Cerebral venous thrombosis: state of the art diagnosis and management

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.

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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.

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Correspondence to Adam A. Dmytriw.

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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.

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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

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Keywords

  • Venous stroke
  • Venous thrombosis
  • Neurovascular
  • Algorithm
  • Review