Cerebral venous thrombosis: imaging patterns

Cerebral venous thrombosis (CVT) is an uncommon condition that is potentially reversible if properly diagnosed and promptly treated. Although CVT can occur at any age, it most commonly affects neonates and young adults. Clinical diagnosis is difficult because the clinical manifestations of CVT are nonspecific, including headache, seizures, decreased level of consciousness, and focal neurologic deficits. Therefore, imaging is crucial for the diagnosis. Radiologists should be able to identify the findings of CVT and to recognize potential imaging pitfalls that may lead to misdiagnosis. Thus, the appropriate treatment (anticoagulation therapy) can be started early, thereby avoiding complications and unfavorable outcomes.

Keywords:
Intracranial venous thrombosis/diagnostic imaging; Tomography, X-ray computed; Magnetic resonance imaging

Authorship

Isabela Magalhães Oliveira Correspondence: Dra. Isabela Magalhães Oliveira. Universidade Estadual de Campinas – Radiologia e Diagnóstico por Imagem. Rua Vital Brasil, 251, Cidade Universitária. Campinas, SP, Brazil, 13083-872. Email: isaamagalhaes17@gmail.com.

Department of Radiology, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil.Universidade Estadual de Campinas (Unicamp)BrazilCampinas, SP, BrazilDepartment of Radiology, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil.

https://orcid.org/0000-0002-2131-7360

Juliana Ávila Duarte

Department of Radiology and Diagnostic Imaging, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.Hospital de Clínicas de Porto Alegre (HCPA)BrazilPorto Alegre, RS, BrazilDepartment of Radiology and Diagnostic Imaging, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.

https://orcid.org/0000-0003-4973-2889

Mariana Dalaqua

Department of Diagnostic and Interventional Imaging, Hôpital du Valais, Sion, Valais, Switzerland.Hôpital du ValaisSwitzerlandSion, Valais, SwitzerlandDepartment of Diagnostic and Interventional Imaging, Hôpital du Valais, Sion, Valais, Switzerland.

https://orcid.org/0000-0001-9360-0547

Vinicius Menezes Jarry

https://orcid.org/0000-0002-7391-1193

Fernanda Veloso Pereira

https://orcid.org/0000-0002-0828-7806

Fabiano Reis

https://orcid.org/0000-0003-2256-4379

Correspondence: Dra. Isabela Magalhães Oliveira. Universidade Estadual de Campinas – Radiologia e Diagnóstico por Imagem. Rua Vital Brasil, 251, Cidade Universitária. Campinas, SP, Brazil, 13083-872. Email: isaamagalhaes17@gmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (12)

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Figure 1.
Intracranial contrast-enhanced MR venogram showing the anatomy of the cerebral venous system, consisting of the deep venous system, superficial venous system, and dural venous sinuses (with superior and inferior components). The superior dural sinuses comprise the superior sagittal sinus (1), the inferior sagittal sinus (2) and the straight sinus (5)—which converge at the torcular herophili—as well as the transverse sinus (3) and sigmoid sinus (4). The inferior dural sinuses comprise the cavernous sinuses, which are connected through the anterior and posterior intercavernous sinuses, and the superior and inferior petrosal sinuses, which drain toward the sigmoid sinus and jugular bulb. The deep system includes the vein of Galen (7), the internal cerebral veins (6), and their tributaries; the Rosenthal veins (basal veins) and its tributaries; and the medullary and subependymal veins, which drain the hemispheric white matter.

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Figure 2.
Coronal reconstruction of an unenhanced CT image showing hyperattenuation in the occluded cortical vein—the so-called “cord sign” (arrow).

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Figure 3.
Axial diffusion-weighted image showing hyperintensities in cortical veins. An apparent diffusion coefficient map (not shown) confirmed true restricted diffusion.

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Figure 4.
A 23-year-old woman with refractory headache. A: Axial MR angiogram showing a lack of flow in the enlarged right transverse sinus. B: Axial FLAIR MRI scan showing hyperintensity in the posterior right temporal lobe, consistent with vasogenic edema of a venous infarct.

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Figure 5.
A 15-year-old female patient with CVT. A: Axial contrastenhanced three-dimensional T1-weighted magnetization prepared rapid gradient echo MRI sequence showing a central triangular flling defect (“empty delta sign”) in the superior sagittal sinus. B: Axial susceptibility-weighted MRI showing intraparenchymal hemorrhages in the frontal and parietal lobes.

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Figure 6.
A 20-year-old woman with right-sided headache and hypoesthesia. A: Sagittal MR angiogram showing a lack of flow in the superior sagittal sinus (arrow). B: Axial FLAIR MRI scan showing subarachnoid hemorrhage in the left central sulcus.

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Figure 7.
A 27-year-old woman with deep CVT. A: MR venogram showing a lack of flow in the internal cerebral veins (arrow), vein of Galen, and straight sinus (not demonstrated). B: Axial susceptibility-weighted MRI scan showing hemorrhagic transformation of a venous infarct in the left head of the caudate nucleus and thalamus.

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Figure 8.
A 75-year-old female patient who underwent MRI for investigation of vertigo of undetermined origin. A: Axial contrast-enhanced three-dimensional (3D) T1-weighted magnetization prepared rapid gradient echo MRI sequence showing a flling defect in the transition between the right transverse and sigmoid venous sinuses. B: Axial maximum intensity projection reformatting of an unenhanced 3D time-of-fight MR angiogram, showing prominence of the right occipital and middle meningeal arteries, as well as branches of the right vertebral and ascending pharyngeal arteries (not shown) supplying a dural arteriovenous fistula consequent to chronic CVT with incomplete recanalization.

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Figure 9.
A 52-year-old woman complaining of holocranial headache. A: Axial CT scan showing opacification of some right mastoid air cells associated with bone sclerosis, indicative of chronic mastoiditis. B: Coronal CT angiogram showing a flling defect in the ipsilateral transverse sinus (arrow).

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Figure 10.
A 43-year-old woman with Behçet’s disease and persistent headache. Sagittal MR venogram showing a lack of flow in the torcular herophili.

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Figure 11.
A 40-year-old man with a closed head injury and skull fractures who presented with a three-day history of a decreased level of consciousness. An unenhanced axial CT scan (not depicted) showed a hyperdense thrombus in the left transverse sinus. A coronal MR venogram (depicted) confirmed the corresponding lack of venous flow.

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Figure 12.
Cortical CVT in a 22-year-old woman who developed intracranial hypotension after epidural anesthesia. A: Sagittal contrast-enhanced three-dimensional T1WI showing dilated venous sinuses and enlargement of the pituitary gland (findings typical of intracranial hypotension). B: Unenhanced coronal T1WI showing a hyperintense thrombus in a cortical vein (arrow).

Figure 1. Intracranial contrast-enhanced MR venogram showing the anatomy of the cerebral venous system, consisting of the deep venous system, superficial venous system, and dural venous sinuses (with superior and inferior components). The superior dural sinuses comprise the superior sagittal sinus (1), the inferior sagittal sinus (2) and the straight sinus (5)—which converge at the torcular herophili—as well as the transverse sinus (3) and sigmoid sinus (4). The inferior dural sinuses comprise the cavernous sinuses, which are connected through the anterior and posterior intercavernous sinuses, and the superior and inferior petrosal sinuses, which drain toward the sigmoid sinus and jugular bulb. The deep system includes the vein of Galen (7), the internal cerebral veins (6), and their tributaries; the Rosenthal veins (basal veins) and its tributaries; and the medullary and subependymal veins, which drain the hemispheric white matter.

Figure 2. Coronal reconstruction of an unenhanced CT image showing hyperattenuation in the occluded cortical vein—the so-called “cord sign” (arrow).

Figure 3. Axial diffusion-weighted image showing hyperintensities in cortical veins. An apparent diffusion coefficient map (not shown) confirmed true restricted diffusion.

Figure 4. A 23-year-old woman with refractory headache. A: Axial MR angiogram showing a lack of flow in the enlarged right transverse sinus. B: Axial FLAIR MRI scan showing hyperintensity in the posterior right temporal lobe, consistent with vasogenic edema of a venous infarct.

Figure 5. A 15-year-old female patient with CVT. A: Axial contrastenhanced three-dimensional T1-weighted magnetization prepared rapid gradient echo MRI sequence showing a central triangular flling defect (“empty delta sign”) in the superior sagittal sinus. B: Axial susceptibility-weighted MRI showing intraparenchymal hemorrhages in the frontal and parietal lobes.

Figure 6. A 20-year-old woman with right-sided headache and hypoesthesia. A: Sagittal MR angiogram showing a lack of flow in the superior sagittal sinus (arrow). B: Axial FLAIR MRI scan showing subarachnoid hemorrhage in the left central sulcus.

Figure 7. A 27-year-old woman with deep CVT. A: MR venogram showing a lack of flow in the internal cerebral veins (arrow), vein of Galen, and straight sinus (not demonstrated). B: Axial susceptibility-weighted MRI scan showing hemorrhagic transformation of a venous infarct in the left head of the caudate nucleus and thalamus.

Figure 8. A 75-year-old female patient who underwent MRI for investigation of vertigo of undetermined origin. A: Axial contrast-enhanced three-dimensional (3D) T1-weighted magnetization prepared rapid gradient echo MRI sequence showing a flling defect in the transition between the right transverse and sigmoid venous sinuses. B: Axial maximum intensity projection reformatting of an unenhanced 3D time-of-fight MR angiogram, showing prominence of the right occipital and middle meningeal arteries, as well as branches of the right vertebral and ascending pharyngeal arteries (not shown) supplying a dural arteriovenous fistula consequent to chronic CVT with incomplete recanalization.

Figure 9. A 52-year-old woman complaining of holocranial headache. A: Axial CT scan showing opacification of some right mastoid air cells associated with bone sclerosis, indicative of chronic mastoiditis. B: Coronal CT angiogram showing a flling defect in the ipsilateral transverse sinus (arrow).

Figure 10. A 43-year-old woman with Behçet’s disease and persistent headache. Sagittal MR venogram showing a lack of flow in the torcular herophili.

Figure 11. A 40-year-old man with a closed head injury and skull fractures who presented with a three-day history of a decreased level of consciousness. An unenhanced axial CT scan (not depicted) showed a hyperdense thrombus in the left transverse sinus. A coronal MR venogram (depicted) confirmed the corresponding lack of venous flow.

Figure 12. Cortical CVT in a 22-year-old woman who developed intracranial hypotension after epidural anesthesia. A: Sagittal contrast-enhanced three-dimensional T1WI showing dilated venous sinuses and enlargement of the pituitary gland (findings typical of intracranial hypotension). B: Unenhanced coronal T1WI showing a hyperintense thrombus in a cortical vein (arrow).

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Cerebral venous thrombosis: imaging patterns

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[1] Correspondence: Dra. Isabela Magalhães Oliveira. Universidade Estadual de Campinas – Radiologia e Diagnóstico por Imagem. Rua Vital Brasil, 251, Cidade Universitária. Campinas, SP, Brazil, 13083-872. Email: isaamagalhaes17@gmail.com.