Noncontrast CT Brain in Cerebral Venous Sinus Thrombosis

Noncontrast CT Brain in a patient with Left transverse and left sigmoid sinus thrombosis

Cerebral venous sinus thrombosis (CVST) commonly presents with headache, raised ICP, seizures and focal neurological deficits. Diagnosis can be made on the basis of CT and MRI brain. The usual initial investigation done is CT brain-plain (non-contrast). It is important to pick up the findings on plain CT so that an early diagnosis can be made.

A 30-year old lady presented with severe headache associated with vomiting of two days duration. She had no focal neurological deficits. Plain CT was done.

CT brain showed: 1. Thrombosis of left sigmoid sinus (green arrow), 2. Thrombosis of left transverse sinus (yellow arrows), 3. Hemorrhagic venous infarct (circled in red)

Thrombosed transverse and sigmoid sinuses are seen as hyperdense areas as shown in the images above.

Venous infarcts can be hemorrhagic or non-hemorrhagic. Clues favouring a diagnosis of venous infarct (due to CVST) are:

1. Location not fitting in an arterial territory,
2. Presence of hemorrhage
3. Bilateral location (as in superior sagittal sinus thrombosis, where bilateral medial frontal/parasagittal areas are affected.
4. Presence of significant edema even in the initial stages
5. Hemorrhage in venous infarcts tend to be fragmented (as seen in this case), as against primary intracerebral hematoma (where the hematoma is usually non-fragmented)

Treatment of CVST-

1. Anticoagulation with heparin should be started as early as possible, even in the presence of hemorrhage,
2. Anti-epileptic drugs
3. Anti-edema measures (steroids)
4. Mechanical thrombectomy or intrasinus thrombolysis (in cases not responding to heparin),
5. Decompressive surgery (in cases of severe mass effect)