High-signal venous sinuses on MR angiography: discrimination between reversal of venous flow and arteriovenous shunting using arterial spin labeling

Abstract

Purpose It is sometimes difficult to differentiate between high signals originating from a reverse flow on magnetic resonance angiography (MRA) and occult arteriovenous shunting. We attempted to determine whether arterial spin labeling (ASL) can be used to discriminate reversal of venous flow from arteriovenous shunting for high-signal venous sinuses on MR angiography. Methods Two radiologists evaluated the signals of the venous sinus on MRA and ASL obtained from 364 cases without arteriovenous shunting. In addition, the findings on MRA were compared with those on ASL in an additional 13 patients who had dural arteriovenous fistula (DAVF). Results In the 364 cases (728 sides) without arteriovenous shunting, a high signal due to reverse flow in the cavernous sinuses (CS) was observed on 99 sides (13.6%) on MRA and none on ASL. Of these cases, a high signal in the sigmoid sinus, transverse sinus, and internal jugular vein was seen on 3, 3, and 8 sides, respectively. All of these venous sinuses showed a high signal from the reverse flow on MRA images. Conclusion ASL is a simple and useful MR imaging sequence for differentiating between reversal of venous flow and CS DAVF. In the sigmoid and transverse sinus, ASL showed false-positives due to the reverse flow from the jugular vein, which may be a limitation of which radiologists should be aware.

Retrograde Flow Into the Internal Jugular Vein in a Hemodialysis Patient Mimicking Dural Arteriovenous Fistula: A Case Report

“…A previous study reported that left-sided compression of the brachiocephalic vein and the absence of enlarged external carotid arteries can be the findings that cause jugular vein reflux [ 5 ]. Although our case matches the latter one, the other reports showed high specificity of hypersignal intensities in the cavernous sinus on ASL to differentiate DAVF from reversal flow [ 4 ]. Our case did not meet this finding.…”

“…Jugular vein reflux is occasionally observed in healthy patients [ 4 , 5 , 14 ], and some reports have described this phenomenon as mainly caused by compression of the left brachiocephalic vein and jugular valve dysfunction [ 5 , 6 ]. Although jugular valve dysfunction has been thought to be related to transient global amnesia [ 15 ], jugular venous reflux is usually detected incidentally in supine position MRI, and most cases are diagnosed incidentally or exhibit pulsatile tinnitus without severe symptoms [ 5 , 14 , 16 ].…”

“…The high-intensity signal of both the transverse sinus and cavernous sinus in ASL and TOF-MRA was confused with DAVF. Although MRA and ASL have high sensitivity to detect abnormal signals due to jugular vein reflux [4][5][6], it is sometimes difficult to differentiate the reversal flow from DAVF [5,7]. In addition, abnormal signals can sometimes be detected due to prolonged arterial arrival times in healthy patients [8].…”

A case of recurrent cavernous sinus dural arteriovenous fistula arising after superselective shunt occlusion and detected by venous arterial spin labeling

“…[ 10 ] TOF-MRA is also available on clinical MRI scanners and is a completely noninvasive modality, but offers lower sensitivity than venous-ASL for the presence of DAVF. [ 2 , 9 ] In the present case, bilateral neuroophthalmic symptoms were worsened at 1 month after from SSSO. However, increased signal intensity in the left SOV had completely resolved and that in the right SOV remained to a slight extent despite the fact that TOF-MRA showed CSDAVF had been completely obliterated.…”

Non-invasive angiographic analysis of dural carotid cavernous fistula using time-of-flight MR angiography and silent MR angiography: a comparative study

“…With reference to CSDAVF, Takahashi et al reported that the most fistulous points of CSDAVF were detected in the posterior portion of the cavernous sinus or in the posterior portion of the intercavernous sinus by contrast-enhanced MRI (12). Even though non-contrast MRA is shown to be reliable for the diagnosis of the cavernous fistula, potential misdiagnosis with benign jugular venous reflux can occur, which can be differentiated by careful radiological interpretation (13,14).…”