shows all ICA segments. The C4 (cavernous) segment has both a posterior and an anterior genu. Together, they form the angio-DSA carotid “siphon

67
Q

Determine the parts of the ACA

A

Graphic shows the relationship of the ACA to the underlying brain. A2 segment ascends in front of

the third ventricle. A3 curves around corpus callosum genu. Pericallosal , callosomarginal arteries

are the major terminal ACA branches. 8-16. Sagittal midline MIP of CTA shows A2 segments of both

ACAs ascending in the interhemispheric fissure in front of the third ventricle, A3 segments curving

around the corpus callosum genu

68
Q

What arte the segments of the MCA

A

Submentovertex graphic depicts the MCA and its relationship to adjacent structures. Note the

horizontal (M1) segment and the genu with bifurcation into M2 branches. 8-20. Coronal graphic

shows the lateral lenticulostriate arteries , M2 segments over the insula , M3 segments running

laterally in the sylvian fissure, M4 (cortical) branches coursing over the lateral surface of the

hemisphere

69
Q

What is shown?

A

Submentovertex graphic shows the PCA segments and their relationship to the midbrain. P1 , P2 , P3 segments are shown. P4 segments (cortical branches) ramify over the occipital and inferior temporal lobes. 8-24. Lateral graphic depicts the PCA above and the superior cerebellar artery

below the oculomotor nerve . Perforating , choroidal , and cortical PCA branches are also shown.

70
Q

What is shown?

A

The same case shows swollen, “blurred” insular cortex compared to the opposite normal side

71
Q

What sign is shown?

A

CTA in the same patient shows an abrupt “cutoff” with a meniscus of contrast in the proximal

left MCA. Contrast in the distal M2 and M3 segments is caused by slow retrograde collateral flow from

pial branches of the ACA across the watershed to M4 (cortical) branches . 8-37D. Left carotid DSA, AP

view, in the same patient shows abrupt “cut-off” of the left M1 MCA segment

72
Q

Describe the CBF and CBV

A

CBF in the same patient shows markedly reduced blood flow to the entire right MCA distribution

with the most profound deficit in the right basal ganglia . The CBV/CBF “mismatch” in the cortex

represents a large ischemic penumbra surrounding the densely ischemic basal ganglia. 8-38D. MTT shows

that blood flow to the right MCA distribution is slow with markedly prolonged transit time.

73
Q

Describe the MRI findings in a pt post thrombolysis

A

Intraarterial thrombolytics were administered because of the large ischemic penumbra. MR obtained

24 hours later shows very hyperintense basal ganglia with mildly swollen, hyperintense gyri in the MCA

distribution . Note the hyperintense vessel indicating slow flow. 8-38F. DWI in the same patient

shows acute restriction in the right basal ganglia with scattered foci of cortical ischemia

74
Q

Describe MRI of pt with acute stroke

A

Acute stroke in a 47-year-old man shows patchy hyperintensity in the left caudate nucleus, lateral

putamen, and parietal cortex. Note multiple linear foci of intravascular hyperintensity , consistent with

slow flow in the MCA distribution. 8-41B. T2* GRE scan shows several linear hypointensities in the

affected MCA branches, consistent with hemoglobin deoxygenation caused by slow, stagnating arterial blood

flow

75
Q

What MRI sequence is shown?

A

DWI in the same patient shows multiple patchy foci of diffusion restriction , consistent with

acute cerebral infarct. 8-41D. Axial source image from 2D TOF MRA shows normal signal intensity in the

right MCA and both ACA branches but no flow in the left MCA vessels

76
Q

What is shown in this pt with subacute stroke

A

FLAIR (left) and GRE (right) in the same case show hemorrhagic transformation in this example

of subacute stroke

77
Q

Determine the age of the CVD

A

T1 C+ FS scan in the same patient shows intense enhancement characteristic of subacute

infarction

78
Q

What effect is shown in this pt with subacute stroke

A

T2 “fogging effect” (left) indicates R PCA infarct is almost isointense, but it enhances strongly on

T1 C+ (right). Subacute stroke

79
Q

What are differentiated?

A

(L) T2WI shows hyperintensity in the same distribution. (R) FLAIR shows the difference between

encephalomalacia , gliosis

80
Q

NECT scan in a patient with infected mitral valve, decreasing mental status

A

(Left) NECT scan in a patient with infected mitral valve, decreasing mental status shows 2 hemorrhagic foci at the GM-WM junctions of both occipital lobes. (Right)

Scan through the corona radiata shows additional hemorrhagic foci . Findings suggest multiple septic emboli. 8-51B. DWI shows multiple foci of restricted diffusion at the GM-WM junctions of both hemispheres. Multiple embolic

septic infarcts

81
Q

What pattern is shown?

Axial FLAIR scan in a 68-year-old man who became confused and then comatose the day after a total

hip replacement shows multifocal hyperintensities

A

Axial FLAIR scan in a 68-year-old man who became confused and then comatose the day after a total

hip replacement shows multifocal hyperintensities in the subcortical and deep cerebral white matter.

8-53B. DWI shows innumerable tiny foci of diffusion restriction in the deep cerebral white matter , the

“star field” pattern characteristic of cerebral fat embolism syndrome.

82
Q

What is shown?

A

Axial FLAIR scan in a 68-year-old man who became confused and then comatose the day after a total

hip replacement shows multifocal hyperintensities in the subcortical and deep cerebral white matter.

8-53B. DWI shows innumerable tiny foci of diffusion restriction in the deep cerebral white matter , the

“star field” pattern characteristic of cerebral fat embolism syndrome. “border zones” represent confluence of all 3 major vessels. Yellow lines indicate the internal (deep

WM) WS zone between perforating arteries, major territorial vessels

83
Q

What is the dx?

A

T2WI shows an absent “flow void” in the right cavernous ICA . The left ICA appears normal ,

yet this is the symptomatic side. 8-59D. 2D TOF MRA image findings explain the patient’s symptoms. (L) Left

ICA demonstrates a “flow gap” characteristic of high-grade carotid stenosis. (R) Right ICA is occluded,

with “rat tail” narrowing . Classic bilateral deep internal watershed zone hypoperfusion ischemia.

84
Q

What is shown?

A

Coronal autopsy specimen from a premature neonate shows grade III germinal matrix hemorrhage

with extension into an adjacent lateral ventricle

85
Q

What is shown?

A

Sagittal ultrasound in a premature infant demonstrates gray matter hemorrhage, seen as an echogenic

focus in the caudothalamic notch

86
Q

What is shown in this 26 week old baby

A

Oblique transfontanelle ultrasound in a 26-week premature infant shows periventricular

hemorrhagic infarction (PVHI) with extension into the lateral ventricles

87
Q

What is shown?

A

Sagittal T1WI shows end-stage cystic encephalomalacia in a term infant imaged 5 weeks after

profound birth asphyxia.

88
Q

Describe TTP findings

A

TTP study is even more striking. The abnormal side is NOT the right MCA distribution (green) but is the left side (blue) where the TTP is markedly shortened. T2WI shows gyral swelling, sulcal effacement, and hyperintensity in the left temporal and parietooccipital cortex/subcortical white matter , basal ganglia . DWI (not shown) was normal. Post-carotid endarterectomy hyperperfusion

syndrome

89
Q

What artery has been infarcted?

A

FLAIR scan in a patient with artery of Percheron infarct shows both medial thalami infarcts

90
Q

The intracranial venous system has two major components,

1

2

A

the dural venous sinuses and the cerebral veins

91
Q

The dural venous sinuses are subdivided into an anteroinferior group and a posterosuperior group. Theposterosuperior group is the more prominent and consists of the:

A

superior sagittal sinus (SSS),

inferior sagittal sinus (ISS),

straight sinus (SS),

sinus confluence (torcular herophili),

transverse sinuses (TSs), sigmoid sinuses, and jugular

bulbs.

92
Q

The anteroinferior group of the dural venous sinus consists of the:

A

cavernous sinus (CS), superior and inferior petrosal sinuses (SPSs, IPSs),

clival venous plexus (CVP), and sphenoparietal sinus (SphPS).

93
Q

The dural sinuses frequently contain arachnoid granulations (AGs), also known as:

A

pacchionian granulations

94
Q

___________are CSF-containing projections that extend from the subarachnoid space (SAS) into dural venous sinuses

A

Arachnoid granulations

95
Q

While AGs can occur in all dural venous sinuses, the most common locations are the_____ and _________

sinus. The cavernous sinus is a relatively uncommon site.

A

transverse and superior sagittal

96
Q

The ___________is a large, curvilinear sinus that parallels the inner calvarial vault. It originates from ascending frontal

veins anteriorly and runs in the midline at the junction of the falx cerebri with the calvaria

A

SSS

97
Q

Filling defects—_____________—within the SSS are common findings on imaging studies.

A

AGs and fibrous septa

98
Q

When present, a ________ AND ___________is both a sensitive and specific sign of cerebral venous occlusive disease in NECT

A

hyperattenuating vein (“cord” sign) or dural venous sinus (“dense triangle” sign)

99
Q

In 70% of cases, CECT scans show an_______sign caused by enhancing dura surrounding nonenhancing

thrombus

A

“empty delta”

100
Q

Appearance of acute sinus thrombosis

A

Acute DST appears isointense with the underlying

cortex on T1WI

101
Q

What sinuses are shown?

A

Graphic shows the numerous interconnections among the cavernous sinuses , clival venous plexus , sphenoparietal sinuses , and the superior and inferior petrosal sinuses

102
Q

What veins are shown?

A

Lateral graphic depicts the superficial cortical veins. The 3 named anastomotic veins—Trolard ,

Labbé , and the superficial middle cerebral vein —are depicted. One or two of the superficial

cortical veins are usually dominant

103
Q

Describe the venous drainage

A

Superficial parts of the brain (cortex, subcortical white matter) are drained by cortical veins and superior sagittal sinus (shown in green).

Central core brain structures (basal ganglia, most white matter, ventricles) are drained by the deep venous system (ICVs, vein of Galen, straight sinus) (red).

The veins of Labbé and the transverse sinuses drain the posterior temporal, inferior parietal lobes (yellow).

The sphenoparietal, cavernous sinuses drain the area around the sylvian fissures (purple

104
Q

What is shown?

A

Gross photograph from the same case shows “currant jelly” clot in the SSS , cortical veins .

105
Q

A 23-year-old woman with “migraine headache.”

A

First NECT scan (left) was called normal. Note

hyperdense thrombus in left TS . CT 1 day later (right) shows vein of Labbé thrombosis and large

hemorrhagic infarct

106
Q

What is shown?

A

NECT in another patient shows hyperdense thrombus in the SS and SSS with bilateral edema

, hematomas, and convexal SAH .

107
Q

What sign is shown?

A

Axial source image from a CTV shows the classic “empty delta” sign formed by enhancing dura surrounding nonenhancing thrombus in the superior axial sinus.

9-21. Coronal T1 C+ scan in a patient with SSS and bilateral TS occlusions demonstrates the “empty delta” sign. Note prominent sulcal enhancement , caused by collateral venous drainage. Original—incorrect—diagnosis was meningitis

108
Q

Which veins are occluded?

A

AP view, venous phase, of vertebrobasilar DSA in a patient with occlusion of the left TS and

sigmoid sinus . Note clot in adjacent tentorial vein

109
Q

Which vessels are thrombosed?

A

Axial T1 C+ FS scan shows the nonenhancing thrombus in the right TS surrounded by the intensely enhancing dura.

The left TS shows an ovoid filling defect with CSF intensity containing a linear central enhancing vein . Findings are characteristic of an arachnoid granulation.

9-25F. Axial MIP of 3D TOF MRV shows nonfilling of the right transverse and sigmoid sinuses. The 2 ovoid filling defects in the left TS are arachnoid granulations

110
Q

What is the age of the thrombus?

A

Late subacute SSS thrombosis shows “empty delta” sign and hyperintense thrombus

111
Q

What is the age of the thrombus

A

Chronic SSS occlusion shows prominent “squiggly” parenchymal veins on T1 C+ and “flow voids” on

SWI

112
Q

What sign is shown?

A

NECT scan shows obvious SSS thrombus with a hyperdense “cord” sign

113
Q

Which vein is infracted?

A 46-year-old man with a family history of brain tumors presented in the ED with headache followed by a first-time seizure

A

. NECT scan shows a hypodense lesion involving both the cortex and subcortical white matter of the right parietal convexity. Note patchy petechial hemorrhage within the lesion. 9- 33B.

MR scan with SWI in the same patient shows isolated thrombosis of the right vein of Trolard . The

superior sagittal sinus is normal

114
Q

NECT scan in a 79-year-old aphasic man imaged for “brain attack”

A

shows hyperdensity in both ICVs

, VofG , and SS . Note hypodensity in both anterior thalami with indistinct gray-white

matter interfaces.

115
Q

What is shown?

A

Sagittal T1WI in the same patient shows lack of normal “flow voids” with isointense clot present in the ICVs , VofG , and SS .

9-38B. Axial T2* GRE scan shows clot with “blooming” hypointensity in the ICVs , VofG , and SS . Note hypointensity caused by venous congestion with slow flow in the medial thalamic and deep WM medullary veins

116
Q

What sinus is thrombosed?

A

CECT source image from CTA in a 28-year-old man with polytrauma shows filling defects in the left cavernous sinus .

The affected CS has a lightly convex lateral margin compared to the normal right

CS . 9-39B. Coronal CTA in the same patient shows occlusion of the left cavernous ICA . The left CS

remains unopacified because it is filled with thrombus . Compare this to the normal right CS

117
Q

What sinus has been occluded?

A

A 5-year-old boy with sinus infection, fever, headache, and periorbital swelling presented to the ED. CECT scan shows proptosis with periorbital edema and ethmoid sinusitis with air-fluid level in the sphenoid sinus.

The cavernous sinuses and both superior ophthalmic veins are filled with nonenhancing thrombus.

9-40B. Axial T2WI in the same patient shows the ethmoid sinusitis and multiple enlarged intraorbital veins .

118
Q

What kind of MRI is shown?

A

MR venogram in a 22-year-old woman shows a dominant right TS. The left TS shows a “missing”

segment , possible filling defect .

119
Q

What can you say about the sinuses?

A

Axial MP-RAGE shows hypoplastic but patent left TS , small sigmoid sinus .

120
Q

Is there thrombosis?

A

NECT scan in a normal newborn infant. The combination of the unmyelinated hypodense brain and the physiologically elevated hematocrit makes the deep veins and dural sinuses appear hyperdense,

mimicking thrombosis

RADIOLOGY OSBORN (5 decks)

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