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Deep Cerebral Venous Thrombosis


KEY FACTS

Terminology

  • Thrombotic occlusion of deep cerebral veins

    • Usually affects both internal cerebral veins (ICVs) ± vein of Galen (VOG), straight sinus (SS)

    • May occur with more widespread dural sinus thrombosis

Imaging

  • NECT

    • Hyperdense ICV ± VOG, SS

    • Hypodense thalami/basal ganglia (BG), loss of gray matter-white matter (WM) interfaces

      • –

        Variable loss of deep gray-white interfaces; thalami seem to “disappear” into background WM hypodensity

    • ± petechial hemorrhages

  • CECT

    • Loss of ICV enhancement, presence of enlarged collateral channels

    • “Shaggy,” irregular veins (collateral channels) in deep WM, around tentorium

  • MR

    • Acute clots hypointense on T2WI, “bloom” on T2*

    • Deep (medullary) WM veins prominent, tortuous on SWI

  • Protocol advice

    • If CT/CECT/CTV scans negative → MR with MRV

    • If MRV equivocal → DSA

Top Differential Diagnoses

  • Other bithalamic/basal ganglia lesions

    • Neoplasm (e.g., bithalamic astrocytoma)

    • Nonvenous ischemia (e.g., artery of Percheron infarct)

    • Toxic/metabolic disorders (e.g., CO poisoning)

Clinical Issues

  • Venous thrombosis = 1-2% of strokes; ICV thrombosis = 10% of venous “strokes”

  • Can present with headaches and coma

Axial graphic depicts thrombosis of both internal cerebral veins (ICVs) and straight sinus (SS)
with 2° hemorrhage in choroid plexus and thalami
. Edema in the thalami, basal ganglia, and deep cerebral white matter (WM) are common findings. Linear WM medullary veins
may become engorged and enhance.

NECT in a 32-year-old woman with severe headache shows hyperdense ICVs
. Both thalami are edematous, symmetrically isodense
(normally hyperdense) compared to the surrounding WM.

Lateral DSA, venous phase, in the same patient shows normal opacification of the superior sagittal sinus
, transverse sinus
, and vein of Labbé
. The ICVs, vein of Galen, and SS are thrombosed and do not fill with contrast. Contrast with normal DSA with deep venous system filling is shown on right.

Normal DSA, lateral view, venous phase, shows opacification of the ICV
, vein of Galen
, and SS
.

TERMINOLOGY

Abbreviations

  • Deep cerebral venous thrombosis (DCVT)

  • Internal cerebral vein (ICV) thrombosis

Definitions

  • Thrombotic occlusion of deep cerebral veins

    • Usually affects both ICVs ± vein of Galen (VOG), straight sinus (SS)

    • Often with widespread dural sinus thrombosis (DST)

IMAGING

General Features

  • Best diagnostic clue

    • Hyperdense ICV ± VOG, SS ± bithalamic hypodensity

      • –

        Loss of deep gray-white matter interfaces

      • –

        Thalami seem to “disappear” into background WM hypodensity

  • Location

    • ICV ± VOG, SS, basal veins of Rosenthal

    • Bilateral ICV thrombosis > > unilateral

    • Edema (venous congestion)

      • –

        Deep gray nuclei, internal capsule, medullary white matter (WM)

      • –

        Variable involvement of midbrain, upper cerebellum

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