Presentation
Dizziness, vertigo, and left-sided paresthesia one week ago.
Patient Data
MRI study shows the superior sagittal sinus eliciting intermediate signal in T1 that is isointense to the grey matter, low signal in T2, and blooming in the T2 GRE together with multiple superficial cortical veins suggestive of acute thrombosis.
Right occipital para sagittal small patchy T2 and FLAIR hyperintensity, probably related to gliotic changes versus mild vasogenic edema.
Few white matter ischemic foci and age-related cerebral involution.
No recent ischemic lesions in DWI.
CT study shows abnormal hyperdensity of the superior sagittal sinus and multiple cortical veins "dense vein sign" suggestive of venous thrombosis.
CT venogram shows non-enhanced superior sagittal sinus and multiple superficial cortical veins confirming venous thrombosis. "Empty delta sign" is evident in the axial plane.
FU CT after 2 wk of anticoagulants Rx
CT study shows the superior sagittal sinus and superficial cortical veins returning to the normal size and density with no evidence of cerebral insult.
Case Discussion
Early detection of cerebral venous thrombosis is crucial to decrease morbidity and mortality. In the presence of clinical suspicion directing early to specific angiographic imaging, the radiologist mission sounds to be not that difficult. The more challenging scenario happens if there is no clinical suspicion about venous thrombosis, and a routine non-enhanced CT or MRI was done.
Here are some helpful tips:
- T2 GRE/ SWI should be included in the routine protocol of any MRI of the brain
- vascular assessment should be done routinely in conventional MRI of the brain. For arteries, T2 is the best while for veins it is a bit more difficult requiring assessment in T1, T2, and T2 GRE/SWI trying to catch a significant signal alteration or blooming
- T2 GRE/SWI is sensitive to the paramagnetic effect of deoxyhemoglobin and hemosiderin
- in acute venous thrombosis, the clot elicits a low signal in T2 that is a major trap giving a false impression of a normal venous sinus that is acutely thrombosed. T2 GRE/ SWI is very helpful in this context