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Radiologic Diagnosis of Cerebral Venous Thrombosis: Pictorial Review

Colin S. Poon1,2, Ja-Kwei Chang1, Amar Swarnkar1, Michele H. Johnson2 and John Wasenko1

1 1Department of Radiology, State University of New York Upstate Medical University, 750 E Adams St., Syracuse, NY 13210.
2 Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT.


Figure 1
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  		Fig. 1A —5-year-old boy with severe headache and eye pain. Thrombosis was found in right lateral sinus (arrows). Unenhanced CT images show thrombosis as hyperdensity (dense clot sign).

 

Figure 2
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  		Fig. 1B —5-year-old boy with severe headache and eye pain. Thrombosis was found in right lateral sinus (arrows). Unenhanced CT images show thrombosis as hyperdensity (dense clot sign).

 

Figure 3
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  		Fig. 1C —5-year-old boy with severe headache and eye pain. Thrombosis was found in right lateral sinus (arrows). Enhanced CT images show same structure as filling defect with enhancing rim (empty delta sign).

 

Figure 4
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  		Fig. 1D —5-year-old boy with severe headache and eye pain. Thrombosis was found in right lateral sinus (arrows). Enhanced CT images show same structure as filling defect with enhancing rim (empty delta sign).

 

Figure 5
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  		Fig. 2A —Cord sign in cortical venous thrombosis in a young woman. Unenhanced CT scans show dense cortical veins (white arrows,A), an uncommon direct sign of cerebral venous thrombosis (CVT) known as cord sign. Note also indirect signs of CVT, including subcortical hemorrhagic infarction (black arrows), diffuse brain swelling, and small ventricular size.

 

Figure 6
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  		Fig. 2B —Cord sign in cortical venous thrombosis in a young woman. Unenhanced CT scans show dense cortical veins (white arrows,A), an uncommon direct sign of cerebral venous thrombosis (CVT) known as cord sign. Note also indirect signs of CVT, including subcortical hemorrhagic infarction (black arrows), diffuse brain swelling, and small ventricular size.

 

Figure 7
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  		Fig. 3A —38-year-old woman with history of pseudotumor cerebri who presented with headache and decreased consciousness. Diagnosis was thrombosis of superior sagittal sinus, straight sinus, and internal cerebral veins. (Long white arrows indicate superior sagittal sinus; short white arrows, straight sinus; black arrows, Rosenthal's veins). Unenhanced CT scans show dense thrombosis. Note nonhemorrhagic infarction in basal ganglia, thalami, and internal capsules, which is typically seen in deep cerebral venous thrombosis.

 

Figure 8
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  		Fig. 3B —38-year-old woman with history of pseudotumor cerebri who presented with headache and decreased consciousness. Diagnosis was thrombosis of superior sagittal sinus, straight sinus, and internal cerebral veins. (Long white arrows indicate superior sagittal sinus; short white arrows, straight sinus; black arrows, Rosenthal's veins). Unenhanced CT scans show dense thrombosis. Note nonhemorrhagic infarction in basal ganglia, thalami, and internal capsules, which is typically seen in deep cerebral venous thrombosis.

 

Figure 9
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  		Fig. 3C —38-year-old woman with history of pseudotumor cerebri who presented with headache and decreased consciousness. Diagnosis was thrombosis of superior sagittal sinus, straight sinus, and internal cerebral veins. (Long white arrows indicate superior sagittal sinus; short white arrows, straight sinus; black arrows, Rosenthal's veins). Axial T2-weighted MR image shows replacement of signal void by thrombus (arrow) in superior sagittal sinus. Veins at internal capsules are engorged.

 

Figure 10
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  		Fig. 3D —38-year-old woman with history of pseudotumor cerebri who presented with headache and decreased consciousness. Diagnosis was thrombosis of superior sagittal sinus, straight sinus, and internal cerebral veins. (Long white arrows indicate superior sagittal sinus; short white arrows, straight sinus; black arrows, Rosenthal's veins). Sagittal contrast-enhanced T1-weighted image (D) shows filling defects in sagittal and straight sinuses, correlating with absence of flow on 2D phase contrast MR venography (E).

 

Figure 11
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  		Fig. 3E —38-year-old woman with history of pseudotumor cerebri who presented with headache and decreased consciousness. Diagnosis was thrombosis of superior sagittal sinus, straight sinus, and internal cerebral veins. (Long white arrows indicate superior sagittal sinus; short white arrows, straight sinus; black arrows, Rosenthal's veins). Sagittal contrast-enhanced T1-weighted image (D) shows filling defects in sagittal and straight sinuses, correlating with absence of flow on 2D phase contrast MR venography (E).

 

Figure 12
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  		Fig. 3F —38-year-old woman with history of pseudotumor cerebri who presented with headache and decreased consciousness. Diagnosis was thrombosis of superior sagittal sinus, straight sinus, and internal cerebral veins. (Long white arrows indicate superior sagittal sinus; short white arrows, straight sinus; black arrows, Rosenthal's veins). After catheter-directed thrombolysis, flow was partially reestablished.

 

Figure 13
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  		Fig. 4A —16-year-old girl with multiple traumatic injuries in head. Initial unenhanced CT (not shown) showed hyperdensity in right internal jugular vein (IJV) and sigmoid sinus that was suspicious for venous thrombosis. Findings were confirmed on CT venography, MRI, and conventional venography. Axial source images from CT venography. Thrombus in IJV (asterisk, A) and sigmoid sinus (black arrow,B) is clearly shown as filling defect. Note collateral veins (white arrow, A) arising from right IJV.

 

Figure 14
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  		Fig. 4B —16-year-old girl with multiple traumatic injuries in head. Initial unenhanced CT (not shown) showed hyperdensity in right internal jugular vein (IJV) and sigmoid sinus that was suspicious for venous thrombosis. Findings were confirmed on CT venography, MRI, and conventional venography. Axial source images from CT venography. Thrombus in IJV (asterisk, A) and sigmoid sinus (black arrow,B) is clearly shown as filling defect. Note collateral veins (white arrow, A) arising from right IJV.

 

Figure 15
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  		Fig. 4C —16-year-old girl with multiple traumatic injuries in head. Initial unenhanced CT (not shown) showed hyperdensity in right internal jugular vein (IJV) and sigmoid sinus that was suspicious for venous thrombosis. Findings were confirmed on CT venography, MRI, and conventional venography. Sagittal planar reconstruction of CT venography shows thrombus extending from right IJV (asterisk) into sigmoid sinus (arrow), correlating well with findings on conventional venography (E).

 

Figure 16
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  		Fig. 4D —16-year-old girl with multiple traumatic injuries in head. Initial unenhanced CT (not shown) showed hyperdensity in right internal jugular vein (IJV) and sigmoid sinus that was suspicious for venous thrombosis. Findings were confirmed on CT venography, MRI, and conventional venography. T1-weighted MR image shows sigmoid sinus thrombosis (arrow) as seen on CT (B).

 

Figure 17
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  		Fig. 4E —16-year-old girl with multiple traumatic injuries in head. Initial unenhanced CT (not shown) showed hyperdensity in right internal jugular vein (IJV) and sigmoid sinus that was suspicious for venous thrombosis. Findings were confirmed on CT venography, MRI, and conventional venography. Venogram (E) shows thrombus as filling defects. Note collateral veins at region of right IJVs, also seen in A. Venogram after suction thrombectomy (F) shows improved patency in right IJV and lateral sinus. Asterisk, right internal jugular vein; solid arrow, sigmoid sinus; open arrow, torcular Herophili.

 

Figure 18
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  		Fig. 4F —16-year-old girl with multiple traumatic injuries in head. Initial unenhanced CT (not shown) showed hyperdensity in right internal jugular vein (IJV) and sigmoid sinus that was suspicious for venous thrombosis. Findings were confirmed on CT venography, MRI, and conventional venography. Venogram (E) shows thrombus as filling defects. Note collateral veins at region of right IJVs, also seen in A. Venogram after suction thrombectomy (F) shows improved patency in right IJV and lateral sinus. Asterisk, right internal jugular vein; solid arrow, sigmoid sinus; open arrow, torcular Herophili.

 

Figure 19
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  		Fig. 5A —4-day-old neonatal boy after idiopathic cardiac arrest. Axial unenhanced CT scans show normal, hyperdense blood commonly seen in neonates and infants.

 

Figure 20
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  		Fig. 5B —4-day-old neonatal boy after idiopathic cardiac arrest. Axial unenhanced CT scans show normal, hyperdense blood commonly seen in neonates and infants.

 

Figure 21
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  		Fig. 5C —4-day-old neonatal boy after idiopathic cardiac arrest. T1-(C) and T2-weighted (D) MR images show normal findings.

 

Figure 22
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  		Fig. 5D —4-day-old neonatal boy after idiopathic cardiac arrest. T1-(C) and T2-weighted (D) MR images show normal findings.

 

Figure 23
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  		Fig. 6A —Middle-aged woman (exact age unknown) with history of multiple myeloma. Axial unenhanced CT images show subdural hemorrhage at right cerebellar convexity that mimics thrombosis of right transverse sinus.

 

Figure 24
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  		Fig. 6B —Middle-aged woman (exact age unknown) with history of multiple myeloma. Axial unenhanced CT images show subdural hemorrhage at right cerebellar convexity that mimics thrombosis of right transverse sinus.

 

Figure 25
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  		Fig. 6C —Middle-aged woman (exact age unknown) with history of multiple myeloma. Axial FLAIR image (C), coronal FLAIR image (D), and unenhanced CT scan (E) at location adjacent to B show similar finding of subdural hemorrhage (white arrow, E) medial to right transverse sinus (black arrow, E).

 

Figure 26
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  		Fig. 6D —Middle-aged woman (exact age unknown) with history of multiple myeloma. Axial FLAIR image (C), coronal FLAIR image (D), and unenhanced CT scan (E) at location adjacent to B show similar finding of subdural hemorrhage (white arrow, E) medial to right transverse sinus (black arrow, E).

 

Figure 27
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  		Fig. 6E —Middle-aged woman (exact age unknown) with history of multiple myeloma. Axial FLAIR image (C), coronal FLAIR image (D), and unenhanced CT scan (E) at location adjacent to B show similar finding of subdural hemorrhage (white arrow, E) medial to right transverse sinus (black arrow, E).

 

Figure 28
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  		Fig. 6F —Middle-aged woman (exact age unknown) with history of multiple myeloma. Contrast-enhanced MR venogram shows patent dural venous sinuses. Right transverse sinus (arrows) is smaller and slightly irregular compared with left, possibly secondary to mass effect from adjacent subdural hematoma.

 

Figure 29
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  		Fig. 7A —7-year-old girl with closed head injury. Unenhanced CT scans on first day show subdural hemorrhage along tentorium cerebelli and skull fracture. Subtle density is seen in right lateral sinus (arrows,B and C) that was not well appreciated initially.

 

Figure 30
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  		Fig. 7B —7-year-old girl with closed head injury. Unenhanced CT scans on first day show subdural hemorrhage along tentorium cerebelli and skull fracture. Subtle density is seen in right lateral sinus (arrows,B and C) that was not well appreciated initially.

 

Figure 31
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  		Fig. 7C —7-year-old girl with closed head injury. Unenhanced CT scans on first day show subdural hemorrhage along tentorium cerebelli and skull fracture. Subtle density is seen in right lateral sinus (arrows,B and C) that was not well appreciated initially.

 

Figure 32
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  		Fig. 7D —7-year-old girl with closed head injury. On next day, repeat CT scan shows dense thrombus in right lateral sinus (arrows) mimicking subdural hematoma (compare E with A).

 

Figure 33
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  		Fig. 7E —7-year-old girl with closed head injury. On next day, repeat CT scan shows dense thrombus in right lateral sinus (arrows) mimicking subdural hematoma (compare E with A).

 

Figure 34
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  		Fig. 7F —7-year-old girl with closed head injury. On sagittal T1-weighted MR images, normal flow void is seen in left lateral sinus (arrow, F), but note isodense thrombus on right (arrow, G).

 

Figure 35
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  		Fig. 7G —7-year-old girl with closed head injury. On sagittal T1-weighted MR images, normal flow void is seen in left lateral sinus (arrow, F), but note isodense thrombus on right (arrow, G).

 

Figure 36
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  		Fig. 8A —4-month-old girl with seizure. Unenhanced CT scans show subdural hemorrhage along falx and tentorium cerebelli, simulating sagittal and transverse sinus thrombosis. Note pseudo empty delta sign (arrow, A). Empty delta sign of cerebral venous thrombosis is applicable only on contrast-enhanced CT. Hyperdensity along posterior parietal convexity simulates transverse sinus thrombosis (black arrow, B). Extension of hyperdensity beyond expected location of transverse sinus suggests this is actually subdural hematoma (white arrow, B) [8].

 

Figure 37
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  		Fig. 8B —4-month-old girl with seizure. Unenhanced CT scans show subdural hemorrhage along falx and tentorium cerebelli, simulating sagittal and transverse sinus thrombosis. Note pseudo empty delta sign (arrow, A). Empty delta sign of cerebral venous thrombosis is applicable only on contrast-enhanced CT. Hyperdensity along posterior parietal convexity simulates transverse sinus thrombosis (black arrow, B). Extension of hyperdensity beyond expected location of transverse sinus suggests this is actually subdural hematoma (white arrow, B) [8].

 

Figure 38
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  		Fig. 9A —29-year-old woman woman with headache. Contrast-enhanced T1-weighted image (A), source image of 2D time-of-flight (TOF) MR venography (B), and maximum-intensity-projection of 2D TOF MR venography image (C) show fenestration of straight sinus (arrow). On basis of A alone, sinus thrombosis is difficult to exclude. However, other imaging series, including unenhanced T1-weighted and FLAIR images (not shown), fail to show abnormal signal intensity to suggest presence of a true thrombus, raising suspicion that this may have another cause. Two-dimensional TOF MR venogram (B) shows fenestration. Note small vessels representing fenestration are round and positioned on opposite sides of expected course of straight sinus. This appearance is unusual for residual patent lumen of dural venous sinus filled with thrombus because residual lumen tends to be irregular or crescent-shaped.

 

Figure 39
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  		Fig. 9B —29-year-old woman woman with headache. Contrast-enhanced T1-weighted image (A), source image of 2D time-of-flight (TOF) MR venography (B), and maximum-intensity-projection of 2D TOF MR venography image (C) show fenestration of straight sinus (arrow). On basis of A alone, sinus thrombosis is difficult to exclude. However, other imaging series, including unenhanced T1-weighted and FLAIR images (not shown), fail to show abnormal signal intensity to suggest presence of a true thrombus, raising suspicion that this may have another cause. Two-dimensional TOF MR venogram (B) shows fenestration. Note small vessels representing fenestration are round and positioned on opposite sides of expected course of straight sinus. This appearance is unusual for residual patent lumen of dural venous sinus filled with thrombus because residual lumen tends to be irregular or crescent-shaped.

 

Figure 40
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  		Fig. 9C —29-year-old woman woman with headache. Contrast-enhanced T1-weighted image (A), source image of 2D time-of-flight (TOF) MR venography (B), and maximum-intensity-projection of 2D TOF MR venography image (C) show fenestration of straight sinus (arrow). On basis of A alone, sinus thrombosis is difficult to exclude. However, other imaging series, including unenhanced T1-weighted and FLAIR images (not shown), fail to show abnormal signal intensity to suggest presence of a true thrombus, raising suspicion that this may have another cause. Two-dimensional TOF MR venogram (B) shows fenestration. Note small vessels representing fenestration are round and positioned on opposite sides of expected course of straight sinus. This appearance is unusual for residual patent lumen of dural venous sinus filled with thrombus because residual lumen tends to be irregular or crescent-shaped.

 

Figure 41
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  		Fig. 10 —Superior sagittal sinus thrombosis in young woman (exact age unknown) on T1-weighted image. Sagittal T1-weighted images can be useful for depiction of extensive superior sagittal sinus thrombosis. However, bright signal of thrombus with methemoglobin (arrow) may mimic patent sinus on contrast-enhanced T1-weighted images and time-of-flight MR venography.

 

Figure 42
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  		Fig. 11A —25-year-old woman with headache. Black arrows indicate left transverse and sigmoid sinuses; white arrows indicate right transverse and sigmoid sinuses. Axial phase contrast MR venogram shows loss of flow signal (arrow).

 

Figure 43
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  		Fig. 11B —25-year-old woman with headache. Black arrows indicate left transverse and sigmoid sinuses; white arrows indicate right transverse and sigmoid sinuses. Axial T1-weighted image fails to show thrombus.

 

Figure 44
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  		Fig. 11C —25-year-old woman with headache. Black arrows indicate left transverse and sigmoid sinuses; white arrows indicate right transverse and sigmoid sinuses. Axial T1-weighted gadolinium-enhanced image shows smooth enhancement in hypoplastic left transverse and sigmoid sinuses.

 

Figure 45
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  		Fig. 11D —25-year-old woman with headache. Black arrows indicate left transverse and sigmoid sinuses; white arrows indicate right transverse and sigmoid sinuses. Coronal reformations of CT venography, from posteriorly to anteriorly, show smooth enhancement in hypoplastic left transverse and sigmoid sinuses. Hypoplasia of ipsilateral jugular foramen also serves as important corroborative evidence of hypoplastic dural sinus.

 

Figure 46
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  		Fig. 11E —25-year-old woman with headache. Black arrows indicate left transverse and sigmoid sinuses; white arrows indicate right transverse and sigmoid sinuses. Coronal reformations of CT venography, from posteriorly to anteriorly, show smooth enhancement in hypoplastic left transverse and sigmoid sinuses. Hypoplasia of ipsilateral jugular foramen also serves as important corroborative evidence of hypoplastic dural sinus.

 

Figure 47
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  		Fig. 11F —25-year-old woman with headache. Black arrows indicate left transverse and sigmoid sinuses; white arrows indicate right transverse and sigmoid sinuses. Coronal reformations of CT venography, from posteriorly to anteriorly, show smooth enhancement in hypoplastic left transverse and sigmoid sinuses. Hypoplasia of ipsilateral jugular foramen also serves as important corroborative evidence of hypoplastic dural sinus.

 

Figure 48
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  		Fig. 12A —74-year-old man with headache and mastoiditis. Contrast-enhanced T1-weighted image shows filling defects (arrows) in bilateral transverse sinuses.

 

Figure 49
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  		Fig. 12B —74-year-old man with headache and mastoiditis. Maximum-intensity-projection of contrast-enhanced MR venography using sagittal 3D spoiled gradient-recalled echo (SPGR) sequence. Diagnosis is suggested by presence of normal patent flow immediately proximal and distal to filling defects, continuity of defects with dural surface, localized round or lobulated appearance, and central enhancement.

 

Figure 50
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  		Fig. 13A —Arachnoid granulations simulating thrombus in dural venous sinuses. In conventional angiography of 16-year-old boy with developmental venous anomaly (long arrow), persistent filling defect is seen in right transverse sinus (short arrow).

 

Figure 51
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  		Fig. 13B —Arachnoid granulations simulating thrombus in dural venous sinuses. Contrast-enhanced T1-weighted image in same patient as in A shows soft-tissue structure (black arrow) at corresponding location. This structure is round and well defined, consistent with arachnoid granulation.

 

Figure 52
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  		Fig. 13C —Arachnoid granulations simulating thrombus in dural venous sinuses. Coronal T2-weighted image in different patient, 40-year-old man, shows typical round arachnoid granulation in left transverse sinus (arrow) that is abutting superior medial wall of transverse sinus. Normal flow void is seen adjacent to this structure (at arrow tip) and in consecutive images (not shown), further supporting this is an arachnoid granulation.

 

Figure 53
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  		Fig. 14A —6-year-old boy with neuroblastoma. T1-weighted image shows isointense lesion (arrow) at region of left transverse sinus, simulating sinus thrombosis.

 

Figure 54
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  		Fig. 14B —6-year-old boy with neuroblastoma. Contrast-enhanced T1-weighted image shows enhancing lesion (black arrow) is dural extension of neuroblastoma, compressing lateral sinus (white arrow). Mass lesion is also seen posterior to torcular Herophili, compressing and displacing it anteriorly. Note mass lesion at lateral wall of left orbit.

 

Figure 55
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  		Fig. 15A —42-year-old woman with headache. Coronal FLAIR image shows hyperintensity in subarachnoid space, consistent with subarachnoid hemorrhage.

 

Figure 56
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  		Fig. 15B —42-year-old woman with headache. Sagittal gadolinium-enhanced T1-weighted image shows extensive filling defects in superior sagittal sinus, straight sinus, and torcular Herophili (arrows).

 

Figure 57
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  		Fig. 15C —42-year-old woman with headache. Coronal gadolinium-enhanced T1-weighted image confirms that loss of flow void in A represents thrombosis of superior sagittal sinus. Note filling defect of thrombus, giving rise to empty delta sign (arrow).

 

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