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Venous Thrombosis Page 1 of 15
The Radiology Assistant
Cerebral Venous Thrombosis

by Barbara Simons, Geert Lycklama a Nijeholt and Robin Smithuis
Radiology department of the Medical Centre Haaglanden in the Hague and the Rijnland hospital in Leiderdorp, the Netherlands
Introduction Publicationdate:21-10-2010
When to think of venous thrombosis
Dense clot sign Cerebral venous thrombosis is an important cause of
Empty delta sign stroke especially in children and young adults.
Absence of normal flow void on MR It is more common than previously thought and
Venous infarction frequently missed on initial imaging.
Imaging in suspected thrombosis It is a difficult diagnosis because of its nonspecific
CT-venography clinical presentation and subtle imaging findings.
MR-venography
DSA In this article we will focus on:
Pitfalls in CT • Findings on routine imaging that should make
Arachnoid Granulations you think of unsuspected venous thrombosis.
Pseudodelta sign • How to image patients in suspected venous
Wrong bolus timing thrombosis.
Hematoma simulating venous thrombosis • Pitfalls.
Pitfalls in MRI
You can enlarge images by clicking on them.
Hypoplastic transverse sinus
Low signal intensity in thrombus This item is not available on the iPhone application.
Flow void on contrast-enhanced MR
Chronic dural sinus thrombosis and related
syndromes
DAVF
Thrombosis and increased CSF pressure
Venous territories

Introduction
Cerebral venous thrombosis is located in descending

order in the following venous structures:
• Major dural sinuses:

Superior sagittal sinus, transverse, straight and
sigmoid sinuses.
• Cortical veins:
◦ Vein of Labbe, which drains the temporal lobe.
◦ Vein of Trolard, which is the largest cortical vein
that drains into the superior sagittal sinus.
• Deep veins:
Internal cerebral and thalamostriate veins.
• Cavernous sinus.
Clinically patients with cerebral venous thrombosis

present with variable symptoms ranging from
headache to seizure and coma in severe cases.
In neonates shock and dehydration is a common
cause of venous thrombosis.
In older children it is often local infection, such as
mastoiditis, or coagulopathy.
In adults, coagulopathies is the cause in 70% and
infection is the cause in 10% of cases.
In women, oral contraceptive use and pregnancy are
strong risk factors.
http://www.radiologyassistant.nl/en/4befacb3e4691 29-04-2011

When to think of venous thrombosis
Venous thrombosis has a nonspecific presentation and

therefore it is important to recognize subtle imaging
findings and indirect signs that may indicate the
presence of thrombosis.
Although these findings are often present on initial
scans, they are frequently detected only in retrospect.
Clinically patients with venous thrombosis often
present with seizures, which is not a symptom in
patients with an arterial infarction.
On a routine non-enhanced MR or CT you should think

of the possibility of venous thrombosis when you see:
• Direct signs of a thrombus

• Infarction in a non-arterial location, especially if it is
bilateral and hemorrhagic
• Cortical or peripheral lobar hemorrhage
• Cortical edema
Dense clot sign

Direct visualization of a clot in the cerebral veins on a
non enhanced CT scan is known as the dense clot
sign.
It is seen in only one third of cases.
Normally veins are slightly denser than brain tissue

and in some cases it is difficult to say whether the
vein is normal or too dense (see pitfalls).
In these cases a contrast enhanced scan is necessary
to solve this problem.
Dense clot sign (2)

Visualization of a thrombosed cortical vein that is seen
as a linear or cord-like density, is also known as the
cord sign.
Another term that is frequently used, is the dense
vessel sign.
Dense clot sign in a thrombosed cortical vein.
Dense clot sign (3)

On the left images of a patient with a hemorrhagic
infarction in the temporal lobe (red arrow).
Notice the dense transverse sinus due to thrombosis
(blue arrows).
Empty delta sign

The empty delta sign is a finding that is seen on a
contrast enhanced CT (CECT) and was first described
in thrombosis of the superior sagittal sinus.
The sign consists of a triangular area of enhancement
with a relatively low-attenuating center, which is the
thrombosed sinus.
The likely explanation is enhancement of the rich
dural venous collateral circulation surrounding the
thrombosed sinus, producing the central region of low
attenuation.
In early thrombosis the empty delta sign may be
absent and you will have to rely on non-visualization
of the thrombosed vein on the CECT.
Two cases of empty delta sign due to thrombosis of the The sign may be absent after two months due to
superior sagittal sinus. recanalization within the thrombus.
Empty delta sign (2)

On the left a case of thrombosis of the right
transverse sinus and the left transverse and sigmoid
sinus (arrows).
There is enhancement surrounding the thrombosed
hypoattenuating veins.
Absence of normal flow void on MR

On spin-echo images patent cerebral veins usually will
demonstrate low signal intensity due to flow void.
Flow voids are best seen on T2-weighted and FLAIR
images, but can sometimes also be seen on T1-
weighted images.
A thrombus will manifest as absence of flow void.
Although this is not a completely reliable sign, it is
often one of the first things, that make you think of
the possibility of venous thrombosis.
The next step has to be a contrast enhanced study.
On the left a T2-weighted image with normal flow void

in the right sigmoid sinus and jugular vein (blue
arrow).
Venous thrombosis with absence of normal flow void on T2- On the left there is abnormal high signal as a result of
weighted image.. thrombosis (red arrow).
Absence of normal flow void on MR (2)

The images on the left show abnormal high signal on
the T1-weighted images due to thrombosis.
The thrombosis extends from the deep cerebral veins
and straight sinus to the transverse and sigmoid sinus
on the right.
Notice the normal flow void in the left transverse sinus
on the right lower image.
Absence of normal flow void on MR-images can be

very helpful in detecting venous thrombosis, but there
are some pitfalls as we will discuss later.
Slow flow can occur in veins and cause T1
hyperintensity.
Venous thrombosis with absence of normal flow void on T1-

weighted image.
Venous infarction
The other sign that can help you in making the
diagnosis of unsuspected venous thrombosis is venous
infarction.
Venous thrombosis leads to a high venous pressure
which first results in vasogenic edema in the white
matter of the affected area.
When the proces continues it may lead to infarction
and development of cytotoxic edema next to the
vasogenic edema.
This is unlike in an arterial infarction in which there is
only cytotoxic edema and no vasogenic edema.
Due to the high venous pressure hemorrhage is seen
more frequently in venous infarction compared to
arterial infarction.
Since we are not that familiar with venous infarctions,

we often think of them as infarctions in an atypical
location or in a non-arterial distribution.
However venous infarctions do have a typical
distribution, as shown on the left.
Since many veins are midline structures, venous

infarcts are often bilateral.
This is seen in thrombosis of the superior sagittal
sinus, straight sinus and the internal cerebral veins.
Venous infarction (2) - Superior sagittal sinus

thrombosis
The most frequently thrombosed venous structure is
the superior sagittal sinus.
Infarction is seen in 75% of cases.
The abnormalities are parasagittal and frequently
bilateral.
Hemorrhage is seen in 60% of the cases.
On the left bilateral parasagittal edema and subte

hemorrhage in a patient with thrombosis of the
superior sagittal sinus.
Bilateral infarction in superior sagittal sinus thrombosis
On the left reconstructed sagittal CT-images in a

patient with bilateral parasagittal hemorrhage due to
thrombosis of the superior sagittal sinus.
The red arrow on the contrast enhanced image
indicates the filling defect caused by the thrombus.
Venous infarcts (3) - vein of Labbe

Another typical venous infarction is due to thrombosis
of the vein of Labbé.
On the left images demonstrating hypodensity in the
white matter and less pronounced in the gray matter
of the left temporal lobe.
There is a broad differential diagnosis including
arterial infarction, infection, tumor etc.
Notice that there is some linear density within the
infarcted area.
This is due to hemorrhage.
In the differential diagnosis we also should include a
venous infarct in the territory of the vein of Labbe.
The subtle density in the area of the left transverse
sinus (arrow) is the key to the diagnosis.
This is a direct sign of thrombosis and the next step is
a CECT, which confirmed the diagnosis (not shown).
Venous infarct in Labbé territory
On the left images of a patient with hemorrhage in the

temporal lobe.
When the hemorrhagic component of the infarction is
large, it may look like any other intracerebral
hematoma with surrounding vasogenic edema.
The clue to the diagnosis in this case is seen on the
contrast enhanced image, which nicely demonstrates
the filling defect in the sigmoid sinus (blue arrow).
Hemorrhagic venous infarct in Labbé territory
On the left a similar case on MR.

There is a combination of vasogenic edema (red
arrow), cytotoxic edema and hemorrhage (blue
arrow).
These findings and the location in the temporal lobe,
should make you think of venous infarction due to
thrombosis of the vein of Labbé.
The next examination should be a contrast enhanced
MR or CT to prove the diagnosis.
Hemorrhagic venous infarct in Labbe territory
Venous infarction (4) - Deep cerebral veins

On the far left a FLAIR image demonstrating high
signal in the left thalamus.
When you look closely and you may have to enlarge
the image to appreciate this, there is also high signal
in the basal ganglia on the right.
These bilateral findings should raise the suspicion of
deep cerebral venous thrombosis.
A sagittal CT reconstruction demonstrates a filling
defect in the straight sinus and the vein of Galen
(arrows).
Venous thrombosis of vein of Galen and straight sinus
On the left a young patient with bilateral abnormalities

in the region of the basal ganglia.
Based on the imaging findings there is a broad
differential including small vessel disease,
demyelinisation, intoxication and metabolic disorders.
Continue with the T1-weighted images in this patient.
Notice the abnormal high signal in the internal

cerebral veins and straight sinus on the T1-weighted
images, where there should be a low signal due to
flow void.
This was unlike the low signal in other sinuses.
The diagnosis is bilateral infarctions in the basal
ganglia due to deep cerebral venous thrombosis.
Bilateral infarctions in the basal ganglia due to deep cerebral

venous thrombosis
Venous infarction (5) - Edema

In some cases of venous thrombosis the imaging
findings can resolve completely.
On the left a patient with a subcortical area of high
signal intensity.
The first impression was that this could be a low grade
glioma.
On a follow up scan the abnormalities had resolved
completely.
In retrospect a dense vessel sign was seen in one of
the cortical veins and the diagnosis of venous
thrombosis was made.
The high signal intensity can be attributed to
vasogenic edema due to the high venous pressure
that resulted from the thrombosis.

Imaging in suspected thrombosis
CT-venography
CT-venography is a simple and straight forward
technique to demonstrate venous thrombosis.
In the early stage there is non-enhancement of the
thrombosed vein and in a later stage there is non-
enhancement of the thrombus with surrounding
enhancement known as empty delta sign, as
discussed before.
Unlike MR, CT-venography virtually has no pitfalls.

The only thing that you don't want to do, is to scan
too early, i.e. before the veins enhance or too late,
i.e. when the contrast is gone.
Some advocate to do a scan like a CT-arteriography
and just add 5-10 seconds delay.
To be on the safe side we advocate 45-50 seconds
delay after the start of contrast injection.
We use at least 70 cc of contrast.
On the left some images of a CT-venography

demonstrating thrombosis in many sinuses.
View more images: 1/5
On the left images of a patient with an infarction in

the area of the vein of Labbé.
On the non-enhanced images you can appreciate the
dense thrombus within the transverse sinus and the
hemorrhage in the infarcted area.
On the enhanced images a filling defect can be seen in
the transverse sinus.
You can scroll through the images.
View more images: 1/3
MR-venography
The MR-techniques that are used for the diagnosis of
cerebral venous thrombosis are:
Time-of-flight (TOF), phase-contrast angiography
(PCA) and contrast-enhanced MR-venography:
• Time-of-Flight angiography is based on the

phenomenon of flow-related enhancement of spins
entering into an imaging slice.
As a result of being unsaturated, these spins give
more signal that surrounding saturated spins.
• Phase-contrast angiography uses the principle that
spins in blood that is moving in the same direction as
a magnetic field gradient develop a phase shift that is
proportional to the velocity of the spins.
This information can be used to determine the
velocity of the spins. This image can be subtracted
from the image, that is acquired without the velocity
encoding gradients, to obtain an angiogram.
Transverse MIP image of a Phase-Contrast angiography. • Contrast-enhanced MR-venography uses the T1-
The right transverse sinus and jugular vein have no signal shortening of Gadolinium.
due to thrombosis. It is similar to contrast-enhanced CT-venography.
When you use MIP-projections, always look at the

source images.
On the left a lateral and oblique MIP image from a

normal contrast-enhanced MR venography.
Notice the prominent vein of Trolard (red arrow) and
vein of Labbe (blue arrow).
Every MR techniques has its own pitfalls as we will
discuss in a moment.
Contrast-enhanced MR venography has the
disadvantage that you need to give contrast, but has
less pitfalls.
DSA
Angiography is only performed in severe cases, when
an intervention is planned.
On the left images of a patient with venous

thrombosis, who was unconsious and did not respond
to anticoagulant therapy.
There is thrombosis of the superior sagittal sinus (red
arrow), straight sinus (blue arrow) and transverse and
sigmoid sinus (yellow arrow).
Continue with the video of the thrombectomy.
On the left a video of the thrombectomy.

Pitfalls in CT
Arachnoid Granulations
Arachnoid granulations are small protrusions of the
arachnoid through the dura mater.
They protrude into the venous sinuses and may mimic
filling defects caused by thrombus.
Usually these granulations are easily to differentiate
from thrombosis.
Pseudodelta sign
The dense triangle sign can be mimicked in infants by
the combination of the hypointensity of the
unmyelinated brain and the physiologic polycythemia
resultig in high density of the blood in the sagittal
sinus.
A pseudodelta sign can also be seen in patients with
hyperattenuating acute subarachnoid hemorrhage
around the sinus or subdural empyema or in patients
with a posterior parafalcine interhemispheric
hematoma.
In these cases, administration of contrast material
should opacify the sinus, obliterating the lucent center
of the pseudodelta.
Pseudodelta sign in an infant
Normally veins are slightly denser than brain tissue

and in some cases it is difficult to say whether it is
normal or too dense.
In these cases a contrast enhanced scan is necessary
to solve this problem.
On the left an image of a thrombosed transverse sinus
and next to it a normal transverse sinus.
Normal transverse sinus (left) and thrombosed transverse

sinus (right).
Wrong bolus timing

On the left three images of a patient with venous
thrombosis in the superior sagittal sinus.
On the far left we see a dense vessel sign on the
unenhanced CT.
In the middle an image made 25 seconds after the
start of the contrast injection.
There is arterial enhancement and it looks as if the
superior sagittal sinus enhances, but in fact what we
see is the shine through of the dense thrombus.
Only on the image on the right, which was made 45
seconds after contrast injection there is an empty
delta sign, which proves the presence of a thrombus
in the sinus.
Hematoma simulating venous thrombosis

Usually there is no problem in differentiating a
hematoma from a thrombosed sinus.
On the left a patient with a peripheral intracerebral
hematoma, that on first impression simulates a
thrombosed transverse sinus.
On the left a patient with an subdural hematoma, that

in the region of the superior sagittal sinus results in a
pseudo empty delta sign.
By scrolling through the data set, it was obvious that
it was an extention of the hematoma.

Pitfalls in MRI
Hypoplastic transverse sinus

Hypoplasia and aplasia of the right or left transverse
sinus is a common finding.
It can easily be mistaken for sinus thrombosis,
because on the MRA one of the transverse sinuses is
missing.
When you suspect, that there is a hypoplastic
transverse sinus, then you should look at the size of
the jugular foramen.
On the left images of a patient with hypoplasia of the
left transverse sinus.
Notice the size difference of the jugular foramen.
On the left a transverse MIP of phase-contrast

images.
To differentiate whether there is a hypoplastic
transverse sinus or thrombosed sinus, you need to
look at the source images.
On the source image on the right you can see that
there is no hypoplasia (blue arrow).
In this case there thrombosis of the left transverse
sinus.
On the left another case that demonstrates that you

cannot fully rely on phase contrast imaging.
The signal in the vein depends on the velocity of the
flowing blood and the velocity encoding by the
technician.
On the far left a patient with non visualization of the
left transverse sinus.
This could be hypoplasia, venous thrombosis or slow
flow.
On the contrast enhanced T1-weighted image it is
obvious that the sinus fills with contrast and is patent.
Low signal intensity in thrombus

Normally when there is low signal in a vein, it is
attributed to flow void and a sign of patency of the
vein.
However at some stage of the thrombus there is
intracellular deoxyhemoglobin, which is dark on T2
and mimics flow void.
On the left there is a thrombosed right transverse
sinus with a delta sign on the contrast enhanced
image.
Thrombus in right transverse sinus is dark on T2 due to The sinus has a low signal intensity on the T2-
intracellular deoxyhemoglobin (Courtesy dr. Howard Rowley) weighted image as a result of the intracellular
deoxyhemoglobin.
On the contrast enhanced T1-weighted image it is
obvious that the sinus is filled with thrombus.
Flow void on contrast-enhanced MR

On the contrast enhanced T1 images on the left there
is an area of low signal intensity within the enhancing
transverse sinus.
This could easily been mistaken for a central thrombus
within the sinus.
This however is the result of flow void.
Continue with the phase contrast images.
On the phase contrast images it is obvious that the

transverse sinus is patent.
We can conclude that MRI has many false positives

and negatives in the diagnosis of venous thrombosis.
Contrast enhanced MR-venography is the most
reliable MR technique. CT-venography is even more
reliable, because it is easy and less sensitive to
pitfalls.
Pitfalls in TOF imaging are:
• Signal loss due to in-plane flow.

• Flow simulated by T1-shine thru of methemoglobin
within thrombus.

Chronic dural sinus thrombosis and
related syndromes
DAVF
Chronic dural sinus thrombosis can lead to dural
arteriovenous fistula formation and to increased CSF
pressure.
A DAVF or dural arteriovenous fistula is an abnormal

connection between dural arteries, which are branches
of the external carotid with the venous sinuses. Sinus
thrombosis is seen in many patients with a dural
arteriovenous fistula, but the pathogenesis is still
unclear (10).
There are two possible mechanisms: (a)
thrombophlebitis of the dural sinus may induce a dural
fistula and (b) in the course of a dural fistula flow
reversal may lead to thrombosis.
Current classifications of DAVF focus mainly on the
presence of leptomeningeal reflux related to cerebral
venous hypertension leading to cerebral venous
infarction or hemorrhage.
On the left DSA images of a patient with a DAVF.

Notice the direct communication between the
branches of the external carotid artery and the
transverse sinus (blue arrow).
Continue with the T2-weighted images.
On the left T2-images during the follow up.

In april 2008 there were no abnormalities.
In january 2009 there are signs of intracranial
hypertension like CSF surrounding the optic nerve and
CSF within the stalk of the hypophysis.
Thrombosis and increased CSF pressure

In some patients dural sinus thrombosis may, even
after recanalisation, lead to persisting disturbances in
venous circulation.
This may lead to raised intracranial CSF pressure as
assessed by lumbar puncture.
Clinically, these patients complain of headaches and
they may have vision disturbances due to papil
edema.
On MRI, one may see increased CSF around the optic
nerve and an empty sella.
Apparently in some patients a residual stenosis
persists.
On the left a T2-weighted image demonstrating papil

edema and an empty sella.
Continue with the sagittal T1-weighted image.
On the left a sagittal T1-weighted image

demonstrating the empty sella (arrow).

Venous territories
On the left an illustration of the territories of the

venous drainage.
There is great variation in these territories and the
illustration should be regarded as a rough guide.
References
1. Imaging of Cerebral Venous Thrombosis: Current Techniques, Spectrum of Findings, and Diagnostic Pitfalls
by James L. Leach et al
October 2006 RadioGraphics, 26, S19-S41
2. Brain, Venous Sinus Thrombosis
in eMedicine by Mahesh R Patel
3. Diagnostic Value of Multidetector-Row CT Angiography in the Evaluation of Thrombosis of the Cerebral Venous
Sinuses
by J. Linn et al
American Journal of Neuroradiology 28:946-952, May 2007
4. Cerebral Venous Thrombosis and Multidetector CT Angiography: Tips and Tricks
by Mathieu H. Rodallec et al
October 2006 RadioGraphics, 26, S5-S18.
5. The Empty Delta Sign
by Emil J. Y. Lee
September 2002 Radiology, 224, 788-789.
6. Radiologic Diagnosis of Cerebral Venous Thrombosis: Pictorial Review
by Colin S. Poon et al
AJR 2007; 189:S64-S75
7. PDF: Cerebral venous thrombosis: pathogenesis, presentation and prognosis
by J van Gijn
JRSM Volume 93, Number 5 Pp. 230-233
8. Superior Sagittal Sinus Thrombosis: Subtle Signs on Neuroimaging
by Phua Hwee Tang et al
Ann Acad Med Singapore 2008;37:397-401
9. Comparison of CT Venography with MR Venography in Cerebral Sinovenous Thrombosis
by N. Khandelwal et al
AJR 2006; 187:1637-1643
10. Intracranial dural arteriovenous fistulas with or without cerebral sinus thrombosis: analysis of 69 patients
by L K Tsai et al
J Neurol Neurosurg Psychiatry 2004;75:1639-1641

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Venous Thrombosis Page 1 of 15

The Radiology Assistant

Cerebral Venous Thrombosis

Cerebral venous thrombosis is located in descending

• Major dural sinuses:

Clinically patients with cerebral venous thrombosis

Venous thrombosis has a nonspecific presentation and

On a routine non-enhanced MR or CT you should think

• Direct signs of a thrombus

Dense clot sign

Normally veins are slightly denser than brain tissue

Dense clot sign (2)

Dense clot sign in a thrombosed cortical vein.

Dense clot sign (3)

Empty delta sign

Empty delta sign (2)

Absence of normal flow void on MR

On the left a T2-weighted image with normal flow void

Absence of normal flow void on MR (2)

Absence of normal flow void on MR-images can be

Venous thrombosis with absence of normal flow void on T1-

Since we are not that familiar with venous infarctions,

Since many veins are midline structures, venous

Venous infarction (2) - Superior sagittal sinus

On the left bilateral parasagittal edema and subte

Bilateral infarction in superior sagittal sinus thrombosis

On the left reconstructed sagittal CT-images in a

Venous infarcts (3) - vein of Labbe

On the left images of a patient with hemorrhage in the

Hemorrhagic venous infarct in Labbé territory

On the left a similar case on MR.

Hemorrhagic venous infarct in Labbe territory

Venous infarction (4) - Deep cerebral veins

Venous thrombosis of vein of Galen and straight sinus

On the left a young patient with bilateral abnormalities

Notice the abnormal high signal in the internal

Bilateral infarctions in the basal ganglia due to deep cerebral

Venous infarction (5) - Edema

Unlike MR, CT-venography virtually has no pitfalls.

On the left some images of a CT-venography

On the left images of a patient with an infarction in

View more images: 1/3

• Time-of-Flight angiography is based on the

When you use MIP-projections, always look at the

On the left a lateral and oblique MIP image from a

On the left images of a patient with venous

Continue with the video of the thrombectomy.

On the left a video of the thrombectomy.

Pseudodelta sign in an infant

Normally veins are slightly denser than brain tissue

Normal transverse sinus (left) and thrombosed transverse

Wrong bolus timing

Hematoma simulating venous thrombosis

On the left a patient with an subdural hematoma, that

Hypoplastic transverse sinus

On the left a transverse MIP of phase-contrast

On the left another case that demonstrates that you

Low signal intensity in thrombus

Flow void on contrast-enhanced MR

Continue with the phase contrast images.

On the phase contrast images it is obvious that the

We can conclude that MRI has many false positives