A 35-year-old male chronic alcoholic presented with a week-long headache and blurry vision. On examination, he had right lateral rectus palsy. CT brain showed hyperdensity in the right frontal region, right transverse sinus, and hypodensity in the superior sagittal sinus, suggestive of parenchymal hemorrhage with cortical vein thrombosis or calcified granuloma. MRI brain found a hemorrhagic lesion in the right high parietal lobe, absence of flow voids in sinuses, and T1 hyperintensity in sinuses confirming sinus thrombosis, which was shown on MR venography. The patient was diagnosed with cerebral vein thrombosis based on imaging findings.

1. IMAGE OF THE WEEK
PROF.DR.G.SUNDARAMURTHY
M2 UNIT
P-VANJI NATHAN

2. CLINICAL HISTORY AND
EXAMINATION
 35 year old male patient, a chronic alcoholic
presented to casualty with history of
headache 1 week, sudden onset,
gradual progression,
associated with blurring of vision.
An episode of vomiting X 1 day.
 O/E Patient was conscious oriented, looked
distressed and had R lateral rectus palsy (diplopia)
on CNS examination.
 Urgent imaging (CT-Brain) was done,

6. FOLLOWING THE ABNORMAL CT
FINDINGS, MRI BRAIN WAS TAKEN

11. CT-BRAIN REPORT
 CT BRAIN AXIAL SECTIONS SHOWING
1. HYPERDENSITY IN THE RIGHT FRONTAL
REGION
2. HYPERDENSITY IN THE R TRANSVERSE
SINUS
3. HYPODENSITY IN THE SUPERIOR SAGITTAL
SINUS (?EMPTY DELTA SIGN)
 SUGGESTIVE OF ?PARENCHYMAL
HEMORRHAGE WITH CORTICAL VEIN
THROMBOSIS ?CALCIFIED GRANULOMA.

12. 1
22
3

13. MRI BRAIN REPORT
 MRI brain shows T1 hyperintense / non
suppressible T2 hyperintensity in the right
high parietal lobe. The lesion shows
peripheral blooming in T2 gradient sequence
suggestive of hemorrhage.
 Absence of flow voids in mid sagittal and
transverse sinus in FLAIR images suggestive
of sinus thrombosis
 T1 hyperintensity noted in superior sagittal
sinus and right transverse sinus suggestive of
thrombosis.
 MR venography confirms the evidence of
thrombosis in superior sagittal sinus and right
transverse sinus.

14. T2 hyper
intensity
Gradient
blooming
T1
hyperintensity
FLAIR
FLOW
VOID

16. CEREBRAL VEINS-VALVELESS,THIN
EXTERNAL
SUPERIOR MIDDLE
SUPER
FICIAL
DEEP
CAVERNOUS OR
SPHENOPARIETAL
SINUSSUPERIOR
SAGITTAL
SINUS
BASAL
VEIN
INTERNAL-2 IN
NUMBER- JOIN TO
FORM GREAT
CEREBRAL VEIN
INFERIOR
SUP.CER.VN
OR CAV.SIN.
BASAL VN
RECEIVES

19. CT FINDINGS IN CVT
 Dense clot sign - Areas of thrombosis in sinuses
appearing as hyperdensities in unenhanced ct.
 Cord sign - Dense cortical veins-uncommon direct
sign of cvt in unenhanced ct.
 Venous infarction is the most non specific indirect
sign in unenhanced ct - presence of multiple
isolated lesions, subcortical involvement, more
than one arterial territory involved.
 Empty delta sign - Filling defect with enhancing
rim on enhanced ct.
 Contrast enhancement secondary to venous stasis
 Diffuse brain swelling with edema and decreased
ventricular size might be present.
 CT venogarhy allows direct visualisation of
thrombus.

21. MRI FINDINGS IN CVT
 Can confirmatively tell presence of CVT.
 Venous thrombus may be directly visualised.
 Patent dural sinuses are seen as flow void
especially when the image is orthogonal to blood
flow direction.
 Thrombus manifest as absence of flow void-best
seen in FLAIR and T2 weighted spin echo
sequences.
 T1 weighted - hyperintensity ; T2 weighted
gradient echo-exaggerated signal loss.
 MR venography - shows direct visualisation of
thrombus.