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Radiologic Diagnosis CVT
Radiologic Diagnosis CVT
LIFELONG LEARNING
FOR RADIOLOGY
Pictorial Review
Colin S. Poon1,2, Ja-Kwei Chang1, Amar Swarnkar1, Michele H. Johnson2, John Wasenko1
Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT.
2
A B C
Fig. 15-year-old boy with severe headache and eye pain. Thrombosis was found in right lateral sinus (arrows).
A and B, Unenhanced CT images show thrombosis as hyperdensity (dense clot sign).
C and D, Enhanced CT images show same structure as filling defect with enhancing rim (empty delta sign).
A B C
D E F
Fig. 338-year-old woman with history of pseudotumor cerebri who presented with headache and decreased consciousness. Diagnosis was thrombosis of superior
sagittal sinus, straight sinus, and internal cerebral veins. (Long white arrows indicate superior sagittal sinus; short white arrows, straight sinus; black arrows, Rosen-
thals veins).
A and B, Unenhanced CT scans show dense thrombosis. Note nonhemorrhagic infarction in basal ganglia, thalami, and internal capsules, which is typically seen in
deep cerebral venous thrombosis.
C, Axial T2-weighted MR image shows replacement of signal void by thrombus (arrow) in superior sagittal sinus. Veins at internal capsules are engorged.
D and E, Sagittal contrast-enhanced T1-weighted image (D) shows filling defects in sagittal and straight sinuses, correlating with absence of flow on 2D phase con-
trast MR venography (E).
F, After catheter-directed thrombolysis, flow was partially reestablished.
Neuroradiology ral sinus may give a dense clot sign (Fig. 1). The cord sign
Unenhanced CT remains the technique of choice for represents direct visualization of a thrombosed cortical
screening patients with nonspecific clinical presentation vein that is seen as linear hyperdensity (Fig. 2).
and a low suspicion of CVT. Contrast-enhanced CT provides More often, unenhanced CT shows only the indirect signs
a more accurate diagnosis of CVT. MRI and MR venogra- of CVT. These are often nonspecific and may include diffuse
phy have been the noninvasive imaging techniques of choice brain edema, leading to hypodensity of the brain (seen in
[46, 9] and are often used as the initial diagnostic test for 2050% of cases) or decreased ventricular size. In young
suspicious cases. CT venography is now emerging as a com- patients, the pathologic decrease in ventricular size may be
peting technique. It has been shown to be comparable to difficult to differentiate from the normally small ventricles
MR venography and, in some situations, to provide better commonly seen in young patients.
diagnostic information [10]. Venous infarction is the most specific indirect sign on unen-
hanced CT images. An infarction not conforming to a major
Unenhanced CT arterial vascular territory, such as the presence of multiple iso-
Direct signs of CVT are uncommon and are seen in only lated lesions, involvement of a subcortical region with sparing
one third of cases. Direct visualization of thrombosis in du- of the cortex, and extension over more than one arterial distri-
A B C
D E F
Fig. 416-year-old girl with multiple traumatic injuries in head. Initial unenhanced CT (not shown) showed hyperdensity in right internal jugular vein (IJV) and sig-
moid sinus that was suspicious for venous thrombosis. Findings were confirmed on CT venography, MRI, and conventional venography.
A and B, Axial source images from CT venography. Thrombus in IJV (asterisk, A) and sigmoid sinus (black arrow, B) is clearly shown as filling defect. Note collateral
veins (white arrow, A) arising from right IJV.
C, Sagittal planar reconstruction of CT venography shows thrombus extending from right IJV (asterisk) into sigmoid sinus (arrow), correlating well with findings on
conventional venography (E).
D, T1-weighted MR image shows sigmoid sinus thrombosis (arrow) as seen on CT (B).
E and F, Venogram (E) shows thrombus as filling defects. Note collateral veins at region of right IJVs, also seen in A. Venogram after suction thrombectomy (F) shows
improved patency in right IJV and lateral sinus. Asterisk, right internal jugular vein; solid arrow, sigmoid sinus; open arrow, torcular Herophili.
bution, is highly suspicious for a venous cause. The infarction the dural sinus, with peripheral enhancement possibly sec-
may be hemorrhagic (Fig. 2) or nonhemorrhagic (Fig. 3A). The ondary to the development of collaterals (Fig. 1).
location of the infarction with respect to the expected course Indirect evidence of CVT may be seen as contrast enhance-
of venous drainage may give a clue to the venous structure ment of the falx and tentorium secondary to venous stasis
involved. Thrombosis in the sagittal sinus often leads to im- and hyperemia of the dura mater, which is seen in approxi-
paired venous drainage and, therefore, parenchymal change in mately 20% of cases.
the parasagittal region. Thrombosis in Labbs vein should One should be aware that in 1030% of cases of CVT, the find-
lead to infarction in the temporal lobe. Bilateral or unilateral ings on either unenhanced or contrast-enhanced CT are negative.
infarction in the thalami, basal ganglia, and internal capsule is Therefore, in highly suspicious cases, further evaluation with CT
typically seen in deep venous thrombosis (Fig. 3). venography, or MRI with MR venography, is warranted.
Contrast-Enhanced CT CT Venography
Direct evidence of CVT on contrast-enhanced CT includes A more recent tool that can be used to evaluate CVT is
the empty delta sign, which may be seen 5 days to 2 months CT venography [1012]. CT venography allows direct visu-
from onset. This sign represents a filling defect (thrombus) in alization of thrombus as filling defects (Fig. 4).
A B C
MRI
On MRI, venous thrombus may be directly visualized. On
TABLE 1: Signs and Symptoms of Cerebral
conventional MRI sequences, patent dural sinuses are often Venous Thrombosis
seen as a flow void. This is particularly well seen when the
Presentation Frequency (%)
imaging plane is orthogonal to the blood flow direction (e.g.,
coronal images are best for visualization of the superior sag- Headache 75
ittal, transverse, and sigmoid sinuses). The effect of a flow Papilledema 49
void may be reduced in a plane parallel to the dural sinus, Seizures 37
although such an imaging plane often offers a better depic- Motor or sensory deficit 34
tion of the complete extent of thrombosis in the dural sinus. Mental status changes 30
For example, a sagittal T1-weighted image may show the
Dysphasia 12
complete extent of the superior sagittal sinus thrombosis as
Cranial nerve palsies 12
an abnormally bright signal filling the sinus. The thrombus
may manifest as absence of a flow void, which is often best Cerebellar incoordination 3
seen on FLAIR images and T2-weighted spin-echo images. Bilateral or alternating cortical signs 3
The abnormal signal intensity follows the signal characteris- Nystagmus 2
tics of intracranial hemorrhage and may evolve through the Hearing loss 2
stages of oxyhemoglobin, deoxyhemoglobin, methemoglo- NotePercentages total > 100% because patients may have multiple presentations.
bin, and hemosiderin [4]. On T1-weighted images, thrombus Adapted from [1].
A B C
D E F
Fig. 6Middle-aged woman (exact age unknown) with history of multiple myeloma.
A and B, Axial unenhanced CT images show subdural hemorrhage at right cerebellar convexity that mimics thrombosis of right transverse sinus.
CE, Axial FLAIR image (C), coronal FLAIR image (D), and unenhanced CT scan (E) at location adjacent to B show similar finding of subdural hemorrhage (white arrow,
E) medial to right transverse sinus (black arrow, E).
F, Contrast-enhanced MR venogram shows patent dural venous sinuses. Right transverse sinus (arrows) is smaller and slightly irregular compared with left, possibly
secondary to mass effect from adjacent subdural hematoma.
A B C
D E F
shown to be superior to TOF MR venography [13, 14] and CT venography has been shown to be superior to traditional
may offer the best evaluation using MRI. The various MR MR venography techniques based on 2D TOF or phase con-
venography techniques are summarized in Table 2. trast techniques [10]. However, a direct comparison between
CT venography and contrast-enhanced MR venography is not
Comparison of MR Venography and CT Venography yet available. These two techniques probably provide compa-
A comparison of CT venography and MR venography is rable performance, and preference will be dictated by the expe-
summarized in Table 3. rience and resources of the individual institutions.
A B C
Diagnostic Pitfalls
Pitfalls are associated with all imaging techniques [15].
To improve diagnostic accuracy, it is important to be aware
of these pitfalls. Always correlate findings on multiple im-
aging sequences. If in doubt, other imaging techniques
should be used to confirm the findings.
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Pitfalls on Unenhanced CT
Hyperdense blood in patent dural sinuses may mimic
thrombosis. Hyperdense blood may be seen in children, par-
ticularly neonates and infants, and in patients with a hemo-
concentration of the blood, as might be present in poly-
cythemia or dehydration. At times, hyperdense blood may
Fig. 10Superior sagittal sinus thrombosis in young woman (exact age un- be difficult to differentiate from true dural venous throm-
known) on T1-weighted image. Sagittal T1-weighted images can be useful for bosis, but symmetry of involvement, homogeneity of the
depiction of extensive superior sagittal sinus thrombosis. However, bright sig-
nal of thrombus with methemoglobin (arrow) may mimic patent sinus on con-
hyperdensity, and involvement of virtually all visualized
trast-enhanced T1-weighted images and time-of-flight MR venography. dural venous sinuses and major venous structures should
A B C
D E F
Fig. 1125-year-old woman with headache. Black arrows indicate left transverse and sigmoid sinuses; white arrows indicate right transverse and sigmoid sinuses.
A, Axial phase contrast MR venogram shows loss of flow signal (arrow).
B, Axial T1-weighted image fails to show thrombus.
C, Axial T1-weighted gadolinium-enhanced image shows smooth enhancement in hypoplastic left transverse and sigmoid sinuses.
DF, Coronal reformations of CT venography, from posteriorly to anteriorly, show smooth enhancement in hypoplastic left transverse and sigmoid sinuses. Hypopla-
sia of ipsilateral jugular foramen also serves as important corroborative evidence of hypoplastic dural sinus.
suggest that hyperdense blood is present rather than venous nuses. Contrast-enhanced MR venography (Fig. 6F) confirms
thrombosis (Figs. 5A and 5B). The presence of normal flow patent dural venous sinuses and no evidence of thrombosis.
void in the venous sinuses should confirm the presence of CVT may mimic subdural hematoma (Fig. 7). CVT should be
patent sinuses. Hyperdense blood may also mimic subdural confined entirely in the expected lumen of the dural venous si-
hemorrhage on CT, but the symmetry of apparent involve- nuses. On the contrary, subdural hemorrhage is seen exterior to
ment, the limitation of the hyperdensity in the expected the dural venous sinuses. Patients with subdural hemorrhage in
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lumen of the dural sinuses, and a negative MRI study would the posterior fossa may be at risk for CVT (possibly as a result of
effectively exclude this possibility (Figs. 5C and 5D). direct injury of the dural venous sinuses or venous stasis). In a
Subdural hematoma may mimic CVT (Figs. 6 and 8). The patient with preexisting subdural hematoma, increasing density
clue to the correct interpretation is that the abnormal signal of at the location of the dural venous sinuses should prompt consid-
the subdural hematoma is located more medial than the expect- eration of the possibility of CVT (Fig. 7).
ed location of the transverse sinus. Figure 6 shows the abnormal Retained contrast material from previous radiologic ex-
FLAIR signal extending too far inferiorly and medially, beyond aminations due to severely slow flow, such as might occur af-
the expected location of the normal transverse and sigmoid si- ter ligation of the internal jugular vein, may mimic CVT.
A B C
However, these conditions may also predispose the patient to MR images (Fig. 10). Slow flow leading to loss of flow void may
developing thrombosis, so a contrast-enhanced study should mimic thrombosis.
be performed to clarify the findings.
Pitfalls on MR Venography
Pitfalls on Contrast-Enhanced CT Signal loss on unenhanced MR venography may result
An empty delta sign may be mimicked by intrasinus sep- from in-plane flow, extremely slow flow, or complex flow,
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A B
A B C
(Fig. 11A) can be misleading if it is interpreted in isolation. The Patients with low clinical suspicion of an intracranial ab-
significant change in blood flow dynamics in stenotic or hyp- normality can be screened with unenhanced CT. If in doubt,
oplastic dural venous sinuses can give rise to loss of flow signal further workup may include CT venography or MRI with MR
(Fig. 11A). Unenhanced T1-weighted images (Fig. 11B) fail to venography. CT venography and contrast-enhanced MR
show thrombus, which should be evident given the severe nar- venography are probably comparable in accuracy for evaluat-
rowing of the left dural sinuses. On the contrary, conventional ing CVT, and the technique of choice will depend on the expe-
gadolinium-enhanced T1-weighted images (Fig. 11C) show rience and resources of individual institutions. Conventional
smooth enhancement in the hypoplastic left transverse and sig- angiography is usually reserved for difficult cases or performed
moid sinuses, which is subsequently confirmed on CT venogra- in conjunction with neurointervention.
phy (Figs. 11 D11F). Hypoplasia of the ipsilateral jugular fora-
men (Figs. 11E and 11F) also serves as important corroborative References
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