0:01

One of the most difficult calls to make in the

0:04

emergency department for neuroimaging is the presence

0:09

of a venous thrombosis on a non-contrast CT scan.

0:15

Quite often, the presentation is either something

0:18

like a severe headache or papilledema, and you're

0:23

in the position of trying to make a judgment

0:25

about whether or not the sinuses are too dense.

0:29

It's a little bit easier when you have a symmetric

0:34

sinus, like the transverse sinus, where you can compare

0:37

one side to the other and assess the density of the

0:41

sinus to make a judgment as to whether there's a clot.

0:44

However, with a patient who has a question of a

0:48

superior sagittal sinus thrombosis, it is a little bit

0:52

more difficult, and that density that you're comparing,

0:55

you should either compare with the transverse sinus,

0:59

or when you compare the posterior to the anterior,

1:02

you may make a judgment about whether it's too bright.

1:05

In this situation, as we look from posterior

1:07

to anterior, there is a gradient where

1:10

the sinus anteriorly is more dense than

1:13

that posteriorly, but it's not dramatic.

1:17

And this is a situation where sometimes

1:20

the clinical assessment will rule.

1:22

Again, looking at the thin-section images may help you.

1:26

In this case, when you window,

1:30

you may wonder about some areas where the

1:33

sinus is more dense internally than other

1:37

areas of lower density in the sagittal sinus.

1:43

This patient went on to get a CT venogram.

1:47

And if we go directly to the MIP image of the CT venogram,

1:53

we can see that there is a filling defect

1:56

in the superior sagittal sinus in this individual.

2:00

The CT venogram MIP may not be as useful as doing the

2:05

high-resolution, thin-section reconstructions yourself.

2:10

When you do that, you can window it a little bit

2:12

more nicely, and you see this very large clot that

2:16

is present all the way into the anteriormost portion

2:20

of the superior sagittal sinus in this individual.

2:23

If I show this to you in the raw data and

2:26

window it, you can see that the patient has

2:30

a clot here in the center of the sinus, which

2:36

is a filling defect outlined by contrast.

2:39

So this individual has evidence of

2:43

superior sagittal sinus thrombosis.

2:45

Nonetheless, as you can see, there aren't areas

2:48

of abnormal density within the brain tissue.

2:52

I would probably prefer to go with an MRI scan to

2:54

look for it on FLAIR or diffusion-weighted imaging.

2:58

But in this case, the patient had sinus thrombosis

3:02

without infarction noted on CT, CT venography.

Case: Superior Sagittal Sinus Thrombosison CT, CTV

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