Cerebral sinuses venous thrombosis


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radiological appearance of cerebral venous thrombosis .
lecture covers :
- brief anatomy.
- relevant clinical anatomy.
- radiological imaging.
- guidelines for management of CVT.

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Cerebral sinuses venous thrombosis

  2. 2. • anatomy • prevalnce clinical presenation • Radiological examination
  3. 3. ANATOMY • Cerebral Venous Sinuses : “ large low-pressure veins within the folds of dura – between fibrous dura and endosteum, except for the inferior sagittal and the straight sinuses which are between two layers of fibrous dura
  4. 4. PREVELANCE • • • CVT is an uncommon and frequently unrecognized type of stroke that affects approximately 5 people per million annually and accounts for 0.5% to 1% of all strokes. CVT is more commonly seen in young individuals. • RISK FACTORS Prothrombotic Conditions • Pregnancy and Puerperium • Oral Contraceptives • Cancer
  5. 5. PREVELANCE • in a retrospective study KAMC-Jeddah , 111 patients diagnosed as CVST were identified from 1990 - 2010. Age mean Age is 29.5 17% Adults 83% children Adult( F>M), pediatric(M>F) Superior Saggital Sinus is most affected
  6. 6. CLINICAL PRESENTATIONS • headache • focal neurologic deficits • seizures • papilledema • decreased level of consciousness
  7. 7. DIAGNOSTIC IMAGING • Diagnostic imaging of CVT may be divided into 2 categories : 1. Noninvasive modalities 2. invasive modalities The goal is to determine vascular and parenchymal changes associated with this medical condition.
  8. 8. NON CONTRAST CT SCAN • The primary sign of acute CVT on a noncontrast CT is hyperdensity of a cortical vein or dural sinus. • Acutely thrombosed cortical veins and dural sinuses appear as a homogenous hyperdensity that fills the vein or sinus and are most clearly visualized when CT slices are perpendicular to the dural sinus or vein
  9. 9. NON CONTRAST CT SCAN • Thrombosis of the posterior portion of the superior sagittal sinus may appear as a dense triangle, the dense or filled delta sign.
  10. 10. Noncontrast computed tomography head scan showed spontaneous hyperdensity of right transverse sinus.
  11. 11. CONTRAST-ENHANCED CT • may show enhancement of the dural lining of the sinus with a filling defect within the vein or sinus. • the classic “empty delta” sign.
  12. 12. • Contrast enhanced CT demonstrates the reverse delta sign (or empty triangle sign – lower image) which can be seen in the superior sagittal sinus from enhancement of the dural leaves surrounding the comparatively less dense thrombosed sinus. • Image Credit : http://www.radiologytutorials.com/
  13. 13. MRI • The principal early signs of CVT on non–contrast-enhanced MRI are the combination of absence of a flow void with alteration of signal intensity in the dural sinus. • a central isodense(hypodense) lesion in a venous sinus with surrounding enhancement. This appearance is the MRI equivalent of the CT empty delta sign. • The secondary signs of MRI may show similar patterns to CT, including cerebral swelling, edema, and/or hemorrhage
  14. 14. T2-weighted magnetic resonance image showing highintensity bland venous infarct in frontal lobe. !
  15. 15. CT VENOGRAPHY • CTV can provide a rapid and reliable modality for detecting CVT. ! • CTV is much more useful in subacute or chronic situations because of the varied density in thrombosed sinus
  16. 16. Computed tomographic venogram (axial) showing extension of the cerebral venous thrombosis down to the jugular vein (black arrow). R-ICA indicates right internal carotid artery; L-ICA, left internal carotid artery; R, right; and L, left. !
  17. 17. MRI VENOGRAPHY The most commonly used MRV techniques are time-of-flight (TOF) MRV and contrast-enhanced magnetic resonance. Phase-contrast MRI is used less frequently, because defining the velocity of the encoding parameter is both difficult and operator-dependent. The 2-dimensional TOF technique is the most commonly used method currently for the diagnosis of CVT, because 2-dimensional TOF has excellent sensitivity to slow flow compared with 3-dimensional TOF
  18. 18. Magnetic resonance venography confirmed thrombosis (black arrows) of right transverse and sigmoid sinuses and jugular vein. !
  19. 19. Magnetic resonance venogram showing thrombosis (black arrows) of the superior sagittal sinus and sigmoid sinuses. A, 2 days after symptom onset. B, 1 year follow-up after oral anticoagulation therapy (OAC). !
  20. 20. CT Scan + CTV MRI + MRV Visualization of the superficial and deep Good visualization of major venous venous systems sinuses +Good definition of brain parenchyma Echoplanar T2 susceptibility-weighted Overall accuracy 90% to 100%, depending imaging combined with MRV are on vein or sinus considered the most sensitive sequences Acute onset of symptoms Emergency setting Early detection of ischemic changes
  21. 21. INVASIVE DIAGNOSTIC ANGIOGRAPHIC PROCEDURES • • Cerebral Angiography Direct Cerebral Venography Invasive cerebral angiographic procedures are less commonly needed to establish the diagnosis of CVT given the availability of MRV and CTV. These techniques are reserved for situations in which the MRV or CTV results are inconclusive or if an endovascular procedure is being considered.
  22. 22. Recommendations • Although a plain CT or MRI is useful in the initial evaluation of patients with suspected CVT, a negative plain CT or MRI does not rule out CVT. A venographic study (either CTV or MRV) should be performed in suspected CVT if the plain CT or MRI is negative or to define the extent of CVT if the plain CT or MRI suggests CVT (Class I; Level of Evidence C). ! • An early follow-up CTV or MRV is recommended in CVT patients with persistent or evolving symptoms despite medical treatment or with symptoms suggestive of propagation of thrombus (Class I; Level of Evidence C).
  23. 23. ! ! • In patients with previous CVT who present with recurrent symptoms suggestive of CVT, repeat CTV or MRV is recommended (Class I; Level of Evidence C). ! • Gradient echo T2 susceptibility-weighted images combined with magnetic resonance can be useful to improve the accuracy of CVT diagnosis70,129,151 (Class IIa; Level of Evidence B). ! • Catheter cerebral angiography can be useful in patients with inconclusive CTV or MRV in whom a clinical suspicion for CVT remains high (Class IIa; Level of Evidence C). ! • A follow-up CTV or MRV at 3 to 6 months after diagnosis is reasonable to assess for recanalization of the occluded cortical vein/sinuses in stable patients (Class IIa; Level of Evidence C).