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Cerebral venous thrombosis

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Cerebral venous thrombosis

  1. 1. Cerebral Venous Thrombosis Dr.Aftab Qadir
  2. 2. Major dural sinuses: • Superior sagittal sinus, transverse, straight and sigmoid sinuses. Cortical veins: • Vein of Labbe, which drains the temporal lobe. • Vein of Trolard, which is the largest cortical vein that drains into the superior sagittal sinus. Deep veins: • Internal cerebral and thalamostriate veins. Cavernous sinus.
  3. 3. CT scan of a 45-year-old woman with clinical suspicion of dural sinus thrombosis. Lateral (A), anteroposterior (B), caudocranial (C), and oblique sagittal (D) MIP of CTA data set after MMBE. The projections demonstrate normal appearance of the superior sagittal sinus (arrowheads), the transverse sinuses (arrows), the deep venous system, and the superficial cortical veins without any overlying bone structures.
  4. 4. Indications For CT and MRI in Acute stroke Indications for CT in suspected stroke • Early diagnosis if possible • Differentiation between ishcemic and heamorrhagic stroke • Exclusion of stroke mimics-tumors
  5. 5. Indication for MRI • If CT is normal and clinical suspicion high • Assessment of diffusion and perfusion mismatch • Detection of stroke in posterior fossa • Detection of underlying cause • Assessment of intra and extracranial vessels by MR angiography • Exclusion of venous sinus thrombosis
  6. 6. Appearance of Blood on Scans On CT • Acute –Higher attenuation than underlying brain • Sub acute-Similar attenuation to brain • Chronic-Lower attenuation than underlying brain
  7. 7. MR Signal Intensity of Aging Blood
  8. 8. WT FAT H2O MUSC LIG BONE T1 B D I D D T2 I B I D D WW2--> water white on T2 weighted image
  9. 9. Venous sinus thrombosis • < 2% of all strokes • Accounts for up to 50% of strokes during pregnancy and puerperium • Important cause of stroke especially in children and young adults • It is a difficult diagnosis because of its nonspecific clinical presentation and subtle imaging findings
  10. 10. ETIOLOGY • Spontaneous Septic causes( especially in children) • Sinusitis, Otitis, Mastoiditis, Sub/epidural empyema • Meningitis, encephalitis, Brain abscess, Face and scalp cellulitis, septicemia Trauma > Fracture through sinus wall,jugular vein catheriziation Low flow states > CHF, Dehydration ,Shock Hypercoagulability states
  11. 11. Pathogenesis • Dural sinus thrombosis leads to venous congestion, venous infarction ,brain edema and heamorrhage
  12. 12. Clinical Manifestations Symptoms of increased Intracranial pressure • Headache, nausea, vomiting, visual blurring Stroke symptoms • Dysphasia, cranial nerve palsy, seizures Others • Drowsiness, confusion, Fever
  13. 13. Imaging • CT brain , CTV • MRI brain and MRV • Cerebral angiography Look for • Direct signs of a thrombus • Infarction in a non-arterial location, especially if it is bilateral and hemorrhagic • Cortical or peripheral lobar hemorrhage • Cortical edema
  14. 14. • Dense Clot sign on NECT • Cord sign • Empty delta sign on CECT • Replacement of flow void by abnormal signal intensity on MRI • MRV absence of flow • Non filling of thrombosed veins on Angiography • Venous infarction, edema
  15. 15. DENSE CLOT SIGN
  16. 16. ABSENCE OF NORMAL FLOW VOID ON MR Patent cerebral veins usually will demonstrate low signal intensity due to flow void. Flow voids are best seen on T2-weighted and FLAIR images. A thrombus will manifest as absence of flow void.
  17. 17. VENOUS INFARCTION Due to the high venous pressure hemorrhage is seen more frequently in venous infarction compared to arterial infarction. Often bilateral and in the midline in an atypical location or in a non-arterial distribution.
  18. 18. Hemorrhagic venous infarct in Labbe territory
  19. 19. CT-venography demonstrating thrombosis in many sinuses.
  20. 20. Transverse MIP image of a Phase-Contrast angiography. The right transverse sinus and jugular vein have no signal due to thrombosis.
  21. 21. Acute thrombus in a 35-year-old woman with a severe headache for 5 days. Axial T2W MR image (a) and axial T1W MR image (b) show a thrombus in the left sigmoid sinus (arrows). The signal in the thrombus, compared with that in the normal brain parenchyma, is hypointense in a and iso- to hyperintense in b. (c) Frontal MIP image from coronal TOF MR venography shows a lack of flow in the distal portion of the left transverse sinus and the sigmoid sinus (arrows).
  22. 22. DSA
  23. 23. PITFALLS IN CT Arachnoid granulations produce well- defined focal filling defects within the dural venous sinuses and measure 2–9 mm in diameter. They are isoattenuating (one- third) or hypoattenuating (two-thirds) relative to brain parenchyma Arachnoid granulations
  24. 24. Pseudodelta sign
  25. 25. Normal transverse sinus (LT) Thrombosed transverse sinus(RT).
  26. 26. Wrong bolus timing
  27. 27. Hematoma simulating venous thrombosis
  28. 28. Transverse sinus flow gap. (a) Coronal image from TOF MR venography shows an apparent interruption of flow in the medial part of the left transverse sinus (arrows). (b) Oblique MIP image from contrast-enhanced MR venography shows enhancement indicative of normal flow in the medial part of the left transverse sinus (arrow).
  29. 29. Interactive SessionInteractive Session
  30. 30. Thank You

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