Clinical and neuroradiological spectrum of isolated cortical vein thrombosis

Amyloid accumulation in cases of suspected comorbid cerebral amyloid angiopathy and isolated cortical venous thrombosis

BACKGROUND AND AIM

The differentiation of isolated cortical venous thrombosis (ICVT) from cerebral amyloid angiopathy (CAA) can be difficult because both diseases share similar neurological symptoms and imaging findings. N-methyl-11C-2-(4'-methylaminophenyl)-6-hydroxybenzo-thiazole (11C-PiB) positron emission tomography (PET) functions as a diagnostic modality for CAA by detecting amyloid deposition. The present prospective study evaluated amyloid deposition using 11C-PiB-PET in consecutive patients with suspected ICVT.

METHOD

This study was a prospective observational study. Patients who attended or were hospitalized between May 2019 and March 2020 were included in the analysis. Consecutive patients who met the criteria for suspicion of ICVT were enrolled in the study, and the clinical course, symptoms, imaging findings (including magnetic resonance imaging), and the 11C-PiB-PET findings of each case were analyzed.

RESULTS

The study cohort included four patients (64-82 years of age, all women). In one younger patient, 11C-PiB-PET afforded no findings suggestive of CAA, whereas the remaining three patients exhibited 11C-PiB-PET findings suggestive of CAA.

CONCLUSION

Although 11C-PiB-PET would be a reasonable modality for distinguishing ICVT from CAA, especially in younger patients, it might be difficult to differentiate ICVT from CAA in elderly patients because of the potential deposition of amyloid.

CLINICAL TRIAL REGISTRATION

URL: https://www.umin.ac.jp/ctr/ Unique identifier: UMIN 000037101.

Utility of 3D T1-weighted turbo spin echo black blood sequence for the diagnosis of cerebral venous thrombosis

PURPOSE

Accurate assessment of dural sinus, deep and cortical venous thrombosis on MR imaging is challenging. The aim of this study is to evaluate the accuracy of 3D-T1 turbo spin echo (T1S), sequences in detecting venous thrombosis and comparing it with susceptibility-weighted imaging (SWI), magnetic resonance venography (MRV) and post contrast T1 magnetization-prepared rapid acquisition gradient echo (T1C).

METHODS

A blinded retrospective observational analysis of 71 consecutive patients evaluated for cerebral venous thrombosis (CVT) and 30 control patients was performed. Multimodality reference standard adopted included T1C, SWI with MRV. Sub-analyses in superficial, deep and cortical venous segments were performed in addition to correlation of signal intensity of thrombus with the clinical stage.

RESULTS

A total of 2222 segments in 101 complete MRI examinations were evaluated. Sensitivity/specificity/positive predictive value/negative predictive value/accuracy and precision of T1S for detection of cortical vein thrombosis was 0.994/1/1/0.967/0.995/1, 1/0.874/0.949/1/0.963/0.950 for detection of superficial venous sinus thrombosis and 1/1/1/1/1/1 for deep venous thrombosis. The AUC yield for T1S was 0.997 for cortical, 1 for deep and 0.988 for superficial venous segments.

CONCLUSION

T1S paralleled the accuracy of conventional sequences in the overall detection of CVT but showed superior accuracy in the detection of cortical venous thrombosis. It makes a fitting addition to the CVT MRI protocol in scenarios demanding negation of gadolinium administration.

Malignant Isolated Cortical Vein Thrombosis as the Initial Manifestation of Primary Antiphospholipid Syndrome: Lessons on Diagnosis and Management From a Case Report

Background

Antiphospholipid syndrome (APS) with isolated cortical vein thrombosis (ICoVT) is an extremely rare but potentially malignant entity. It is particularly challenging to diagnose APS-related ICoVT because of the non-specific clinical manifestations and the frequent absence of typical neuroimaging. Moreover, there is currently limited knowledge on the clinical features and management strategies for the condition. Delays in diagnosis and treatment may lead to life-threatening consequences.

Case Presentation

We present a rare case of a 74-year-old Chinese woman who presented with sudden onset of headache and right arm weakness that mimicked acute ischemic stroke. Her initial computed tomography was unremarkable, and intravenous thrombolysis was performed. Serial neuroimages confirmed ICoVT 4 days after symptom onset, and low-molecular-weight heparin (LMWH) was started at a dose of 0.4 ml twice per day, according to the 2019 Chinese guidelines. The workup for the predisposing causes of ICoVT revealed triple positivity APS. LMWH dose was adjusted according to the anti-Xa chromogenic assay. However, the patient’s condition deteriorated rapidly, and there was a progressive enlargement of the venous infarction despite treatment with anticoagulants. Transtentorial herniation developed on day 12, and decompressive craniectomy was immediately performed. The patient’s symptoms did not improve significantly after surgery, and she remained aphasic and hemiplegic at the 3-month follow-up, with a modified Rankin Scale score of 5.

Conclusion

ICoVT is a rare yet potentially fatal manifestation of APS, and its diagnosis and treatment are extremely challenging. Timely diagnosis, prompt treatment, and close monitoring are essential to improve the clinical prognosis of patients with APS-related ICoVT.

Isolated thrombosis of cortical veins - Clinical and radiological correlation

Isolated cortical venous thrombosis (ICVT) is a relatively rare clinical entity with non-specific clinical presentations. Anatomical variations in cortical veins and the lack of a gold standard imaging feature make the diagnosis of ICVT challenging. Headache and seizures were the most common presentations. The Vein of Trolard followed by superficial middle cerebral vein (SMCV) were the most commonly involved. Susceptibility Weighted Imaging (SWI) cord sign was observed in 100% of the cases. CT cord sign and filling defects on contrast enhanced CT were evident in 46.7% and 10% of the cases, respectively. Notably, in the absence of filling defect visualized on contrast CT, MRI, replacement of flow void was the surrogate marker for the ICVT. A high index of clinical suspicion, a thorough understanding of neurovascular anatomy, multiparametric, multiplanar MRI protocol is required to diagnose this rare entity. A serpiginous blooming structure within the subarachnoid space identifiable in less than two contiguous sections on SWI in the vicinity of haemorrhagic infarction should alert the clinician to the imaging possibility of ICVT.

Cortical Vein Thrombosis after Infliximab Treatment for Crohn's Disease

Inflammatory bowel disease (IBD) including ulcerative colitis and Crohn's disease puts patients at high risk of thromboembolism accidents. These patients may take infliximab for active and fistulating Crohn's disease, which can also increase the risk of thrombosis. Deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) are more common among these patients, but cerebrovascular, mesenteric, portal and retinal veins can also be affected. In this paper, we report a case of isolated right Labbe vein thrombosis after infliximab therapy for Crohn's disease. To the best of our knowledge, our patient is the first case report of isolated cortical vein thrombosis following administration of rituximab for Crohn's disease.

Isolated cortical venous thrombosis after fetal demise

Isolated cortical venous thrombosis (ICVT) occurring in the absence of dural venous thrombosis, constitutes about 2%-5% of all cerebral venous thrombosis. Its vague, non-specific presentation makes it a difficult and challenging diagnosis that needs an extensive workup especially in young patients. Outcome and prognosis depend mainly on early diagnosis and treatment. Here we discuss the clinical presentation, diagnosis and the treatment of a young woman diagnosed with ICVT with acute ischaemic venous stroke, in the setting of eclampsia and family history of coagulation disease.

Spontaneous Intracranial Hypotension with Isolated Cortical Vein Thrombosis and Subarachnoid Haemorrhage

Spontaneous intracranial hypotension (SIH) associated with subarachnoid haemorrhage (SAH) has never been reported. Here, we report on a case of a 33-year-old woman with SIH, who developed simple partial sensory seizures 3 weeks later. Neuroimaging studies, including brain computed tomography and angiography, were initially normal, but revealed an isolated cortical venous thrombosis at 3 weeks. One week later, brain magnetic resonance imaging showed SAH around the thrombosed cortical vein. We postulate that the decline in the venous blood flow velocity due to SIH may have resulted in cortical venous thrombosis, which in turn led to rupture of the vessel wall and SAH in this patient.

Malignant isolated cortical vein thrombosis with type II protein S deficiency: a case report

Background

The incidence of cerebral venous thrombosis (CVT) is low, and in particular, isolated cortical vein thrombosis (ICVT) is very rare. The diagnosis of ICVT is difficult by using conventional computed tomography (CT) and magnetic resonance imaging (MRI). However, with appropriate treatment, ICVT has a good prognosis.

Case presentation

Herein, we present a rare case of a 40-year-old woman with ICVT and type II protein S (PS) deficiency, who experienced a stroke. She initially presented with generalized convulsions. A CT scan showed intracerebral hemorrhage (ICH) in the left temporoparietal region. However, her condition rapidly deteriorated and she went into a coma approximately 20 h after admission. A second CT scan revealed significant ICH expansion and transfalcine herniation. Decompressive hemicraniectomy with duraplasty was performed, and ICVT was confirmed owing to abnormal vascular tone and black appearance of the cortical vein. She underwent anticoagulation therapy and rehabilitation, and gradually recovered.

Conclusion

We experienced an extremely rare case of isolated cortical vein thrombosis related with type II PS deficiency. CT-digital subtraction angiography is a useful supportive technique in the diagnosis of ICVT. Decompressive hemicraniectomy is effective for hemorrhage extension cases, and ICVT with hemorrhage might require early anticoagulation therapy.

Isolated cortical vein thrombosis: case series

OBJECT

Isolated cortical vein thrombosis (ICVT) accounts for less than 1% of all cerebral infarctions. ICVT may cause irreversible parenchymal damage, rendering early and accurate diagnosis critical. This case series and literature review presents the clinical and radiological findings in 7 patients with ICVT, and highlights risk factors and imaging modalities that may be most beneficial in rendering an accurate and timely diagnosis.

METHODS

Patients with CT and MRI findings consistent with ICVT examined between January 2011 and June 2014 were included in this retrospective review.

RESULTS

Seven patients (5 females, 2 males), ranging in age from 11 months to 34 years, met the inclusion criteria. The most common clinical presentations were headaches (n = 4) and seizures (n = 3). The most common comorbidities noted in these patients were hypercoagulable states (n = 4) and intracranial hypotension (n = 3). Five patients had intraparenchymal involvement. CT suggested the correct diagnosis in 4 patients, and MRI confirmed the diagnosis in all 7 patients. All patients who received anticoagulation therapy (n = 5) experienced complete resolution of their symptoms.

CONCLUSIONS

The majority of these patients were adult females, consistent with published data. Seizures and headaches were the most common presenting symptoms. Hypercoagulable state and intracranial hypotension, both known risk factors for thrombosis, were the most commonly noted ICVT risk factors. Intraparenchymal involvement was prevalent in nearly all ICVT cases and presented as vasogenic edema, early intraparenchymal hemorrhage, or hemorrhagic venous infarction. Susceptibility-weighted imaging was the most sensitive imaging technique in diagnosing ICVT.

Isolated Cortical Vein Thrombosis with Long Cord Sign

Isolated cortical vein thrombosis (ICVT) is a rare disease, accounting for less than 1% of strokes. A 46-year-old woman presented with progressive left side weakness. Magnetic resonance (MR) imaging with T2^*-gradient echo (T2^*-GE) sequence showed long cord sign at the right frontal cortex. The patient was treated with low molecular weight heparin, followed by oral warfarin for 6 months. The 3-month follow-up MR imaging showed recanalization of the previously thrombosed cortical vein. She was completely recovered without neurological deficits after 6 months. This provides that MR imaging with T2^*-GE sequence can help to diagnosis the ICVT and outcomes of the ICVT are generally favorable.

Isolated superficial sylvian vein thrombosis with long cord sign: case report and review of the literature

Isolated cortical vein thrombosis (ICVT) is extremely rare. Only single case or small series of ICVT have been reported; clinical details are still uncertain. We report a case of isolated superficial sylvian vein thrombosis with exceedingly long cord sign. A 14-year-old female with severe sudden onset headache visited our hospital. Fluid attenuated inversion recovery and echo-planar T2(*) susceptibility-weighted imaging (T2(*)SW) showed a long cord sign on the surface of the sylvian fissure. The patency of dural sinuses and deep cerebral veins were confirmed by magnetic resonance venography (MRV), and diagnosis of ICVT was made. She recovered completely without anticoagulant agents. To clarify the clinical characteristics of ICVT, we reviewed 51 ICVT cases in the literature. In many cases, T2(*)SW was the most useful examination to diagnose ICVT. In contrast with general cerebral venous thrombosis, MRV and conventional angiography were either supporting or useless. Anastomotic cortical veins were involved frequently; symptoms of gyri around the veins were common. It also suggested that ICVTs of the silent area might have been overlooked because of nonspecific symptoms, and more patients with ICVT may exist. In cases involving patients with nonspecific symptoms, the possibility of ICVT should be considered.

Diagnosis and treatment of cerebral venous thrombosis

Dural sinus or cerebral venous thrombosis (CVT) is a frequently unrecognized cause of stroke affecting predominantly young women. Typical clinical signs include headache, visual problems and seizures. Both computed tomography and magnetic resonance venous angiography are suitable for the detection of CVT, although magnetic resonance angiography is more sensitive to detect small cortical venous thrombosis. Evidence for efficacy of initial treatment with heparin in acute CVT comes from two randomized placebo-controlled studies that together included 79 patients. Although not evidence-based, postacute treatment with oral anticoagulation is recommended for up to 12 months after CVT. Long-term anticoagulation is recommended only in patients suffering from a severe coagulopathy or with recurrent CVT.

Isolated cortical vein thrombosis: a widely variable clinicoradiological spectrum

BACKGROUND/AIMS

The aim of this study is to highlight the variable clincoradiological spectrum of isolated cortical vein thrombosis (ICoVT), which seems to remain a challenge to clinicians.

CASES REPORTS

We reported 3 patients with this diagnosis. One presented with only an epileptic seizure, one with worsening headache, seizures, mental disorder, speech disturbance and right-sided weakness, and the other with seizures and fluctuating paralysis in her left-sided limbs. Brain images were manifested with a strand-like abnormal signal, a large hemorrhagic infarction and a continuously enlarged space-occupying massive edema, respectively.

CONCLUSIONS

Neurologic features and brain imaging of ICoVT are highly variable, which might be partly responsible for the underestimation of ICoVT. Clinical diagnosis should probably be evoked more often.

Atypical clinical and pathological findings in a patient with isolated cortical vein thrombosis

Isolated cortical vein thrombosis often produces a focal lesion. Because of the rapid development of collateral circulation, increased intracranial pressure has never been reported in a patient with isolated cortical vein thrombosis. The diagnosis of isolated cortical vein thrombosis is based mainly on MRI, catheter digital subtraction angiography, and histological findings, but may be challenging. We report a patient who presented with intermittent seizures and left-sided limb weakness. Her symptoms gradually progressed, and she eventually developed signs of increased intracranial pressure. Imaging studies showed a space-occupying lesion in the right frontal lobe of the brain. As we could not diagnose isolated cortical vein thrombosis based on the preoperative findings, surgical excision of the lesion was performed under general anesthesia. Histological examination showed destruction of the brain parenchyma with infiltration of macrophages, proliferation of reactive astrocytes and small vessels, and foci of hemorrhage. Further examination found that a number of small vessels in both the subarachnoid space and brain parenchyma were filled with thrombus, some of which was organized. Elastic fiber staining showed that the obstructed vessels were veins. We diagnosed isolated cortical vein thrombosis with atypical clinical features.

The clinico-radiological spectrum of isolated cortical vein thrombosis

Isolated cortical vein thrombosis (ICVT) in the absence of sinus or great venous involvement is rare. Various MRI sequences have been proposed for diagnostic accuracy, although follow-up data are limited. The optimal management strategy remains uncertain. Patients with ICVT treated between 2006 and 2008 were retrospectively studied. Diagnostic and follow-up neuroimaging were reviewed independently, and we evaluated their treatment and outcomes. Five patients (mean age 41 years; range, 25-54 years) were included. All presented with seizures. Focal neurological deficits were noted in one patient only. T2 susceptibility-weighted MRI abnormalities were observed in all patients. T2-weighted parenchymal hyperintensities involving the cortical-subcortical regions around the ICVT had completely resolved on follow-up scans. Clinical outcomes were uniformly good, despite variable treatment strategies. We observed significant, yet reversible, parenchymal T2-weighted MRI lesions in our patients with ICVT. Follow-up clinical and radiological studies demonstrate recovery independent of treatment regimes. T2-weighted MRI was found to be a useful diagnostic tool and might improve diagnostic accuracy in carefully selected patients with new-onset seizures.

Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND

The purpose of this statement is to provide an overview of cerebral venous sinus thrombosis and to provide recommendations for its diagnosis, management, and treatment. The intended audience is physicians and other healthcare providers who are responsible for the diagnosis and management of patients with cerebral venous sinus thrombosis.

METHODS AND RESULTS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represent different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 1966 and used the American Heart Association levels-of-evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee.

CONCLUSIONS

Evidence-based recommendations are provided for the diagnosis, management, and prevention of recurrence of cerebral venous thrombosis. Recommendations on the evaluation and management of cerebral venous thrombosis during pregnancy and in the pediatric population are provided. Considerations for the management of clinical complications (seizures, hydrocephalus, intracranial hypertension, and neurological deterioration) are also summarized. An algorithm for diagnosis and management of patients with cerebral venous sinus thrombosis is described.

Cortical Vein Thrombosis as a Mimic for Isolated Cortical Subarachnoid Hemorrhage and Transient Ischemic Attack

Isolated cortical subarachnoid hemorrhage is rare and poorly understood. Differential diagnoses and proposed pathophysiology vary widely and the diagnostic work-up for these patients who present with transient ischemic attack-like episodes and characteristic imaging findings is still unclear. We report a case of isolated subarachnoid hemorrhage and transient neurologic deficits due to isolated cortical vein thrombosis that was not detected by noninvasive tests. A 75-year-old woman with a history of a lobar intracerebral hemorrhage presented to the Academic Medical Center with sudden-onset transient left upper extremity weakness. Head CT showed a linear hyperdensity in the right precentral gyrus suggestive of isolated subarachnoid hemorrhage. MRI showed susceptibility in the corresponding area. CT angiogram and MRV showed no evidence of a venous thrombosis. The main outcome measures were results of computerized tomography and CT angiogram, magnetic resonance parenchymal and vascular imaging, angiography findings and clinical follow-up at 3 months. Cortical vein thrombosis was detected on conventional angiography. MRI was negative for microhemorrhages. The patient was anticoagulated and had no recurrences of her symptoms. We conclude that cortical vein thrombosis can present as isolated subarachnoid hemorrhage and transient ischemic attack-like episodes and may require angiography for definitive diagnosis.

Cortical vein thrombosis: the diagnostic value of different imaging modalities

INTRODUCTION

Cortical vein thrombosis (CVT) is a rare disorder, and its diagnosis is challenging. The aim of our study was to evaluate the value of different imaging modalities for the detection of CVT.

METHODS

Thirteen patients with CVT, either isolated (n = 3) or in combination with sinus thrombosis (n = 10), and 20 control patients without any venous pathologies were included in this study. The analysis was performed independently by three blinded readers who evaluated the following imaging modalities and sequences separately: non-enhanced computed tomography (NCCT); multi-detector row CT angiography (MDCTA); diffusion-weighted (DWI), T1-weighted (T1w), PD-weighted (PDw), T2*-weighted (T2*w), and fluid-attenuated inversion recovery-weighted (FLAIRw) magnetic resonance (MR) sequences; as well as venous MR angiography (vMRA). The sensitivity, specificity, positive (PPV) and negative predictive values, and interobserver agreement of the different modalities were calculated.

RESULTS

T2*w showed the highest sensitivity for the detection of CVT (97.4%), followed by T1w (70%). FLAIRw and vMRA had a sensitivity of 50% and 41.7%, respectively, whereas the sensitivity of NCCT, MDCTA, DWI, and PDw was below 30%. The specificity and PPV of all modalities was 100%, with good to perfect interobserver agreement.

CONCLUSION

T2*w was the superior MR imaging sequence for diagnosing CVT. Besides T2*w, only T1w reached a sensitivity of over 50% for CVT, followed by FLAIRw, and vMRA. On the contrary, our results suggest that NCCT but also MDCTA might not be suitable for diagnosing CVT.

MR imaging features of isolated cortical vein thrombosis: diagnosis and follow-up

BACKGROUND AND PURPOSE

To our knowledge, very few MR imaging data have been reported in isolated cortical venous thrombosis (ICoVT). The purpose of this study was to describe MR imaging features, including T2*gradient-echo (GE) sequence, in presumed ICoVT.

MATERIALS AND METHODS

MR imaging examinations were performed in 8 patients with ICoVT (MR venography was performed in all patients and digital substraction angiography in 4) at the time of diagnosis and during the follow-up at 15 days (4 patients) and at 3 (8 patients), 6 (6 patients), 12 (3 patients), and 18 months (1 patient). We assessed the presence of a magnetic susceptibility effect (MSE) on T2*GE imaging at each site of cerebral venous thrombosis and the presence or absence of a normal flow void and iso-, hypo-, or hyperintense signal intensity on T1, T2, diffusion-weighted imaging (DWI), and fluid-attenuated inversion recovery (FLAIR) images. Parenchymal signal-intensity changes were also assessed on the same sequences.

RESULTS

MSE was detected on T2*GE imaging at the site of a cortical vein in all subjects at the first MR imaging examination. The occluded vein appeared as hyperintense in 3 patients, iso- to slightly hyperintense in 1 on T1, hypointense in 6 on FLAIR images, and as signal-intensity loss on DWI in 3. At follow-up, persisting signal-intensity abnormalities on T2*GE imaging were detected at the venous sites in all patients, whereas signal-intensity changes on T1- and T2-weighted images were no longer present. Parenchymal hyperintensities on FLAIR and DWI (increased apparent diffusion coefficient [ADC]) were observed in close vicinity to the thrombosis in 6/8 patients. Petechial hemorrhages (n = 3) or hematoma (n = 2) was present on T2*GE imaging in 5/8 patients. During the follow-up, all cerebral tissue signal-intensity changes on T1, T2, and FLAIR images decreased both in volume and intensity. ADC values normalized within the tissue after 3 months in all patients.

CONCLUSIONS

On T2*GE imaging, MSE of hemoglobin products within the thrombus was observed both at the early and late phases of ICoVT and appears to be of high diagnostic value compared with the other signal intensity changes detected on standard MR imaging.

A series of patients with subpial hemorrhage: clinical manifestation, neuroradiological presentation and therapeutic implications

Subpial hemorrhage is a rare finding in patients with a variable spectrum of neurological symptoms and signs. Here we present a series of 10 patients with subpial hemorrhage, 53 to 80 years old, diagnosed and treated within the last 4 years at a single center. Patients were identified based on imaging criteria with either magnetic resonance imaging (MRI) or computed tomography (CT) showing blood along the cortical surface. Presenting symptoms were diverse, with seizures being the most frequent followed by headaches and focal neurological signs such as sensory or motor deficits. Of 7 patients undergoing lumbar puncture, none showed fresh blood or cerebrospinal fluid (CSF) xanthochromia. Neither digital subtraction angiography (DSA) nor MR venography (MRV) confirmed cerebral vein thrombosis as a possible etiologic factor for subpial hemorrhage. Patients for whom follow-up was available (n=8), showed complete recovery indicating an excellent prognosis. Overall, the etiology of subpial hemorrhage remains obscure. Treatment should be symptomatic with particular attention to antiepileptic medication.

Cerebral venous thrombosis: an update

Cerebral venous thrombosis (CVT) is a rare type of cerebrovascular disease that can occur at any age, including in neonates, and it accounts for 0.5% of all stroke. The widespread use of neuroimaging now allows for early diagnosis and has completely modified our knowledge on this disorder. CVT is more common than previously thought and it is recognised as a non-septic disorder with a wide spectrum of clinical presentations, numerous causes, and usually a favourable outcome with a low mortality rate. MRI with T1, T2, fluid-attenuated inversion recovery, and T2* sequences combined with magnetic resonance angiography are the best diagnostic methods. D-dimer concentrations are raised in most patients but normal D-dimers do not rule out CVT, particularly in patients who present with isolated headache. Heparin is the first-line treatment, but in a few cases more aggressive treatments, such as local intravenous thrombolysis, mechanical thrombectomy, and decompressive hemicraniectomy, may be required.