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.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
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
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
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
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
Coutinho JM (2015) Cerebral venous thrombosis. J Thromb Haemost 13:S238–S244. https://doi.org/10.1111/jth.12945
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
Stam J (2003) Cerebral venous and sinus thrombosis: incidence and causes. Adv Neurol 92:225–232
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
van Gijn J (2009) Cerebral venous thrombosis: pathogenesis, presentation and prognosis. J R Soc Med 93:230–233. https://doi.org/10.1177/014107680009300504
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
Chiewvit P, Piyapittayanan S, Poungvarin N (2011) Cerebral venous thrombosis: diagnosis dilemma. Neurol Int 3:e13. https://doi.org/10.4081/ni.2011.e13
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
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
Bousser MG (2000) Cerebral venous thrombosis: diagnosis and management. J Neurol 247:252–258. https://doi.org/10.1007/s004150050579
Soleau SW, Schmidt R, Stevens S, Osborn A, MacDonald JD (2003) Extensive experience with dural sinus thrombosis. Neurosurgery 52:534–544 discussion 542-534
Simonds GR, Truwit CL (1994) Anatomy of the cerebral vasculature. Neuroimaging Clin N Am 4:691–706
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Widjaja E, Griffiths PD (2004) Intracranial MR venography in children: normal anatomy and variations. AJNR Am J Neuroradiol 25:1557–1562
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
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
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
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
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
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
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
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
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
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
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
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
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
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
The authors would like to thank Drs. Reza Forghani and Almudena Perez of the Jewish General Hospital, McGill University, for case and illustration contributions.
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.
• 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.
About this article
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
- Venous stroke
- Venous thrombosis