Deep cerebral vein thrombosis is a subset of cerebral venous thrombosis involving the internal cerebral veins, often coexisting with cortical vein thrombosis or dural venous sinus thrombosis, and with different clinical presentations relying on which segment is involved.
As such please refer to the cerebral venous thrombosis article for a general discussion.
Deep cerebral vein thrombosis may occur at any age. A female predilection exists, and pregnant/peripartum women as well as women on the contraceptive pill are over represented. Elderly patients are more likely to be affected. Please refer to the generic article for a broad discussion on epidemiology and risk factors: cerebral venous thrombosis.
Presentation is highly variable, but compared to run-of-the-mill dural venous sinus thrombosis is usually shorter and more rapidly progressive to profound deficit 3. Presentation can include: nausea, vomiting, headache, focal neurological deficit, seizure, hemiparesis, aphasia, and coma.
Please refer to the generic article for a broad discussion on pathology and risk factors: cerebral venous thrombosis.
Typically the thalami are bilaterally oedematous with potential superimposed venous infarction and haemorrhage, although occasionally the findings will be markedly asymmetric or unilateral 3. For unknown reasons the right side is more often involved than the left when the involvement is asymmetric or unilateral.
Non-enhanced CT is usually the first imaging investigation performed given the non-specific clinical presentation in this cases. When not associated with venous haemorrhage or infarction, it can be hard to make the diagnosis. Potential findings include:
- dense clot sign
- cortical oedema
- peripheral haemorrhage (cortical linear density or gyriform heterogeneous haemorrhage)
With contrast administration, especially with a CT venogram, then a filling defect in the veins and sinuses is sought.
MRI is able to both visualise the clot as well as the sequelae.
- T1: The acute clot is isointense becoming hyperintense in the subacute phase; see ageing blood on MRI
- acute clot is hypointense on T2 (this can mimic a flow void)
- hyperintense swelling of thalami and basal ganglia
- MR venography: will demonstrate lack of flow
Treatment and prognosis
For general discussion on treatment please refer to the parent article: cerebral venous thrombosis.
Compared to dural venous sinus thrombosis, deep cerebral venous thrombosis, especially when the internal cerebral veins are involved, carries a poorer prognosis 3.
- midline and bilateral infarction areas (e.g. involving thalami or parasagittal cortex)
- cortical or peripheral haemorrhage, especially when heterogeneous and gyriform
- cortical oedema
- direct signs of a thrombus (e.g. dense clot sign, cord sign)
- 1. Rodallec Mathieu H., Alexandre Krainik, Antoine Feydy et al. “Cerebral Venous Thrombosis and Multidetector CT Angiography: Tips and Tricks.” Radiographics 26, no. suppl_1 (October 1, 2006): S5-18. doi:10.1148/rg.26si065505.
- 2. Ferro Jose M., Patricia Canhao, Jan Stam et al. “Prognosis of Cerebral Vein and Dural Sinus Thrombosis: Results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT).” Stroke 35, no. 3 (March 1, 2004): 664-670. doi:10.1161/01.STR.0000117571.76197.26.
- 3. Herrmann Karin A., Bernd Sporer and Tarek A. Yousry. “Thrombosis of the Internal Cerebral Vein Associated with Transient Unilateral Thalamic Edema: A Case Report and Review of the Literature.” AJNR Am J Neuroradiol 25, no. 8 (September 1, 2004): 1351-1355. [Link].
- 4. Rodallec MH, Krainik A, Feydy A et-al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics. 2006;26 Suppl 1 (suppl_1): S5-18. doi:10.1148/rg.26si065505 - Pubmed citation