Sinusthrombose Sinus sagittalis superior

Ausgedehnte

Sinusthrombose in der nativen Computertomografie: Wie beim "dense artery sign" zeigt sich das Thrombusmaterial hyperdens. Betroffen sind sowohl der Sinus sagittalis superior, wie auch der Sinus rectus und die tiefen Hirnvenen.

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Spontaneous

cerebral venous thrombosis in a two-year-old infant with Cystathionine β-synthase deficiency. (B) Sagittal contrast-enhanced 3D-TFE T1-weighted image confirming this extensive thrombus (arrows).

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Spontaneous

cerebral venous thrombosis in a two-year-old infant with Cystathionine β-synthase deficiency. The high-density cortical vein thrombus (arrowhead) can be seen and reaches the still open superior sagittal sinus (arrows).

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Spontaneous

cerebral venous thrombosis in a two-year-old infant with Cystathionine β-synthase deficiency. Axial contrast-enhanced CT images made 12 hours after Fig. 1. The thrombus (arrowhead) in the cortical vein can be followed to the lateral part of the enhancing open superior sagittal sinus (arrows)

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Spontaneous

cerebral venous thrombosis in a two-year-old infant with Cystathionine β-synthase deficiency. (A) Axial contrast-enhanced 3D-TFE T1-weighted image showing the increased thrombus size with now occlusion of a long segment of the superior sagittal sinus (arrows) and multiple thrombosed cortical veins (arrowheads).

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Spontaneous

cerebral venous thrombosis in a two-year-old infant with Cystathionine β-synthase deficiency. (C) Curved reformatted contrast-enhanced 3D-TFE T1-weighted image of the superior sagittal sinus with similar findings.

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Spontaneous

cerebral venous thrombosis in a two-year-old infant with Cystathionine β-synthase deficiency. (D) MR venography showing absence of contrast opacification of the superior sagittal sinus and multiple cortical veins (arrows). Dilated deep cerebral and ophthalmic veins (arrowheads) secondary to the thrombus.

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Superior sagittal sinus thrombosis (SSST) is the most common type of dural venous sinus thrombosis and is potentially devastating.

This article focuses on the specific features related to the superior sagittal sinus thrombosis, please refer to the d ural venous sinus thrombosis article for a general discussion.

Risk factors include pregnancy, dehydration, hypercoagulable states, pancreatitis.

Clinical presentation

As with all cerebral venous thrombosis, the presentation is highly variable, ranging from completely asymptomatic to a rapid fulminant course with cerebral hemorrhage and death. Presentation includes:

headache: 53%, most common
seizures: 48%
hemi-, quadri-, or paraplegia: 48%
visual disturbances: 25%
nuchal rigidity: 18%

Radiographic features

Features are the same as those for other sinuses (please refer to dural venous sinus thrombosis).

CT

Unenhanced CT is usually the first imaging investigation performed given the nonspecific clinical presentation in this case. When not associated with venous hemorrhage or infarction, it can be a subtle finding on CT images, relying on hyperdensity of the sinus being identified. Potential findings include:

cord sign
dense vein sign
- a potential pitfall is interpreting the distal superior sagittal sinus as being hyperdense near the torcular herophili
- the walls at this location can be thick, measuring up to 2-3 mm
cerebral edema: secondary to venous hypertension
cortical/cerebral swelling
unilateral or bilateral venous hemorrhage

With contrast administration, especially with a CT venogram, a filling defect in the sinus is sought. Multiplanar reformatted CT venography has been reported with a sensitivity of 95% for this diagnosis. When in the superior sagittal sinus it is referred to as the empty delta sign. Signs of contrast CT include:

empty delta sign (is specific to the superior sagittal sinus)
gyral enhancement
prominent intramedullary veins

MRI

The clot acutely is isodense on T1 and hypointense on T2 (this can mimic a flow void), with subacute clot becoming hyperintense on T1. All the findings listed in the CT section are also seen on MRI. MRV will demonstrate lack of flow.