Skip to main content

Advertisement

SpringerLink
Log in

Cerebral venous thrombosis: state of the art diagnosis and management

  • Review
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusions

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15

Similar content being viewed by others

References

  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

    Article  PubMed  Google Scholar 

  2. Linn J, Ertl-Wagner B, Seelos KC, Strupp M, Reiser M, Brückmann H, Brüning R (2007) Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses. AJNR Am J Neuroradiol 28:946–952

    PubMed  CAS  Google Scholar 

  3. Leach JL, Fortuna RB, Jones BV, Gaskill-Shipley MF (2006) Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. Radiographics 26:S19–S41. https://doi.org/10.1148/rg.26si055174

    Article  PubMed  Google Scholar 

  4. Buyck P-J, De Keyzer F, Vanneste D, Wilms G, Thijs V, Demaerel P (2013) CT density measurement and H:H ratio are useful in diagnosing acute cerebral venous sinus thrombosis. Am J Neuroradiol 34:1568–1572. https://doi.org/10.3174/ajnr.A3469

    Article  PubMed  Google Scholar 

  5. Coutinho JM (2015) Cerebral venous thrombosis. J Thromb Haemost 13:S238–S244. https://doi.org/10.1111/jth.12945

    Article  PubMed  Google Scholar 

  6. Coutinho JM, Zuurbier SM, Aramideh M, Stam J (2012) The incidence of cerebral venous thrombosis: a cross-sectional study. Stroke 43:3375–3377. https://doi.org/10.1161/STROKEAHA.112.671453

    Article  PubMed  Google Scholar 

  7. Stam J (2003) Cerebral venous and sinus thrombosis: incidence and causes. Adv Neurol 92:225–232

    PubMed  Google Scholar 

  8. Poon CS, Chang J-K, Swarnkar A, Johnson MH, Wasenko J (2007) Radiologic diagnosis of cerebral venous thrombosis: pictorial review. Am J Roentgenol 189:S64–S75. https://doi.org/10.2214/AJR.07.7015

    Article  Google Scholar 

  9. van Gijn J (2009) Cerebral venous thrombosis: pathogenesis, presentation and prognosis. J R Soc Med 93:230–233. https://doi.org/10.1177/014107680009300504

    Article  Google Scholar 

  10. Leach JL, Wolujewicz M, Strub WM (2007) Partially recanalized chronic dural sinus thrombosis: findings on MR imaging, time-of-flight MR venography, and contrast-enhanced MR venography. AJNR Am J Neuroradiol 28:782–789

    PubMed  CAS  Google Scholar 

  11. Chiewvit P, Piyapittayanan S, Poungvarin N (2011) Cerebral venous thrombosis: diagnosis dilemma. Neurol Int 3:e13. https://doi.org/10.4081/ni.2011.e13

    Article  PubMed  PubMed Central  Google Scholar 

  12. Masuhr F, Mehraein S, Einhaupl K (2004) Cerebral venous and sinus thrombosis. J Neurol 251:11–23. https://doi.org/10.1007/s00415-004-0321-7

    Article  PubMed  CAS  Google 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

    Article  PubMed  CAS  Google Scholar 

  14. Bousser MG (2000) Cerebral venous thrombosis: diagnosis and management. J Neurol 247:252–258. https://doi.org/10.1007/s004150050579

    Article  PubMed  CAS  Google Scholar 

  15. Soleau SW, Schmidt R, Stevens S, Osborn A, MacDonald JD (2003) Extensive experience with dural sinus thrombosis. Neurosurgery 52:534–544 discussion 542-534

    Article  PubMed  Google Scholar 

  16. Simonds GR, Truwit CL (1994) Anatomy of the cerebral vasculature. Neuroimaging Clin N Am 4:691–706

    PubMed  CAS  Google Scholar 

  17. Oka K, Rhoton AL Jr, Barry M, Rodriguez R (1985) Microsurgical anatomy of the superficial veins of the cerebrum. Neurosurgery 17:711–748. https://doi.org/10.1227/00006123-198511000-00003

    Article  PubMed  CAS  Google Scholar 

  18. Roland T, Jacobs J, Rappaport A, Vanheste R, Wilms G, Demaerel P (2010) Unenhanced brain CT is useful to decide on further imaging in suspected venous sinus thrombosis. Clin Radiol 65:34–39. https://doi.org/10.1016/j.crad.2009.09.008

    Article  PubMed  CAS  Google 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

    Article  PubMed  CAS  Google Scholar 

  20. Lee SK, terBrugge KG (2003) Cerebral venous thrombosis in adults: the role of imaging evaluation and management. Neuroimaging Clin N Am 13:139–152. https://doi.org/10.1016/S1052-5149(02)00095-3

    Article  PubMed  Google Scholar 

  21. Ozsvath RR, Casey SO, Lustrin ES, Alberico RA, Hassankhani A, Patel M (1997) Cerebral venography: comparison of CT and MR projection venography. AJR Am J Roentgenol 169:1699–1707. https://doi.org/10.2214/ajr.169.6.9393193

    Article  PubMed  CAS  Google Scholar 

  22. Provenzale JM, Kranz PG (2011) Dural sinus thrombosis: sources of error in image interpretation. Am J Roentgenol 196:23–31. https://doi.org/10.2214/AJR.10.5323

    Article  Google Scholar 

  23. Tsai FY, Wang AM, Matovich VB, Lavin M, Berberian B, Simonson TM, Yuh WT (1995) MR staging of acute dural sinus thrombosis: correlation with venous pressure measurements and implications for treatment and prognosis. AJNR Am J Neuroradiol 16:1021–1029

    PubMed  CAS  Google Scholar 

  24. Yoshikawa T, Abe O, Tsuchiya K, Okubo T, Tobe K, Masumoto T, Hayashi N, Mori H, Yamada H, Aoki S, Ohtomo K (2002) Diffusion-weighted magnetic resonance imaging of dural sinus thrombosis. Neuroradiology 44:481–488. https://doi.org/10.1007/s00234-002-0772-4

    Article  PubMed  CAS  Google Scholar 

  25. Lovblad KO, Bassetti C, Schneider J, Ozdoba C, Remonda L, Schroth G (2000) Diffusion-weighted MRI suggests the coexistence of cytotoxic and vasogenic oedema in a case of deep cerebral venous thrombosis. Neuroradiology 42:728–731. https://doi.org/10.1007/s002340000395

    Article  PubMed  CAS  Google Scholar 

  26. Bergui M, Bradac GB, Daniele D (1999) Brain lesions due to cerebral venous thrombosis do not correlate with sinus involvement. Neuroradiology 41:419–424. https://doi.org/10.1007/s002340050775

    Article  PubMed  CAS  Google 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

    Article  PubMed  CAS  Google Scholar 

  28. Wetzel SG, Kirsch E, Stock KW, Kolbe M, Kaim A, Radue EW (1999) Cerebral veins: comparative study of CT venography with intraarterial digital subtraction angiography. AJNR Am J Neuroradiol 20:249–255

    PubMed  CAS  Google 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) 14:349–354

    Google Scholar 

  30. Bergui M, Bradac GB (2003) Clinical picture of patients with cerebral venous thrombosis and patterns of dural sinus involvement. Cerebrovasc Dis 16:211–216. https://doi.org/10.1159/000071118

    Article  PubMed  Google Scholar 

  31. Walecki J, Mruk B, Nawrocka-Laskus E, Piliszek A, Przelaskowski A, Sklinda K (2015) Neuroimaging of cerebral venous thrombosis (CVT)—old dilemma and the new diagnostic methods. Pol J Radiol 80:368–373. https://doi.org/10.12659/PJR.894386

    Article  PubMed  PubMed Central  Google 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

    Article  PubMed  Google Scholar 

  33. Mittal S, Wu Z, Neelavalli J, Haacke EM (2009) Susceptibility-weighted imaging: technical aspects and clinical applications. Part 2. AJNR Am J Neuroradiol 30:232–252. https://doi.org/10.3174/ajnr.A1461

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  34. Majoie CB, van Straten M, Venema HW, den Heeten GJ (2004) Multisection CT venography of the dural sinuses and cerebral veins by using matched mask bone elimination. AJNR Am J Neuroradiol 25:787–791

    PubMed  Google 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

    Article  PubMed  Google Scholar 

  36. Ducreux D, Oppenheim C, Vandamme X, Dormont D, Samson Y, Rancurel G, Cosnard G, Marsault C (2001) Diffusion-weighted imaging patterns of brain damage associated with cerebral venous thrombosis. AJNR Am J Neuroradiol 22:261–268

    PubMed  CAS  Google Scholar 

  37. Isensee C, Reul J, Thron A (1994) Magnetic resonance imaging of thrombosed dural sinuses. Stroke 25:29–34. https://doi.org/10.1161/01.STR.25.1.29

    Article  PubMed  CAS  Google 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

    Article  PubMed  Google Scholar 

  39. Rollins N, Ison C, Reyes T, Chia J (2005) Cerebral MR venography in children: comparison of 2D time-of-flight and gadolinium-enhanced 3D gradient-echo techniques. Radiology 235:1011–1017. https://doi.org/10.1148/radiol.2353041427

    Article  PubMed  Google Scholar 

  40. Yang JYK, Chan AKC, Callen DJA, Paes BA (2010) Neonatal cerebral sinovenous thrombosis: sifting the evidence for a diagnostic plan and treatment strategy. Pediatrics 126:e693–e700. https://doi.org/10.1542/peds.2010-1035

    Article  PubMed  Google 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

    Article  Google Scholar 

  42. Hashmi M, Wasay M (2011) Caring for cerebral venous sinus thrombosis in children. J Emerg Trauma Shock 4:389–394. https://doi.org/10.4103/0974-2700.83870

    Article  PubMed  PubMed Central  Google Scholar 

  43. Dlamini N, Billinghurst L, Kirkham FJ (2010) Cerebral venous sinus (sinovenous) thrombosis in children. Neurosurg Clin N Am 21:511–527. https://doi.org/10.1016/j.nec.2010.03.006

    Article  PubMed  PubMed Central  Google Scholar 

  44. Cure JK, Van Tassel P, Smith MT (1994) Normal and variant anatomy of the dural venous sinuses. Semin Ultrasound CT MR 15:499–519. https://doi.org/10.1016/S0887-2171(05)80019-8

    Article  PubMed  CAS  Google Scholar 

  45. Widjaja E, Griffiths PD (2004) Intracranial MR venography in children: normal anatomy and variations. AJNR Am J Neuroradiol 25:1557–1562

    PubMed  CAS  Google Scholar 

  46. Black DF, Rad AE, Gray LA, Campeau NG, Kallmes DF (2011) Cerebral venous sinus density on noncontrast CT correlates with hematocrit. AJNR Am J Neuroradiol 32:1354–1357. https://doi.org/10.3174/ajnr.A2504

    Article  PubMed  CAS  Google Scholar 

  47. Mamourian AC, Towfighi J (1995) MR of giant arachnoid granulation, a normal variant presenting as a mass within the dural venous sinus. AJNR Am J Neuroradiol 16:901–904

    PubMed  CAS  Google Scholar 

  48. Oppenheim C, Domigo V, Gauvrit JY, Lamy C, Mackowiak-Cordoliani MA, Pruvo JP, Méder JF (2005) Subarachnoid hemorrhage as the initial presentation of dural sinus thrombosis. AJNR Am J Neuroradiol 26:614–617

    PubMed  Google Scholar 

  49. Choudhri O, Feroze A, Marks MP, Do HM (2014) Endovascular management of cerebral venous sinus thrombosis. Neurosurg Focus 37:1. https://doi.org/10.3171/2014.V2.FOCUS14186

    Article  PubMed  Google Scholar 

  50. Star M, Flaster M (2013) Advances and controversies in the management of cerebral venous thrombosis. Neurol Clin 31:765–783. https://doi.org/10.1016/j.ncl.2013.03.013

    Article  PubMed  Google 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

    Article  PubMed  CAS  Google Scholar 

  52. Sandercock PA, Leong TS (2017) Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke. Cochrane Database Syst Rev 4:CD000119. https://doi.org/10.1002/14651858.CD000119.pub4

    Article  PubMed  Google 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

    Article  Google 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

    Article  PubMed  PubMed Central  Google Scholar 

  55. Li G, Zeng X, Hussain M, Meng R, Liu Y, Yuan K, Sikharam C, Ding Y, Ling F, Ji X (2013) Safety and validity of mechanical thrombectomy and thrombolysis on severe cerebral venous sinus thrombosis. Neurosurgery 72:730–738. https://doi.org/10.1227/NEU.0b013e318285c1d3

    Article  PubMed  Google Scholar 

  56. Siddiqui FM, Dandapat S, Banerjee C, Zuurbier SM, Johnson M, Stam J, Coutinho JM (2015) Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases. Stroke 46:1263–1268. https://doi.org/10.1161/STROKEAHA.114.007465

    Article  PubMed  Google Scholar 

  57. Ilyas A, Chen C-J, Raper DM, Ding D, Buell T, Mastorakos P, Liu KC (2017) Endovascular mechanical thrombectomy for cerebral venous sinus thrombosis: a systematic review. J Neurointerv Surg 9:1086–1092. https://doi.org/10.1136/neurintsurg-2016-012938

    Article  PubMed  Google Scholar 

  58. Viegas LD, Stolz E, Canhão P, Ferro JM (2014) Systemic thrombolysis for cerebral venous and dural sinus thrombosis: a systematic review. Cerebrovasc Dis 37:43–50. https://doi.org/10.1159/000356840

    Article  PubMed  CAS  Google 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

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Drs. Reza Forghani and Almudena Perez of the Jewish General Hospital, McGill University, for case and illustration contributions.

Author information

Authors and Affiliations

  1. Department of Medical Imaging, University of Toronto, 263 McCaul St, 4th Floor, Toronto, ON, M5T 1W7, Canada

    Adam A. Dmytriw, Jin Soo A. Song & Eugene Yu

  2. Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA

    Colin S. Poon

Authors
  1. Adam A. Dmytriw
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jin Soo A. Song
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eugene Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Colin S. Poon
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Adam A. Dmytriw.

Ethics declarations

Funding

No funding was received for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

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.

Informed consent

This article does not contain any studies with human participants or animals performed by any of the authors.

Additional information

Key points

• The empty delta sign more frequent presents between day 5 to 2 months after onset and may be associated with development of collaterals which provide peripheral enhancement surrounding the filling defect.

• Detection is more successful on unenhanced MRI when the imaging plane is orthogonal to the blood flow trajectory. For this reason, thrombosis of the sigmoid, sagittal, and transverse sinuses is better appreciated in coronal plane.

• T1WI high signal intensity of a superior sagittal sinus thrombosis is better seen in subacute thrombosis, due to methemoglobin thrombus composition.

• After 15 days, the diagnosis of CVT via MRI may be challenging as chronic thrombosis shows partial recanalization and the signal of the clot is iso- to hyperintense on T2WI and isointense on T1WI.

• TOF is a useful alternative to CE-MRV in pregnant or breastfeeding patients, as well as in case of severe renal failure. 2D TOF is superior to its 3D TOF due to low saturation effects and sensitivity with slow flow states.

• In neonates and infants, US is a useful screening method to demonstrate brain edema and to rapidly assess for possible complications from CVT. Between one and two thirds of children may develop intraparenchymal hemorrhage and ischemia.

• Given the propensity towards normal physiologic enhancement in the inner dural border zone in children, investigation with Doppler US can troubleshoot equivocal cases.

• On unenhanced CT, if there is a hemoconcentrated state that is increasing the density of the blood, arterial and venous structures will be equally affected,

• With CECT and CTV, a split or fenestrated sinus and intrasinus septa may cause a filling defect indistinguishable from the classic empty delta sign.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dmytriw, A.A., Song, J.S.A., Yu, E. et al. Cerebral venous thrombosis: state of the art diagnosis and management. Neuroradiology 60, 669–685 (2018). https://doi.org/10.1007/s00234-018-2032-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-018-2032-2

Keywords

Search

Navigation