Pediatric Radiology

, Volume 43, Issue 2, pp 173–188 | Cite as

Cerebral sinovenous thrombosis in pediatric practice

  • Gary L. Hedlund


Cerebral sinovenous thrombosis (CSVT) in the pediatric population is a relatively uncommon yet under-appreciated and potentially life-threatening neurological condition. Early symptoms and signs are often vague and the clinician requesting a cranial imaging study might not even suspect sinovenous thrombosis. If left undiagnosed, or if the diagnosis of CSVT is delayed, progressive neurological deterioration, coma and death can follow. The purpose of this review is to highlight pertinent development of the cerebral venous system, discuss the causal factors of cerebral sinovenous thrombosis in the pediatric population, review practical imaging strategies using cranial sonography augmented with color and pulsed Doppler, unenhanced brain CT, CT venography, cerebral MRI, and MR venography (MRV). Finally, this review will illustrate the imaging features of sinovenous thrombosis, including a discussion of the common causes of false-positive and false-negative CT and MRI studies.


Cerebral sinovenous thrombosis CT venography 2-D time-of-flight MR venography 3-D SPGR Children 



I would like to thank Ms. Starlyn Brandt for manuscript preparation and acknowledge the following colleagues for referring cases for this review: Drs. Richard Boyer, Kevin Moore, John Rampton, Dave Dansie and Logan Mclean.


  1. 1.
    Leach JL, Fortuna RB, Jones BV et al (2006) Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. Radiographics 26:S19–S41, discussion S42-S43PubMedCrossRefGoogle Scholar
  2. 2.
    Jonas Kimchi T, Lee SK, Agid R et al (2007) Cerebral sinovenous thrombosis in children. Neuroimaging Clin N Am 17:239–244PubMedCrossRefGoogle Scholar
  3. 3.
    Carvalho KS, Bodensteiner JB, Connolly PJ et al (2001) Cerebral venous thrombosis in children. J Child Neurol 16:L574–L580Google Scholar
  4. 4.
    Shroff M, deVeber G (2003) Sinovenous thrombosis in children. Neuroimaging Clin N Am 13:115–138PubMedCrossRefGoogle Scholar
  5. 5.
    Shevell MI, Silver K, O’Gorman AM et al (1989) Neonatal dural sinus thrombosis. Pediatr Neurol 5:161–165PubMedCrossRefGoogle Scholar
  6. 6.
    Huisman TA, Holzmann D, Martin E et al (2001) Cerebral venous thrombosis in childhood. Eur Radiol 11:1760–1765PubMedCrossRefGoogle Scholar
  7. 7.
    Wasay M, Dai AI, Ansari M et al (2008) Cerebral venous sinus thrombosis in children: a multicenter cohort from the United States. J Child Neurol 23:26–31PubMedCrossRefGoogle Scholar
  8. 8.
    Tan M, deVeber G, Shroff M et al (2011) Sagittal sinus compression is associated with neonatal cerebral sinovenous thrombosis. Pediatrics 128:e429–e435PubMedCrossRefGoogle Scholar
  9. 9.
    Sebire G, Tabarki B, Saunders DE et al (2005) Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome. Brain 128:477–489PubMedCrossRefGoogle Scholar
  10. 10.
    DeVeber G, Andrew M, Adams C et al (2001) Cerebral sinovenous thrombosis in children. N Engl J Med 345:417–423PubMedCrossRefGoogle Scholar
  11. 11.
    Raybaud C (2010) Normal and abnormal embryology and development of the intracranial vascular system. Neurosurg Clin N Am 21:399–426PubMedCrossRefGoogle Scholar
  12. 12.
    Jimenez JL, Lasjuanias P, Terbrugge K et al (1989) The trans-cerebral veins: normal and non-pathologic angiographic aspects. Surg Radiol Anat 11:63–72PubMedCrossRefGoogle Scholar
  13. 13.
    Oran I, Memis A, Sener RN et al (1999) The so-called transcerebral veins: appearance in three different cases. Comput Med Imag Graph 23:127–131CrossRefGoogle Scholar
  14. 14.
    Benedict SL, Bonkowsky JL, Thompson JA et al (2004) Cerebral sinovenous thrombosis in children: another reason to treat iron deficiency anemia. J Child Neurol 19:526–531PubMedCrossRefGoogle Scholar
  15. 15.
    Krasnokutsky M (2011) Cerebral venous thrombosis: a potential mimic of primary traumatic brain injury in infants. AJR 197:W503–W507PubMedCrossRefGoogle Scholar
  16. 16.
    Barnes PD (2011) Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine. Radiol Clin North Am 49:205–209PubMedCrossRefGoogle Scholar
  17. 17.
    Barnes PD, Krasnokutsky M (2007) Imaging of the central nervous system in suspected or alleged nonaccidental injury, including the mimics. Top Magn Reson Imag 18:53–74CrossRefGoogle Scholar
  18. 18.
    Singh S, Kumar S, Joseph M et al (2005) Cerebral venous sinus thrombosis presenting as subdural haematoma. Australas Radiol 49:101–103PubMedCrossRefGoogle Scholar
  19. 19.
    Matsuda M, Matsuda I, Sato M et al (1982) Superior sagittal sinus thrombosis followed by subdural hematoma. Surg Neurol 18:206–211PubMedCrossRefGoogle Scholar
  20. 20.
    Takamura Y, Morimoto S, Uede T et al (1996) Cerebral venous sinus thrombosis associated with systemic multiple hemangiomas as chronic subdural hematoma—case report. Neurol Med Chir (Tokyo) 36:650–653CrossRefGoogle Scholar
  21. 21.
    Kalita J, Bansal V, Misra UK et al (2008) Intracerebral hemorrhage due to cerebral venous sinus thrombosis. QJM 101:247–249PubMedCrossRefGoogle Scholar
  22. 22.
    McLean LA, Frasier LD, Hedlund GL (2012) Does intracranial venous thrombosis cause subdural hemorrhage in the pediatric population? AJNR. doi: 10.3174/ajnr.A2967, Epub ahead of print
  23. 23.
    Tang PH, Chai J, Chan YH et al (2008) Superior sagittal sinus thrombosis: subtle signs on neuroimaging. Ann Acad Med Singapore 37:397–401PubMedGoogle Scholar
  24. 24.
    Zimmerman RD, Ernst RJ (1992) Neuroimaging of cerebral venous thrombosis. Neuroimage Clin North Am 2:463–485Google Scholar
  25. 25.
    Provenzale J, Kranz P (2011) Dural sinus thrombosis: sources of error in image interpretation. AJR 196:23–31PubMedCrossRefGoogle Scholar
  26. 26.
    Provenzale JM, Joseph G, Barboriak D (1998) Dural sinus thrombosis: findings on CT and MR imaging and diagnostic pitfalls. AJR 170:777–783PubMedCrossRefGoogle Scholar
  27. 27.
    Linn J, Pfefferkorn T, Ivanicova K et al (2009) Noncontrast CT in deep cerebral venous thrombosis and sinus thrombosis: comparison of its diagnostic value for both entities. AJNR 30:728–735PubMedCrossRefGoogle Scholar
  28. 28.
    Virapongse C, Cazenave C, Quisling R et al (1987) The empty delta sign: frequency and significance in 76 cases of dural sinus thrombosis. Radiology 162:779–785PubMedGoogle Scholar
  29. 29.
    Nelson MD, Thompson JR, Hinshaw DB et al (1981) Radiodense dural sinuses: new CT sign in patients at risk for hypoxemic insult. AJNR 2:545–548PubMedGoogle Scholar
  30. 30.
    Ferro JM, Canhao P, Stam J et al (2009) Delay in the diagnosis of cerebral vein and dural sinus thrombosis: influence on outcome. Stroke 40:3133–3138PubMedCrossRefGoogle Scholar
  31. 31.
    Majoie CB, van Straten M, Venema HW et al (2004) Multisection CT venography of the dural sinuses and cerebral veins by using mask bone elimination. AJNR 24:787–791Google Scholar
  32. 32.
    Black DF, Rad AE, Gray LA et al (2011) Cerebral venous sinus density on noncontrast CT correlates with hematocrit. AJNR 32:1354–1357PubMedCrossRefGoogle Scholar
  33. 33.
    Puig J, Pedraza S, Demchuk A et al (2012) Quantification of thrombus Hounsfield units on noncontrast CT predicts stroke subtype and early recanalization after intravenous recombinant tissue plasminogen activator. AJNR 33:90–96PubMedCrossRefGoogle Scholar
  34. 34.
    Croft P, Reichard R (2009) Microscopic examination of grossly unremarkable pediatric dura mater. Am J Forensic Med Pathol 30:10–13PubMedCrossRefGoogle Scholar
  35. 35.
    Valdueza JM, Schultz M, Harms L et al (1995) Venous transcranial Doppler ultrasound monitoring in acute dural sinus thrombosis. Report of two cases. Stroke 26:1196–1199PubMedCrossRefGoogle Scholar
  36. 36.
    Tsai FY, Wang AM, Matovich VB et al (1995) Acute thrombosis of the intracranial dural sinus; direct thrombolytic treatment. AJNR 16:2021–2029Google Scholar
  37. 37.
    Sze G, Simmons B, Krol G et al (1988) Dural sinus thrombosis: verification with spin-echo techniques. AJNR 9:679–686PubMedGoogle Scholar
  38. 38.
    Selim M, Fink J, Linfante I et al (2002) Diagnosis of cerebral venous thrombosis with echo-planar T2*-weighted magnetic resonance imaging. Arch Neurol 59:1021–1026PubMedCrossRefGoogle Scholar
  39. 39.
    Tsuruda JS, Shimakawa A, Pelc NJ et al (1991) Dural sinus occlusion: evaluation with phase-sensitive gradient-echo MR imaging. AJNR 12:481–488PubMedGoogle Scholar
  40. 40.
    Thamburaj K, Choudhary A (2009) Hyperintense vessel sign: isolated cortical venous thrombosis after L-asparaginase therapy. Pediatr Radiol 39:757PubMedCrossRefGoogle Scholar
  41. 41.
    Leach JL, Bluas RV, Ernst RJ et al (1996) MR imaging of isolated cortical vein thrombosis: the hyperintense vein sign. J Neurovasc Dis 1:1–7Google Scholar
  42. 42.
    Baumgartner RW, Studer A, Arnold M et al (2003) Recanalisation of cerebral venous thrombosis. J Neurol Neurosurg Psychiatry 74:459–461PubMedCrossRefGoogle Scholar
  43. 43.
    Idbaih A, Boukobza M, Crassard I et al (2006) MRI clot in cerebral venous thrombosis. High diagnostic value of susceptibility-weighted images. Stroke 37:991–995PubMedCrossRefGoogle Scholar
  44. 44.
    Ducreux D, Oppenheim C, Vandamme X et al (2001) Diffusion-weighted imaging patterns of brain damage associated with cerebral venous thrombosis. AJNR 22:261–268PubMedGoogle Scholar
  45. 45.
    Favrole P, Guichard J, Crassard I et al (2004) Diffusion-weighted imaging of intravascular clots in cerebral venous thrombosis. Stroke 35:99–103PubMedCrossRefGoogle Scholar
  46. 46.
    Yoshikawa T, Abe O, Tsuchiya K et al (2002) Diffusion-weighted magnetic resonance imaging of dural sinus thrombosis. Neuroradiology 44:481–488PubMedCrossRefGoogle Scholar
  47. 47.
    Widjaja E, Shroff M, Blaser S et al (2006) 2D time-of-flight MR venography in neonates: anatomy and pitfalls. AJNR 27:1913–1918PubMedGoogle Scholar
  48. 48.
    Widjaja E, Griffiths PD (2004) Intracranial MR venography in children: normal anatomy and variations. AJNR 25:1557–1562PubMedGoogle Scholar
  49. 49.
    Ayanzen RH, Bird CR, Keller PJ et al (2000) Cerebral MR venography: normal anatomy and potential diagnostic pitfalls. AJNR 21:74–78PubMedGoogle Scholar
  50. 50.
    Leach JL, Jones BV, Tomsick TA et al (1996) Normal appearance of arachnoid granulations on contrast-enhanced CT and MR of the brain: differentiation from dural sinus disease. AJNR 17:1523–1532PubMedGoogle Scholar
  51. 51.
    Klingebiel R, Bauknecht HC, Bohner G et al (2007) Comparative evaluation of 2D time-of-flight and 3D elliptic centric contrast-enhanced MR venography in patients with presumptive cerebral venous and sinus thrombosis. Eur J Neurol 14:139–143PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  1. 1.Department of Medical Imaging, Primary Children’s Medical CenterUniversity of Utah School of MedicineSalt Lake CityUSA

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