Acute cerebrovascular incident in a young woman: Venous or arterial stroke? – Comparative analysis based on two case reports

Abstract

SummaryBackgroundCerebrovascular diseases are the most common neurological disorders. Most of them are arterial strokes, mainly ischemic, less often of hemorrhagic origin. Changes in the course of cerebral venous thrombosis are less common causes of acute cerebrovascular events. Clinical and radiological presentation of arterial and venous strokes (especially in emergency head CT) may pose a diagnostic problem because of great resemblance. However, the distinction between arterial and venous stroke is important from a clinical point of view, as it carries implications for the treatment and determinates patient’s prognosis.Case ReportIn this article, we present cases of two young women (one with an acute venous infarction, the second with an arterial stroke) who presented with similar both clinical and radiological signs of acute vascular incident in the cerebral cortex. We present main similarities and differences between arterial and venous strokes regarding the etiology, clinical symptoms and radiological appearance in various imaging techniques.ConclusionsWe emphasize that thorough analysis of CT (including cerebral vessels), knowledge of symptoms and additional clinical information (e.g. risk factors) may facilitate correct diagnosis and allow planning further diagnostic imaging studies. We also emphasize the importance of MRI, especially among young people, in the differential diagnosis of venous and arterial infarcts.

A Case-Based Review of Cerebral Venous Infarcts With Perfusion Imaging and Comparison to Arterial Ischemic Stroke

“…The imaging diagnosis of CVT is challenging in its varied and somewhat non-specific findings, compounded by generous variation in normal venous anatomy. Despite intraparenchymal hemorrhage, edema, and mass effect, tissue injury in CVT is more reversible than that in AIS (5,15). We have reviewed the classic imaging findings of CVT and CVI in conjunction with ASL and MRI perfusion imaging, which has, to the best of our knowledge, not been explored together in the literature to date.…”

“…However, CVI in the postoperative neurologic surgery setting is more common in the elderly population ( 14 ). Whereas, AIS are predominantly associated with risk factors of cardiovascular disease such as atherosclerosis, diabetes, hypertension, and atrial fibrillation leading to ischemia, the etiologies of CVT can be characterized by Virchow's triad of hemodynamic stasis, endothelial injury, and hypercoagulable states ( 15 ). As presented in Figure 1 , the risk factors of CVI can be explained by genetic prothrombotic conditions, as well as acquired risks.…”

“…Unlike the systemic veins, the cerebral veins and sinuses are valveless and, consequentially, have bidirectional flow ( 7 ). Additionally, the drainage of the cerebral venous system does not mirror that of the cerebral arterial distribution as is the case with the systemic circulation, leading to distinctive patterns of parenchymal lesions in CVI ( 7 , 15 ). The intracranial venous system can be divided into the dural venous sinuses and cerebral veins, which are further partitioned into the superficial and deep cerebral veins.…”

“…Intraluminal or extrinsic cerebral venous occlusion leads to dilation of the venous and capillary bed, resulting in elevated venous pressure and reduced capillary perfusion pressure typically with an increase in cerebral blood volume (CBV) and interstitial brain edema ( 8 , 17 , 18 ). Blood–brain barrier (BBB) disruption occurs secondary to erythrocyte diapedesis in the setting of increased venous and capillary pressure and results in vasogenic edema ( 3 , 5 , 8 , 15 ). If the rise in venous pressure is rapid and in the absence of adequate venous collateral recruitment, the valveless and friable cerebral veins may be unable to withstand the pressure gradient, leading to rupture of the cerebral veins and parenchymal hemorrhage ( 6 , 8 ).…”

“…Summary of the defining characteristics of cerebral arterial ischemic vs. venous infarcts (AIS vs. CVI) with highlights on the distinctive imaging features of each entity in relation to the pathophysiology(1,2,6,8,11,15).…”