Isolated cortical vein thrombosis: case series

Cortical Brush Sign: A Novel Finding on Thin-slice 3T Susceptibility-weighted Imaging in Acute Cerebral Infarct and Cerebral Venous Thrombosis

We observed a new SWI finding, "cortical brush sign," that represents prominent venous structures in the cortex of patients with acute cerebral infarct with or without moyamoya disease and cerebral venous thrombosis. The cortical brush sign disappeared on follow-up SWI in all cases. Cortical brush sign may help to understand the pathophysiology of venous structures in the cortex at acute phase.

Imaging Outcomes of Emergency MRI in Patients with Suspected Cerebral Venous Sinus Thrombosis: A Retrospective Cohort Study

Cerebral venous sinus thrombosis (CVST) is a rare neurological emergency condition with non-specific symptoms. Imaging options to rule out CVST are computed tomography (CT) and magnetic resonance imaging (MRI). This study aimed to determine the imaging outcomes of emergency MRI as a first-line imaging method in patients with suspected CVST. In this retrospective cohort study, we analyzed emergency brain MRI referrals from a five-year period in a tertiary hospital for suspicion of CVST. We recorded patient characteristics, risk factors mentioned in the referrals, and imaging outcomes. Altogether 327 patients underwent emergency MRI on the grounds of suspected CVST. MRI showed evidence of CVST among five patients (1.5%). Imaging showed other clinically significant pathology in 15% of the patients and incidental findings in 5% of the patients. Despite clinical suspicion, the diagnostic yield of emergency MRI for CVST is low and similar to that previously reported for CT. MRI is an alternative imaging method devoid of ionizing radiation in patients with suspected CVST.

Case Report: Surgical thrombectomy in a patient with isolated cortical vein thrombosis previously misdiagnosed as brain tumor

Introduction

As a rare type of cerebral venous thrombosis, isolated cortical vein thrombosis (ICVT) is easily misdiagnosed as brain tumor, especially in the cases with prominent signs of parenchymal brain lesions. Despite controversy concerning the efficacy and safety, anticoagulant treatment dominates in current therapeutic strategies for ICVT. As yet, surgical thrombectomy in the treatment of ICVT has not been reported. We present hereafter a female with ICVT previously misdiagnosed as brain tumor who had successful surgical thrombectomy.

Case description

A 54-year-old female with progressive left-sided limb weakness suddenly developed focal tonic-clonic epileptic seizure. Physical examination indicated strength of 0/5 in the left limbs. Magnetic resonance imaging (MRI) showed an irregular juxtacortical lesion surrounded with massive edema in the frontoparietal cortex, which was initially diagnosed as glioma. However, it turned out to be ICVT of the central sulcus vein during craniotomy. Then, venotomy and thrombectomy were performed, with instant recanalization of the vein noticed during surgery. In retrospect, we identified the suspected ICVT of the central sulcus vein in preoperative magnetic resonance venotography (MRV) and contrast MRI images. Laboratory tests also revealed homocysteinemia and hypercoagulable states in the patient. Follow-up MRV obtained 3 months after discharge showed cortical vein recanalization. At the one-year follow-up, she exhibited subtle sequelae of weakness in the left lower limb with a modified Rankin scale score of 1.

Discussion

Physicians should be aware of ICVT in the differential diagnoses in patients with risk factors, classical symptoms, and parenchymal brain lesions in or near cortex. Surgical thrombectomy excels at realizing definite recanalization and avoiding systematic complications of anticoagulation. It might be a therapeutic alternative for ICVT, especially when craniotomy is performed for treating intracranial hypertension or a definite diagnosis is made during craniotomy.

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.

Sphenoparietal sinus and superficial middle cerebral vein thrombosis: A case report and review of literature

BACKGROUND

Cerebral venous sinus thrombosis is rare and might be overlooked by healthcare providers. It often occurs in the transverse sinuses, superior sagittal sinus, and the vein of Trolard. Sphenoparietal sinus (SPS) and/or superficial middle cerebral vein (SMCV) thrombosis is rare and only 12 cases reported in the literature.

CASE DESCRIPTION

We report a 47-year-old woman with iron deficiency anemia associated with myoma uteri who developed left SPS and SMCV thrombosis. She presented with sudden unconsciousness, right hemiplegia, and aphasia. Brain computed tomography showed subcortical hemorrhages in the left frontal and temporal lobes. Magnetic resonance imaging did not reveal the cause of the bleeding. Although antihypertensive treatment with nicardipine was initiated, she deteriorated into coma the next day and underwent emergency decompressive craniectomy. Thrombosis of the SMCV was identified during surgery. Re-examination of preoperative T2 star-weighted imaging revealed thrombosis of the SPS and SMCV.

CONCLUSION

All but one of the reviewed cases had the thrombosis develop on the left side, which may be attributed to anatomical and brain functional laterality. When an edematous change or cortical hemorrhage of unknown cause is encountered within the perisylvian region, especially on the left side, the possibility of SPS and SMCV thrombosis should be considered.

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.

Neurovascular disorders in children: an updated practical guide

Neurovascular disorders are an important cause of brain injury in the paediatric population, leading to substantial mortality and morbidity. These include ischaemic, haemorrhagic strokes, and cerebral venous sinus thromboses. Despite remarkable improvements in our understanding and management of strokes in general, and in the quality of immediate care and rehabilitation, the outcomes in childhood strokes lag far behind adult strokes. This is a multifaceted problem. There remain several challenges including delays in recognition due to vague clinical presentations, a failure to consider strokes in many cases, delays in obtaining imaging and inadequate imaging when performed, as well as limited evidence and availability for hyper acute intervention in children. Stroke in children is also a vastly different entity to adult strokes, with a unique set of risk factors and often with an underlying cause to be found. This review is by no means exhaustive, but instead aims to provide an overview of the epidemiology, sub-classification and aetiology of paediatric neurovascular disorders, mainly ischaemic, haemorrhagic strokes and cerebral venous sinus thrombosis. We also focus on the risk factors for each of these, the clinical presentation, recommended diagnostic protocol, pertinent imaging findings, as well as the current treatment and follow-up practices.

Isolated cortical vein thrombosis after nitrous oxide use in a young woman: a case report

Background

Nitrous oxide has become a popular inhalant as abused substance by young Chinese people in recent years. It has been mainly associated with medical conditions including megaloblastic anemia and myeloneuropathy.

Case presentation

We report a case of a 25-year-old high school graduate who had been abusing nitrous oxide for twenty months. She had a history of peripheral neuropathy and subacute combined degeneration in between. The young woman presented with headache, motor aphasia and right arm paralysis of eight hours after intermittently consuming nitrous oxide for one week. D-dimer was increased (1.1 mg/ml). Blood vitamin B12, folate, homocysteine and beta-HCG levels were normal. Head CT showed hemorrhagic infarction and subarachnoid hemorrhage. MR angiography and venography were normal. Head MRI identified left frontal isolated cortical vein thrombosis. Her muscle strength and verbal fluency significantly improved after initiation of Low Molecular Weight Heparin and serial head MRI showed continuous reduction in the size of thrombus.

Conclusions

For the first time nitrous oxide use is found to be related to isolated cortical vein thrombosis. Public education regarding the potential consequences of abusing nitrous oxide especially in high-risk individuals is urgently needed.

The characteristics of brain injury following cerebral venous infarction induced by surgical interruption of the cortical bridging vein in mice

Cerebral venous infarction (CVI) caused by the injury of cortical bridging veins (CBVs), is one of the most serious complications following neurosurgical craniotomy. Different from cerebral artery infarction, this CVI pathological process is more complicated, accompanied by acute venous hypertension, brain edema, cerebral ischemia and hemorrhage in the veins bridged brain area. Therefore, a reliable and stable small animal model is particularly important for the pathological study of CVI induced by surgical CBV interruption (CBVi). A mouse model established by cutting off the right CBVs from bregma to lambda with microsurgical technique is used for the assessment of the pathological process. Adult male mice underwent craniotomy after transection of the parietal skin under anesthesia. The right CBVs were exposed by removing the right skull along the right lateral edge of the sagittal sinus (forming a 4 mm × 3 mm bone window from bregma to lambda) with a drill under the operating microscope. Following the final inspection of the cerebral veins, the CBVs (30% one, 60% two, 10% none) were sacrificed using bipolar coagulation technique. Intracranial pressure (ICP) monitoring, motor function examination, brain edema assessment and brain histopathological observation after perfusion were performed at different time points (6 h, 12 h, 24 h, and 48 h) in the postoperative mice. Cerebral hemisphere swelling, midline shift and subcortical petechial hemorrhage were found on histological sections 6 h after CBVs dissection. The change of ICP was consistent with cerebral edema and peaked at 12 h after surgery, as well as the disruption of the blood-brain barrier assessed by Evans Blue staining. Tissue necrosis, nerve cell loss and monocytes infiltration were also dynamically increased in the postoperative hemispheric cortex. Behavioral tests showed obvious somato- and forelimb-motor dysfunction, and severe somatosensory disorder on the operative mice at 12 h, which were substantially recovered at 48 h. Our study provided a novel mouse model of CVI caused by surgical CBVi that was close to clinical practice, and preliminarily confirmed its pathological process. This model might become an important tool to study the clinical pathology and the molecular mechanism of nerve injury following CVI.

Endovascular Mechanical Thrombectomy and On-Site Chemical Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare cause of cerebral infarction. Once patients survive the acute phase, long-term prognosis is generally satisfactory. CVST patients who harbored risk factors known for poor prognosis (e.g., deterioration of consciousness/neurological functions and seizures) were oftentimes unresponsive to systemic heparin treatment. The advantage of combined endovascular mechanical thrombectomy (EMT) and on-site chemical thrombolysis (OCT) plus systemic heparin for CVST over the heparin treatment alone has not been proved. A retrospective study was conducted to analyze consecutive patients with CVST from 2005 to 2015. Patients having clinical improvement or stable disease after heparin treatment were in I/S group; patients having continuous deterioration of consciousness/neurological functions and refractory seizures (despite the use of multiple anti-epileptic drugs) after heparin treatment were in D group. EMT and OCT were indicated for patients in D group. Imaging studies and medical records were reviewed for statistical analysis. Safety issues included new-onset/progression of symptomatic intracerebral hemorrhages (ICH) or procedure-related complications. Total thirty patients were included (I/S group = 16; D group = 14). In D group, the mean time frame from the start of heparin treatment to the endovascular treatment was 3.2 days. Compared with I/S group, all patients in D group had complete stenosis of the sinuses, with higher initial mRS, lower initial GCS, and more seizures (p = 0.006, 0.007, and 0.031, respectively), but no significant differences in the mRS at discharge (p = 0.504). Shorter length of thrombosis and lower initial mRS were associated with better outcomes (p = 0.009 and 0.003, respectively). Thrombosis involving the superior sagittal sinus (SSS) was associated with bad outcomes (p = 0.026). There were two patients (6.7%) with worsening symptomatic ICH, one in each group, managed surgically. The overall mortality of the study was 6.7% (2/30). Combined EMT and OCT after heparin treatment for severe CVST were reasonably safe, which might be considered as a salvage treatment in severe CVST patients who are unresponsive to heparin with heavy clot burden involving SSS in the acute phase. However, further studies are needed to confirm its efficacy and validity.

Cortical vein thrombosis in adult patients of cerebral venous sinus thrombosis correlates with poor outcome and brain lesions: a retrospective study

BACKGROUND

Cortical vein thrombosis (CVT) receives little attention in adult patients with cerebral venous sinus thrombosis (CVST). This study aimed to investigate the clinical and radiological features of adult CVST patients with concomitant CVT.

METHODS

From May 2009 to May 2016, we recruited 44 adult CVST patients (diagnosed within 1 month of onset; 33.8 ± 14.0 years of age, 28 males). CVT was primarily confirmed using computed tomography venography and magnetic resonance imaging sequence of contrast enhanced three dimensions magnetization prepared rapid acquisition with gradient echo. Patients with concomitant CVT were divided into the CVT group; otherwise, the patients were placed into the non-CVT group. The clinico-radiological characteristics were compared between the two groups.

RESULTS

The CVT group included 27 patients (61.4%), and the non-CVT group included 17 patients (38.6%). Seizure (63.0% versus 11.8%), focal neurological deficits (44.4% versus 5.9%), and consciousness disorders (33.3% versus 0) occurred more frequently in the patients in the CVT group than in those of the non-CVT group (P < 0.05). The modified Rankin Scale (mRS) score at discharge was higher for the CVT group patients (median 2, range 1-4) than for the non-CVT group patients (median 0, range 0-4) (P < 0.001). Venous infarction (63.0% versus 11.8%), parenchymal hemorrhage (40.7% versus 5.9%), and subarachnoid hemorrhage (22.2% versus 0) were identified more frequently in the CVT group than in the non-CVT group (P < 0.05).

CONCLUSIONS

This study demonstrates that concomitant CVT is a common finding in adult patients with CVST and is associated with severe clinical manifestations, poor short-term outcomes, and brain lesions.

Stent retriever thrombectomy combined with local thrombolytic therapy for cerebral venous sinus thrombosis: A case report

The present study reports the effect of successful treatment of cerebral venous sinus thrombosis (CVST) with stent retriever thrombectomy combined with local thrombolytic therapy. Medical records of 29 patients were retrospectively analyzed following a diagnosis of CVST with magnetic resonance venography (MRV) or digital subtraction angiography (DSA). Systemic anticoagulation was the initial treatment in all patients following admission. In group A, stent retriever thrombectomy combined with local thrombolytic therapy was performed on 14 patients who met the criteria of endovascular therapy. Stent-assisted angioplasty was also performed when patients presented with venous sinus stenosis. A total of 15 patients in group B received systemic anticoagulant treatment. Subsequently, warfarin was administered orally for 3 to 12 months as a continuous anticoagulant therapy. International normalized ratio was monitored when patients were receiving anticoagulant therapy. Additionally, clinical presentation, decision to escalate therapy, recanalization, Glasgow Coma Scale, modified Rankin Scale (mRS) and the clinical outcome was assessed. A total of 14 patients (9 female patients, 5 male patients), with ages ranging from 17 to 57 years, met the criteria of endovascular therapy. The clinical symptoms of 12 patients had improved after receiving endovascular therapy and only 2 patients suffered from intracranial hemorrhage following the procedure. Complete recanalization of venous sinus was exhibited in 10/14 (71.4%) patients in group A when compared with 1/15 (6.7%) patients in group B. mRS were improved in the 12-month follow-up in groups A and B when compared with that at admission. In the present study, patients with acute CVST treated with stent retriever thrombectomy combined with local thrombolytic therapy had a favorable outcome. To conclude, the present study provides a treatment option in treating CVST, particularly for patients that present with evident cortical venous outflow stasis or deteriorate neurology, despite appropriate anticoagulant therapy.

Neonatal Vein of Labbé Infarction Size is Associated With Long-Term Language Outcomes

BACKGROUND

The vein of Labbé is a superficial cortical vein, which drains the lateral surface of the temporal lobe. Thrombosis of the vein of Labbé can occur in the neonatal period. The developmental outcomes of infants who had vein of Labbé thrombosis are unknown as few studies of outcomes exist.

METHODS

We completed a retrospective review of infants born ≥34 weeks of gestation, diagnosed with vein of Labbé thrombosis, and/or infarction on neuroimaging during the first 30 days of life. Size of each temporal lobe infarction was estimated based on the number of temporal lobe segments involved. Primary outcomes were the presence of major neurodevelopmental impairments in childhood and Bayley scores at two years.

RESULTS

Our cohort of 19 infants had a median gestational age of 38 weeks (interquartile range 36 to 39) and mean birth weight 2892 ± 920 grams. The most common presenting symptoms of vein of Labbé thrombosis and infarction of surrounding tissue were seizures, apnea, lethargy, and either hypertonia or hypotonia. At the latest clinical follow-up appointment documented in the electronic medical record (mean 4.4 ± 3.08 years), 44% had major neurodevelopmental impairment. Patients with large vein of Labbé infarctions had significantly worse average Bayley scores than those with small to moderate lesions, and differences in language composite were statistically significant (72.7 vs 107.8, P = 0.017).

CONCLUSIONS

Neonates with large vein of Labbé infarctions are more likely to have poor language outcomes. This finding suggests a need for targeted surveillance to ensure early identification of deficits and referral for intervention.

Pathways for Neuroimaging of Childhood Stroke

BACKGROUND

The purpose of this article is to aid practitioners in choosing appropriate neuroimaging for children who present with symptoms that could be caused by stroke.

METHODS

The Writing Group members participated in one or more pediatric stroke neuroimaging symposiums hosted by the Stroke Imaging Laboratory for Children housed at the Hospital for Sick Children in Toronto, Ontario, Canada. Through collaboration, literature review, and discussion among child neurologists with expertise diagnosing and treating childhood stroke and pediatric neuroradiologists and neuroradiologists with expertise in pediatric neurovascular disease, suggested imaging protocols are presented for children with suspected stroke syndromes including arterial ischemic stroke, cerebral sinovenous thrombosis, and hemorrhagic stroke.

RESULTS

This article presents information about the epidemiology and classification of childhood stroke with definitions based on the National Institutes of Health Common Data Elements. The role of imaging for the diagnosis of childhood stroke is examined in depth, with separate sections for arterial ischemic stroke, cerebral sinovenous thrombosis, and hemorrhagic stroke. Abbreviated neuroimaging protocols for rapid diagnosis are discussed. The Writing Group provides suggestions for optimal neuroimaging investigation of various stroke types in the acute setting and suggestions for follow-up neuroimaging. Advanced sequences such as diffusion tensor imaging, perfusion imaging, and vessel wall imaging are also discussed.

CONCLUSIONS

This article provides protocols for the imaging of children who present with suspected stroke.

Susceptibility-weighted Imaging in Neurovascular Disease

Susceptibility-weighted imaging (SWI) has become an important imaging sequence in the evaluation of patients with neurovascular disease. In this review, we provide a general overview of the physics of SWI and describe how image contrast is produced with this technique. We provide a general approach and differential diagnosis for 2 commonly encountered radiographic patterns seen with SWI in neurovascular disease. Finally, we discuss specific neurovascular applications of SWI, including its application in acute stroke, vascular malformations, venous thrombosis, and evaluation of cerebral microbleeds.