The stroke syndrome of cortical vein thrombosis

Abstract

Cortical vein thrombosis without sinus involvement is rarely diagnosed, although it may commonly be overlooked. We report four cases of cerebral venous thrombosis limited to the cortical veins. The diagnosis was made on surgical intervention in one patient and by angiography in three patients. Together with a survey of the published cases, the clinical and neuroimaging patterns of our patients allow delineation of several features suggestive of cortical venous stroke. Focal or generalized seizures followed by hemiparesis, aphasia, hemianopia, or other focal neurologic dysfunction in the absence of signs of increased intracranial pressure should suggest this possibility. Neuroimaging (CT, MRI) shows an ischemic lesion that does not follow the boundary of arterial territories and often has a hemorrhagic component, without signs of venous sinus thrombosis. Conventional angiography demonstrates no arterial occlusion but may show cortical vein thrombosis corresponding to the infarct, although these may also be nonspecific findings. The role of MR angiography, which is well-established in sinus thrombosis, remains to be assessed in patients with brain ischemia due to isolated cortical vein occlusion.

An Updated Definition of Stroke for the 21st Century

“…Finally, thrombosis of the venous sinuses may cause no focal brain abnormalities (infarction, hemorrhage, or edema), but impaired venous drainage from the cranial cavity causes increased intracranial pressure without other neurological abnormalities. [156][157][158][159][160][162][163][164] The clinical presentation mirrors these various scenarios, although some symptoms such as headache occur with high frequency (≈80%) across the spectrum of presentations. 165 Other symptoms reflect the topography and course of the venous occlusion.…”

“…[156][157][158][159][160][161] The occlusion of the venous structures can lead to several mechanisms of brain injury. Tissue ischemia and infarction may result from venous stasis.…”

Early Seizures in Cerebral Vein and Dural Sinus Thrombosis

“…Parenchymal cerebral lesions, particularly when located supratentorially, may have cortical involvement with an increased risk of seizures. Occlusion of the superior sagittal sinus and cortical veins, 17 which drain venous blood from the upper convexity of the brain, including the motor and sensory cortices, could also increase such risk. The risk of seizures was increased in patients with motor deficits, again pointing to the relevance of damage to the motor cortex.…”

MR Imaging Features of Isolated Cortical Vein Thrombosis: Diagnosis and Follow-Up

“…10 However, because the number and location of these veins are highly variable, these changes are difficult to visualize. Hypointensity on T2*GE images of the thrombosed vein has been reported in only isolated cases.…”

“…[4][5][6][7][8] Isolated CVT (ICoVT) (ie, without sinus involvement) appears extremely rare and has been mainly reported as isolated case reports or in small series. [9][10][11][12][13][14][15][16][17][18] ICoVT is particularly difficult to diagnose by using only T1-weighted, T2-weighted, and MRV imaging for different reasons: 1) Cortical veins are extremely variable in number, size, and location, 2) occluded small veins at the cortical level are difficult to identify by using these MR images, and 3) only the occlusion of the largest veins is detectable on MRV. Therefore, digital substraction angiography (DSA) is usually required for diagnostic confirmation in most cases of ICoVT to show indirect signs such as collateral venous pathways, tortuous veins, or delayed local venous drainage.…”