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All right. Our last case comes with a history of altered mental

0:03

status.

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You dig deeper into the chart and find out this is

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a 61 year old patient. They've had a history

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of rectal cancer. They had an episode of sudden

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confusion that was characterized also by

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diffuse weakness, but they couldn't really tell you it was

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going on. They don't really remember the episode very well, but onlookers say

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they were nonverbal or a little bit but then

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they recovered their strength returned on examination. Now

0:28

in the emergency department their NIH Stroke Scale

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is only one. So we're gonna check out our non-con

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head CT in this situation. I'm going to

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point out a couple of abnormalities that I think are potentially relevant

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potentially incidental also not

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point out all the abnormalities. So take a close. Look at these images

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for any findings that you may see. One

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thing I will point out is that there are

0:52

some scattered cortical calcifications. These might be due to

0:55

Chronic calificosis.

0:58

And then there's also a hypertensity here in the left Sylvian

1:01

fissure. That was thought to

1:04

be small amount of subarachnoid hemorrhage, okay.

1:08

But we did not see any loss of gray white

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differentiation to indicate early ischemic change.

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And there is one additional abnormality that is

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on this image, but I'm not going to point it out because I

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will give it give the case away. Okay?

1:30

So now we're going to move on to the CT perfusion.

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So I'm gonna pull up the summary Maps. First of

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all, there is nothing segmented as CBF less than 30%

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There was a small finding that was highlighted

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as team X-ray and then six seconds, but I think some of it is

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kind of motion artifact

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or caliberium some of the corresponds to

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Superior sagittal sinus.

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And so we're going to take a closer. Look at the color

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maps to try to figure out what is

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exactly going on here.

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So I'm going to pull up the TMax and

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while I'm doing

2:12

this we can activate the poll question. I'm going to pull up

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something else, which is the TTD which is

2:18

provided by single via not rapid,

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but this stands for time to train.

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it's kind of a complementary measure to TMax TMax is

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a time to get the peak of the of the

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Time attenuation curve and time to train as the

2:35

kind of down slope to that.

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And so you notice that there is a asymmetry here.

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There's a little bit higher T-Mac a

2:44

little bit higher time to train in the ripe right

2:47

a little bit in the left right A lobe as well as

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the right occipital lobe and maybe even

2:53

posterior temporal lobe question is

2:57

what which were the following diagnoses is most likely in

3:00

this case. We also see an area the team axis

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decrease, you know, it's like very deep blue. So there's

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a suggestion this is hyper perfused. If

3:09

we examine the CVB Maps, we can

3:12

support that suspicion. There's elevated cbv in this

3:15

left parietal region. So kind

3:18

of have kind of complementary of bilateral

3:21

after maladies going on this patient.

3:24

So is it transient ischemic attacks Ruble Venous

3:27

Thrombosis posterior reversible encephalopathy syndrome

3:30

metastatic disease and so forth.

3:33

And it looks like now great job

3:36

everyone 66% of you chose the

3:39

right answer which is super Venous Thrombosis. Now, I want

3:42

to rewind a

3:45

little bit and take a look at our non-con SAT

3:48

to see in retrospect. Can we see the abnormality that

3:51

we're looking at it? So there is this hyper density in

3:54

this right transfer sinus extending into

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the superior sagittal sinus at the hyperdense drove

4:00

in a sinus is concerning for thrombosis.

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I'm gonna pull up our CTP again because of

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the perfusion abnormalities and the parietal lobes.

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and the right occipital lobe

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it did raise this suspicion for cerebral Venous Thrombosis.

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Simply because this territory is a little bit too big for posters artery.

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It doesn't seem like a arterial territory seems a

4:26

little bit wider than that. And so we're gonna review our CTA

4:29

with an eye towards that and I know not all the time

4:32

on ctas. Do we have a good a Venus

4:35

evaluation? But in

4:38

this case we so happen to have a pretty good

4:41

venous evaluation. So

4:46

Yeah, but let it buffer a little bit. So we

4:49

see good contrast modification in

4:52

the straight sinus.

4:55

a anacalan kind of deep struggle veins region,

4:58

but then none of classification of the super sagittal scientists where we

5:01

saw that hyper density on CT and

5:07

it's taking a little bit for me

5:10

to load all these images. I'm gonna pull the thicker

5:13

slice and just to demonstrate that non-passification of the

5:16

super recital sinus transfer sinus.

5:19

right sigmoid sinus

5:21

extending into the internal jugular vein where we see in

5:24

the neck to expanded with clot.

5:28

All Upstream of this central venous catheter they have a chest

5:31

port for their rectal cancer chemo. And so

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we have this thrombosis coming out

5:37

from the neck into the head along the

5:40

door being a sinuses so that can confirms

5:43

our diagnosis of cerebral Venus barboses involving,

5:47

you know, drawing a sinuses and that

5:50

explains the prolongation of the

5:53

time to drain in the right posterior

5:56

cerebral hemisphere a little bit in the

5:59

middle part of the left cerebral hemisphere as well.

6:02

And this hyper perfusion area is chalked up

6:05

to be periodical hyper perfusion. Okay, so

6:08

we have in the periodic table period an elevation

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of CBF and cbv in

6:14

the immediate kind of periodal and

6:18

postictal period and then it the cerebral blood

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volume declines after that.

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And so this is see here either as a consequence of

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the several Venus

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kind of thrombosis or it can be due to

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irritation for that small amount of subarachary that we

6:37

saw Alchemy interrelated somehow the causation direction of

6:40

causation is not exactly clear. So

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So once again just summarize in retrospect we

6:48

could see hybrid ends droving a sinuses and non-conct. We

6:51

saw a little bit of hemorrhage. We see some cortical

6:54

Health calcifications that could cause seizure. So

6:57

we're on high alert for stroke mimics. In this case. In this

7:00

case. We saw hyper perfusion left parietal lobe and this

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may be periyaktal in nature. But we

7:06

also saw kind of bilateral abnormality and

7:09

delayed time to drain in the right occipital and bilateral

7:12

parietal lobes and and our suspicion

7:15

for Venous Thrombosis confirmed on the CT angiography

7:18

which which fortunately, you know,

7:21

kind of contaminated with a lot of venous phase but we can

7:24

make the diagnosis very commonly based on

7:27

the constellation of all these abnormalities this patient

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did go on to get an MRI just to confirm some of

7:33

the

7:35

The vascular findings as well as to better evaluate

7:38

the brain parenchyma. So here's

7:41

our diffusion weighted image just to

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see you know, there are a few spots and dots of

7:47

DWI hyperintensity here. And there there's this cortical area

7:50

of slight DWI hyperintensity and left

7:53

parietal region that corresponds to

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some Fair hyperintensity as well. This is

7:59

either post ictal swelling or it could

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be a Venus in farq or result of

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Venus congestion, and and we

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did to

8:11

Like I post contrast sequence to

8:15

win weighted gray and echo-based sequence

8:18

that re-identify is that feeling defect in

8:21

the superior sagittal sinus extending all the way down into the

8:24

right transverse and sigmoid sinuses and down

8:27

into the neck as well confirming the diagnosis. So

8:31

so basically MRI redemonstrating what we could

8:34

tell on close scrutiny of the non-con CT

8:37

the CTA and the CT profusion. This patient

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was managed with anti-seizure medications and anticoagulation.

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So in summary was this case about this is case a cerebral Venus thrombosis

8:49

and had related congestion that

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we could see as elevated TMax and time to

8:55

train on our CT perfusion as well as superimposed Perry

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ictal hyper perfusion that's elevated cbv and

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CBF in that left Bridal region. It was in

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a non-vascular non-arterial territory and taking

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together with the clinical context of the kind of

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transient symptoms was most

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compatible with seizure recent seizure

9:16

following several Venus thrombosis, and this is

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a stroke mimic