Coronal MRV shows occlusion of IJV with multiple mature venous collaterals in suprahyoid neck. Septic transverse or. The superior sagittal sinus drains into the transverse sinus. Cavernous sinus thrombosis (CST) — The cavernous sinuses are the most centrally located of the dural sinuses. Note small amount of edema fluid in retropharyngeal space . Purpose. Asking an older child to walk a line on a square-tiled floor helps quantify gait disturbance. This prevents blood from draining out of the brain. Axial CECT of acute left IJV thrombosis shows low-density IJV thrombus . 7-3A). Our patient had IJVT related to an inherited coagulopathy, but no trigger factors were identified. The accompanying local inflammatory reaction in the mastoid led to bone penetration and caused a sigmoid sinus thrombosis. The signs and symptoms of septic cavernous sinus thrombosis are fever, headache, and diplopia. She was hospitalized for administration of intravenous heparin therapy during the acute stage, followed by oral anticoagulants. The patient was started on oral warfarin. Extensive retropharyngeal edema is also present without peripheral enhancement . Venous thrombosis affects mainly the lower extremities [1, 2]. Their irregular shape and location at the base of the skull make them a primary target for infection. Axial T1WI C+ MR in the same patient shows heterogeneous enhancement of the middle ear and mastoid. Thrombophilic abnormalities, either inherited (antithrombin, protein C, or protein S deficiency, with mutations in the FVL, FII, or MTHFR genes) or acquired (antiphospholipid antibodies) should be investigated in patients with CVT, as well as those with hyperhomocysteinemia [1]. A duplex ultrasound of her limbs identified left deep vein thrombosis. Cerebral venous sinus thrombosis This involves the presence of thrombosis in the deep cerebral veins. Deep and superficial collateral veins indicate that IJV occlusion is chronic. Coronal MPR shows a tubular multilocular collection with narrowing of the right IJV . In more rare cases, the cause of sinuso-vascular phlebitis can be acute purulent otitis media and acute mastoiditis. Seven months later, when she was adequately anticoagulated, she developed a second thrombosis. Imaging of the brain, initially computed tomography, followed by magnetic resonance venography, confirmed a diagnosis of sigmoid sinus thrombosis with associated venous infarction. Transverse sinus thrombosis (in about 45%, see figure 3) typically causes temporoparietal haemorrhagic infarction (from occlusion of the vein of Labbé) with headache and, if left sided, aphasia, sometimes with seizures. The major cerebral venous sinuses. The complex enhancing peripheral collection is adjacent abscess . • Main cause of acute death with CVT is transtentorial herniation due to large hemorrhagic lesion • Second is herniation due to multiple lesions or to diffuse brain edema. Diplopia may be present secondary to abducens neuropathy and should increase the clinical suspicion for this diagnosis. In necrotizing external otitis, a rare and severe infection almost exclusively affecting the diabetic and immunocompromised patient, MRI is the best choice to image the extent of the disease. Axial T2 FS MR reveals the right thrombosed IJV to be of heterogeneous signal intensity and the adjacent deep fat to be hyperintense. Sigmoid sinus dehiscence or sigmoid sinus diverticulum are some of the most commonly identified causes of pulse-synchronous tinnitus, occurring in 4 – 40% of cases of PST (3-6). Sigmoid-sinus thrombosis has been described in association with ear infections (12, 16) or as part of the thrombosis of the multiple dural sinuses from various septic or aseptic causes, including penetrating trauma to the head , vasculitis , oral contraceptives (8, 18), pregnancy , fibrinolytic therapy , and hypercoagulable states . 4.13). Dural Venous Sinus Thrombosis – This involves the formation of clot on the superficial veins in the dura mater. Axial CECT shows partial IJV thrombosis medially with small residual intraluminal enhancement . Doubtful: Cavernous sinus thrombosis is a very serious acute condition which causes progressive and severe headache along with eye and other neurological abnorm ... Read More Send thanks to the doctor Coronal CECT in a patient on hemodialysis with prior right IJV catheter and subsequent left IJV hemodialysis catheter shows that the patient presented with bilateral IJV thrombosis. Only the protein C activity (49, normal range > 60) and level (20, normal range > 20) were lower than normal. Tsumoto T, Miyamoto T, Shimizu M, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Axial CECT shows partial thrombosis of the left IJV in a young patient with Lemierre syndrome. Papilloedema develops which is usually bilateral (but can be unilateral), drowsiness, coma, and seizures can occur. The IJV is patent inferiorly. Sigmoid sinus dehiscence or sigmoid sinus diverticulum are some of the most commonly identified causes of pulse-synchronous tinnitus, occurring in 4 – 40% of cases of PST (3-6). Edema is seen around the left carotid sheath . In neonates shock and dehydration is a common cause of venous thrombosis. The authors declare that there is no conflict of interests regarding the publication of this paper. An etiological workup revealed a homozygous MTHFR gene mutation. In the case of acute otomastoiditis, a rather rare infection mostly seen in children, CT is helpful to demonstrate coalescence of mastoid cells and the eventual breakthrough of the bony mastoid walls, with risk for formation of a subperiostal abscess or, Regional and Intracranial Complications of Acute Otitis Media. Apart from a tension-type headache, she had no neurological symptoms. Doubtful: Cavernous sinus thrombosis is a very serious acute condition which causes progressive and severe headache along with eye and other neurological abnorm ... Read More Send thanks to the doctor Other recognized causes include malignancy, pregnancy, hormonal contraceptive therapy, and coagulation disorders [1]. Note surrounding inflammation and fat stranding supporting acuity. Increased density (CT) or abnormal signal intensity (MR) in affected dural sinus of posterior fossa, Thrombophlebitis most commonly starts at transverse-sigmoid confluence, DST may involve ≥ 1 of following posterior fossa sinuses: Torcular Herophili, transverse sinus (TS) ± vein of Labbé, sigmoid sinus (SS), jugular bulb, In acute thrombosis, affected sinus may be enlarged, Caveat : Transverse sinus size typically asymmetric from side to side in individual, Conforms to shape of dural sinus affected, Fusiform enlargement of venous structure acutely, Important for distinguishing DST from arachnoid granulation (focal filling defect), ↑ density thrombus in affected dural sinus, Dense triangle of thrombus, δ sign, if sinus seen in cross section, Phrase used mainly to describe sagittal sinus thrombosis, Sagittal CT reconstruction of TS or coronal reconstruction of SS could show δ sign, Parenchymal venous infarction may be associated (∼ 1/3 of cases), Parenchymal hypodensity (edema ± infarction), Temporal or occipital lobe location with TS thrombosis, Cerebellar hemisphere location with distal TS & SS thrombosis, Cortical/subcortical hemorrhages (may be petechial), Reverse or empty δ sign, enhancing dural leaves surrounding less dense thrombus (25% of cases), Filling defect in TS ± SS; may extend into jugular bulb or vein, Shaggy, dilated, irregular cortical veins (collateral channels), CECT alone unreliable for diagnosis of DST extent (high-density clot may appear like patent enhancing sinus), When performed per arterial protocol, enhancement phase too early to evaluate venous sinuses, Hyperdense sinus could potentially be confused with venous contrast, 10-15 second delay beyond CTA image acquisition allowing venous timing for CT venogram, Filling defect in dural venous sinus with surrounding dural enhancement, Acute DST: Absent flow void with isointense clot (similar to gray matter), Subacute DST: Hyperintense clot (methemoglobin), Acute DST: Hypointense clot (deoxyhemoglobin), Additional findings if parenchymal infarction present, Gyral swelling, sulcal effacement in temporal lobe, Hyperintense if venous infarction is acute, May be petechial (many small cortical foci), ↑ signal & swelling in adjacent brain parenchyma if associated acute infarction occurs, Profound hypointense signal or blooming on T2* sequences with acute or subacute thrombosis, May be difficult to discern against bone, air (in adjacent temporal bone), Chronic thrombus is isointense to hyperintense on GRE sequences, Parenchymal hemorrhage in venous infarct ↓ signal in acute stage, Acute & subacute clot may demonstrate restricted diffusion, Acute parenchymal venous infarct shows restricted diffusion, Parenchymal DWI abnormalities are more likely reversible compared to arterial ischemic insults, Filling defect may nearly completely fill dural sinuses, Peripheral enhancement may be reactive dura or residual flow around clot, Chronic DST may enhance intensely & should be correlated with MRV findings, Irregular enhancing venous channels may be seen with incomplete recanalization; enhancement within recanalized clot may mimic normal sinus enhancement, Associated parenchymal venous infarction may show patchy enhancement, Lack of flow-related signal in TS-SS, ± jugular bulb, Complete lack of flow in affected dural sinuses, Central filling defect with surrounding contrast, Arteriovenous transit time often delayed in affected area, MR with MRV is best single imaging exam for DST, Almost all MR sequences show signal abnormality in dural sinuses, Complications (venous infarct, hemorrhage) easily identified, Susceptibility weighted imaging (SWI) may prove to be useful technique, CT/CTV diagnoses DST but less sensitive for complications, If cross-sectional imaging equivocal, consider conventional angiography, Coronal & sagittal CTV reconstructions ± MRV sequences very helpful for TS & SS thrombosis evaluation, Contrast-enhanced MRV decreases false-positive DST in small but patent dural sinus, Use MRV with multiple encoding gradients to distinguish physiological flow asymmetry from thrombus, IMAN NASERI MD, STEVEN E. 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