脑静脉窦血栓形成的影像学表现及脑实质病变预测

目的总结脑静脉窦血栓形成(CVST)患者的临床和MRI表现特征并探讨继发脑实质病变的预测因素。方法回顾57例CVST患者的临床及头颅MRI资料,分析患者MRI表现特征,并对临床及影像学指标进行对比分析。结果57例患者中男22例,女35例,年龄15~72岁(平均35岁)。临床症状头痛29例,癫痫发作11例,感觉变化8例,局灶性神经功能缺损9例;头颅MRI示静脉窦血栓形成部位上矢状窦9例,横窦2例,乙状窦1例,直窦1例,其中同时累及2个或2个以上静脉窦44例。静脉窦血栓伴发脑实质病变36例,其中出血性静脉梗死20例,非出血性静脉梗死12例,脑实质内出血4例。对伴和不伴脑实质病变2组患者的对比分析显示,伴脑实质病变组女性比例明显高于不伴脑实质病变组;伴脑实质病变组癫痫、感觉异常及局部神经功能缺损症状发生率均明显高于不伴脑实质病变组;伴脑实质病变组直窦血栓的发生率明显高于不伴脑实质病变组(P<0.05)。结论MRI可清楚显示CVST的直接及间接征象,通过分析CVST患者的临床和静脉窦血栓表现特征还可帮助预测严重的脑实质病变发生风险。     

脑静脉窦血栓形成的诊断与血管内治疗

目的 探讨脑静脉窦血栓形成的诊断和血管内溶栓治疗。方法 对8例以顽固性头痛、呕吐伴或不伴局灶性神经功能缺损或癫发作为主要表现的患者，采用颅脑MRI和脑血管造影检查确定诊断，并施行经颈内动脉、静脉窦内接触性溶栓或静脉窦内支架成形术协同抗凝治疗。结果 MRI显示相应脑静脉窦区出现长T2WI，短T1WI信号，DSA显示脑静脉窦闭塞、静脉侧支循环建立和脑动静脉循环时间延长。治疗后静脉窦完全或部分再通，脑循环时间接近正常，临床病情显著缓解。结论 血管内介入治疗可能是脑静脉窦血栓形成最有效的治疗方法之一，有待大样本研究证实。     

MRI和MRV在脑静脉和静脉窦血栓诊断中的价值

目的探讨MRI和MRV对脑静脉和静脉窦血栓(CVST)形成的诊断价值。方法回顾性分析16例CVST患者的临床和影像学资料。结果受累的脑静脉和静脉窦有上矢状窦9例,横窦5例,直窦3例,乙状窦2例,大脑大静脉合并大脑内静脉2例。常规MRI可见受累静脉窦流空信号消失,静脉窦内信号高低不一,11例脑实质内出现静脉性脑梗死表现,其中4例合并出血。增强扫描15例静脉窦内出现充盈缺损及静脉窦壁强化表现,9例脑实质内出现脑回样强化。MRV表现为受累静脉窦部分或广泛高血流信号缺失、狭窄。结论MRI和MRV是诊断和随访CVST形成的最佳检查方法。     

Cerebral venous thrombosis associated with tentorial subdural hematoma during oxymetholone therapy

Androgen was reported to cause cerebral venous thrombosis (CVT) during replacement therapy for aplastic anemia. Oxymetholone, a synthetic androgen analogue, has been widely used in the treatment of aplastic anemia. A 40-year-old woman with aplastic anemia visited our hospital because of severe headache, nausea, vomiting, blurred vision and diplopia for a period of 1 month. She had taken oxymetholone for 2 years. Neurological examination revealed bilateral papilledema and bilateral sixth nerve palsies. Brain magnetic resonance imaging (MRI), performed at the time of admission, demonstrated left-sided tentorial SDH, and focal cerebral thrombosis of the left superficial sylvian vein and sigmoid sinus. MR venography revealed multiple irregularities in the superior sagittal sinus and left transverse sinus. CVT with tentorial subdural hematoma (SDH) caused by oxymetholone was strongly suggested. Oxymetholone was immediately discontinued, and her symptoms and signs disappeared. Because of the thrombocytopenia, anticoagulation was not started. She was discharged and visited the outpatient clinic without neurological symptoms for 6 months. This report supports the cautions given about the risk of CVT with oxymetholone supplementation in aplastic anemia. To the best of our knowledge, this is the first report of CVT associated with tentorial SDH that was probably caused by oxymetholone.     

Severe cerebral venous sinus thrombosis and dural arteriovenous fistula in an infant with protein S deficiency

A 12-month-old infant presented with cerebral seizures and neurological deficits. MRI scan of the brain and angiography showed massive cerebral venous sinus thrombosis complicated by a dural arteriovenous fistula. Subsequent clotting analysis revealed a protein S deficiency. Screening for inherited coagulation inhibitor deficiency is recommended in children with unexplained or atypical thrombotic events. Received: 12 May 1998     

磁共振静脉血管造影对颅内静脉窦血栓形成的诊断价值及正常人静脉窦变异情况研究

目的评价MRV与MRI诊断颅内静脉窦血栓形成的一致性,观察正常人MRV表现及其静脉窦变异情况。方法共29例颅内静脉窦血栓形成患者行MRI和MRV检查,计算二者诊断一致性;同时观察11例正常对照者颅内静脉窦在血流和连接方式等方面的变异情况。结果 MRV与MRI诊断颅内静脉窦血栓形成的一致率：3.0T为92.59%（25/27）、1.5T为88.24%（15/17）。正常对照者静脉窦变异主要集中在横窦,11例中双侧横窦显影粗细大致相同5例、右侧横窦较粗5例、左侧横窦较粗1例。结论MRV与MRI诊断颅内静脉窦血栓形成具有较高的一致性,但对于先天性变异无法区分,需结合MRI综合分析。正常人静脉窦变异主要集中在横窦,传统认为右侧横窦可较左侧横窦粗,但根据目前数据也可出现右侧横窦比左侧横窦细的情况。     

Familial hyperhomocysteinemia-related cerebral venous sinus thrombosis and pulmonary embolism: a case report

Elevated plasma homocysteine levels are associated with an increased risk of deep vein thrombosis. Herein we report a case of familial hyperhomocysteinemia-related cerebral venous sinus thrombosis and pulmonary embolism in a 21-year-old man who presented with severe headache over bilateral frontal areas. Neurological examination revealed no evidence of focal neurological deficit. Chest CT showed pulmonary thromboembolism in bilateral basal lung fields and brain MRI disclosed right transverse and sigmoid venous sinus thrombosis. Routine immunological tests, coagulation factors and occult tumor screening were normal, as were vitamin B12 and folate levels. The DIC profile was negative, The only risk factor we were able to identify was an elevated serum homocysteine level, namely 46.23 microM/L. Hyperhomocysteinemia was also noted in the patient's asymptomatic elder brother (68.0 microM/L) and, to a lesser extent, in his parents (father 12.5 microM/L; mother 11.7 microM/L). In conclusion, the cause of cerebral venous thrombosis and pulmonary embolism in this young patient was most likely related to familial hyperhomocysteinemia, with the thromboembolic events precipitated by a preceding systemic infection. After anticoagulation therapy; the patient recovered completely without any residual neurological deficit.     

脑静脉窦血栓形成的MR诊断及MRV的应用

目的探讨脑静脉窦血栓形成（cerebral venous sinus thrombosis, CVST）的MR征象及磁共振脑静脉系血管成像（magnetic resonance venography, MRV）的技术方法。方法4例脑静脉窦血栓形成患者,男2例,女2例,年龄32～51岁,全部经常规MRI及MRV检查,2例患者行增强扫描,全部患者经DSA检查证实。结果4例患者平扫SE序列均可见静脉窦内正常流空信号消失,代之以异常等或高信号。出血性脑梗死3例;广泛脑肿胀及脑水肿1例。MR增强可见静脉窦异常低信号或闭塞;对比增强磁共振血管造影检查（contrast enhanced magnatic resonance venography, CE-MRV）见受累静脉窦腔内血流信号不规则或信号完全消失。结论MRI结合3D-CE-MRA是诊断脑静脉窦血栓形成的有效手段。     

Unilateral decompressive craniectomy in left transverse and sigmoid sinus thrombosis

Cerebral venous and dural sinus thrombosis is a rare cause of stroke. We explore the controversial issue of anticoagulation therapy and indication for decompressive craniectomy in association with severe sinus thrombosis. The 62-year-old female patient was admitted to hospital, because of first generalized seizure. A computed tomographic (CT) scan of the brain revealed a left occipital hemorrhage. Digital subtraction angiogram showing thrombosis of the left transverse and sigmoid sinus. An intravenously administered regimen of heparin was begun, because of a protein S deficiency. On the 6th day the patients level of consciousness deteriorated, necessitating intubation, hyperventilation, and mannitol. Repeat CT scan revealed increasing edema with midline shift and obliteration of the basal cisterns, although the hemorrhagic lesion was unchanged. The patient developed signs of diencephalic dysfunction. A large left temporoparietooccipital craniectomy was performed and the dura was opened. The multiloculated intraparenchymatous hemorrhage portion of the brain was not removed. In addition, the patient was treated postoperatively with heparin therapy for three months, than a regimen of phenprocoumon was begun. Twelve months later the hemianopsia had not improved and she had an incomplete Wernicke's dysphasia. When, despite adequate anticoagulation therapy and intensive care, neurological deterioration occurs in sigmoideus and/or transversus dural sinus thrombosis with unilateral edema, a decompressive craniectomy should be considered especially in young patients.     

Impaired washout--embolism and ischemic stroke: further examples and proof of concept

We previously posited that impaired washout of emboli was an important mechanism of brain infarction in patients with cerebral hypoperfusion. Hyperviscosity and hypoperfusion enhance thrombus formation promoting embolization of fresh thrombi. Hypoperfusion also reduces dissolution of emboli due to reduced flow velocity leading to classic hemodynamic patterns of stroke. To prove this concept further, we identified patients with severe hemodynamic compromise of either arterial or venous origin, or both, and natural or iatrogenic mechanisms of embolism. Three conditions were investigated in a stroke MRI protocol: 5 patients who had conventional cerebral angiography for the diagnosis of moyamoya disease, 1 patient with atrial fibrillation and thrombosis of the left transverse dural sinus and 1 patient with a patent foramen ovale with atrial septum aneurysm presenting with thrombosis of cortical cerebral veins. In all patients, subcortical arterial embolization within an atypical borderzone of hypoperfusion was observed.     

Dural scalp and intracranial hemangiomas causing hydrocephalus and venous sinus thrombosis in an infant

Cutaneous scalp hemangiomas may herald the presence of occult intracranial hemangiomas. A previously healthy 4-month-old girl presented with a bleeding scalp hemangioma, a bulging fontanel, and anemia. Magnetic resonance imaging (MRI) of the brain revealed hydrocephalus along with multiple intracranial hemangiomas. These lesions compressed the jugular foramina, resulting in venous sinus thrombosis involving the right transverse sinus, the left sigmoid sinus, and the torcular herophili. The patient had no family history of phakomatoses or other genetic abnormalities. A thrombophilia work-up result was unremarkable. The patient was treated with prednisolone (10 mg twice daily) and low molecular weight heparin (1 mg/kg/dose) twice daily. This treatment decreased the size of her cutaneous and intracranial hemangiomas and led to the resolution of her venous sinus thromboses and hydrocephalus. Innocuous scalp hemangioma in an infant may herald more concerning intracranial pathology, which can be treated effectively if diagnosed with appropriate imaging studies.     

颅内静脉窦血栓形成（9例临床报道）

目的:探讨脑静脉血栓形成(CVT)的临床特点与影像学表现。方法:回顾性分析本院9例CVT的临床及影像学资料。结果:①临床表现:头痛(77%)、癫样抽搐(66%)、局灶性神经功能缺失(66%)、视乳头水肿(44%)、不同程度意识障碍(22%)。②影像学资料及治疗转归:1例头颅CT示弥漫性脑水肿,蛛网膜下隙出血合并多发出血性脑梗死,因颅内压持续增高,予外科手术行去骨板减压术,见大脑表面浅静脉怒张呈绳索状并多数点片状出血灶。8例行头颅MRI和MRV,显示直接征像8例、间接征像6例。其中2例同时行DSA,均显示多个静脉和静脉窦充盈缺损。静脉血栓部位:上矢状窦合并浅静脉血栓1例,上矢状窦合并侧窦及多处静脉受累7例,直窦血栓1例。7例行肝素抗凝等对症治疗、1例行血管内局部溶栓、1例行矢状窦手术取栓并抗凝治疗。症状缓解至痊愈7例,病死2例。结论:首诊时诊断不明确,可先作头颅CT,排除颅内非CVT性病变,临床已拟诊CVT时,应首选MRI+MRV,进行综合判断是目前诊断和随访CVT的最好方法,婴幼儿CVT常表现为癫发作起病,提示CVT是婴幼儿重要的未被识别的性发作原因之一。     

Venous Sinus Thrombosis: A Misdiagnosis Using MR Angiography

Introduction  Magnetic resonance venography (MRV) is a non-invasive imaging modality that is used in many centers to supplant conventional cerebral digital subtraction angiography (DSA) for the diagnosis of dural venous sinus thrombosis. Discussion  We present the case of a pregnant female diagnosed with dural venous sinus thrombosis by serial time-of-flight (TOF) MRV examinations, and treated with long-term anticoagulation based on these examinations. Results   The appearance of the affected dural sinus did not change on MRV over the treatment period. The patient returned during follow-up with new-onset pulsatile tinnitus, which prompted us to perform DSA to exclude a dural arteriovenous fistula. DSA revealed that the segment of venous sinus diagnosed as thrombosed on MRV actually was patent but had a septation in its midsection. Conclusions  We concluded that the patient did not have a venous sinus thrombosis at the time of MRV examinations but rather an anatomical variant mimicking a thrombosis, which would not have required any treatment. MRV, particularly TOF MRV, is limited by artifacts in correctly identifying vascular anatomy and pathology and should be interpreted carefully. DSA remains the reference standard for most vascular imaging.     

A case of venous dural sinus thrombosis presenting dementia syndrome. An autopsy case

We report clinical and pathological features of a case of dementia syndrome due to dural sinus thrombosis. In three years before admission, the patient, a 64-year old man, had had four convulsive attacks; scattered calcification shadows were disclosed by plain CT. Ten months before the admission, he complained of progressive memory disturbance and dyscalculia. General physical examination showed no remarkable abnormalities except for bruit at the left mastoid process. Although his time orientation was poor, he was otherwise fully awake. Neurologically, memory disturbance, finger agnosia, and dyscalculia were observed. Right Barré's sign, and exaggerated right patellar tendon reflex were observed. Plain X-ray CT revealed calcification-like, scattered high-density areas in the floor of the cerebral cortical sulci. Enhanced CT showed abnormal vessel high-density areas in both the cerebrum and brainstem. Cerebral angiography showed thrombosis of bilateral transverse sinuses, arterio-venous fistula in the left transverse sinus, and remarkably dilated cortical veins over both cerebral hemispheres. Positron emission tomography revealed misery perfusion areas in bilateral cerebral hemispheres. We presume that the mass effect of venous engorgement and chronic ischemia due to the arterio-venous fistula caused the dementia syndrome. These clinical manifestations were improved by amantadine and the patient was discharged. During follow-up, he died of subarachnoid hemorrhage, and an autopsy was performed. Pathological findings were as follows: 1) cortical and subcortical multiple-infarction in the cerebrum, 2) hematoma in the subarachnoid space, 3) venous dilatation of the cortical veins and pseudocalcification of their walls, and 4) thrombus in the transverse dural sinus.     

Dural Sinus Thrombosis with Nonsymptomatic Persistent Falcine Sinus: A Case Report

A 24-year-old woman was admitted to our hospital after convulsive status epilepticus. A cerebral magnetic resonance venography revealed a persistent fetal falcine sinus. Additionally, the posterior third of the superior sagittal sinus was hypoplastic and the abnormal deep venous drainage was accompanied. These abnormalities had already been detected by magnetic resonance imaging several years ago. In the present scan, we discovered a sinus thrombosis in the hypoplastic superior sagittal sinus. In the cerebral angiography, we observed delayed venous return in the left parieto-occipital lobe and hypothesized that cerebral venous stasis due to the thrombus caused the convulsive status epilepticus. The patient was treated with intravenous administration of heparin along with an antiepileptic drug, and she recovered with no neurological defects. In the present case, the falcine sinus and the anomalous venous return were likely congenital while the status epilepticus was derived from thrombosis in the hypoplastic superior sagittal sinus. Although the falcine sinus functioned as an alternative pathway for the superior sagittal sinus, the hypoplastic superior sagittal sinus itself may also play an important role as a venous drainage channel.     

Diagnostic value of combined conventional magnetic resonance imaging and magnetic resonance angiography in sinus venous thrombosis

25 patients are presented, who were diagnosed with cerebral sinus venous thrombosis by a combination of Magnetic Resonance Angiography (MRA) and conventional Spin-Echo sequences. An angiography in DSA technique was carried out additionally in 12 cases. In 24 patients MR-angiographic control examinations were conducted. In seven cases MRA revealed an isolated thrombosis of the superior sagittal sinus (SSS) whereas in eleven patients there was an additional occlusion of other sinuses or cerebral veins. The transverse sinus (ST) was the second most affected. DSA essentially confirmed the MR-imaging data. Despite anticoagulation follow up MRA's showed complete recanalisation in only 7 patients, in 8 cases partial recanalisation was observed and in 9 cases a complete occlusion persisted. In contrast to these findings neurological examinations during the follow up period were unremarkable in 16 patients and the remainder revealed only mild residual symptoms. In general no further morphological alterations of the cerebral sinus system were detectable by MRA after 6 months. Follow up imaging beyond 6 months therefore appears unnecessary, unless a relapse is suspected.     

妊娠相关性脑静脉及静脉窦血栓形成和可逆性后部白质脑病的磁共振鉴别

目的探讨MRI和MRV在妊娠相关性脑静脉及静脉窦血栓形成(CVST)和可逆性后部白质脑病综合征(RPLS)鉴别诊断中的价值。方法回顾性分析3例妊娠相关性CVST和6例重度子痫前期、子痫发生RPLS患者的影像学资料。所有患者均行MRI和DSA检查,其中7例患者行MRV检查。结果 3例CVST患者中,1例孤立性大脑上静脉前组血栓形成,MRI表现为相应部位T1WI低、等信号,T2WI、FLAIR等、稍高信号,DWI为等、高信号,ADC图为低、稍高信号;2例横窦血栓形成,表现为双侧枕叶皮质、皮质下白质片状T1WI低信号,T2WI、FLAIR高信号,DWI、ADC高信号,可不对称性地累及顶叶、小脑半球,MRV与DSA检查结果相符。6例RPLS患者MRI显示双侧顶、枕叶皮质、皮质下白质多发性、斑片状、对称性病变,部分严重患者大脑半球呈弥漫性、大片状受累,表现为T1WI低信号,T2WI、FLAIR高信号,DWI、ADC高信号;1例患者MRV检查示左侧横窦未显影,DSA检查示左侧横窦通畅。结论横窦血栓形成和RPLS患者MRI均显示血管源性脑水肿,两者脑水肿主要发生于双侧枕、顶叶,但前者范围较局限,后者范围更广泛,可累及基底节、额叶、颞叶。RPLS患者MRV检查可有假阳性,DSA是鉴别两者的重要检查方法。     

Dural sinus thrombosis: a mechanism-based classification and review of 42 cases

Cranial venous outflow obstruction due to dural sinus thrombosis may result in venous hypertension, cerebral infarction, cerebral haemorrhage or impaired cerebrospinal fluid (CSF) absorption with consequent pseudotumour syndrome. We propose a mechanism based classification of dural sinus thrombosis from these four outcomes. Forty two cases of dural sinus thrombosis presenting to Royal Prince Alfred Hospital between 1986-1997 were retrospectively reviewed. These cases were classified according to mechanism of presentation and relevance of this to site of thrombosis, treatment and prognosis. This study shows that the superior sagittal sinus and transverse sinus are the commonest sites of thrombosis, and multiple sites of thrombosis (69%) are more frequent than a single site. Magnetic resonance imaging (MRI) with venous flow studies is the investigation of first choice for diagnosis but angiography remains the gold standard. A pseudotumour syndrome is the commonest presentation (43%) followed by cerebral haemorrhage (31%). The overall prognosis for sinus thrombosis is good, with 71% of cases recovering to normal function.     

脑静脉窦血栓形成的CT、MRI影像特点及文献回顾

目的探讨脑静脉窦血栓形成的CT、MRI影像特点,以便早期诊断、及时治疗、有效减少误诊误治. 方法回顾性分析5例脑静脉窦血栓患者的影像特征及相关文献. 结果5例患者均有不同程度的头痛、烦躁、神经系统定位体征,MRI表现为一侧或双侧顶叶近大脑镰处梗塞或夹杂有出血性改变. 结论头痛、烦躁、神经系统定位体征是脑静脉窦血栓的常见症状和体征.MRI的特征性表现为脑肿胀,顶叶的局部性梗死,多数伴有出血.     

颅内静脉窦血栓形成13例

目的探讨颅内静脉窦血栓形成(CVST)的临床特点与治疗方法。方法分析13例CVST患者的临床、影像学特征及治疗方法。结果 13例多为中青年患者,临床表现头痛12例(92.3%),癫痫发作8例(61.5%)。11例腰穿显示脑脊液压力增高。头颅CT显示脑静脉窦异常5/13例(38.5%);MRI显示脑静脉窦异常7/13例(53.8%);MRV显示脑静脉窦异常7/12例(58.3%);DSA显示脑静脉窦异常6/6例(100%)。患者均应用脱水和抗凝治疗,部分予溶栓治疗,13例中5例基本痊愈,6例明显好转,2例遗留有不同程度的偏瘫、癫痫等症状。结论 CVST的临床特点是中青年人发生率高,以头痛、呕吐等颅高压症状为主要表现;MRI+MRV及DSA确诊率高;一旦确诊应及时予抗凝治疗,重症患者可行溶栓治疗。