Differentiation of transverse sinus thrombosis from congenitally atretic cerebral transverse sinus with CT

Can the sigmoid notch sign be used on cranial computed tomography to differentiate between thrombosis and hypoplasia of the cerebral transverse venous sinus?

OBJECT

In patients with headache, the distinction between transverse sinus (TS) atresia/hypoplasia and TS thrombosis in cranial magnetic resonance venography (MRV) may be misleading. In this study, we aimed to distinguish TS thrombosis from atretic or severely hypoplastic TS, with the help of cranial computed tomography (CT).

METHOD

Non-contrast cranial CT scans of 51 patients with no or severely thin signal on MRV were analyzed retrospectively using the bone window. Absence or asymmetry of the sigmoid notches on the CT predicted atretic or severe hypoplastic TS, and symmetry predicted thrombotic TS. Afterwards, it was investigated whether the patient's other imaging findings and confirmed diagnoses matched with the predictions.

FINDINGS

Of the 51 patients included in the study, 15 were diagnosed with TS thrombosis, and 36 were diagnosed with atretic/hypoplastic TS. All 36 of the congenital atresia/hypoplasia diagnoses were correctly predicted. Thrombosis was predicted correctly in 14 of 15 patients with TS thrombosis. In cranial CT, the symmetry or asymmetry of the sigmoid notch sign was examined, and it was found that the evaluation predicted with 93.3% sensitivity (95% confidence interval (CI): 68.05-99.83) and 100% specificity (95% CI: 90.26-100.00) the distinction between TS thrombosis and atretic/hypoplastic sinus.

CONCLUSION

Symmetry or asymmetry of the sigmoid notch on CT is a reliable method that can be used to differentiate congenital atresia/hypoplasia from the TS thrombosis in patients with very thin or absent TS signal on the cranial MRV.

Can occipital lobe bending, Gibraltar sign of superior sagittal sinus groove and jugular foramen dimensions predict transverse sinus dominance?

BACKGROUND

Asymmetry between the transverse sinuses (TS) is quite common. We sought to test the possible hypothesis that certain anatomical features - namely, occipital lobe bending, Gibraltar sign of superior sagittal sinus groove (SSS) and jugular foramen (JF) dimensions - can predict dominance of the transverse sinuses on routine axial T1- and T2-weighted images.

MATERIALS AND METHODS

One hundred consecutively acquired combined MRI-MRV studies of brain were reviewed. On non-contrast axial T1WI, each reviewer assessed the occipital lobe bending, and Gibraltar sign of SSS groove; on axial T2-weighted images, JF dimensions were measured. TS cross-sectional area was measured on non-contrast sagittal 2-dimensional phase contrast MRV images and served as the reference standard.

RESULTS

Of the 51 subjects with right-dominant TS, 37 had occipital bending to the right side and 35 showed sloping of the Gibraltar sign to right side. Of the 18 subjects with left dominant TS, 10 had occipital bending to left side and 13 showed left-sided sloping of the Gibraltar sign. Of the 31 subjects with co-dominant TS, 15 had no occipital bending and 20 showed no sloping of the Gibraltar sign. Mean right and left JF dimensions were higher in the right and left dominant TS respectively with no significant differences in patients with co-dominant sinus (p < 0.02).

CONCLUSION

Right occipital bending had a good association with right TS dominance. The other two parameters- Gibraltar sign of superior sagittal sinus groove and jugular foramen dimensions - did not have a very good association with respect to TS dominance.

Prognostic nutritional index predicts clinical outcomes in patients with cerebral venous sinus thrombosis

Background

Lower prognostic nutritional index (PNI) is related to the poor prognosis of cardiovascular diseases. However, little is known about PNI and its relationship with the prognosis of cerebral venous sinus thrombosis (CVST).

Methods

CVST patients were retrospectively identified from January 2013 till June 2019. Patients in the acute / subacute phase were selected as subjects. Poor prognosis was defined as a modified Rankin Scale (mRS) of 3–6. Multivariate logistic regression analysis was used to confirm if lower PNI was associated with a poor prognosis.

Results

A total of 297 subjects with follow-up data were enrolled. Thirty-three (11.1%) had a poor outcome. Multivariate logistic regression analysis suggested that PNI was an important predictive factor of poor outcome in acute/subacute CVST (odds ratio, 0.903; 95% CI, 0.833–0.978; P = 0.012). The optimal cut-off value for predicting the poor prognosis of PNI was 44.2. Kaplan-Meier analysis and log-rank test suggested that the lower the PNI value, the higher the mortality rate (P < 0.001). In addition, the nomogram that was set up showed that lower PNI was an index of poor prognosis. The c-index for acute/subacute patients with CVST was 0.872.

Conclusion

Lower PNI is correlated with a higher risk of adverse clinical outcomes in patients with acute/subacute CVST.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02436-w.

Case series of idiopathic intracranial hypertension in three patients with immune-complex glomerulonephritis

BACKGROUND

Idiopathic intracranial hypertension (IIH) is defined by an increased cerebrospinal fluid pressure in the absence of inflammation, structural obstructions, or mass lesions. Although the underlying pathogenesis of IIH is not fully understood, associations with specific risk factors as obesity, obstruction of cerebral venous sinuses, medications, endocrine or systemic conditions and chronic kidney disease have been described. Immune-complex glomerulonephritis as IgA-nephropathy is a frequent cause of chronic kidney failure, which was reported previously in one IIH patient. To date, there is no knowledge about the variable relation of immune-complex nephritis, kidney function and the course of IIH.

CASE PRESENTATION

We report three cases (two females) of concurrent diagnosis of IIH and immune-complex glomerulonephritis. All patients presented with typical IIH symptoms of headache and visual disturbances. Two patients had been diagnosed with IgA-nephropathy only few weeks prior to IIH diagnosis. The third patient had been diagnosed earlier with terminal kidney failure due to a cryoglobulin glomerulonephritis.

CONCLUSION

We propose a possible link between renal deposition of immune-complexes and increased cerebrospinal fluid pressure. Pathophysiological hypotheses and clinical implications are discussed. We recommend clinical awareness and further systematic research to obtain more information on the association of IIH and immune-complex glomerulonephritis.

High-Resolution Magnetic Resonance Black Blood Thrombus Imaging and Serum D-Dimer in the Confirmation of Acute Cortical Vein Thrombosis

Cerebral cortical vein thrombosis (CCVT) is often misdiagnosed because of its non-specific diagnostic symptoms. Here, we analyzed a cohort of patients with CCVT in hopes of improving understandings and treatments of the disease. A total of 23 patients with CCVT (confirmed with high-resolution imaging), who had been diagnosed between 2017 and 2019, were enrolled in this cohort study. Baseline demographics, clinical manifestations, laboratory data, radiological findings, treatment, and outcomes were collected and analyzed. Fourteen females and nine males were enrolled (mean age: 32.7 ± 11.9 years), presenting in the acute (within 7 days, n = 9), subacute (8–30 days, n = 7), and chronic (over 1 month, n = 7) stages. Headaches (65.2%) and seizures (39.1%) were the most common symptoms. Abnormally elevated plasma D-dimers were observed in the majority of acute stage patients (87.5%). The diagnostic accuracy of contrast-enhanced magnetic resonance venography (CE-MRV) and high-resolution magnetic resonance black-blood thrombus imaging (HR-MRBTI) in detecting CCVT were 57.1 and 100.0%, respectively. All patients had good functional outcomes after 6-month of standard anticoagulation (mRS 0–1) treatment. However, four CCVT patients that had cases involving multiple veins showed symptom relief after batroxobin therapy (p = 0.030). HR-MRBTI may be a fast and accurate tool for non-invasive CCVT diagnosis. HR-MRBTI combined with D-dimer can also precisely identify the pathological stage of CCVT. Batroxobin may safely accelerate cortical venous recanalization in combination with anticoagulation. Follow-up studies with larger sample sizes are suggested to evaluate the safety and efficacy of batroxobin for treating CCVT.

[Diagnosis and therapy of cerebral venous and sinus thrombosis]

Although cerebral venous and sinus thrombosis (CVST) is a rare cerebrovascular disease, it is being diagnosed with increasing frequency due to increased clinical awareness, better imaging capabilities, and higher survival rates in patients with predisposing conditions. This article shows how the diagnosis can be made effectively and what therapeutic options exist in the acute phase and secondary prophylaxis.

Venous anatomy of the infratentorial compartment

Approximately 7%-12% of all intracranial meningiomas are located in the posterior fossa (PF), a region which contains-among many other critical neurovascular structures-numerous major veins and sinuses draining blood away from the PF structures. There is a growing body of evidence indicating that venous sacrifice or injury during surgery are linked to serious postoperative complications-which may lead to significant morbidity and mortality. Thus, it is of paramount importance that clinicians charged with the preoperative, surgical, and postoperative care of patients undergoing treatment for meningioma are familiar with the general anatomy of the PF veins, as well as their structural nuances and drainage variations. The present chapter surveys the relevant anatomy in a manner that aims to be useful for an interdisciplinary team of clinicians and concludes with a discussion of emerging imaging technologies that may assist them in their clinical decision-making.

Does measurement of the jugular foramen diameter on MRI help to differentiate transverse sinus thrombosis from unilateral transverse sinus hypoplasia?

BACKGROUND AND PURPOSE

The transverse sinus (TS) is a frequent location of cerebral venous thrombosis. However, unilateral TS hypoplasia is a frequent variation and radiological imaging pitfall in the diagnosis because it may mimic unilateral TS thrombosis. The purpose of this study is to find a cutoff value for bilateral jugular foramen (JF) diameter ratios on magnetic resonance imaging (MRI) for differentiating TS thrombosis from TS hypoplasia.

MATERIALS AND METHODS

We retrospectively reviewed magnetic resonance venography results for 174 patients with reduced unilateral TS caliber resulting from either unilateral thrombosis (80 patients) or unilateral hypoplasia (94 patients). We calculated the ratio by proportioning the diameter of the JF ipsilateral to the TS with caliber reduction to the diameter of the contralateral JF. The Mann-Whitney U test was used to compare the ratios between thrombosis and hypoplasia groups, and the cutoff value was calculated by receiver-operating characteristic curve analysis.

RESULTS

The ratio of bilateral JF diameters was lower in patients with hypoplasia than those with thrombosis (P < .01). The cutoff value to determine the diagnosis of TS hypoplasia with maximum accuracy was 0.638, with a sensitivity of 91.3% and specificity of 64.9%.

CONCLUSION

In equivocal cases, calculating the cutoff value by proportioning the diameter of JF ipsilateral to the TS with caliber reduction to the contralateral JF seems to be an efficient, quick, and straightforward method and valuable aid to differentiate TS thrombosis from TS hypoplasia.

Labbé vein thrombosis

PURPOSE

Evaluate the prevalence of Labbé vein thrombosis (LVT) and its liability for the lesions observed in the case of associated ipsilateral transverse sinus thrombosis (TST).

METHODS

MRI findings of 58 consecutive patients (≥ 18 years) with acute LVT and TST (group 1) were compared with those of 149 patients with acute TST-no LVT (group 2) observed during the same period.

RESULTS

The prevalence of LVT was 15.2%. Group 1: TST extended to sigmoid sinus in 94.8%, resulting in complete sinuses occlusion. Any lesion was observed in 81% within LV territory: swelling (n = 5, 8.6%), edema (n = 9; 15.5%), non-hemorrhagic Infarct (n = 1; 1.7%), multiple temporal lobe hemorrhages (n = 31; 53.5%), temporal lobe hematoma (n = 13; 22.4%), and pericerebral hemorrhages (n = 28; 50%). The hemorrhagic lesions were not related to dominant TST or to extensive venous thrombosis. There was a prevalence of left TST- LVT (n = 32; 55.2%) and a higher prevalence of hemorrhagic lesions in this subset (59.4%). Risk factors were also associated (p = 0.03). Group 2: the TST resulted in an occlusion of the TS: (i) complete (n = 16; 10.7%); (ii) incomplete (n = 97; 82.8%); and (iii) segmental, involving the TS before (n = 32; 21.5%) or after (n = 10; 6.7%) LV ending within the TS. No parenchymal/pericerebral lesions were associated.

CONCLUSION

This study shows a strong association between the following: (i) the extent of thrombosis in the TS and the presence of LVT (p < 0.0001), (ii) the concomitance of LVT-TST and the presence of lesions in the LV territory and at the temporo-frontal convexity, (iii) risk factors and group 1 (p = 0.03).

Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of clinical management of cerebral venous sinus thrombosis

Aim

Cerebral venous sinus thrombosis (CVST) is a less common cerebrovascular disease that predominantly affects young patients. The incidence of CVST is 2–5/10 000 000/year, accounting for 0.5%–1% of all stroke. To reduce mortality and morbidity associated with CVST, Chinese Stroke Association commissioned the authors to write the current guideline on the management of CVST.

Methods

PubMed (MEDLINE), CNKI and Wanfang database were searched for studies related to CVST from 1 January 1990 to 31 July 2019. Data were synthesised by evidence tables. Each recommendation was fully discussed by the writing group members and reviewed by Chinese Stroke Association Stroke Fellow Committees. Levels of evidence grading algorithm of Chinese Stroke Association was used to grade each recommendation.

Results

This guideline mainly focuses on the diagnostic evaluation, therapeutic strategies and secondary prevention of CVST. CT/CTV and MRI/MRV are recommended in the initial imaging evaluation of patients with suspected CVST. Anticoagulation therapy with low-molecular weight heparin should be initiated in patients with CVST immediately. After the acute stage, warfarin is recommended for 3–6 months to prevent the recurrence of CVST and other venous thromboembolic events.

Conclusions

The guideline summarises the current evidence regarding the management of CVST, and provides references for diagnosis, treatment and secondary prevention of CVST in China.

Unilateral Nonvisualization of a Transverse Dural Sinus on Phase-Contrast MRV: Frequency and Differentiation from Sinus Thrombosis on Noncontrast MRI

BACKGROUND AND PURPOSE

Unilateral decreased/nonvisualization of a transverse dural sinus on MRV poses a diagnostic dilemma when gadolinium administration is contraindicated. We determined the frequency of unilateral decreased/nonvisualization of the transverse dural sinus and the performance of pregadolinium MR imaging sequences in diagnosing transverse sinus thrombosis in the presence of unilateral decreased/nonvisualization on phase-contrast MRV.

MATERIALS AND METHODS

We conducted a retrospective review of consecutive 3D phase-contrast MRV (VENC, 30 cm/s) and routine brain imaging (noncontrast sagittal T1, axial T2, FLAIR, DWI, GRE, and postgadolinium 3D-MPRAGE images) performed during a 3-year period for a total of 208 patients. Nonvisualization of a transverse dural sinus was defined as ≥50% nonvisualization of the transverse sinus caliber versus the contralateral side on MRV. Noncontrast imaging findings were considered abnormal when hyperintense signal was present on T2, FLAIR, T1, and DWI, and there were T2* blooming artifacts on GRE and DWI. Postgadolinium 3D-MPRAGE was used to confirm the diagnosis of transverse sinus thrombosis.

RESULTS

Nonvisualization of a transverse dural sinus was observed in 72/208 (34.6%) patients on MRV; 56/72 (77.8%) were without transverse sinus thrombosis, and 16/72 (22.2%) patients had transverse dural sinus thrombosis. Nonvisualization of a transverse dural sinus was seen in 56/192 (29.2%) patients without transverse sinus thrombosis and 16/16 (100%) with transverse sinus thrombosis. Abnormal findings on DWI (transverse sinus hyperintense signal or T2* blooming artifact) are 93.8% sensitive and 100.0% specific for transverse sinus thrombosis. Other noncontrast MR imaging sequences ranged from 56.3%-68.8% sensitive and 91.1%-100.0% specific.

CONCLUSIONS

Nonvisualization of a transverse dural sinus is a frequent phenomenon on phase-contrast MRV. DWI can be effectively used to exclude sinus thrombosis when nonvisualization of a transverse dural sinus is a diagnostic conundrum on phase-contrast MRV and contrast-enhanced studies are contraindicated.

Oral contraceptive-related transverse sinus thrombosis as an initial manifestation of antiphospholipid syndrome in the absence of systemic lupus erythematosus

BACKGROUND

Cerebral venous sinus thrombosis is a rare and potentially life-threatening neurologic manifestation of antiphospholipid syndrome. Oral contraceptive pills (OCP) may increase the risk of vascular events, even in people without family history of venous thrombosis.

CASE PRESENTATION

A 31-year-old woman with four weeks of constant headache and history of taking OCP for one year has been selected for this study. The results of magnetic resonance imaging (MRI) of brain and venography confirmed a diagnosis of cerebral venous sinus thrombosis. The serum anticardiolipin and antiphospholipid antibodies were elevated and a definitive diagnosis of antiphospholipid syndrome was made.

CONCLUSION

The present report demonstrates the importance of screening for antiphospholipid antibodies in patients presenting with cerebral venous sinus thrombosis despite history of taking OCP.

Cerebral Venous Sinus Thrombosis Incidence Is Higher Than Previously Thought: A Retrospective Population-Based Study

BACKGROUND AND PURPOSE

The incidence of cerebral venous thrombosis (CVT) varies between studies, but it is estimated to be between 2 and 5 per million per year. A recent study in the Netherlands with comprehensive ascertainment suggested a much higher incidence. It is uncertain whether these differing estimates reflect the quality of ascertainment or true variation. The purpose of this study was to determine the incidence of CVT in Adelaide, using a novel clinical and radiological methodology.

METHODS

We retrospectively identified CVT International Classification of Diseases-coded cases from all Adelaide public hospitals from 2005 to 2011. We also searched all neuroimaging studies (259 101) from these hospitals for text variations containing venous thromb. All potential cases were reviewed, and cases of incident CVT ascertained. Associations and outcomes were determined.

RESULTS

Of 169 possible cases, 105 cases of CVT were confirmed (59 cases by both coding and neuroimaging, 40 from neuroimaging alone, and 6 from coding alone). In our population of 953 390 adults, this represented an incidence of 15.7 million per year (95% confidence interval, 12.9-19.0), the highest incidence reported. Of these cases, a possible procoagulant predisposition was identified in 48%. Fifty-five of 105 cases occurred in females. Relative risk of CVT in females of reproductive age was insignificantly higher than in males (1.18 [95% confidence interval, 0.94-1.48]).

CONCLUSIONS

Cerebral venous sinus thrombosis in our study was more common than previously reported, perhaps because of more complete ascertainment. Future CVT incidence studies should include comprehensive capture and review of neuroimaging.