Download Cerebral Venous Thrombosis

Gagandeep Singh, 2012
May 2012
Cerebral Venous
Thrombosis
Gagandeep Singh
Guru Gobind Singh Medical College
Gagandeep Singh, 2012
Patient P.W.

P.W. is a 41 yr woman with a history of
chronic headaches of unclear etiology,
depression, and OCP use presents with a
2 days history of severe headache
associated with nausea/vomiting.

Physical exam: n/a
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Gagandeep Singh, 2012
CT
CT Head w/o contrast
was ordered to r/o any
acute condition

Axial view
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Gagandeep Singh, 2012
CT
Axial view
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Gagandeep Singh, 2012
CT
Axial view
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Gagandeep Singh, 2012
When to think of venous
thrombosis:

Direct sign of thrombosis
–
–
–
–

Cord sign
Empty delta
Dense clot sign
Loss of normal void on MR

Clinically
– Seizures
– Headache
– Loss of consciousness
Venous Infarction
– Bilateral – parasagittal
bithalamic
– Temporal lobe infarction
– Cortical Edema or hemorrhage
– Peripheral lobar hemorrhage
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Introduction

Cerebral venous thrombosis is located in descending order as:
– Major dural sinuses:




Superior saggital sinus
Transverse sinus
Straight sinus
Sigmoid sinus
– Cortical veins
 Vein of Labbe
 Vein of Trolard
– Deep veins
 Internal cerebral vein
 Thalamostriate vein
– Cavernous sinus
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Gagandeep Singh, 2012
Dense Clot Sign
 Direct visualization
of clot in the
cerebral veins on
NCCT is known as
Dense Clot Sign
Axial view
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Gagandeep Singh, 2012
Cord Sign
 Direct visualization
of the clot in the
cortical vein on a
NCCT is known as
the Cord Sign
Axial View
NCCT
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Gagandeep Singh, 2012
Empty Delta Sign
 A triangular area
of enhancement with
central filling defect
on CECT is known as
Empty Delta Sign
Axial View
CECT
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Gagandeep Singh, 2012
Loss of normal flow
void on MR
 Flow voids (blue arrow) are
best seen on T2-weighted
and FLAIR images
 A Thrombus (red arrow)
manifests as absence of flow
void
 Next step after finding
this has to be contrast
enhanced study.
Axial view
T2WI
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Venous Infarction
Venous
infarcts are often
bilateral in the
midline and
hemorrhagic

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Gagandeep Singh, 2012
Hemorrhagic venous infarct
in Labbe territory
• Red arrow pointing
toward hemorrhage in
the temporal lobe on
NCCT
• Blue arrow showing
filling defect in the
sigmoid sinus on CECT
Axial CT
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Gagandeep Singh, 2012
Hemorrhagic venous infarct
in Labbe territory
• Red arrow pointing
toward vasogenic
edema
• Blue arrow pointing
toward hemorrhage
Axial MR
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Gagandeep Singh, 2012
Imaging in Suspected thrombosis

CT- venography

MR- venography

DSA
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CTV
 Filling defects in
the CTV confirms
the diagnosis of
cerebral venous
thrombosis.
Axial view
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Gagandeep Singh, 2012
CTV
 Arrow pointing
towards filling
defect in the
Sigmoid sinus
Axial view
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Gagandeep Singh, 2012
CTV
 Arrow pointing
towards filling
defect in the
Transverse sinus
Axial view
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Gagandeep Singh, 2012
CTV
 Arrow pointing
towards filling
defect in the
Posterior part of
Superior sagittal
and Straight sinus
Axial view
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Gagandeep Singh, 2012
CTV
 Arrow pointing
towards filling
defect in the
Posterior part of
Superior sagittal
and Straight sinus
Saggital view
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3D Reconstruction
images
3D MIP Image
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3D Reconstruction
images
3D VR Image
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Gagandeep Singh, 2012
3D Reconstruction
images
3D MIP Images
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Gagandeep Singh, 2012
3D reconstruction
images
3D VR Images
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Gagandeep Singh, 2012
MR- venography
 MR-techniques used for the diagnosis of
Cerebral venous thrombosis are:
 Time-of-Flight angiography
 Phase-contrast angiography
 Contrast-enhanced MR-venography
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 The Right
transverse sinus and
Jugular vein have no
signal due to
thrombosis
Transverse MIP image of a
phase contrast angiography
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Gagandeep Singh, 2012
DSA
 DSA showing
thrombosis of the:
– Superior sagittal
sinus (red arrow)
– Straight sinus
(blue arrow)
– Transverse and
Sigmoid sinus
(yellow arrow)
Digital subtraction angiography
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Pitfalls In Imaging
 Pitfalls in CT
– Pseudodelta sign
– Wrong bolus timing
– Hematoma simulating
venous thrombosis
– Arachnoid
Granulations
 Pitfalls in MR
– Low signal intensity in
thrombus
– Flow void on contrastenhanced MR
– Hypoplastic transverse
sinus
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Predictors of poor long-term
prognosis are:



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Age > 37 years
Male gender
Mental status abnormality
Glasgow coma scale score <9 on admission
Hemorrhage on head CT or MRI
Central nervous system infection
Thrombosis of the deep venous system
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Treatment
 Acute Antithrombotic Treatment:
– Anticoagulation: with LMW heparin followed by oral
anticoagulant s for 1-3 months
– Endovascular thrombolysis
– Thrombectomy
 Anti – epileptics for control of seizures
 Control of acutely elevated ICP
 Neurological Deficit – physical therapy and
rehabilitation
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Gagandeep Singh, 2012
Acknowledgements
•
•
•
•
•
•
Dr. Gillian Lieberman
Dr. Rafeeque A.Bhadalia
Dr Rafael Rojas
Dr. Krithica Kaliannan
Dr. Harald Brodoefel
Dr. Ann Leylek
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Gagandeep Singh, 2012
References

http://www.radiologyassistant.nl/en/4befacb3e4
691
 http://www.uptodate.com/contents/etiologyclinical-features-and-diagnosis-of-cerebralvenous-thrombosis
 http://www.ajnr.org/content/30/2/344.full
 http://radiology.rsna.org/content/224/3/788.f
ull.pdf
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