DOI: 10.1148/rg.26si065505
Cerebral Venous Thrombosis and Multidetector CT Angiography: Tips and Tricks1
Mathieu H. Rodallec, MD,
Alexandre Krainik, MD, PhD,
Antoine Feydy, MD, PhD,
Annick Hélias, MD,
Jean-Michel Colombani, MD,
Marie-Christine Jullès, MD,
Véronique Marteau, MD and
Marc Zins, MD
1 From the Department of Radiology, Fondation Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75674 Paris cedex 14, France (M.H.R., M.C.J., V.M., M.Z.); the Department of Neuroradiology/MRI Unit, Centre Hospitalier Universitaire de Grenoble, Grenoble, France (A.K.); the Department of Radiology B, Hôpital Cochin, Paris, France (A.F.); and the Department of Radiology, Hôpital Beaujon, Clichy, France (A.H., J.M.C.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received February 2, 2006; revision requested March 8 and received April 6; accepted April 21. All authors have no financial relationships to disclose.
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Figure 1a. Influence of the prescanning delay on sinus enhancement. (a) Axial contrast-enhanced CT image obtained with a prescanning delay of 25 seconds shows inadequate enhancement of the sigmoid sinuses and jugular foramina. (b) Axial contrast-enhanced CT image obtained with a prescanning delay of 45 seconds clearly shows a thrombus (arrow) in the right sigmoid sinus.
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Figure 1b. Influence of the prescanning delay on sinus enhancement. (a) Axial contrast-enhanced CT image obtained with a prescanning delay of 25 seconds shows inadequate enhancement of the sigmoid sinuses and jugular foramina. (b) Axial contrast-enhanced CT image obtained with a prescanning delay of 45 seconds clearly shows a thrombus (arrow) in the right sigmoid sinus.
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Figure 2a. Normal sinovenous anatomy. (a, b) Axial MIP CT image (a) and 3D volume-rendered image from CT venography (oblique anterosuperior view) (b) show the internal cerebral veins (ICV), basal veins of Rosenthal (BVR), vein of Galen (VOG), and straight sinus (StrS). On the volume-rendered image, note the asymmetric appearance of the torcular herophili (TH), which is formed by the union of the superior sagittal sinus (SSS), straight sinus, and transverse sinuses (TS). The volume-rendered image also shows the sigmoid sinus (SS) and superficial middle cerebral vein (SMCV). (c) Sagittal MIP CT image shows the inferior sagittal sinus (ISS), as well as the internal cerebral vein, superior sagittal sinus, straight sinus, and vein of Galen.
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Figure 2b. Normal sinovenous anatomy. (a, b) Axial MIP CT image (a) and 3D volume-rendered image from CT venography (oblique anterosuperior view) (b) show the internal cerebral veins (ICV), basal veins of Rosenthal (BVR), vein of Galen (VOG), and straight sinus (StrS). On the volume-rendered image, note the asymmetric appearance of the torcular herophili (TH), which is formed by the union of the superior sagittal sinus (SSS), straight sinus, and transverse sinuses (TS). The volume-rendered image also shows the sigmoid sinus (SS) and superficial middle cerebral vein (SMCV). (c) Sagittal MIP CT image shows the inferior sagittal sinus (ISS), as well as the internal cerebral vein, superior sagittal sinus, straight sinus, and vein of Galen.
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Figure 2c. Normal sinovenous anatomy. (a, b) Axial MIP CT image (a) and 3D volume-rendered image from CT venography (oblique anterosuperior view) (b) show the internal cerebral veins (ICV), basal veins of Rosenthal (BVR), vein of Galen (VOG), and straight sinus (StrS). On the volume-rendered image, note the asymmetric appearance of the torcular herophili (TH), which is formed by the union of the superior sagittal sinus (SSS), straight sinus, and transverse sinuses (TS). The volume-rendered image also shows the sigmoid sinus (SS) and superficial middle cerebral vein (SMCV). (c) Sagittal MIP CT image shows the inferior sagittal sinus (ISS), as well as the internal cerebral vein, superior sagittal sinus, straight sinus, and vein of Galen.
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Figure 3. Normal sinovenous anatomy. Three-dimensional integral image from CT venography (lateral view) shows the anastomotic vein of Trolard (AVOT) draining into the superior sagittal sinus (SSS), the anastomotic vein of Labbé (AVOL) draining into the transverse sinus (TS), and the superficial middle cerebral vein (SMCV).
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Figure 4. Normal sinovenous anatomy. Axial MIP CT image shows asymmetric transverse sinuses (TS). The sigmoid sinuses (SS) begin where the transverse sinuses leave the tentorial margin. The right cavernous sinus (CS) is also demonstrated.
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Figure 5. Arachnoid granulation of Pacchioni in the parasagittal region. Axial contrast-enhanced CT image shows the calvarial impression produced by a parasagittal arachnoid granulation.
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Figure 6a. Arachnoid granulations of Pacchioni in the venous sinuses. (a) Sagittal 2D MIP image from CT venography show arachnoid granulations (arrows) in the superior sagittal sinus and straight sinus. (b) Axial contrast-enhanced CT image shows a well-limited lobulated defect (arrow) in the right transverse sinus.
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Figure 6b. Arachnoid granulations of Pacchioni in the venous sinuses. (a) Sagittal 2D MIP image from CT venography show arachnoid granulations (arrows) in the superior sagittal sinus and straight sinus. (b) Axial contrast-enhanced CT image shows a well-limited lobulated defect (arrow) in the right transverse sinus.
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Figure 7a. Thrombosis of the superior sagittal sinus in a 20-year-old woman. (a, b) Axial unenhanced CT images obtained at different levels show subarachnoid hemorrhage with a "dense triangle" sign (arrowhead) and a cord sign (arrow), findings suggestive of sinus and cortical vein thrombosis. (c) Three-dimensional integral image from CT venography (posterosuperior view) shows filling defects in the superior sagittal sinus and parieto-occipital veins, an appearance indicative of thrombosis.
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Figure 7b. Thrombosis of the superior sagittal sinus in a 20-year-old woman. (a, b) Axial unenhanced CT images obtained at different levels show subarachnoid hemorrhage with a "dense triangle" sign (arrowhead) and a cord sign (arrow), findings suggestive of sinus and cortical vein thrombosis. (c) Three-dimensional integral image from CT venography (posterosuperior view) shows filling defects in the superior sagittal sinus and parieto-occipital veins, an appearance indicative of thrombosis.
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Figure 7c. Thrombosis of the superior sagittal sinus in a 20-year-old woman. (a, b) Axial unenhanced CT images obtained at different levels show subarachnoid hemorrhage with a "dense triangle" sign (arrowhead) and a cord sign (arrow), findings suggestive of sinus and cortical vein thrombosis. (c) Three-dimensional integral image from CT venography (posterosuperior view) shows filling defects in the superior sagittal sinus and parieto-occipital veins, an appearance indicative of thrombosis.
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Figure 8a. Thrombosis of the left transverse sinus in a 42-year-old woman. (a, b) Axial unenhanced CT images show left cerebellar and temporal hematoma with increased attenuation in the left transverse sinus (cord sign) (* in a). (c) On a 3D MIP image from CT venography, the left transverse sinus is not visible.
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Figure 8b. Thrombosis of the left transverse sinus in a 42-year-old woman. (a, b) Axial unenhanced CT images show left cerebellar and temporal hematoma with increased attenuation in the left transverse sinus (cord sign) (* in a). (c) On a 3D MIP image from CT venography, the left transverse sinus is not visible.
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Figure 8c. Thrombosis of the left transverse sinus in a 42-year-old woman. (a, b) Axial unenhanced CT images show left cerebellar and temporal hematoma with increased attenuation in the left transverse sinus (cord sign) (* in a). (c) On a 3D MIP image from CT venography, the left transverse sinus is not visible.
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Figure 9a. Deep cerebral venous thrombosis in a 41-year-old woman. (a) Axial unenhanced CT image shows an area of low attenuation in both thalami (*) associated with increased attenuation in the straight sinus (arrow) and internal cerebral veins (arrowheads). Note the hemorrhage in the left choroid plexus. (b) Axial contrast-enhanced CT image shows filling defects in the straight sinus (arrow) and internal cerebral veins (white arrowheads), an appearance consistent with thrombosis. Compare this appearance with the normally enhancing superior sagittal sinus (black arrowhead).
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Figure 9b. Deep cerebral venous thrombosis in a 41-year-old woman. (a) Axial unenhanced CT image shows an area of low attenuation in both thalami (*) associated with increased attenuation in the straight sinus (arrow) and internal cerebral veins (arrowheads). Note the hemorrhage in the left choroid plexus. (b) Axial contrast-enhanced CT image shows filling defects in the straight sinus (arrow) and internal cerebral veins (white arrowheads), an appearance consistent with thrombosis. Compare this appearance with the normally enhancing superior sagittal sinus (black arrowhead).
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Figure 10a. Thrombosis of the left transverse and sigmoid sinuses and temporo-occipital veins in a 45-year-old woman. (a, b) Axial unenhanced CT images show parieto-occipital subarachnoid hemorrhage (arrowhead in b) with superficial temporo-occipital areas of high attenuation (arrow in a), findings suggestive of thrombosed cortical veins (cord sign). (c) Axial contrast-enhanced CT image shows thrombosis of the left transverse and sigmoid sinuses (arrows). (d) Three-dimensional integral image from CT venography shows filling defects in the left transverse sinus and temporo-occipital veins, an appearance consistent with thrombosis.
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Figure 10b. Thrombosis of the left transverse and sigmoid sinuses and temporo-occipital veins in a 45-year-old woman. (a, b) Axial unenhanced CT images show parieto-occipital subarachnoid hemorrhage (arrowhead in b) with superficial temporo-occipital areas of high attenuation (arrow in a), findings suggestive of thrombosed cortical veins (cord sign). (c) Axial contrast-enhanced CT image shows thrombosis of the left transverse and sigmoid sinuses (arrows). (d) Three-dimensional integral image from CT venography shows filling defects in the left transverse sinus and temporo-occipital veins, an appearance consistent with thrombosis.
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Figure 10c. Thrombosis of the left transverse and sigmoid sinuses and temporo-occipital veins in a 45-year-old woman. (a, b) Axial unenhanced CT images show parieto-occipital subarachnoid hemorrhage (arrowhead in b) with superficial temporo-occipital areas of high attenuation (arrow in a), findings suggestive of thrombosed cortical veins (cord sign). (c) Axial contrast-enhanced CT image shows thrombosis of the left transverse and sigmoid sinuses (arrows). (d) Three-dimensional integral image from CT venography shows filling defects in the left transverse sinus and temporo-occipital veins, an appearance consistent with thrombosis.
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Figure 10d. Thrombosis of the left transverse and sigmoid sinuses and temporo-occipital veins in a 45-year-old woman. (a, b) Axial unenhanced CT images show parieto-occipital subarachnoid hemorrhage (arrowhead in b) with superficial temporo-occipital areas of high attenuation (arrow in a), findings suggestive of thrombosed cortical veins (cord sign). (c) Axial contrast-enhanced CT image shows thrombosis of the left transverse and sigmoid sinuses (arrows). (d) Three-dimensional integral image from CT venography shows filling defects in the left transverse sinus and temporo-occipital veins, an appearance consistent with thrombosis.
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Figure 11a. Chronic thrombosis of the left sigmoid sinus and jugular foramen in a 78-year-old woman with a history of breast carcinoma. (a) Axial unenhanced CT image shows low attenuation in the left sigmoid sinus (arrow) and jugular foramen (arrowhead). (b) Axial contrast-enhanced CT image shows thrombi in the left sigmoid sinus (arrow) and jugular foramen (arrowhead).
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Figure 11b. Chronic thrombosis of the left sigmoid sinus and jugular foramen in a 78-year-old woman with a history of breast carcinoma. (a) Axial unenhanced CT image shows low attenuation in the left sigmoid sinus (arrow) and jugular foramen (arrowhead). (b) Axial contrast-enhanced CT image shows thrombi in the left sigmoid sinus (arrow) and jugular foramen (arrowhead).
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Figure 12a. Effect of window settings on the detection of sinus and venous thrombosis. (a) Axial contrast-enhanced CT image obtained with wide window settings (width = 260 HU, level = 130 HU) shows thrombi in the superior sagittal sinus (arrowhead) and a cortical vein (arrow). (b) The thrombi are not visible on an axial contrast-enhanced CT image obtained with parenchymal window settings (width = 90 HU, level = 50 HU).
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Figure 12b. Effect of window settings on the detection of sinus and venous thrombosis. (a) Axial contrast-enhanced CT image obtained with wide window settings (width = 260 HU, level = 130 HU) shows thrombi in the superior sagittal sinus (arrowhead) and a cortical vein (arrow). (b) The thrombi are not visible on an axial contrast-enhanced CT image obtained with parenchymal window settings (width = 90 HU, level = 50 HU).
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Figure 13a. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 13b. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 13c. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 13d. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 13e. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 13f. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 13g. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 13h. Thrombosis of superficial cerebral veins in a 44-year-old man with Behçet disease. (a) Axial unenhanced CT image shows parietal subcortical hematoma with the cord sign (arrowhead) in a cortical vein (presumably the anastomotic vein of Trolard). (b, c) Axial (b) and coronal reformatted (c) unenhanced CT images show the cord sign in the right superficial middle cerebral vein (arrowhead) along the lateral fissure. (d–f) Axial (d, e) and coronal reformatted (f ) contrast-enhanced CT images show enlargement and vascular defects of the right superficial middle cerebral vein (arrowhead in f) and of a cortical vein (arrowhead in d) (presumably the anastomotic vein of Trolard), with extension of the thrombus to the superior sagittal sinus. (g, h) Posterosuperior (g) and lateral (h) 3D integral images from CT venography show thrombosis of the right superficial middle cerebral vein (short arrow) and of the anastomotic vein of Trolard (arrowhead) with extension to the superior sagittal sinus (long arrow in g) and swelling of the gyri.
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Figure 14a. Thrombosis of the superior sagittal sinus in a 31-year-old woman. (a) Coronal reformatted 2D MIP CT image shows the empty delta sign in the superior sagittal sinus with enlargement and a vascular defect of the adjacent cortical vein. Note the small collateral vein (arrow) under the enlarged thrombosed cortical vein. (b) Three-dimensional integral image from CT venography (superior view) shows thrombosis of the anterior part of the superior sagittal sinus with extension to the left frontoparietal cortical veins. (c) Three-dimensional volume-rendered image from CT venography with an inferior cut (same projection as in b) shows the collateral pathways along the superior sagittal sinus and under the enlarged thrombosed cortical vein (arrow).
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Figure 14b. Thrombosis of the superior sagittal sinus in a 31-year-old woman. (a) Coronal reformatted 2D MIP CT image shows the empty delta sign in the superior sagittal sinus with enlargement and a vascular defect of the adjacent cortical vein. Note the small collateral vein (arrow) under the enlarged thrombosed cortical vein. (b) Three-dimensional integral image from CT venography (superior view) shows thrombosis of the anterior part of the superior sagittal sinus with extension to the left frontoparietal cortical veins. (c) Three-dimensional volume-rendered image from CT venography with an inferior cut (same projection as in b) shows the collateral pathways along the superior sagittal sinus and under the enlarged thrombosed cortical vein (arrow).
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Figure 14c. Thrombosis of the superior sagittal sinus in a 31-year-old woman. (a) Coronal reformatted 2D MIP CT image shows the empty delta sign in the superior sagittal sinus with enlargement and a vascular defect of the adjacent cortical vein. Note the small collateral vein (arrow) under the enlarged thrombosed cortical vein. (b) Three-dimensional integral image from CT venography (superior view) shows thrombosis of the anterior part of the superior sagittal sinus with extension to the left frontoparietal cortical veins. (c) Three-dimensional volume-rendered image from CT venography with an inferior cut (same projection as in b) shows the collateral pathways along the superior sagittal sinus and under the enlarged thrombosed cortical vein (arrow).
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Copyright © 2006 by the Radiological Society of North America.
