Hemorajik venöz infarkt

Özet

Baş ağrısı, nöbet veya fokal defisitle gelen ve venöz sinüs trombozu riski taşıyan hastada, arteriyel enfarktı taklit eden hemorajik ödem venöz çıkış tıkanıklığının işareti olabilir. Kontrastsız BT kanama ve ödemi hızla gösterir; venöz fazda BT venografi sinüs ve büyük venlerde trombüsü ya da dolum defektini araştırır. Lezyonlar arteriyel sulama alanlarına uymaz, parasagittal veya bilateral olabilir ve venöz hipertansiyona bağlı kanama içerebilir. Yalnızca parankim kanamasına odaklanmak altta yatan trombozu ve ilerleyici venöz konjesyonu gözden kaçırabilir.

Faz ve pencere

Kontrastsız tanısal

Ödemli parankimde noktasal veya birleşen hiperdens kan odakları ve hematomalar görülebilir; diffüz ödem nedeniyle sulkuslar daralabilir; tromboze sinüs bazen spontan hiperdens olarak izlenebilir. Arteriyel sınırlara uymayan parasagittal, kortikal veya bilateral dağılım venöz kökeni düşündürür.

Venöz tanısal

Venöz zamanlamalı BT venografide superior sagittal, transvers-sigmoid sinüsler ve derin venöz sistem kontrastla opaklaşır; trombüs ilgili segmentte dolum defekti veya opaklaşmama olarak aranır. Damar açıklığı BT venografi veya MR venografi gibi venöz görüntülemeyle değerlendirilir.

Önerilen pencereler: Beyin (G 80 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Arteriyel olmayan dağılım — ödem ve kanama birden fazla arter alanını geçebilir.
• Parasagittal hemorajik odak — falx komşuluğundaki frontal veya parietal korteks-altı dokuda ödemle çevrili kan.
• Bilateral talamik ödem/kanama — derin venöz sistem veya straight sinus tıkanıklığını akla getirir.
• Kortikal ven hiperdensliği — kontrastsız incelemede tromboze kortikal ven boyunca kord benzeri atenüasyon artışı.
• Sinüs dolum defekti — venöz zamanlamalı görüntülerde kontrastla çevrili trombüs veya segmental opaklaşmama.
• Venöz konjesyon etkisi — sulkusların daralması, lokal kitle etkisi ve eşlik eden subaraknoid ya da intraventriküler kanama.

Normalde

Normal parasagittal düzeyde iki hemisferin korteksi ve beyaz cevheri benzer dansitededir; falx boyunca simetrik sulkuslar seçilir ve venöz sinüs lümeni kesintisiz izlenir. Şüpheli tarafta ödemin sulkusları kapatıp kapatmadığını, peteşiyel kanın ödem alanı içine dağılımını ve karşı hemisferde eş lezyon bulunup bulunmadığını karşılaştırın.

Ayırıcı tanı

Arteriyel hemorajik dönüşüm

tipik bir arter sulama alanını izler ve ilgili arter tıkanıklığı/iskemisi eşlik edebilir.

Hipertansif hematomlar genellikle derin yapıları etkilerken, venöz infarktlar arteriyel sulama sınırlarını aşarak daha yaygın ve asimetrik bir dağılım gösterir.

Kanamalı metastaz

kontrastlanan kitle lezyonu ve intralezyonel kanama ile görülebilir.

Travmatik kontüzyon

sıklıkla kortikal yüzeyde ve darbe karşıtı bölgelerde kümelenir; travma bulguları eşlik eder.

Ensefalit

temporal/limbik ödem ve bazen kanama yapabilir; sinüs dolum defekti beklenmez.

Tuzaklar

• Birden fazla arter alanını geçen kanamalı ödemi yalnızca embolik arter enfarktı diye sınıflamayın; venöz sinüsleri ve derin venleri ayrıca inceleyin.
• Kontrastsız BT'de hiperdens görünen sinüsü tek başına trombüs saymayın; yüksek hematokrit ve akım artefaktını düşünerek venöz dolum defekti arayın.
• Normal kontrastsız BT venöz trombozu dışlamaz; erken dönemde parankim bulgusu silik olabilir ve doğrudan damar görüntülemesi gerekir.

Kendini dene

1. Baş ağrısı ve nöbeti olan hastada bilateral talamik ödem ile küçük kanama odakları var. En olası damar sorunu nedir?

   • Straight sinus trombozu
   • Baziler arter tıkanıklığı
   • Hipertansif hematom
   • Düşük dereceli gliom
   Cevabı göster

   Straight sinus trombozu. Bilateral talamik konjesyon ve hemorajik ödem derin venöz drenaj tıkanıklığını, özellikle straight sinus düzeyini düşündürür. Derin gri cevher ve talamik lezyonlar, arteriyel sulama sınırlarını aşan venöz infarktların tipik yerleşimidir; bu bulgu seti için venöz tromboz önceliklidir.

2. Parasagittal kanamalı ödem iki arter alanını aşıyor. Hangi inceleme trombüsü doğrudan gösterebilir?

   • BT venografi
   • BT anjiyografi
   • Kontrastsız sinüs BT
   • Kemik algoritması
   Cevabı göster

   BT venografi. Venöz zamanlamalı BT venografi sinüs ve büyük venlerdeki opaklaşma kusurunu gösterir. Kontrastsız BT bulguları dolaylı olabilir; şüpheli olgularda trombüsü dolum defekti olarak değerlendirmek için BT venografi veya MR venografi yapılır.

Kaynaklar

Bu sayfadaki 37 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 6 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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