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Laszlo Mechtler, MD 1/16/2012 Summary Normal anatomy Normal varients Incidental findings Laszlo Mechtler MD Venous disease Co-director of Neuroimaging 1. Deep venous thrombosis 2. Cortical venous thrombosis Dent Neurologic Institute 3. Jugular vein thrombosis 4. CCSVI Buffalo NY 5. Benign Intracranial Hypertension 6. Venous obstruction due to neoplasm 7. Vein of Galan Malformation (21).Gre Green – Superior sagittal sinus Yellow- Basal dural sinuses Blue- Transverse sinuses 1 1/16/2012 superior sagittal sinus frontopolar [1], anterior frontal [2], superior sagittal sinus and posterior frontal [3] veins inferior sagittal sinus straight sinus confluence of the sinuses transverse sinuses sigmoid sinuses internal jugular veins Trolard vein [superior anastomotic vein] [4]; and anterior parietal veins [5]) and the larger named veins on the lateral surface of the cerebrum (the superficial sylvian vein [superficial middle cerebral vein] [6], which typically drains into the sphenoparietal sinus or the cavernous sinus, and the Labbé vein [7 Lateral MIP image from contrast-enhanced MR venography shows the major components of the deep venous system: the thalamostriate vein (1), septal vein (2), internal cerebral vein (3), basal vein (Rosenthal vein) (4), and vein of Galen (5). 1), septal vein (2), internal cerebral vein (3), basal vein (Rosenthal vein) (4), and vein of Galen (5). 2 1/16/2012 vein of Trolard – large anastomotic cerebral vein that courses cephalad from the sylvian fissure to the superior sagittal sinus – more dominant on the nondominant side vein of Labbe – courses posterolaterally from the sylvian fissure to the transverse sinus – more prominent on the dominant side Axial MR image with color overlay shows the drainage territory of the deep cerebral veins (internal cerebral vein, vein of Galen) (pink), in which parenchymal abnormalities due to deep venous occlusion typically arePink- found. Vein of Galen via internal cerebral vein Blue-Medullary veins Leach J L et al. Radiographics 2006;26:S19-S41 3 1/16/2012 Occipital sinus Superior sagittal sinus angulation SSS torcula Transverse sinuses were found to be right (A), left (B), and codominant (C) in 59%, 25%, and 16% of the cases examined, respectively. 4 1/16/2012 To differentiate whether there is a hypoplastic transverse sinus or thrombosed sinus, you need to look at the source images……dx-thrombosis of the When you suspect, that there is a hypoplastic transverse sinus, left transverse sinus then you should look at the size of the jugular foramen. The superior sagittal sinus (straight arrow), straight sinus Sinus Pericranii (arrowhead ), and vein of Galen (curved arrow) are clearly depicted, and were seen in all 100 cases studied, without flow gaps. Anomalous communication between intracranial (IC) and extracranial venous circulation The right vein of Labbe (C, arrow) was seen in 91% of the cases. The right vein of Trolard (D, arrow), depicted as a large tributary to the superior sagittal sinus, was seen in only 37% of the Best diagnostic clue: Vascular scalp lesion cases communicating with underlying DVS 5 1/16/2012 Classic appearance of arachnoid granulations. pacchionian bodies Arachnoid Granulations • MR Findings • T1WI: Venous sinus defect isointense to CSF Pathology • T2WI • Hyperintense, homogeneous lesion, surrounded Mutations in chromosome 9p by normal flow void of major venous sinus Most common cerebral vascular malformation at autopsy • Single or multiple 15-20% occur with co-existing CM • T1WI C+: Focal nonenhancing venous sinus lesion Radially oriented dilated medullary veins surrounded by enhancing blood within sinus Venous radicals are separated by normal brain • MRV • Focal smooth filling defect within venous sinus on Clinical Issues source images or multi-planar reformations Usually asymptomatic • Venous flow is normal proximal & distal to lesion Stenosis or thrombosis of draining vein increases hemorrhage risk 6 1/16/2012 • MR Findings in DVA • T1WI • Can be normal if DVA is small • Variable signal depending on size, flow • "Flow void" appearance possible • Hemorrhage may occur if associated with CM or with draining vein thromboses • Best diagnostic clue: "Medusa head" (dilated medullary white matter • T2WI veins) draining into solitary major venous trunk • ±"Flow void" • Location • ± Blood products • FLAIR: Usually normal; may show hyperintense region if venous ischemia or hemorrhage • Periventricular white matter: Main venous trunk drains into deep present venous system • T2* GRE • Usually into the thalamostriate/ependymal vein in the lateral • Hypointensity may bloom if co-existing CM present with short T2 hemorrhagic products • Hypointense blooming may also occur from intravascular conversion of oxyhemoglobin to aspect of the lateral ventricle deoxyhemoglobin due to slow flow • Near frontal horn = most common site • DWI • Other: Adjacent to fourth ventricle • Usually normal • Subcortical white matter: Main venous trunk drains into the dural • Rare: Acute venous infarct seen as hyperintense area of restricted diffusion • T1WI C+ venous sinuses • Strong enhancement • Supratentorial: Usually into the superficial sagittal sinus • Stellate, tubular vessels converge on collector vein • Infratentorial: Usually into the transverse sinus • Collector vein drains into dural sinus/ependymal vein • MRA • Size: Varies (may be extensive) but usually < 2-3 cm • Arterial phase usually normal • Morphology • Contrast-enhanced MRA may demonstrate slow-flow DVA • Umbrella-like collection of enlarged medullary (white matter) veins • MRV: Delineates "Medusa head" and drainage pattern • Large "collector" vein drains into dural sinus or deep ependymal vein • MRS: Normal; deoxyhemoglobin or short T2 hemorrhagic products may result in peak broadening • Usually solitary • Can be multiple in blue rubber-bleb nevus syndrome 7 1/16/2012 Terminology Congenital cerebral vascular anomaly with angiogenically mature venous elements Imaging Findings Best diagnostic clue: "Medusa head" (dilated medullary white matter veins) draining into solitary major venous trunk Collector vein drains into dural sinus/ependymal vein Protocol advice: Include T2* sequence to look for hemorrhage, mixed CM Top Differential Diagnoses AVM, Cavernous Malformation, Capillary Telangiectasia Vascular Neoplasm Dural Sinus Occlusion (with Venous Stasis, Collateral Drainage) Sturge-Weber Syndrome DVA SUMMARY • Large area of brain parenchyma • Paucity of connecting or bridging veins • Single, dominant “transcortical vein” • Multiple smaller veins drain into the “head” • Probable increased venous pressure • Associated with Cavernous Malformations • Hemorrhage likely from the CCM 8 1/16/2012 • MR • Acute thrombus isointense on T1WI • Hypointense on T2WI (can mimic flow void) • T2* GRE best (clot usually blooms) Deep Cerebral Venous Thrombosis • MRV • 2D time of flight (TOF) MRV shows "missing" ICVs, variably absent signal in VOG, SS • May see abnormal collateral channels • Contrast-enhanced MRV (CE-MRV) • Faster; better depicts nonenhancing thrombus and small veins than TOF • TOF limitations • T1 hyperintense thrombus falsely appears as patent flow on MIP • Always evaluate source images and conventional MR sequences • Phase contrast MRV: T1 hyperintense thrombus not misrepresented as flow Venous infarcts - vein of Labbe 9 1/16/2012 Deep Cerebral Venous Thrombosis Deep Cerebral Venous Thrombosis • Best imaging tool • Best imaging tool • NECT/CECT ± CTV venogram • NECT/CECT ± CTV venogram • CT • CT • Hyperdense ICV ± bithalamic hypodensity • Hyperdense ICV ± bithalamic hypodensity • Variable loss of deep gray-white interfaces • Variable loss of deep gray-white interfaces • ± petechial hemorrhages • ± petechial hemorrhages • Protocol advice • Protocol advice • If CT/CECT/CTV scans negative → MR with MRV • If CT/CECT/CTV scans negative → MR with MRV • If MRV equivocal → DSA • If MRV equivocal → DSA • MR: Clot hypointense, "blooms" on T2 • MR: Clot hypointense, "blooms" on T2 abnormal high signal in the internal cerebral veins and straight sinus on the T1-weighted images. The diagnosis is bilateral infarctions in the basal ganglia due to deep cerebral venous thrombosis 10 1/16/2012 angiography demonstrated occlusion of all major sinuses. An IV catheter was advanced directly to the occluded sinuses, and 40 mg of tissue plasminogen activator was injected, which resulted in restoration On the left a lateral and oblique MIP image from a normal contrast- of the sinus flow enhanced MR venography. Notice the prominent vein of Trolard (red arrow) and vein of Labbe (blue arrow). MR Findings T1WI: Subacute to chronic phase: Tubular mass in the posterolateral CS with high signal on T1 images secondary to T1 shortening from the paramagnetic effect of methemoglobin T2WI Acute-subacute phase: May have a bizarre tumorous MRV: Absent signal in the region of appearance, especially in coronal plane; adjacent fat thrombosis; may have artifactual signal from appears infiltrated incorporation of high signal methemoglobin High signal from methemoglobin can be seen within thrombus on TOF MRV → underestimate Loss of normal flow void extent of thrombosis Edema in the retropharyngeal space T1WI C+: Filling defect in the IJV 11 1/16/2012 • MR Findings in CVT • T1WI • Thrombus is isointense early, hyperintense later • ± venous infarct • Gyral swelling, edema hypointense • Iso- to slightly hyperintense foci if hemorrhagic • T2WI • NECT • Thrombus hypointense acutely, hyperintense much later • Acute clot can mimic flow void • Venous infarct • "Cord" sign (hyperdense
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