Magnetic Resonance Venography Research Articles

The Role of Magnetic Resonance Venography in Headache Due to Suspected Cerebral Venous Sinus Thrombosis in the Presence of Normal T1 and T2 Dural Sinus Signal

The Role of Magnetic Resonance Venography in Headache Due to Suspected Cerebral Venous Sinus Thrombosis in the Presence of Normal T1 and T2 Dural Sinus Signal

Non-Contrast Enhanced Magnetic Resonance Venography Using the Fast Imaging Employing Steady-State Acquisition (FIESTA) Pulse Sequence in Preoperative Evaluation of Liver Donors: Can it Replace CT Venography?

Background: Liver transplantation has now become the preferred treatment for patients with liver failure. Pre-operative assessment of hepatic/portal vein anatomy of donors is necessary for which CT venography is most commonly used but it exposes the donors to huge radiation burden. To avoid this, non-contrast MR venography is the most preferred alternative for evaluation of veins. Objective: To determine diagnostic yield of magnetic resonance venography using Fast Imaging Employing Steady-State Acquisition (FIESTA) pulse sequence in comparison to computed tomography venography for the determination of portal/hepatic venous anatomy of potential liver donors. Methods: Retrospective study was conducted in which the venous phase CT scan and FIESTA (b-SSFP) sequence of 50 potential liver donors between 01-07-2021 and 30-11-2021 were reviewed. The hepatic and portal venous anatomy was reviewed. The assessment comprised the type of portal venous anatomy, the number of prominent tributaries from segment VIII and V of liver having diameter of 4mm or more emptying into the middle hepatic vein and the total number of accessory inferior right hepatic veins from segment VI and VII emptying into inferior vena cava (IVC). Results: With 100% sensitivity and specificity, the FIESTA sequence precisely identified the portal vein anatomy, total number of accessory inferior right hepatic veins, and the total number of 4 mm thick tributaries from segment V and VIII draining into middle hepatic vein Conclusion: We propose that magnetic resonance venography using FIESTA sequence can be used instead of CT venography to determine hepatic and portal vein anatomy of liver donors.

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

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). 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. 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. 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.

Application of Neuronavigation in Microvascular Decompression: Optimizing Craniotomy and 3D Reconstruction of Neurovascular Compression.

Microvascular decompression (MVD) is the best curative treatment for trigeminal neuralgia and hemifacial spasm. We used the neuronavigation to reconstruct the 3D image of cranial nerve and blood vessel to identify the neurovascular compression, and to reconstruct the venous sinus and skull to optimize craniotomy. A total of 11 trigeminal neuralgia and 12 hemifacial spasm cases were selected. All patients had preoperative MRI which included 3D Time of Flight (3D-TOF), Magnetic Resonance Venography (MRV) and computer tomography (CT) for navigation. Imaging sequences were fused and reconstructed by navigation system before operation. The 3D-TOF images were used to delineate cranial nerve and vessel. The CT and MRV images were used to mark transverse sinus and the sigmoid sinus for craniotomy. All patients underwent MVD and have the preoperative view compared with intraoperative findings. Approaching to the cerebellopontine angle right after opening the dura and got no cerebellar retracion or petrosal vein rupture during craniotomy. Ten of 11 trigeminal neuralgia and all 12 hemifacial spasm patients got excellent preoperative 3D reconstruction fusion images, which were also confirmed by intraoperative findings. All 11 trigeminal neuralgia patients and 10 of 12 hemifacial spasm patients were symptom free without any neurological complications just after the surgery. Other 2 hemifacial spasm patients got delayed resolution in 2 months after surgery. Through the neuronavigation guided craniotomy and the 3D neurovascular reconstruction, surgeons can better identify the compression of nerve and blood vessel, and reduce complications.

Serum Levels of Ferritin, Iron, and Total Iron Binding Capacity in Cerebral Venous Sinus Thrombosis

Background: Cerebral venous sinus thrombosis (CVST) is a potentially life-threatening condition with a wide range of clinical presentations, from localized headache (the most common symptom) to mental status disturbances, seizures, and coma. Objectives: The main purpose of this study was to evaluate serum levels of ferritin, iron, and total iron binding capacity (TIBC) and their possible relationship with different parameters in CVST patients. Methods: Thirty patients with a definitive diagnosis of CVST based on brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) results participated in the study. During the first 24 hours after admission, 5 cc of blood sample was collected from each patient and delivered to the laboratory to measure serum ferritin, iron, and TIBC levels. Results: Twenty-four women and six men (mean age: 42.6 ± 16.33 years) participated in the study. The mean levels of serum iron, TIBC, and ferritin were within normal ranges (99.40 ± 29.97 mg/dL, 324.50 ± 49.57 mg/dL, and 87.36 ± 88.84 ng/mL, respectively). There were no significant relationships between serum ferritin, iron, TIBC levels, oral contraceptive pills consumption, history of CVST or cerebrovascular accident (CVA), underlying diseases, and the involved sinus. Conclusions: The current study showed no possible benefits of using serum ferritin, iron, and TIBC indices in CVST patients.

Analysis of the efficacy of microdissection of paravebous sinus meningiomas invading large venous sinuses

ObjectiveThe management of paravebous sinus meningiomas that invade major venous sinuses is a subject of debate, particularly concerning the necessity of complete resection of the tumor and reconstruction of the venous sinus. This article aims to demonstrate the outcomes of total removal of the lesion (including the invading venous sinus portion) and the effects of restoring or not restoring venous circulation in terms of recurrence of the tumor, mortality, and post-operative complications.MethodsThe authors conducted a study involving 68 patients with paravebous sinus meningiomas. Of the 60 parasagittal meningiomas, 23 were located in the anterior third, 30 in the middle third, and 7 in the posterior third. Additionally, 3 lesions were located in the sinus confluence area, and 5 in the transverse sinus. All patients underwent surgery, and the degree of venous sinus involvement was classified into six types. For type I meningiomas, the outer layer of the sinus wall was stripped off. For types II to VI, two strategies were employed: non-constitutional, wherein the tumor and affected venous sinuses were removed without repair, and reconstructive, wherein the tumor was completely removed and the venous sinuses were sutured or repaired. Karnofsky Performance Status (KPS) scale and Magnetic Resonance Venography (MRV) were utilized to assess the outcomes of the surgical procedures.ResultsThe study group of 68 patients underwent complete tumor resection in 97.1%, with sinus reconstruction attempted in 84.4% of cases with sinus wall and sinus cavity invasion. The recurrence rate of this group was 5.9%, with follow-up ranging from 33 to 57 months. It was found that the recurrence rate was significantly higher in cases with incomplete resection than in those with complete resection. The overall mortality rate was 4.4%, with all cases resulting from malignant brain swelling due to the failure to perform venous reconstruction after resectioning of the meningioma type VI. Furthermore, 10.3% of patients experienced worsening symptoms of neurological deficits or complete loss of neurological function, with a significantly higher incidence in those without venous reconstruction than in the venous reconstruction group (P < 0.0001, Fisher test). No statistically significant pre-operative and post-operative KPS differences were observed in patients with type I to V. However, in patients with type VI (who did not receive venous reconstruction), the post-operative KPS score was significantly worse.ConclusionThe results of this study suggest the necessity of a complete resection of the tumor, including the invasive venous sinus component, as the recurrence rate was found to be relatively low at 5.9%. Moreover, patients who did not undergo venous reconstruction showed significant deterioration in their clinical condition compared to other subgroups, thus highlighting the importance of venous sinus reconstruction.

Abstract #1402477: Sixth-Nerve Palsy in Uncontrolled Type 1 Diabetes with Insulin Dependence

Diabetic retinopathy is the most common and well-known ophthalmologic complications in diabetic patients. However, oculomotor palsy is one of the most frequent neuro-ophthalmologic complications of diabetic patients. Specifically, sixth nerve palsy is the most common, however infrequently studied. Our patient is a 51-year-old female with a past medical history of insulin-dependent diabetes mellitus, hypertension, chronic sinusitis, and chronic pain syndrome that presented with complaints of worsening headache and diplopia. Patient was hemodynamically stable on admission. Upon examination of the eye, the patient's right eye did not cross the midline in lateral gaze and was found to have diplopia in primary and lateral gaze of left eye. She was found to have recurrent sixth nerve palsy upon further evaluation of her visual deficit. Labs showed creatinine of 0.61 mg/dl (0.66-1.25 mg/dL), sodium of 129 mmol/L (135-145 mmol/L), potassium of 4.4 mmol/L (3.5-5.1 mmol/L), an anion gap of 2 mmol/L (3-13 mmol/L), blood glucose in the 300-400 mg/dL range (70-100 mg/dL) with most recent blood glucose of 168 mg/dL. Her hemoglobin A1C is 13.0 (< 6%). Her complete blood count shows a white blood cell count of 6,000/uL (3,600-10,700/uL) and a hemoglobin of 14 g/dL (13.0-18.0 g/dL). Magnetic resonance venography of the head was negative for cerebral venous sinus thrombosis and magnetic resonance imaging of the brain was negative for acute abnormalities. She was treated with basal insulin of 30 units nightly and bolus insulin of 3 units three times a day before meals for type 1 diabetes with hyperglycemia with long-term insulin use. Visual deficit was treated by observation by ophthalmology with symptomatic help through eyeglass prisms. She was discharged after one night of hospital stay with recommendations to control her home basal insulin with a carbohydrate-controlled bolus dose during meals. She was recommended to follow-up with endocrinology outpatient to discuss use of insulin pump to better control her diabetes. Sixth-nerve palsy is a frequent but lesser-known neuro-ophthalmologic complication of poorly controlled diabetic patients. Studies have shown a higher incidence of diabetes in patients with sixth-nerve palsy, warranting a more focused medical evaluation along with close observation and tighter control of blood glucose levels and hemoglobin A1C.

Abstract #1412731: Sixth-Nerve Palsy in a Patient with Type 1 Diabetes

Oculomotor palsy is one of the most frequent neuro-ophthalmologic complications in patients with diabetes. Specifically, sixth nerve palsy is the most common. A 51-year-old female with a past medical history of type 1 diabetes on insulin and hypertension presented with complaints of worsening headache and diplopia. Physical exam was remarkable for recurrent sixth nerve palsy. Patient was hemodynamically stable. Labs showed blood glucose of 367 mg/dL (70-100 mg/dL), an anion gap of 2 mmol/L (3-13 mmol/L), creatinine of 0.61 mg/dl (0.66-1.25 mg/dL), sodium of 129 mmol/L (135-145 mmol/L), and potassium of 4.4 mmol/L (3.5-5.1 mmol/L). Her hemoglobin A1C was 13.0% Her complete blood count shows a white blood cell count of 6,000/uL (3,600-10,700/uL) and a hemoglobin of 14 g/dL (13.0-18.0 g/dL). Magnetic resonance venography of the head was negative for cerebral venous sinus thrombosis and magnetic resonance imaging of the brain was negative for acute abnormalities. Blood glucose readings improved during hospitalization after optimizing her insulin regimen. She was recommended to follow-up with outpatient endocrinology to discuss use of insulin pump to better control her diabetes. Sixth-nerve palsy is a frequent but lesser-known neuro-ophthalmologic complication of poorly controlled diabetic patients. Studies have shown a higher incidence of diabetes in patients with sixth-nerve palsy, warranting a more focused medical evaluation along with close observation and tighter control of blood glucose levels and hemoglobin A1C.

Clinical importance of imaging anatomical signs in predicting transverse sinus dominance using conventional magnetic resonance imaging

Background: Differentiating flow gaps associated with hypoplastic transverse sinus from venous thrombosis is a diagnostic challenge in brain magnetic resonance imaging with venography. Objectives: To assess the clinical benefit of anatomical signs to anticipate the side of the dominant transverse sinus. Patients and Methods: A total of 100 patients underwent brain magnetic resonance imaging with venography at the radiology department /medical city and were retrospectively reviewed for the direction of superior sagittal sinus flow void, inclination of sulcus for the superior sagittal sinus, angulation of the posterior falx and direction of occipital lobe bending in axial non-contrast T1 weighted image, then compare these findings with a side of the dominant transverse sinus in magnetic resonance venography. Results: Inclination of sulcus for superior sagittal sinus and superior sagittal sinus flow void direction toward the right side had high positive predictive values (95.5%) and (93.2 %) in proper matching with the right transverse sinus dominance, respectively. Right-sided angulation of the posterior flax and rightward direction of the occipital lobe had a positive predictive value of (90.9 %) in predicting transverse sinus dominance. Conclusion: The side of dominant transverse sinus can be anticipated by reviewing anatomical signs in T1 weighted image, which may help to differentiate hypoplastic transverse sinus from venous thrombosis that aid in better interpretation of brain MRI- MRV examinations.

Rivaroxaban for the treatment of cerebral venous thrombosis (P7-5.020)

<h3>Objective:</h3> This study aims to assess the effectiveness and bleeding risk of Rivaroxaban in comparison with Warfarin for the treatment of CVT. <h3>Background:</h3> New Oral Anticoagulants (NOACs) such as Rivaroxaban are introduced as alternatives to conventional vitamin-K antagonists in the long-term treatment of thrombotic events due to their lower bleeding risk. There is a lack of evidence on the effectiveness and safety of Rivaroxaban in Cerebral venous thrombosis (CVT). <h3>Design/Methods:</h3> 36 patients with a diagnosis of CVT were included. Clinical and background information was assessed on admission and patients were followed for at least 12 months. Measured outcomes were modified Rankin Scale (mRS), evidence of recanalization on contrast-enhanced Brain MR venography (MRV), and major or minor bleeding. Patients were divided into two groups according to the type of oral anticoagulant (Rivaroxaban vs Warfarin). Groups were compared in terms of final outcomes and side effects. <h3>Results:</h3> Overall, 13 (36.11%) patients received Warfarin and 23 (63.89%) received Rivaroxaban. Optimal mRS score (0–1) was attained in 9 of 10 (90%) of patients treated with Rivaroxaban and 19 of 22 (86.36%) of patients who received Warfarin. MRV showed complete or partial recanalization in 12 of 14 (85.71%) patients treated with Rivaroxaban and all patients in the Warfarin group. There was no significant difference between the two groups in terms of major and minor hemorrhage. <h3>Conclusions:</h3> Rivaroxaban holds promise for the treatment of CVT. <b>Disclosure:</b> Dr. Esmaeili has nothing to disclose. Dr. Mirzaasgari has nothing to disclose. Dr. Zabeti has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion. Dr. Zabeti has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech. Dr. Zabeti has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Alexion. Dr. Zabeti has received personal compensation in the range of $50,000-$99,999 for serving on a Speakers Bureau for Biogen. Dr. Zabeti has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Biogen. Dr. Zabeti has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Genentech. Dr. Zabeti has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Sanofi-Genzyme. Dr. Zabeti has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Horizon. Dr. Zabeti has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Janssen . Dr. Zabeti has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for BMS.

Rapid Development of High-Grade Dural Arteriovenous Fistula During Pregnancy: A Case Report (P14-5.010)

<h3>Objective:</h3> We present a case of minimally symptomatic, radiographically occult dural arteriovenous fistula (dAVF) evolving into intracerebral hemorrhage shortly after pregnancy. <h3>Background:</h3> dAVFs are generally acquired arteriovenous shunts thought to be caused by pathological neo-arterialization within an occluded vein. While a relatively common entity, rapid dAVF development has rarely been described in the setting of pregnancy. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 30-year-old nulliparous woman was referred to our outpatient clinic following subacute onset of left-predominant pulsatile tinnitus and mild bifrontal headache. Brain magnetic resonance imaging (MRI) revealed diffuse evidence of intracranial hypertension, which was supported by elevated opening pressure on lumbar puncture (LP). MR angiography and venography were within normal limits. She was diagnosed with idiopathic intracranial hypertension and started on acetazolamide with improvement in symptoms. At 6-month follow-up, she was seven weeks pregnant and reported mild worsening of tinnitus After discontinuation of acetazolamide. She remained clinically stable until three weeks after an uneventful spontaneous vaginal delivery when she presented with thunderclap headache, confusion, and aphasia. Head computed tomography (CT) was significant for a 4 mL acute frontotemporal intracerebral hemorrhage. CT angiography demonstrated a large vascular malformation of the left sphenoid wing. Cerebral angiogram confirmed a dAVF fed by the left inferolateral trunk, middle meningeal arteries, and arteries of the foramina spinosum, ovale, and rotundum, and draining into enlarged cortical veins. The fistula was successfully obliterated transarterially with a liquid embolic system. Three months following embolization, she has made complete neurological recovery with resolution of tinnitus. <h3>Conclusions:</h3> Radiographically occult dAVF can emerge and become symptomatic during pregnancy and the post-partum period. Potential mechanisms include systemic changes in hormone levels, shifting hemodynamics, and local phenomena of thrombosis, hypoxia, and secondary angiogenesis. Neurologists should consider this entity when evaluating women with new headache or focal symptoms in the peripartum setting. <b>Disclosure:</b> Dr. Sheibani has nothing to disclose. Dr. Voetsch has nothing to disclose. Prof. Orru has nothing to disclose. Dr. Lerner has received publishing royalties from a publication relating to health care. Dr. Culbertson has nothing to disclose.

Acute Cerebellar Stroke of Unclear Etiology Complicated by Lemierre’s Disease and Papillary Thyroid Carcinoma (P2-10.001)

<h3>Objective:</h3> NA <h3>Background:</h3> Lemierre’s Disease is a rare condition that is usually caused by bacterial oropharyngeal infection, most common organism being Fusobacterium necrophorum, that is complicated by thrombophlebitis of the internal jugular vein. Below, is a case in which our stroke patient was found to have Lemierre’s Disease after obtaining a Karius panel. <h3>Design/Methods:</h3> Chart review for case report presentation. <h3>Results:</h3> 53-year-old female with no known medical history presented with headache, nausea, vomiting, fever and chills for three days. Lumbar puncture obtained was suggestive of bacterial source with elevated WBCs, nucleated cells with neutrophilic predominance, though her meningitis/encephalitis PCR panel was negative. Broad spectrum antibiotics was started. MRI brain showed a large ischemic right cerebellar infarct with mass effect. CTA of the head and neck, CT venography and MR venography showed nonocclusive thrombi of right proximal internal jugular vein and sigmoid sinuses. Repeat scans showed increasing hydrocephalus requiring EVD placement with eventual removal after improvement of mental status and serial imaging. Karius panel was positive for Fusobacterium nucleatum and porphyromonas gingivalis, and patient’s antibiotics was narrowed to reflect results. CT maxillofacial and neck showed extensive cervical lymphadenopathy and multiple periapical lucencies in teeth. IR guided cervical lymph node biopsies confirmed papillary thyroid carcinoma. Dentistry removed patient’s affected teeth. <h3>Conclusions:</h3> Although our patient had a large ischemic infarct, the more concerning issue was her concurrent meningitis from a bacterial source that caused a hypercoagulable state. With the Karius panel’s result, we promptly localized the infection and adjusted the patient’s antimicrobial management accordingly. Her clinical presentation continued to improve with treatment, and she was discharged to acute rehabilitation. Given the Karius panel’s rapid turnaround, in comparison to other metagenomic sequencing of CSF, we conclude that it is imperative to consider utilizing Karius panel testing for meningitis evaluation, especially in the setting of unremarkable meningitis/encephalitis PCR panel. <b>Disclosure:</b> Dr. Ho has nothing to disclose. Dr. Long has nothing to disclose. Dr. Kronfeld has nothing to disclose.

Dural sinus narrowing in patients with spontaneous anterior skull base cerebrospinal fluid leak.

Current evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak. A retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test. Analysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In patient with sCSF leaks, there was a significantly higher proportion of patients with DVS narrowing compared with published literature examining this condition in the general population (80% vs. 40%, CI 0.59-0.93, p < .001). The prevalence of DVS narrowing in patients with sCSF leaks is substantial and likely greater than the general population. Moreover, there appears to be narrowing in most patients with sCSF leak. Preoperative radiological evaluation of the DVS using MR venography may be useful in patients with sCSF leaks as DVS stenosis may be an underdiagnosed etiology. Further study is needed to evaluate this. IV.

RETRACTED: Australian and New Zealand Society for Vascular Surgery clinical practice guidelines on venous outflow Obstruction of the femoral-iliocaval veins

BackgroundThe overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO) in Australia and New Zealand. MethodsA group of vascular surgeons from the Australian and New Zealand Society for Vascular Surgery with specific interest, training, and experience in the management of VOO were surveyed to assess current local practice. The results were analyzed and areas of disagreement identified. Following this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. Finally, a selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. ResultsThe document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with a CEAP (Clinical-Etiologic-Anatomic-Physiologic) score of ≥3 or a venous clinical severity score for pain of ≥2, or both, and evidence of >50% stenosis on venography, computed tomography venography, magnetic resonance venography, and/or intravascular ultrasound should be considered for venous stenting (level of recommendation Ib) Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion has been uncovered, should be considered for venous stenting (level of recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should be considered for venous stenting (level of recommendation Ic). Asymptomatic patients should not be offered venous stenting (level of recommendation IIIc). ConclusionsPatients with deep VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. The advent of simpler and safer treatment options has revolutionized its management, but, unfortunately, formal training for venous disease has not grown at the same rate. Simplifying the technology and training required can result in inconsistent outcomes. These guidelines are aimed at developing standards of care and will serve as an educational platform for future developments.

Preprocedural imaging modalities in patients undergoing iliocaval venous recanalization and stent placement.

To determine the diagnostic accuracy of preinterventional imaging modalities in patients being evaluated for iliocaval venous recanalization and stent placement. Consecutive patients with iliocaval postthrombotic obstructions or nonthrombotic iliac vein lesions (NIVL), who were scheduled for recanalization, underwent duplex ultrasound (DUS), magnetic resonance venography (MRV), multiplanar venography (MPV), and intravascular ultrasound (IVUS). The diagnostic accuracies of DUS, MRV, and MPV were analyzed using IVUS as reference. A total of 216 limbs in 108 patients (80 patients with postthrombotic obstructions, 28 patients with NIVL) were examined. In patients with postthrombotic obstructions, the diagnostic sensitivities for the detection of lesions of the common femoral vein were 81% (95% CI 71-89%) for DUS, 76% (95% CI 65-85%) for MRV, and 86% (95% CI 76-93%) for MPV. The sensitivities for detecting lesions of the iliac veins were 96% (95% CI 89-99%) for DUS, 99% (95% CI 92-100%) for MRV, and 100% (95% CI 94-100%) for MPV. Regarding the inferior vena cava, the sensitivities were 44% (95% CI 24-65%) for DUS, 52% (95% CI 31-73%) for MRV, and 70% (95% CI 47-86%) for MPV. The sensitivities for detecting NIVL were 58% (95% CI 34-79%) for DUS, 90% (95% CI 68-97%) for MRV, and 95% (95% CI 73-99%) for MPV. In patients scheduled for recanalization of iliocaval postthrombotic obstructions, the sensitivities of DUS, MRV, and MPV were similar. In patients with suspected inferior vena cava involvement and in patients with NIVL, additional imaging with MR or conventional venography is required.

Clinical Profile and in Hospital Outcome of Cerebral Venous Sinus Thrombosis at Tertiary Care Centre of Central India

Objectives: The objectives of the study are as follows: Clinical profile and in hospital outcome of cerebral venous sinus thrombosis (CVST) at tertiary care centre in central India. To study clinical presentation and outcomes of CVST. Material and Methods: A cross-sectional study was performed in a tertiary care centre from October 2020–October 2022. All patients suspected to have CVST based on clinical history and examination were evaluated but only those with confirmed diagnosis (based on neuroimaging) of CVST were taken for study. Results: Total of 62 patients were studied, most common age group was between 21 and 30 years. Among them males and females are 61.29 and 38.71, respectively. In our study, we found dehydration (62.90%) as the most common predisposing risk factor of CVST, followed by alcohol (48.38%). Headache (83.87%) is the most common symptom and followed by vomiting (59.68%) and convulsion (48.39%), least common was altered sensorium. The most common sinuses involved were superior sagittal sinus (67.74%) and superior sagittal plus sigmoid sinus (14.52%). Among 62 patients, 48 are discharged (77.42%). Death was reported in 14 (22.58%) cases. Conclusion: CVST is an important cause of intracranial hypertension, seizures and stroke in young people. Clinical presentation is extremely variable and a high index of suspicion is needed. Magnetic resonance imaging brain with magnetic resonance venography is the current diagnostic modality of choice.

Nutcracker Syndrome: Challenges in Diagnosis and Surgical Treatment

Nutcracker syndrome (NCS) is an uncommon syndrome that presents with signs and symptoms caused by compression of the left renal vein (LRV), whereas 'nutcracker phenomenon' is solely used to refer to the anatomical configuration without clinical symptoms. Treatment for NCS may include nonoperative management, open surgical intervention, and in some instances endovascular stenting. We present a single-center retrospective case series of patients who presented with NCS managed with open surgical interventions. A single-center, retrospective review of patients managed from 2010-2021. We diagnosed NCS via a thorough clinical examination and additional cross-sectional imaging studies including magnetic resonance venography and/or computed tomography venography. For further confirmation of the diagnosis, duplex ultrasound was frequently combined with contrast venography. Thirty eight patients were included in our study from 2010-2021. Twenty one (55.3%) patients presented with symptoms including flank pain, abdominal pain, hematuria, and fatigue. The remaining 17 (44.7%) patients had nutcracker phenomenon. Within the group of patients diagnosed with NCS, 11 patients underwent LRV transposition. Symptoms related to NCS improved in 10 patients. Hematuria in 1 patient did not improve. Transposition of the LRV is an effective treatment for NCS. Nonoperative management is an option for those patients experiencing less severe or nonspecific clinical symptoms.

VARIANT ANATOMY IN MR VENOGRAPHY OF BRAIN

Introduction:Identifying the variations in cerebral dural venous sinus anatomy on magnetic resonance (MR) venography is important for the adequate diagnosis of cerebral venous sinus thrombosis (CVST). There is limited documentation available on gender differences in cerebral dural venous sinus anatomical variants. Aims and Objectives:This study aimed to investigate gender-related variations as well as the typical variance of the cerebral venous system anatomy in asymptomatic individuals as shown by MR venography (3D). Material and Methods:This Hospital-based retrospective study was carried out over 24 months from December 2020 to November 2022 at the Department of Radiodiagnosis, Narayana medical college, Nellore. The study was done on 100 patients. All patients underwent 3D MR Venography on 3.0 Tesla (GE DISCOVERY 750W) MRI machine. Results: 1. Headache was the most prevalent clinical symptom for an MR venography (81%). 2. The most frequent anatomical variant was hypoplastic left transverse sinus (27%). 3. Males had a greater likelihood than females to have a hypoplastic left transverse sinus (12 versus 11). 4. Hypoplastic anterior one-third SSS was the most prevalent anatomical variant of the superior sagittal sinus (SSS). Conclusion:In the current research, the most frequent structural variant was found to be hypoplastic left transverse sinus, which was more prevalent in males than females. Other dural venous sinus structural differences did not show a significant difference between genders.

Hypercoagulability and Cavernous Sinus Thrombosis due to Protein C Deficiency. A Case Report

Background: Thrombophilia due to Protein C deficiency is a rare condition, present in 0.2% of general population. Cerebral venous thrombosis has an incidence of 3-4 cases per million in adults. A combination of both is very uncommon. Patients with these conditions are prone to life-threatening superinfections. Case: A 51-year-old woman presented with pressing frontal headache accompanied with left periorbital edema, fever, diplopia, and disorientation. Laboratory findings showed low protein C levels. Computed tomography demonstrated sphenoidal rhinosinusitis. Magnetic resonance venography revealed cavernous sinus thrombosis. The patient was started on empiric antibiotic treatment (vancomycin, ceftriaxone, and metronidazole) and anticoagulants. Conclusion: This case report emphasizes the importance of early diagnosis and appropriate management of patients with protein C deficiency complicated by septic cavernous sinus thrombosis. Background: Thrombophilia due to Protein C deficiency is a rare condition, present in 0.2% of general population. Cerebral venous thrombosis has an incidence of 3-4 cases per million in adults. A combination of both is very uncommon. Patients with these conditions are prone to life-threatening superinfections. Case: A 51-year-old woman presented with pressing frontal headache accompanied with left periorbital edema, fever, diplopia, and disorientation. Laboratory findings showed low protein C levels. Computed tomography demonstrated sphenoidal rhinosinusitis. Magnetic resonance venography revealed cavernous sinus thrombosis. The patient was started on empiric antibiotic treatment (vancomycin, ceftriaxone, and metronidazole) and anticoagulants. Conclusion: This case report emphasizes the importance of early diagnosis and appropriate management of patients with protein C deficiency complicated by septic cavernous sinus thrombosis.

Ultrasound and magnetic resonance of extrinsic stenosis and hypoplasia of internal jugular veins

Highlights. Ultrasound and MR venography of internal jugular veins in case of unilateral cerebellar hypoplasia or extrinsic stenosis enables noninvasively and without contrast agents differentiation of these conditions due to local and region-specific indicators, including the area and velocity of blood flow, arterial-venous balance, visualization of low blood flow, compression factor, and the overall clinical picture of venous network of the neck remodeling and the development of collateral circulation.Aim. To compare the visual and hemodynamic characteristics of ultrasound and magnetic resonance venography of extrinsic stenosis and hypoplasia of internal jugular veins (IJV).Methods. Ultrasound and magnetic resonance (MR) venography were performed in 47 patients with extrinsic stenosis and 23 patients with hypoplasia of one of internal jugular veins, and in the control group (30 patients).Results. In case of obvious vein compression and deformation and local stenosis (65% on average), there is a decrease in the vein cross-sectional area by 2 times compared with the contralateral vein, the blood flow velocity in the stenotic vein in acute cases increases (on average, up to 45 cm/s), and in chronic cases it significantly (p = 0.00001) decreases (to 13 cm/s on average). The criteria for hypoplasia are the small caliber of the vein (on average 0.22 cm², within the range of 0.13–0.46 cm²) throughout its entire length - with the cross-sectional area not exceeding that of the common carotid artery, and the vein being 4 times smaller than IJV on contralateral side, as well as a significant (p = 0.0006) velocity increase on the contralateral side (on average 40.9±12.52 cm/s) with normal velocity in the hypoplastic vein. Ultrasound assessment of the arterial-venous balance (AVB) makes it possible to evaluate the contribution of each IJV to the outflow of venous blood from the brain separately. From the hypoplastic side it was only 11.01±6.72%, and from the stenotic side it was 18.22±17 42% on average, which is significantly (p = 0.000001) below the norm, but does not allow us to differentiate these conditions. The total AVB for IJVs on both sides was within normal values (65–85%), and the absence of a pronounced expansion of the vertebral veins during MR venography confirms their insignificant role in the compensatory mechanisms of ensuring adequate outflow of venous blood from the brain in cases of unilateral hypoplasia and extrinsic stenosis of IJV.Conclusion. Ultrasound and MR venography of internal jugular veins in cases of unilateral hypoplasia or extrinsic stenosis enable noninvasively and without contrast agents differentiation of these conditions due to local and region-specific indicators, including the area and velocity of blood flow, arterial-venous balance, visualization of low blood flow, compression factor, and the overall clinical picture of venous network of the neck remodeling and the development of collateral circulation.