Digital subtraction angiography in the diagnosis of superior sagittal sinus thrombosis

Cerebral Venous Sinus Thrombosis: Prognostic and Therapeutic Significance of an Early Radiologic Diagnosis

We describe the CT and MRI patterns of cerebral venous sinus thrombosis (CVST) on the basis of the venous angioarchitecture and the underlying pathophysiological mechanism. We also investigated if any radiologic data exist to establish which patients can be followed conservatively and which warrant endovascular treatment.

The clinical, CT-CTA and MRI-MRA findings of 11 patients (2 men; 9 women; 24 to 69 years-old) with CVST were reviewed. The morphological patterns of CVST were divided into two major groups: Vascular signs: spontaneous sinusal hyperdensity (9); spontaneous all-sequences hyperintensity (4); venous engorgement (9); empty delta sign (4); lack of sinusal contrast-enhancement (3); delayed sinusal transit-time (11); lack of flow-related signal (3). Parenchymal signs: mass effect and cortical sulcal effacement (8), white matter edema (7), venous ischemia (6), haemorrhagic infarct (3), breakdown of the blood-brain barrier (4), hydrocephalus (2).

The clinical and radiologic pictures are related to cerebral venous angioarchitecture and underlying pathophysiologic mechanism of venous thrombosis. Reversibility of clinical symptoms and parenchymal lesions is far more frequent, because vessel damage slowly and progressively develops, whereas damage to brain tissue occurs later. Consequently, a prompt CT-MRI diagnosis may allow a good prognosis. Treatment using selective sinusal instillation of urokinase is considered only when the patient clinically and radiologically does not improve within the first two weeks after heparinization.

Cerebral dural sinus thrombosis. A case report

Cerebral dural sinus thrombosis is an uncommon syndrome that a patient presents with severe headache, which may be associated with complex physical and neurologic findings. The authors present a thirty-two-year-old woman with severe headache, focal motor seizures, and subsequent hemiparesis when she was ten weeks pregnant, diagnosed as having a dural sinus thrombosis by magnetic resonance imaging and magnetic resonance angiography. In this report, the application of magnetic resonance techniques, including angiography to diagnose and monitor therapy for dural sinus thrombosis, is presented.

Risk factors of aseptic intracranial venous occlusive disease

INTRODUCTION

Risk factors for aseptic intracranial venous occlusive disease are varied but only few epidemiologic studies were performed to verify the relative importance of particular factors.

PATIENTS AND METHODS

A 2-year hospital-based prospective study was conducted in two hospitals to identify the clinical characteristics and risk factors of patients with confirmed aseptic intracranial venous occlusive disease.

RESULTS

21 patients were identified, representing 0.9% of the total neurological admissions. Men were more commonly affected than women; 81% of the patients presented in a clinical picture indistinguishable from idiopathic intracranial hypertension. Risk factors included Behçet's disease in 4, the puerperium in 3, thrombophelia in 3, familial Mediterranean fever in 2, malignancies in 1, lupus anticoagulant in 1, and the contraceptive pill in 1.

CONCLUSION

Aseptic intracranial venous occlusive disease proved to be not rare in Arabs. It should be considered seriously in the differential diagnosis of idiopathic intracranial hypertension, particularly in males. Several risk factors were incriminated.

Children with cerebral venous thrombosis diagnosed with magnetic resonance imaging and magnetic resonance angiography

From 1985 to 1991, 13 children were diagnosed at the University of Illinois College of Medicine at Peoria, Saint Francis Medical Center, with cerebral venous thrombosis (CVT) by magnetic resonance imaging scan. Ages ranged from newborn to 5 years. Six children were premature neonates, five were term neonates and two were 5 years old. In the premature neonates, thrombosis was usually associated with other problems. All the term neonates had seizures. In all neonates, thrombosis resolved without any specific treatment. In the two older children, one presented with pseudotumor cerebri and one with coma. These children required neurosurgical intervention. Follow-up magnetic resonance imaging scans were obtained in 9 of 13 children and showed thrombus resolution in each case. Three children were studied in the acute and convalescent stages by magnetic resonance angiography using time-of-flight techniques. Each follow-up magnetic resonance angiogram showed improvement in venous flow consistent with their clinical course and other imaging studies. We conclude that 1) CVT in children encompasses a range of clinical conditions which may or may not require neurosurgical intervention; 2) magnetic resonance imaging is superior to other modalities for the diagnosis of CVT; and 3) magnetic resonance angiography is an alternative means to monitor the evolution of CVT and efficacy of therapeutic intervention.

Improvement in sagittal sinus thrombosis by MRI

A 33-year-old woman developed headaches, papilledema, and evanescent neurologic signs. MRI demonstrated thrombosis of the sagittal, transverse, and sigmoid sinuses. After initial heparinization and three months of oral anticoagulation therapy, papilledema was still present but the neurologic signs and symptoms had markedly improved. Repeat MRI scan revealed improvement in all dural thromboses.

MRI assessment of unsuspected dural sinus thrombosis

In three patients with clinically unsuspected diagnosis, MRI has afforded a positive and conspicuous demonstration of dural sinus thrombosis, allowing specific treatment and followed by improvement in the patients' condition. Even in retrospect, CT examinations were nondiagnostic. Presenting symptoms were usual and nonspecific. CT and radionuclide scanning have proved valuable when performed on a clinically oriented basis. Angiography cannot be carried out without clear indications. MRI offers advantages in being a non-invasive technique without ionising radiation, allowing direct visualization and accurate delineation of the thrombus. MRI is definitely the method of choice to assess clinically suspected cerebral venous occlusion. As MRI diagnosis relies on a routine examination protocol, we believe that it will detect other unsuspected cases of dural sinus thrombosis.

Cerebral venous thrombosis as a cause of neonatal seizures

Intracranial venous thrombosis has been described in newborns, but there have been no reports of intractable neonatal seizures due to this condition. We report cortical venous sinus thrombosis in two term neonates who presented with seizures in the first 24 hours of life. The diagnosis was made by cranial computed tomography and was confirmed by cerebral angiography. Both patients improved clinically after the intracranial venous thrombosis resolved. These patients demonstrate that intracranial venous thrombosis should be considered in the differential diagnosis of neonatal seizures.

Superior sagittal sinus thrombosis in neonates

Three neonatal patients with superior sagittal sinus thrombosis are reported. The neurologic signs were bulging of the anterior fontanel and clonic hemi-convulsions. Neonatal polycythemia was believed to be an etiologic factor in two patients. Computed tomography revealed massive edema with slit-like ventricles in two patients. Increased density of the torcular Herophili and straight sinus also were demonstrated in two patients. The diagnosis of superior sagittal sinus thrombosis was confirmed by cerebral angiography in one patient and by digital subtraction angiography in the other two patients. Digital subtraction angiography appears to offer a definite advantage in the diagnosis of cerebral sinus thrombosis in the neonatal period.

Appearance and disappearance of empty delta sign in superior sagittal sinus thrombosis

The diagnostic value of the empty delta sign on post-infusion CT films was investigated in five patients with superior sagittal sinus thrombosis subsequently verified angiographically and/or pathologically. The empty delta sign, which has been considered to be unique and reliable in the diagnosis of cerebral venous sinus occlusion, was observed only on CT films taken one to four weeks after onset, and was not seen in the extremes of the acute or the chronic stage of the illness. These observations may explain why this sign has not been apparent in some reports concerning the CT findings of superior sagittal sinus thrombosis. Recanalization within the thrombus may be the reason why this sign was no longer apparent in the chronic stage of the patients with superior sagittal sinus thrombosis.

Cerebral venous thrombosis--a review of 38 cases

A series of 38 patients with angiographically proven cerebral venous thrombosis (CVT) affecting dural sinuses is reported. This study shows that CVT is not rare, that the clinical diagnosis is extremely difficult because of the variable modes of onset and groupings of symptoms, that most CT findings are non specific and that angiography remains the best diagnostic tool. Only 4 patients died, which suggests a more benign outcome than classically described. None of the 23 heparin treated patients died, which indicates that anticoagulants were not harmful in this series.