Cerebral venous thrombosis: state of the art diagnosis and management
This review article aims to discuss the pathophysiology, clinical presentation, and neuroimaging of cerebral venous thrombosis (CVT). Different approaches for diagnosis of CVT, including CT/CTV, MRI/MRV, and US will be discussed and the reader will become acquainted with imaging findings as well as limitations of each modality. Lastly, this exhibit will review the standard of care for CVT treatment and emerging endovascular options.
A literature search using PubMed and the MEDLINE subengine was completed using the terms “cerebral venous thrombosis,” “stroke,” and “imaging.” Studies reporting on the workup, imaging characteristics, clinical history, and management of patients with CVT were included.
The presentation of CVT is often non-specific and requires a high index of clinical suspicion. Signs of CVT on NECT can be divided into indirect signs (edema, parenchymal hemorrhage, subarachnoid hemorrhage, and rarely subdural hematomas) and less commonly direct signs (visualization of dense thrombus within a vein or within the cerebral venous sinuses). Confirmation is performed with CTV, directly demonstrating the thrombus as a filling defect, or MRI/MRV, which also provides superior characterization of parenchymal abnormalities. General pitfalls and anatomic variants will also be discussed. Lastly, endovascular management options including thrombolysis and mechanical thrombectomy are discussed.
CVT is a relatively uncommon phenomenon and frequently overlooked at initial presentation. Familiarity with imaging features and diagnostic work-up of CVT will help in providing timely diagnosis and therapy which can significantly improve outcome and diminish the risk of acute and long-term complications, optimizing patient care.
KeywordsVenous stroke Venous thrombosis Neurovascular Algorithm Review
The authors would like to thank Drs. Reza Forghani and Almudena Perez of the Jewish General Hospital, McGill University, for case and illustration contributions.
Compliance with ethical standards
No funding was received for this study.
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
This article does not contain any studies with human participants or animals performed by any of the authors.
- 1.Saposnik G, Barinagarrementeria F, Brown RD, Bushnell CD, Cucchiara B, Cushman M, deVeber G, Ferro JM, Tsai FY, on behalf of the American Heart Association Stroke Council and the Council on Epidemiology and Prevention (2011) Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 42:1158–1192. https://doi.org/10.1161/STR.0b013e31820a8364 CrossRefPubMedGoogle Scholar
- 13.Kumral E, Polat F, Uzunkopru C, Calli C, Kitis O (2012) The clinical spectrum of intracerebral hematoma, hemorrhagic infarct, non-hemorrhagic infarct, and non-lesional venous stroke in patients with cerebral sinus-venous thrombosis. Eur J Neurol 19:537–543. https://doi.org/10.1111/j.1468-1331.2011.03562.x CrossRefPubMedGoogle Scholar
- 19.Meckel S, Reisinger C, Bremerich J, Damm D, Wolbers M, Engelter S, Scheffler K, Wetzel SG (2010) Cerebral venous thrombosis: diagnostic accuracy of combined, dynamic and static, contrast-enhanced 4D MR venography. AJNR Am J Neuroradiol 31:527–535. https://doi.org/10.3174/ajnr.A1869 CrossRefPubMedGoogle Scholar
- 27.Liauw L, van Buchem MA, Spilt A, de Bruïne FT, van den Berg R, Hermans J, Wasser MNJM (2000) MR angiography of the intracranial venous system. Radiology 214:678–682. https://doi.org/10.1148/radiology.214.3.r00mr41678 CrossRefPubMedGoogle Scholar
- 29.Kajtazi NI, Zimmerman VA, Arulneyam JC, Al-Shami SY, Al-Senani FM (2009) Cerebral venous thrombosis in Saudi Arabia. Clinical variables, response to treatment, and outcome. Neurosciences (Riyadh) 14:349–354Google Scholar
- 32.Idbaih A, Boukobza M, Crassard I, Porcher R, Bousser MG, Chabriat H (2006) MRI of clot in cerebral venous thrombosis: high diagnostic value of susceptibility-weighted images. Stroke 37:991–995. https://doi.org/10.1161/01.STR.0000206282.85610.ae CrossRefPubMedGoogle Scholar
- 35.Favrole P, Guichard JP, Crassard I, Bousser MG, Chabriat H (2004) Diffusion-weighted imaging of intravascular clots in cerebral venous thrombosis. Stroke 35:99–103. https://doi.org/10.1161/01.STR.0000106483.41458.AF CrossRefPubMedGoogle Scholar
- 38.Farb RI, Scott JN, Willinsky RA, Montanera WJ, Wright GA, terBrugge KG (2003) Intracranial venous system: gadolinium-enhanced three-dimensional MR venography with auto-triggered elliptic centric-ordered sequence--initial experience. Radiology 226:203–209. https://doi.org/10.1148/radiol.2261020670 CrossRefPubMedGoogle Scholar
- 41.Monteiro AMV, Lima CMAO, Ribeiro ÉB, Lins MC, Miranda S, Miranda LE (2010) Diagnóstico por imagem e aspectos clínicos da trombose venosa cerebral em recém-natos a termo sem dano cerebral: revisão em 10 anos. Radiol Bras 43:149–153. https://doi.org/10.1590/S0100-39842010000300004 CrossRefGoogle Scholar
- 51.Ferro JM, Bousser M-G, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, Aguiar de Sousa D, Stam J, the European Stroke Organization (2017) European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis—endorsed by the European Academy of Neurology. Eur J Neurol 24:1203–1213. https://doi.org/10.1111/ene.13381 CrossRefPubMedGoogle Scholar
- 53.Afshari D, Moradian N, Nasiri F, Razazian N, Bostani A, Sariaslani P (2015) The efficacy and safety of low-molecular-weight heparin and unfractionated heparin in the treatment of cerebral venous sinus thrombosis. Neurosciences (Riyadh) 20:357–361. https://doi.org/10.17712/nsj.2015.4.20150375 CrossRefGoogle Scholar
- 54.Siddiqui FM, Banerjee C, Zuurbier SM, Hao Q, Ahn C, Pride GL, Wasay M, Majoie CBLM, Liebeskind D, Johnson M, Stam J (2014) Mechanical thrombectomy versus intrasinus thrombolysis for cerebral venous sinus thrombosis: a non-randomized comparison. Interv Neuroradiol 20:336–344. https://doi.org/10.15274/INR-2014-10032 CrossRefPubMedPubMedCentralGoogle Scholar
- 59.Salottolo K, Wagner J, Frei DF, Loy D, Bellon RJ, McCarthy K, Jensen J, Fanale C, Bar-Or D (2017) Epidemiology, endovascular treatment, and prognosis of cerebral venous thrombosis: US center study of 152 patients. J Am Heart Assoc 6(6):e005480. https://doi.org/10.1161/JAHA.117.005480 CrossRefPubMedPubMedCentralGoogle Scholar