Prevalence of venous sinus stenosis in Pseudotumor cerebri (PTC) using digital subtraction angiography (DSA)

Objectives

To study the prevalence of intracranial venous stenosis in Pseudotumor cerebri patients.

Patients and methods

Thirty patients were diagnosed having PTC according to Dandy criteria. All underwent general and neurological assessment. Radiological assessment included CT scan brain ±MRI brain without contrast, MRV. All underwent digital subtraction angiography (DSA) (venous phase) to confirm the validity of filling gaps seen at the level of MRV.

Results

MRV brain showed that 24 patients (80%) showed filling gaps. Digital subtraction cerebral angiography (venous phase) showed 9 patients (30%) had stenosis in their dural sinuses. MRV showed to be a good screening tool since it had 100% sensitivity and negative predictive value. However, since it has a moderate specificity (62%) with a positive predictive value (PPV) of only 35%, then lesions detected should be confirmed with digital subtraction cerebral angiography (venous phase) particularly those involving the transverse and sigmoid sinus.

Conclusion

Studying the intracranial venous system in patients with PTC is an important step in understanding the pathophysiology of the disease. Detection of venous sinus stenosis opens the way to a novel therapeutic option for refractory patients like venous sinus stenting.     

Prognostic indices for cerebral venous thrombosis on CT perfusion: A prospective study

Purpose

We determined the prognostic significance of CT perfusion characteristics of patients with cerebral venous sinus thrombosis (CVST) and assessed the change in perfusion parameters following anticoagulation therapy.

Materials and methods

20 patients with CVST diagnosed on non-contrast computed tomography (NCCT), magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) were included in this study. The initial CT perfusion study was performed at the time of admission. The following perfusion parameters: relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) were calculated in the core and periphery of the affected area of the brain. Follow-up CT perfusion studies were performed at 1 month following anticoagulation therapy and the perfusion parameters thus obtained were compared with pre-treatment results. Receiver operating characteristic (ROC) curve analysis was performed to determine the prognostic significance of perfusion parameters.

Results

All patients in this study showed areas of hypoperfusion on CT perfusion. To determine the favorable clinical outcome on basis of perfusion parameters, ROC curve analysis was performed which showed that the optimal threshold for rCBF > 60.5%, rCBV > 75.5%, and rMTT < 148.5% correlated with better clinical outcomes. Post treatment perfusion parameters showed significant correlation in core of the lesion (p < 0.05) than in the periphery.

Conclusion

CT perfusion studies in CVST are a good prognostic tool and yield valuable information regarding clinical outcome.     

CT Density Measurement and H:H Ratio Are Useful in Diagnosing Acute Cerebral Venous Sinus Thrombosis

BACKGROUND AND PURPOSE:Brain CT is widely used to exclude or confirm acute cerebral venous sinus thrombosis. The purpose of this study was to assess the value of attenuation measurement and the H:H ratio on unenhanced brain CT scans in the diagnosis of acute cerebral venous sinus thrombosis.MATERIALS AND METHODS:This retrospective study evaluated 20 patients with acute cerebral venous sinus thrombosis and 20 age- and sex-matched control participants without thrombosis. Three experienced observers independently evaluated the unenhanced brain CT scan for the presence of cerebral venous sinus thrombosis and measured the attenuation in the dural sinuses. Interreader differences were examined, as well as densities and H:H ratio between patients with acute cerebral venous sinus thrombosis and control participants.RESULTS:A significant difference in the average sinus attenuation was found between patients with acute cerebral venous sinus thrombosis (73.9 ± 9.2 HU) and the control group (52.8 ± 6.7 HU; P < .0001). A similar difference was found for the H:H ratio (1.91 ± 0.32 vs 1.33 ± 0.12 in patients with and without cerebral venous sinus thrombosis, respectively; P < .0001). Optimal thresholds of 62 HU and 1.52 lead to accuracies of 95% for average sinus attenuation and 97.5% for the H:H ratio, respectively.CONCLUSIONS:Hyperattenuation and the H:H ratio in the dural sinuses on unenhanced brain CT scans have a high accuracy in the detection of acute cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is a challenging neurologic disorder because of the wide variety of clinical manifestations. The annual incidence is estimated at 2 to 7 cases per a population of 1 million. There are numerous causes and predisposing factors for CVST. The clinical features are nonspecific, and as a consequence, brain CT scan is often requested for exclusion of CVST.¹ Although timely and correct anticoagulation or thrombolytic therapy may improve clinical outcomes, the diagnosis is often delayed.Unenhanced brain CT scan is a cost-effective and widely available imaging technique in an emergency setting. The classic sign of acute CVST on unenhanced CT images is an increase in attenuation of the occluded sinus, reflecting a newly formed thrombus.² It is accepted as a useful technique to decide on further imaging and is reported to have a sensitivity and specificity of 64.6% and 97.2%, respectively, in the detection of CVST.^3,4The attenuation of blood on unenhanced CT scans is predominantly caused by the protein factor of hemoglobin within the red blood cells. As a result, a linear relationship existed between the attenuation of blood and hemoglobin and HCT levels in a large series of 166 patients.⁵ The most common cause of false-positive interpretation of CVST on unenhanced CT scans is a high HCT (eg, in patients with polycythemia vera), causing a hyperattenuated sinus.^6,7Because an apparent increase in attenuation can be misleading and is not always visually picked up, measurement of attenuation in the sinus might be a more reliable method. Normalization of measured attenuation regarding HCT may further improve the detection of CVST on unenhanced CT scans.⁵Black et al⁵ also measured the attenuation of the venous sinus in 8 patients with CVST and suggested the potential usefulness of attenuation measurements and H:H ratio to diagnose CVST. The purpose of our study was to assess the clinical usefulness of attenuation measurement and to compare its normalized ratio with HCT in the diagnosis of acute CVST on unenhanced brain CT scans.     

Risk of cerebral venous thrombosis in oral contraceptives pills users

The aim of this study is to assess the relative risk of cerebral venous sinus thrombosis (CVST) in Oral contraceptive pills (OCP) users compared with a control group of non-hormone users.

脑静脉窦血栓形成的MRI诊断

目的 :探讨MRI和MR血管成像 (MRA ,MRV)对脑静脉窦血栓形成 (CVST)的诊断价值。方法 :回顾性分析 10例CVST患者的临床和影像资料。全部病例行常规MRI和MRA( 3DTOF)、MRV( 2DTOF)检查 ,其中 9例行增强扫描。结果 :MR常规扫描示脑实质内均出现异常信号 ,仅 1例T2 WI未见异常信号 ,增强扫描 9例全部出现静脉异常强化。有 5例MRA除可见动脉正常显影外 ,还可见受累的静脉和静脉窦显影。MRV示栓塞的静脉窦不显影或显影欠佳。结论 :常规MRI结合MRA、MRV是诊断CVST的无创和有效手段     

Catheter direct thrombolysis: Role of actilyse in treatment of acute deep venous thrombosis

Purpose

To evaluate the short and long term efficiency of catheter directed thrombolysis using recombinant tissue type plasminogin activator (r-TPA; Actilyse), in treating acute deep venous thrombosis of the lower limb.

Material and methods

Twenty-eight patients with acute lower limb deep venous thrombosis underwent treatment by direct intra clot injection of thrombolytic therapy; Actilyse.

Result

Thrombus lysis was completed in 23 (82.2%) of 28 patients, partial in 4 (14.3%) patients and not achieved in one (3.5%) patient. There was no major complication. There was no rethrombosis or post thrombotic syndrome in any of the treated 23 patients over the follow up period of one year.

Conclusion

The treatment of acute lower limb deep venous thrombosis using recombinant tissue type plasminogin activator (r-TPA; Actilyse), is safe, effective and achieves significantly better short and long term clinical outcome for patients.     

Cerebral venous thrombosis: state of the art diagnosis and management

Purpose

This review article aims to discuss the pathophysiology, clinical presentation, and neuroimaging of cerebral venous thrombosis (CVT). Different approaches for diagnosis of CVT, including CT/CTV, MRI/MRV, and US will be discussed and the reader will become acquainted with imaging findings as well as limitations of each modality. Lastly, this exhibit will review the standard of care for CVT treatment and emerging endovascular options.

Methods

A literature search using PubMed and the MEDLINE subengine was completed using the terms “cerebral venous thrombosis,” “stroke,” and “imaging.” Studies reporting on the workup, imaging characteristics, clinical history, and management of patients with CVT were included.

Results

The presentation of CVT is often non-specific and requires a high index of clinical suspicion. Signs of CVT on NECT can be divided into indirect signs (edema, parenchymal hemorrhage, subarachnoid hemorrhage, and rarely subdural hematomas) and less commonly direct signs (visualization of dense thrombus within a vein or within the cerebral venous sinuses). Confirmation is performed with CTV, directly demonstrating the thrombus as a filling defect, or MRI/MRV, which also provides superior characterization of parenchymal abnormalities. General pitfalls and anatomic variants will also be discussed. Lastly, endovascular management options including thrombolysis and mechanical thrombectomy are discussed.

Conclusions

CVT is a relatively uncommon phenomenon and frequently overlooked at initial presentation. Familiarity with imaging features and diagnostic work-up of CVT will help in providing timely diagnosis and therapy which can significantly improve outcome and diminish the risk of acute and long-term complications, optimizing patient care.

     

脑静脉窦和静脉血栓形成的影像学诊断与分析

目的 探讨脑静脉窦和静脉血栓形成(CVST)的影像特征及诊断体会.方法 回顾性分析28例CVST患者的影像学表现、影像诊断特征.结果 (1)CVST的CT及MRI影像学表现只有少数病例可见典型的"条索状"直接征象(3.57%);最常见的间接征象为非典型性的脑出血(50.00%)及脑梗死(CT:32.14%,MRI:39.29%),发病部位以双侧性较多(75.00%).(2)大部分CVST患者的磁共振静脉成像(MRV)或CT静脉血管成像(CTV)出现静脉窦连续性中断,充盈缺损区,完全性或虫蚀状改变等直接征象(CTV:100%,MRV:83.33%),还可出现远端静脉窦增粗及引流静脉扩张等间接征象.结论 CVST的CT及MRI常规影像学表现无明显特异性,而CTV和MRV影像学表现具有较高的特异性,若怀疑CVST应尽早行MRV或CTV检查以明确诊断.     

脑静脉窦和静脉血栓形成的影像学诊断与分析

目的 探讨脑静脉窦和静脉血栓形成(CVST)的影像特征及诊断体会.方法 回顾性分析28例CVST患者的影像学表现、影像诊断特征.结果 (1)CVST的CT及MRI影像学表现只有少数病例可见典型的"条索状"直接征象(3.57%);最常见的间接征象为非典型性的脑出血(50.00%)及脑梗死(CT:32.14%,MRI:39.29%),发病部位以双侧性较多(75.00%).(2)大部分CVST患者的磁共振静脉成像(MRV)或CT静脉血管成像(CTV)出现静脉窦连续性中断,充盈缺损区,完全性或虫蚀状改变等直接征象(CTV:100%,MRV:83.33%),还可出现远端静脉窦增粗及引流静脉扩张等间接征象.结论 CVST的CT及MRI常规影像学表现无明显特异性,而CTV和MRV影像学表现具有较高的特异性,若怀疑CVST应尽早行MRV或CTV检查以明确诊断.     

Assessment of the lacrimal recess of the maxillary sinus on computed tomography scans

Objective

To assess the frequency of the lacrimal recess in the maxillary sinus (MS) in computed tomography (CT) of the paranasal sinuses.

Methods

CT of the paranasal sinuses (CT PNS) done in a total of 78 patients. According to the discoveries, the MS were classified in two types: anterior or lateral.

Results

41 CT PNS of 41 patients of a total of 78 patients preselected were excluded. 37 CT of the paranasal sinuses from 37 patients, in a total of 68 maxillary sinuses were studied. In the 33 right maxillary sinuses, 10 lacrimal recesses were found, 9 from male patients. Eleven left maxillary sinuses with lacrimal recess were found from a total of 35 left maxillary sinuses.

Conclusion

From the analysis of 68 MS, a frequency of 30.9% of lacrimal recesses in the maxillary sinuses in CT was observed.     

脑静脉及静脉窦血栓21例CT磁共振表现及漏误诊分析

目的总结颅内静脉与静脉窦血栓形成(CVST)的CT及磁共振(MR)表现,分析漏误诊的原因。方法回顾性分析21例CVST病例的CT和MR影像,全部病例均有MR资料,12例有低场强磁共振脑静脉窦血管成像(MRV)资料,15例有CT资料。结果 CVST的CT表现为病变静脉窦的高密度影、束带征及Delta征;MR主要表现为病变静脉窦内短T1长T2信号;MRV表现为血栓形成静脉窦的闭塞;本组21例CVST,影像科初诊漏诊2例,误诊5例。结论正确认识CVST的束带征、急性早期征象及静脉性脑梗死的改变,能减少漏误诊的发生。     

Evaluation of the Interpretation of Serial Ultrasound Examinations in the Diagnosis of Deep Venous Thrombosis in Children: A Retrospective Cohort Study

Purpose

To assess ultrasound intrascan variability and the potential error rate of serial ultrasounds in the diagnosis of deep venous thrombosis in children.

Methods

A retrospective cohort review of imaging results of children having at least 3 serial ultrasound examinations of the same region within a 2-month period. The results were interpreted as either (1) inadequately visualized or (2) the absence or presence of deep venous thrombosis, and were categorized by location. Serial imaging findings then were further categorized based on results and clinical information.

Results

Sixty-four patients and 157 vessel segments were included in the study. Deep venous thrombosis was documented in 58 patients. Concordant results were observed in 26 patients (40.1%), clot resolution in 17 patients (26.6%), clot formation in 12 patients (18.8%), and discordant results in 9 patients (14%). Twenty-one of 64 patients (32.8%) had at least 1 vessel inadequately imaged.

Conclusions

The inconsistency of serial ultrasound results in up to 25% of patients calls attention to the potential inaccuracy of ultrasound for diagnosis and follow-up of deep venous thrombosis in children. The high proportion of patients with at least 1 inadequately visualized vessel also highlights the limitation of ultrasound in the diagnosis of pediatric deep venous thrombosis.     

MRI联合磁共振静脉成像诊断脑静脉窦血栓形成的价值

目的:探讨MRI及磁共振静脉成像(MRV)对脑静脉窦血栓形成的诊断价值.方法:回顾性分析37例DSA确诊脑静脉窦血栓形成患者的临床资料及影像表现.37例中有30例行常规MRI检查,29例行MRV(2D TOF)检查.结果:30例常规MRI检查中28例静脉窦有异常信号,其中26例MRI表现为静脉窦T1WI、T2WI高信号,2例T1WI等信号、T2WI低信号,并部分伴有脑组织梗死、出血.29例MRV检查均发现静脉窦充盈缺损或中断.结论:MRI与MRV结合对诊断脑静脉窦血栓形成具有高度敏感性,是诊断静脉窦血栓形成的首选检查方法.     

颅内静脉血栓形成的磁共振诊断

目的:探讨磁共振成像(MRI)及磁共振静脉成像(MRV)对颅内静脉窦血栓形成(CVST)的诊断价值。方法:回顾性分析经临床和影像学方法确诊的14例CVST患者。MR检查技术包括平扫,增强扫描及MRV,14例均行CT平扫,其中1例行DSA检查。结果:14例CVST累及上矢状窦血栓形成4例,横窦血栓形成6例、乙状窦5例,MRI可清晰显示颅内静脉窦血栓形成的直接征象和间接征象,MRV可显示受累静脉窦不显影或者充盈缺损形成。结论:常规MRI结合MRV对颅内静脉窦血栓形成的早期诊断具有重要价值。     

Retrievable Günther Tulip Vena Cava Filter in the prevention of pulmonary embolism in patients with acute deep venous thrombosis in perinatal period

Objectives

To evaluate the feasibility and efficacy of the retrievable Günther Tulip Vena Cava Filter in the prevention of pulmonary embolism in patients with acute deep vein thrombosis in the perinatal period and to discuss the technical demands associated with the filter's implantation and retrieval.

Methods

Between 1996 until 2007, eight women (mean age 27.4 years, range 20–42 years) with acute deep iliofemoral venous thrombosis in the perinatal period of pregnancy and increased risk of pulmonary embolism during delivery were indicated for retrievable Günther Tulip Vena Cava Filter implantation. All filters were inserted and removed under local anesthesia from the jugular approach.

Results

The Günther Tulip Vena Cava Filter was implanted suprarenally in all patients on the day of caesarean delivery. In follow-up cavograms performed just before planned filter removal, no embolus was seen in the filter in any patient. In all patients the filter was retrieved without complications on the 12th day after implantation.

Conclusions

Retrievable Günther Tulip Vena Cava Filters can be inserted and removed in patients during the perinatal period without major complications.     

Endovascular treatment of carotid cavernous fistulae (CCF). Direct venous puncture using road mapping in dural CCF

Introduction

Endovascular treatment offers different options to treat CCF by less invasive approach avoiding morbidity and residual fistulas. The choice depends on the anatomy of the fistula and operator/Institutional preferences.

Objective

Describe options in endovascular treatment of Barrow Type A and Type D Carotid Cavernous fistulas (CCF).

Patients and methods

We report 10 cases of carotid cavernous fistula (CCF) that received endovascular treatment using coils and liquid embolic materials. Seven cases Barrow Type A, done through an arterial approach and three cases Barrow Type D, done through venous approach. The cavernous sinus in Type D cases was approached via the inferior petrosal sinus in one case and the other two cases by direct puncture of the facial and supra-orbital veins using road mapping. Using road mapping in venous approach to treat CCF is not reported in the literature before.

Results

Successful obliteration of the fistula was achieved in all cases with transient VI nerve palsy in one case and post procedure ophthalmic vein thrombosis in another.

Conclusion

With the observed favorable outcomes and lack of significant procedural morbidity, direct puncture of the facial and supra-orbital veins using road mapping to reach the cavernous sinus, might be an addition in the armamentarium available for endovascular treatment of CCF.     

Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up

Purpose

To prospectively evaluate the primary and long-term venographic and clinical results of catheter-directed thrombolysis in the treatment of proximal deep vein thrombosis (DVT) of lower extremity.

Materials and methods

Fifty-six patients with mean age of 48 (range 15–81) years with acute DVT (symptom duration of less than 2 weeks), extending to high femoral (16 patients) or iliac vein (40 patients) were treated with selective catheter-directed thrombolysis. The mean total dose of 3.8 (range 1.0–8.1) million units of urokinase was administered during a mean of 39 (range 6–72) hours. Endovascular stenting was performed in 9 of the iliac DVT patients.

Results

Complete procedural venographic success was achieved in 79% of patients. Major complications were noted in 7% of patients and the total rate of complications was 13%. Mean venographic follow-up was 3.5 years (range 3 months to 9.6 years); well preserved femoral vein valves and fully recanalized deep crural veins were observed in 83% and 57% of patients. Normal clinical findings in the affected limb were noted during the latest follow-up visit in 67% of patients. Clinical post-thrombotic syndrome occurred in 9% of patients.

Conclusion

Catheter-directed thrombolysis achieves good primary success with acceptable complication rate and effectively reduces prevalence of post-thrombotic syndrome.     

Intra-arterial tirofiban infusion for thromboembolic complication during coil embolization of ruptured intracranial aneurysms

Introduction

Intra-arterial (IA) thrombolytic intervention for acute thrombosis has been challenged due to the risk of bleeding during the endovascular treatment of ruptured aneurysms. We present the results of IA tirofiban infusion for thromboembolic complications during coil embolization in patients with ruptured intracranial aneurysms.

Methods

Thromboembolic events requiring thrombolytic intervention occurred in 39 (10.5%) cases during coil embolization of 372 consecutive ruptured intracranial aneurysms. Maximal aneurysm diameters of 39 patients (mean age, 54.7 ± 13.2 years; 23 female, 16 male) ranged from 2.1 to 13.1 mm (mean, 6.6 ± 3.0 mm). The anterior communicating artery was the most common site (n = 13), followed by the middle cerebral artery (n = 9) and the posterior communicating artery (n = 7). In this series, we used intracranial stents in 10 patients during the procedure. Superselective IA tirofiban infusion through a microcatheter was performed to resolve thrombi and emboli. We assessed the efficacy and safety of IA tirofiban infusion in patients with ruptured aneurysms.

Results

Intraarterially administered tirofiban doses ranged from 0.25 to 1.25 mg (mean, 0.71 ± 0.26 mg). Effective thrombolysis or recanalization was achieved in 34 patients (87.2%), and three patients (7.7%) suffered distal migration of clots with partial recanalization. The rest (5.1%) had no recanalization. Nonconsequent intracerebral hemorrhage occurred in two patients (5.1%) after the procedure. Thromboemboli-related cerebral infarction developed in eight patients, and only two patients remained infarction related disabilities.

Conclusion

IA tirofiban infusion seems to be efficacious and safe for thrombolysis during coil embolization in patients with ruptured intracranial aneurysms.     

Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses

BACKGROUND AND PURPOSE: The diagnosis of cerebral venous and sinus thrombosis (CVST) as a rare but important cause of stroke is challenging. We aimed to investigate the diagnostic value of multidetector-row CT angiography (MDCTA) as a fast and cost-effective imaging tool in diagnosing CVST. MATERIALS AND METHODS: Nineteen patients who presented with clinical symptoms of a possible CVST were included. All patients had received both MDCTA and MR imaging with venous MR-angiography. Three blinded readers were asked to identify the cerebral sinuses and veins in MDCTA and to evaluate the presence of CVST in MDCTA. Consensus reading with interpretation of the MR imaging served to establish the definite diagnosis. RESULTS: The consensus reading revealed CVST in 10 of the 19 patients. With MDCTA, the venous sinuses could be identified in 99.2% and the cerebral veins in 87.6% of cases. The sensitivity and specificity of MDCTA for the diagnosis of CVST were 100%. CONCLUSION: Our study demonstrates that MDCTA provides excellent sensitivity and specificity for the diagnosis of CVST. Further studies are needed to evaluate the diagnostic potential of MDCTA in specific subsets of the general entity of CVST such as cortical venous thrombosis, thrombosis of the cavernous sinus, and thrombosis of the internal cerebral veins.