Cerebral sinovenous thrombosis. Neuroimaging diagnosis and clinical management.

Abstract

Cerebral sinovenous thrombosis (CSVT) is an uncommon disorder that affects the dural venous sinus and cerebral vein. In our study, thirty- four patients were examined. Pre and/or post contrast-enhanced CT was done in 28 patients. MRI studies were done in 24 patients. 2-D TOF MR venography (MRV) and contrast-enhanced MRV (CEMRV) were done in 19 cases. Digital subtraction angiography (DSA) was done in 18 patients. Sixteen patients received systemic intravenous heparinization, and 12 received endovascular thrombolytic treatment with urokinase combined with anticoagulant therapy. Neuroimages of CSVT can be acquired by direct visualization of the thrombus within the dural sinus or by parenchymal changes secondary to venous occlusion. As there are some pitfalls to MRI in the diagnosis of CSVT, the combination of MRI and MRV is now the gold standard in the diagnosis of CSVT. Usually, accuracy can be improved by applying 2-D TOF MRV and CE MRV. Furthermore, the source image of MRV is critical in differentiating between normal sinus variations and diseased ones. DSA is the best tool for demonstrating dynamic intracranial circulation in CSVT and mostly is used for endovascular treatment. Systemic intravenous anticoagulant therapy with heparin is accepted as a first line treatment. Except for clinical manifestations after systemic heparinization, abnormal MR findings of parenchymal change can be used to determine when to initiate thrombolytic treatment. Endovascular therapy can be finished at the antegrade flow within the dural sinus and continuous anticoagulation is sufficient to facilitate clinical improvement. Clinical suspicion and excellent neuroimaging are crucial in making the diagnosis of CSVT. Proper management with anticoagulants and/or endovascular thrombolytic therapy is mandatory in preventing propagation of the thrombosis and improving the clinical outcome.