Radiologische Hinweise auf zerebrale Venenthrombose

Die zerebrale Venenthrombose ist potenziell reversibel, sofern sie umgehend und in geeigneter Weise diagnostiziert und behandelt wird. Da die klinischen Manifestationen unspezifisch sind, kommt der bildgebenden Diagnostik dabei eine wichtige Rolle zu. Der Beitrag beschreibt deshalb die verschiedenen Subtypen der zerebralen Venenthrombose mit den für sie typischen bildgebenden Befunden sowie die Eignung der verschiedenen Bildgebungstechniken.

Abstract

Cerebral venous thrombosis (CVT) is uncommon, representing approximately 0,5 % of all cases of cerebrovascular disease worldwide. Many factors, alone or combined, can cause CVT. Although CVT can occur at any age, it most commonly affects neonates and young adults. CVT is difficult to diagnose clinically because patients can present with a wide spectrum of nonspecific manifestations, the most common of which are headache in 89 – 91 %, focal deficits in 52 – 68 %, and seizures in 39 – 44 % of patients. Consequently, imaging is fundamental to its diagnosis. MRI is the most sensitive and specific technique for diagnosis of CVT. The different MRI sequences, with and without the use of contrast material, have variable strengths. Contrast material-enhanced MR venography has the highest accuracy compared with sequences without contrast enhancement.

Kernaussagen

• Obwohl bei den meisten Patienten mit ZVT mehr als ein Risikofaktor vorliegt, sind bis zu 20 % der Fälle idiopathischer Natur. Deshalb schließt das Fehlen von Risikofaktoren die Diagnose nicht aus.

• Prinzipiell kann eine ZVT in jedem Alter auftreten, meist sind jedoch Neugeborene und junge Erwachsene betroffen.

• Klinisch ist eine ZVT schwierig zu diagnostizieren, da die Patienten mit einem breiten Spektrum unspezifischer Manifestationen vorstellig werden können (am häufigsten mit Kopfschmerzen, fokalen Defiziten und Konvulsionen).

• Das Empty-Delta-Zeichen besteht in der CT in einem dreieckig geformten Areal mit Kontrastmittelanreicherung rund um ein hypodenses Zentrum, das dem Thrombus entspricht. Dieses Zeichen findet sich zwar klassischerweise im Sinus sagittalis superior, ein ähnliches Zeichen kann sich jedoch auch in sagittalen und koronaren Aufnahmen des Sinus transversus darstellen.

• Bei der MRT handelt es sich um die sensitivste und zugleich spezifischste Technik für die Diagnose einer ZVT. Die kontrastverstärkte MR-Venografie verfügt gegenüber nativen Sequenzen über die höchste Genauigkeit.

• Im Bereich des Parenchyms sind die häufigsten Befunde ein vasogenes und ein zytotoxisches Ödem, gelegentlich gemeinsam, sowie eine intraparenchymale Blutung.

• In der nativen MRT stellt sich die tiefe ZVT typischerweise als bilaterales Thalamusödem dar, das bei annähernd 86 % der Patienten zu beobachten ist. Dieses Ödem kann sich bis zu den Basalganglien (in ⅓ der Fälle) und zur benachbarten tiefen weißen Substanz ausdehnen.

• Wenn ein Ödem oder eine kortikale bzw. subkortikale fokale Blutung entdeckt wird, ist es wichtig, die Dichte und/oder Signalintensität der benachbarten kortikalen Venen zu beurteilen, vor allem wenn diese Läsionen nicht der arteriellen Verteilung folgen.

Schlüsselwörter

Zerebrale Venenthrombose - Anatomie des zerebralen Venensystems - Bildgebung - Fallstricke

Keywords

Cerebral venous thrombosis - anatomy of the cerebral venous system - imaging techniques - pitfalls

Publication History

Article published online:
06 August 2020

• Literatur

• 1 Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005; 352: 1791-1798
• 2 Coutinho JM. Cerebral venous thrombosis. J Thromb Haemost 2015; 13 (Suppl. 01) S238-S244
• 3 Devasagayam S, Wyatt B, Leyden J. et al. Cerebral venous sinus thrombosis incidence is higher than previously thought: a retrospective population-based study. Stroke 2016; 47: 2180-2182
• 4 Gunes HN, Cokal BG, Guler SK. et al. Clinical associations, biological risk factors and outcomes of cerebral venous sinus thrombosis. J Int Med Res 2016; 44 : 1454-1461
• 5 Zuurbier SM, Middeldorp S, Stam J. et al. Sex differences in cerebral venous thrombosis: a systematic analysis of a shift over time. Int J Stroke 2016; 11: 164-170
• 6 Tsai FY, Wang AM, Matovich VB. et al. MR staging of acute dural sinus thrombosis: correlation with venous pressure measurements and implications for treatment and prognosis. AJNR Am J Neuroradiol 1995; 16: 1021-1029
• 7 Itrat A, Shoukat S, Kamal AK. Pathophysiology of cerebral venous thrombosis: an overview. J Pak Med Assoc 2006; 56: 506-508
• 8 Frerichs KU, Deckert M, Kempski O. et al. Cerebral sinus and venous thrombosis in rats induces long-term deficits in brain function and morphology: evidence for a cytotoxic genesis. J Cereb Blood Flow Metab 1994; 14: 289-300
• 9 Schaller B, Graf R, Sanada Y. et al. Hemodynamic changes after occlusion of the posterior superior sagittal sinus: an experimental PET study in cats. AJNR Am J Neuroradiol 2003; 24: 1876-1880
• 10 Rhoton Jr. AL. The cerebral veins. Neurosurgery 2002; 51: S159-S205
• 11 Ferro JM, Canhão P, Stam J. et al. ISCVT investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004; 35: 664-670
• 12 Sassi SB, Touati N, Baccouche H. et al. Cerebral venous thrombosis: a tunisian monocenter study on 160 patients. Clin Appl Thromb Hemost 2017; 23: 1005-1009
• 13 Saposnik G, Barinagarrementeria F, Brown Jr. RD. et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association / American Stroke Association. Stroke 2011; 42: 1158-1192
• 14 Wasay M, Bakshi R, Bobustuc G. et al. Cerebral venous thrombosis: analysis of a multicenter cohort from the United States. J Stroke Cerebrovasc Dis 2008; 17: 49-54
• 15 de Freitas GR, Bogousslavsky J. Risk factors of cerebral vein and sinus thrombosis. Front Neurol Neurosci 2008; 23: 23-54
• 16 Ferro JM, Bousser MG, Canhão P. et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis: endorsed by the European Academy of Neurology. Eur J Neurol 2017; 24: 1203-1213
• 17 Dmytriw AA, Song JSA, Yu E. et al. Cerebral venous thrombosis: state of the art diagnosis and management. Neuroradiology 2018; 60: 669-685
• 18 Poon CS, Chang JK, Swarnkar A. et al. Radiologic diagnosis of cerebral venous thrombosis: pictorial review. AJR Am J Roentgenol 2007; 189: S64-S75
• 19 Guenther G, Arauz A. Cerebral venous thrombosis: a diagnostic and treatment update. Neurologia 2011; 26: 488-498
• 20 Masuhr F, Busch M, Amberger N. et al. Risk and predictors of early epileptic seizures in acute cerebral venous and sinus thrombosis. Eur J Neurol 2006; 13: 852-856
• 21 Masuhr F, Mehraein S, Einhäupl K. Cerebral venous and sinus thrombosis. J Neurol 2004; 251: 11-23
• 22 Chiewvit P, Piyapittayanan S, Poungvarin N. Cerebral venous thrombosis: diagnosis dilemma. Neurol Int 2011; 3: e13
• 23 Absoud M, Hikmet F, Dey P. et al. Bilateral cavernous sinus thrombosis complicating sinusitis. J R Soc Med 2006; 99: 474-476
• 24 Razek AA, Castillo M. Imaging lesions of the cavernous sinus. AJNR Am J Neuroradiol 2009; 30: 444-452
• 25 Lee JH, Lee HK, Park JK. et al. Cavernous sinus syndrome: clinical features and differential diagnosis with MR imaging. AJR Am J Roentgenol 2003; 181: 583-590
• 26 Vijay RK. The cord sign. Radiology 2006; 240: 299-300
• 27 Virapongse C, Cazenave C, Quisling R. et al. The empty delta sign: frequency and significance in 76 cases of dural sinus thrombosis. Radiology 1987; 162: 779-785
• 28 Teasdale E. Cerebral venous thrombosis: making the most of imaging. J R Soc Med 2000; 93: 234-237
• 29 Walecki J, Mruk B, Nawrocka-Laskus E. et al. Neuroimaging of cerebral venous thrombosis (CVT): old dilemma and the new diagnostic methods. Pol J Radiol 2015; 80: 368-373
• 30 Lee EJ. The empty delta sign. Radiology 2002; 224: 788-789
• 31 Leach JL, Fortuna RB, Jones BV. et al. Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. RadioGraphics 2006; 26 (Suppl. 01) S19-S41 discussion S42–S43
• 32 Bianchi D, Maeder P, Bogousslavsky J. et al. Diagnosis of cerebral venous thrombosis with routine magnetic resonance: an update. Eur Neurol 1998; 40: 179-190
• 33 Macchi PJ, Grossman RI, Gomori JM. et al. High field MR imaging of cerebral venous thrombosis. J Comput Assist Tomogr 1986; 10: 10-15
• 34 Bousser MG, Ferro JM. Cerebral venous thrombosis: an update. Lancet Neurol 2007; 6: 162-170
• 35 Idbaih A, Boukobza M, Crassard I. et al. MRI of clot in cerebral venous thrombosis: high diagnostic value of susceptibility-weighted images. Stroke 2006; 37: 991-995
• 36 Favrole P, Guichard JP, Crassard I. et al. Diffusion-weighted imaging of intravascular clots in cerebral venous thrombosis. Stroke 2004; 35: 99-103
• 37 Lövblad KO, Bassetti C, Schneider J. et al. Diffusion-weighted MR in cerebral venous thrombosis. Cerebrovasc Dis 2001; 11: 169-176
• 38 Chu K, Kang DW, Yoon BW. et al. Diffusion-weighted magnetic resonance in cerebral venous thrombosis. Arch Neurol 2001; 58: 1569-1576
• 39 Farb RI, Scott JN, Willinsky RA. et al. Intracranial venous system: gadolinium-enhanced three-dimensional MR venography with auto-triggered elliptic centric-ordered sequence – initial experience. Radiology 2003; 226: 203-209
• 40 Liauw L, van Buchem MA, Spilt A. et al. MR angiography of the intracranial venous system. Radiology 2000; 214: 678-682
• 41 Ayanzen RH, Bird CR, Keller PJ. et al. Cerebral MR venography: normal anatomy and potential diagnostic pitfalls. AJNR Am J Neuroradiol 2000; 21: 74-78
• 42 Liang L, Korogi Y, Sugahara T. et al. Evaluation of the intracranial dural sinuses with a 3D contrast-enhanced MP-RAGE sequence: prospective comparison with 2D-TOF MR venography and digital subtraction angiography. AJNR Am J Neuroradiol 2001; 22: 481-492
• 43 Lettau M, Laible M, Barrows RJ. et al. 3-T contrast-enhanced MR angiography with parallel imaging in cerebral venous and sinus thrombosis. J Neuroradiol 2011; 38: 275-282
• 44 Ozsvath RR, Casey SO, Lustrin ES. et al. Cerebral venography: comparison of CT and MR projection venography. AJR Am J Roentgenol 1997; 169: 1699-1707
• 45 Meckel S, Reisinger C, Bremerich J. et al. Cerebral venous thrombosis: diagnostic accuracy of combined, dynamic and static, contrast-enhanced 4D MR venography. AJNR Am J Neuroradiol 2010; 31: 527-535
• 46 Khandelwal N, Agarwal A, Kochhar R. et al. Comparison of CT venography with MR venography in cerebral sinovenous thrombosis. AJR Am J Roentgenol 2006; 187: 1637-1643
• 47 Putaala J, Hiltunen S, Salonen O. et al. Recanalization and its correlation to outcome after cerebral venous thrombosis. J Neurol Sci 2010; 292: 11-15
• 48 Stolz E, Trittmacher S, Rahimi A. et al. Influence of recanalization on outcome in dural sinus thrombosis: a prospective study. Stroke 2004; 35: 544-547
• 49 Sadigh G, Mullins ME, Saindane AM. Diagnostic performance of MRI sequences for evaluation of dural venous sinus thrombosis. AJR Am J Roentgenol 2016; 206: 1298-1306
• 50 Renowden S. Cerebral venous sinus thrombosis. Eur Radiol 2004; 14: 215-226
• 51 Meder JF, Chiras J, Roland J. et al. Venous territories of the brain. J Neuroradiol 1994; 21: 118-133
• 52 Zubkov AY, McBane RD, Brown RD. et al. Brain lesions in cerebral venous sinus thrombosis. Stroke 2009; 40: 1509-1511
• 53 Bergui M, Bradac GB, Daniele D. Brain lesions due to cerebral venous thrombosis do not correlate with sinus involvement. Neuroradiology 1999; 41: 419-424
• 54 Forbes KPN, Pipe JG, Heiserman JE. Evidence for cytotoxic edema in the pathogenesis of cerebral venous infarction. AJNR Am J Neuroradiol 2001; 22: 450-455
• 55 Röttger C, Trittmacher S, Gerriets T. et al. Reversible MR imaging abnormalities following cerebral venous thrombosis. AJNR Am J Neuroradiol 2005; 26: 607-613
• 56 Manzione J, Newman GC, Shapiro A. et al. Diffusion- and perfusion-weighted MR imaging of dural sinus thrombosis. AJNR Am J Neuroradiol 2000; 21: 68-73
• 57 Sarma D, Farb RI, Mikulis DJ. et al. Reversal of restricted diffusion in cerebral venous thrombosis: case report. Neuroradiology 2004; 46: 118-121
• 58 Keiper MD, Ng SE, Atlas SW. et al. Subcortical hemorrhage: marker for radiographically occult cerebral vein thrombosis on CT. J Comput Assist Tomogr 1995; 19: 527-531
• 59 Provenzale JM, Kranz PG. Dural sinus thrombosis: sources of error in image interpretation. AJR Am J Roentgenol 2011; 196: 23-31
• 60 Alper F, Kantarci M, Dane S. et al. Importance of anatomical asymmetries of transverse sinuses: an MR venographic study. Cerebrovasc Dis 2004; 18: 236-239
• 61 Liang L, Korogi Y, Sugahara T. et al. Normal structures in the intracranial dural sinuses: delineation with 3D contrast-enhanced magnetization prepared rapid acquisition gradient-echo imaging sequence. AJNR Am J Neuroradiol 2002; 23: 1739-1746
• 62 Leach JL, Jones BV, Tomsick TA. et al. Normal appearance of arachnoid granulations on contrast-enhanced CT and MR of the brain: differentiation from dural sinus disease. AJNR Am J Neuroradiol 1996; 17: 1523-1532
• 63 Singh M, Nagashima M, Inoue Y. Anatomical variations of occipital bone impressions for dural venous sinuses around the torcular herophili: with special reference to the consideration of clinical significance. Surg Radiol Anat 2004; 26: 480-487
• 64 van den Bergh WM, van der Schaaf I, van Gijn J. The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis. Neurology 2005; 65: 192-196
• 65 Terazzi E, Mittino D, Rudà R. et al. Cerebral venous thrombosis: a retrospective multicentre study of 48 patients. Neurol Sci 2005; 25: 311-315
• 66 Luo Y, Tian X, Wang X. Diagnosis and treatment of cerebral venous thrombosis: a review. Front Aging Neurosci 2018; 10: 2
• 67 Crombé D, Haven F, Gille M. Isolated deep cerebral venous thrombosis diagnosed on CT and MR imaging: a case study and literature review. JBR-BTR 2003; 86: 257-261
• 68 Herrmann KA, Sporer B, Yousry TA. Thrombosis of the internal cerebral vein associated with transient unilateral thalamic edema: a case report and review of the literature. AJNR Am J Neuroradiol 2004; 25: 1351-1355
• 69 Sidek S, Rahmat K, Ramli N. Imaging findings of an isolated deep cerebral venous thrombosis in the absence of superficial sinus thrombosis. Neurol Asia 2015; 20: 191-195
• 70 Taoka T, Fukusumi A, Miyasaka T. et al. Structure of the medullary veins of the cerebral hemisphere and related disorders. RadioGraphics 2017; 37: 281-297
• 71 Arrigoni F, Parazzini C, Righini A. et al. Deep medullary vein involvement in neonates with brain damage: an MR imaging study. AJNR Am J Neuroradiol 2011; 32: 2030-2036
• 72 Menon G, Nair S, Sudhir J. et al. Bilateral thalamic lesions. Br J Neurosurg 2010; 24: 566-571
• 73 Smith AB, Smirniotopoulos JG, Rushing EJ. et al. Bilateral thalamic lesions. AJR Am J Roentgenol 2009; 192: W53-W62
• 74 McKinney AM, Jagadeesan BD, Truwit CL. Central-variant posterior reversible encephalopathy syndrome: brainstem or basal ganglia involvement lacking cortical or subcortical cerebral edema. AJR Am J Roentgenol 2013; 201: 631-638
• 75 Boukobza M, Crassard I, Bousser MG. et al. MR imaging features of isolated cortical vein thrombosis: diagnosis and follow-up. AJNR Am J Neuroradiol 2009; 30: 344-348
• 76 Sagduyu A, Sirin H, Mulayim S. et al. Cerebral cortical and deep venous thrombosis without sinus thrombosis: clinical MRI correlates. Acta Neurol Scand 2006; 114: 254-260
• 77 Krasnokutsky MV. Cerebral venous thrombosis: a potential mimic of primary traumatic brain injury in infants. AJR Am J Roentgenol 2011; 197: W503-W507
• 78 Yu Y, Ren M, Yao S. et al. Pathological confirmation of 4 cases with isolated cortical vein thrombosis previously misdiagnosed as brain tumor. Oncol Lett 2016; 11: 649-653
• 79 Coutinho JM, Ferro JM, Canhão P. et al. Unfractionated or low-molecular weight heparin for the treatment of cerebral venous thrombosis. Stroke 2010; 41: 2575-2580
• 80 Borhani Haghighi A, Edgell RC, Cruz-Flores S. et al. Mortality of cerebral venous-sinus thrombosis in a large national sample. Stroke 2012; 43: 262-264
• 81 Nasr DM, Brinjikji W, Cloft HJ. et al. Mortality in cerebral venous thrombosis: results from the national inpatient sample database. Cerebrovasc Dis 2013; 35: 40-44
• 82 Dentali F, Gianni M, Crowther MA. et al. Natural history of cerebral vein thrombosis: a systematic review. Blood 2006; 108: 1129-1134
• 83 Baumgartner RW, Studer A, Arnold M. et al. Recanalisation of cerebral venous thrombosis. J Neurol Neurosurg Psychiatry 2003; 74: 459-461