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24F with Down Syndrome,
presents with confusion
& left sided weakness.
Krithika Srikanthan, MD
Jeffrey Guzelian, MD
Leo Wolansky, MD
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Image with annotations
• Please include findings in captions
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?
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Deep Cerebral Venous Thrombosis
with Venous Infarct
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• Hyperattenuation of
straight dural sinus
(red arrow)
• Hypoattenuation of
right thalamus and
surrounding basal
ganglia (blue arrow)
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Straight sinus
Internal Cerebral Vein
Vein of Galen
Inferior sagittal sinus
Increased density of straight sinus, extending into the inferior
sagittal sinus, vein of Galen, & internal cerebral veins
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Magnified view shows hypodense edema of splenium
(yellow arrow) contrasted by relatively normal genus of
corpus callosum (white arrow).
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Axial DWI demonstrates
hyperintensity involving the right thalamus
(blue arrow)
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• Postcontrast
subtraction MRV
demonstrates near
complete occlusion
of straight dural
sinus (red arrow)
• The superior
sagittal sinus is
patent (blue arrow)
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Cerebral Venous Thrombosis
Dural Sinus
Thrombosis
Cortical Vein
Thrombosis
Deep
(Subependymal)
Cerebral Vein
Thrombosis
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CT FindingsNon-contrast CT
– Early imaging findings often subtle
– Hyperdense sinus (compare to carotid arteries)
• Usually > 65 HU
• Distinguish thrombus vs. hyperdense sinus from high
hematocrit (HCT)
– HU:HCT ratio in thrombus 1.9 ± 0.32 vs. 1.33 ± 0.12 in
nonthrombus
– ± hyperdense cortical veins ("cord" sign)
– ± venous infarct (50%)
• White matter edema
• Cortical/subcortical hemorrhages common
• Thalamus/basal ganglia edema (if straight sinus, vein of
Galen, and/or internal cerebral vein occlusion)
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CT Findings• Contrast Enhanced CT
– "Empty delta" sign (25-30%)
• Enhancing dura surrounds nonenhancing thrombus
– "Shaggy," enlarged/irregular veins (collateral channels)
– gyral enhancement
– prominent intramedullary veins
• CTA/CTV
– Filling defect (thrombus) in dural sinus
• Caution: Acute clot can be hyperdense, obscured on
CECT/CTV
–Always include NECT for comparison
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Differential Diagnosis• Asymmetric anatomy: hypoplasia or atresia of the
transverse sinus. The right transverse sinus is larger in 75-80% of cases.
– If the sinus is small or absent, then the ipsilateral sigmoid sinus groove and jugular fossa should also be small.
• Arachnoid granulations: usually characterized as well-defined focal filling defects within the dural venous sinuses (measuring <10 mm in diameter)
– more commonly in the lateral aspects of the transverse sinuses
– Should be isointense to CSF (or nearly so) on all MRI sequences.
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Dural Sinus Thrombosis• Etiology:
– Trauma (especially skull fractures extending to duralvenous sinus
– Infection (especially mastoid sinus-dural sinus occlusive disease)
– Inflammation
– Hormonal: Peripartum/pregnancy, OCP, steroids
– Metabolic (dehydration, thyrotoxicosis, cirrhosis)
– Prothrombotic hematologic conditions: factor 5 Leiden mutation, Protein S deficiency, Prothrombin (factor II) gene mutation, polycythemia
– Collagen-vascular disorders (APLA syndrome)
– Vasculitis (Behçet)
– Malignancy
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Dural Sinus Thrombosis• Pathophysiology
1. Thrombus forms in dural sinus
2. Clot propagates into cortical veins
3. Venous drainage obstructed, venous pressure elevated
4. Blood-brain barrier breakdown with vasogenic edema, hemorrhage
5. Venous infarct with cytotoxic edema (DWI: mixed restriction)
• Locations:
– Transverse Sinus
– Superior Sagittal Sinus
– Straight Sinus
– Sigmoid Sinus
– Cavernous Sinus
• Associated abnormalities
– Dural AV fistula; venous occlusive disease
may be underlying etiologic factor
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Dural Sinus Thrombosis
• Presentation: HA*, n/v, +/- neuro deficit
• F > M, any age
• Up to 50% progress to venous infarction
• Rx: Heparin/Warfarin (even in the setting
of venous hemorrhage); mechanical
thrombectomy +/- local heparin infusion in
more severe cases.
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References
1. Statdx
2. https://radiopaedia.org/articles/dural-venous-sinus-thrombosis
3. http://pubs.rsna.org/doi/full/10.1148/rg.26si055174
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3858762/
5. https://clinicalgate.com/anatomy-and-physiology-of-cerebral-and-spinal-cord-circulation/