Cerebral Venous Sinus Thrombosis: Prognostic and Therapeutic Significance of an Early Radiologic Diagnosis

Abstract

We describe the CT and MRI patterns of cerebral venous sinus thrombosis (CVST) on the basis of the venous angioarchitecture and the underlying pathophysiological mechanism. We also investigated if any radiologic data exist to establish which patients can be followed conservatively and which warrant endovascular treatment. The clinical, CT-CTA and MRI-MRA findings of 11 patients (2 men; 9 women; 24 to 69 years-old) with CVST were reviewed. The morphological patterns of CVST were divided into two major groups: Vascular signs: spontaneous sinusal hyperdensity (9); spontaneous all-sequences hyperintensity (4); venous engorgement (9); empty delta sign (4); lack of sinusal contrast-enhancement (3); delayed sinusal transit-time (11); lack of flow-related signal (3). Parenchymal signs: mass effect and cortical sulcal effacement (8), white matter edema (7), venous ischemia (6), haemorrhagic infarct (3), breakdown of the blood-brain barrier (4), hydrocephalus (2). The clinical and radiologic pictures are related to cerebral venous angioarchitecture and underlying pathophysiologic mechanism of venous thrombosis. Reversibility of clinical symptoms and parenchymal lesions is far more frequent, because vessel damage slowly and progressively develops, whereas damage to brain tissue occurs later. Consequently, a prompt CT-MRI diagnosis may allow a good prognosis. Treatment using selective sinusal instillation of urokinase is considered only when the patient clinically and radiologically does not improve within the first two weeks after heparinization.

Imaging of Neurologic Disorders Associated with Pregnancy and the Postpartum Period

“…MR imaging is more sensitive than CT in early detection of thrombosis and more accurate in depicting the extent and complications of CVT. Simultaneous high signal intensity of the venous sinuses with all routine sequences (T1-weighted, T2-weighted, and FLAIR) is a reliable sign of CVT (Fig 7b-7d) (39). High signal intensity on T1-weighted images with a corresponding filling defect after gadolinium enhancement may develop within the first week after clinical onset (Fig 7e).…”

“…Contrast-enhanced CT may show the typical filling defect commonly referred to as the empty delta sign. However, it may take 7-10 days for the empty delta sign to show on CT scans after the onset of symptoms (39). MR imaging is more sensitive than CT in early detection of thrombosis and more accurate in depicting the extent and complications of CVT.…”

“…High signal intensity on T1-weighted images with a corresponding filling defect after gadolinium enhancement may develop within the first week after clinical onset (Fig 7e). Lack of physiologic enhancement of the venous sinus is an early sign and is typically seen within the first week of CVT on both CT and MR images (39). MR venography can add to the diagnostic value of routine MR imaging and better demonstrates the layout of the major cerebral veins and dural venous sinuses (Fig 7f).…”

Anatomical Variations of Superior Sagittal Sinus and Tributary Bridging Veins: A Cadaveric Study

“…Similarly, the highest lateralization in the B-L portion of the SSS was 30 mm, whereas the L-I segment showed only 4.1 mm as the highest value. 3, 4 Statistically significant difference in the mean diameter of BVs between hemispheric sides in the N-B segment 3 and along the entire length of SSS 4 (N-I segment, p<0.01 in both comparisons) 5 Statistically significant trend showing decreasing average distance from the midline to the lateral insertion points of BVs with each consecutive SSS segment (N-B, B-L, and L-I, p<0.01) 6 Statistically significant difference in the lateralization of BVs drainage points between hemispheric sides in B-L segment (p<0.01) BV: bridging vein; N: Nasion; B: Bregma; L: Lambda; I: Inion…”

“…Although permanent neurological sequelae after venous drainage obliteration are less common in comparison to the arterial system, (in)advert interruption of cortical venous outflow nonetheless might lead to potentially preventable complications such as bleeding, cerebral edema, infarction, and ultimately severe neurological outcomes. Similarly, besides the hazards associated with the BVs termination, injury to the SSS might expose the patient to the risk of an air embolism, requiring a technically-demanding surgical repair, and, if unsuccessful, ligation of the SSS in order to prevent detrimental hemorrhage [ 2 , 3 ]. The risk of profuse bleeding and permanent neurological deficits increases exponentially as more tributaries pool into the dural structure [ 4 ].…”