1. Neuroimaging findings in pediatric cerebral sinovenous thrombosis
EP-120
Neuroimaging findings in pediatric cerebral sinovenous thrombosis
Matthias W. Wagner ¹, Thangamadhan Bosemani ¹, Alexander Oshmyansky 1,2, Andrea Poretti ¹, Thierry A.G.M. Huisman ¹
¹Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; ²School of Mathematical Sciences, Faculty of Science and Engineering, Queensland University of Technology, Brisbane, QLD, Australia
ASNR 53rd Annual Meeting, Chicago, April 25-30, 2015

2. Disclosure We have nothing to disclose
No relevant financial relations interfering with the presentation

3. Cerebral sinovenous thrombosis (CSVT)
Thrombosis in:
Superficial (cortical veins, superior sagittal sinus, transverse sinus, sigmoid sinus, and jugular vein) or
Deep (inferior sagittal sinus, internal cerebral veins, vein of Galen, straight sinus) venous system
Incidence: 1 of 100,000 children
Accounts for 1 in 4 cases of pediatric stroke
Mortality rate = 8-19%
Severe long-term neurological sequelae in 38-48% of patients

4. CSVT and neuroimaging Role of neuroimaging in the diagnosis of CSVT:
To visualize and characterize the thrombus
To identify the degree of impaired flow within affected venous system
To rule out secondary complications (venous ischemia / hemorrhage)
Techniques
CT ± venography (CTV)
MRI ± venography (MRV)
Conventional angiography
Trans-fontanel Doppler ultrasonography
MRI = modality of choice in pediatric CSVT
Conventional sequences (T1, T2, FLAIR)
Advanced sequences (DWI/DTI, SWI)

5. Purpose
Analysis of MRI signal changes of the thrombus over time in pediatric CSVT
Evaluation of the role of DWI/DTI in the diagnosis of pediatric CSVT

6. Inclusion criteria Age at MRI < 18 years
Neuroimaging diagnosis of CSVT

7. Methods 1 Clinical histories reviewed for: Definition of thrombus age:
Age and gender of children
Risk factors for CSVT
Neurologic manifestation related to CSVT
Time point of 1) onset of symptoms and 2) neuroimaging diagnosis
Definition of thrombus age:
Interval: onset of symptoms/findings  neuroimaging diagnosis of CSVT

8. Methods 2 Retrospective evaluation of thrombi for:
Location
Number
Signal characteristics
Assessment of intraparenchymal edema and/or hemorrhagic infarction secondary to CSVT

9. Methods 3 MRI sequences used:
T1w/T2w/FLAIR: iso-, hypo-, hyperintense signal compared to adjacent gray matter
CE-MRV and TOF-MRV: presence or absence of flow
DTI: normal or restricted diffusion
SWI: hypointense signal

10. Methods 4 Statistical analysis:
Evaluation of relation between age of thrombus and appearance of thrombus on T1w, T2w, FLAIR, and DWI/DTI images  z-test
p-value <0.05 = statistically significant

11. Results 1: Patients 33 children with CSVT 18 male (55%)
Median age at time of brain MRI: 5.59 years (range: 4 days to years)
5 patients (15%) = neonates
10 patients (30%) = < 1 year

12. Results 2: Risk factors Risk factors found in 28 children (85%):
Traumatic head injury (12 patients, 37%)
Head and neck infections (6 patients, 18%)
Bacterial meningitis (Strep. pneumoniae / anginosus, MRSA), 4 children
Viral encephalitis (presumed Herpes simplex virus), 1 child
Lemierre syndrome, 1 child
Otitis media complicated by mastoiditis due to Strep. pneumoniae, 1 child
Prothrombotic disorders (5 patients, 15%)
Acute lymphatic leukemia, Antiphospholipid syndrome, Prothrombin G20210A mutation, Antithrombin III deficiency, Elevated homocysteine level, each 1 child
Other (5 patients, 15%)

13. Results 3: Neurologic manifestation
Seizures = 11 children (37%)
Diffuse neurologic signs:
Decreased level of consciousness = 15 children (50%)
Headache = 11 children (37%)
Papilledema = 1 child (3%)
Focal neurologic signs:
Hemiparesis = 2 children (7%)
Acute visual, speech or hearing impairment = 4 children (13%)
Paraplegia = 1 child (3%)
None = 3 children (9%)

14. Results 4: Thrombus age/location
Data for thrombus age calculation available in 26/33 children:
<1 day = 15 patients (45%); <8 days = 10 children (31%); >8 days = 1 child (3%)
33 children  total of 77 thrombi
Multiple thrombi found in 24 patients (73%):
5 thrombi = 1 child; 4 thrombi = 3 children; 3 thrombi = 9 children; 2 thrombi = 11 children; 1 thrombus = 9 patients
Location:
89% in superficial venous system  transverse (34%) / sigmoid (24%) sinuses most common locations

15. Results 5: MRI characteristics
Number of thrombi
Hypo
Iso
Hyper
Reduced/absent flow
Restricted diffusion
T1w
77 (100%)
14 (19%)
21 (28%)
39 (53%) -
T2w
16 (22%)
20 (27%)
38 (51%)
FLAIR
14 (21%)
6 (8%)
48 (71%)
TOF-MRV
47 (61%)
40 (85%)
CE-MRV
14 (18%)
14 (100%)
DTI
72 (94%)
29 (40%)
SWI
33 (43%)
11 (33%)
9 (27%)
Intraparenchymal changes in 11/33 children (33%)  cytotoxic edema + hemorrhagic infarction in 7, cytotoxic edema in 2, hemorrhagic infarction in 2 patients

16. Results 6: MRI pattern of 77 thrombi
T1w
T2w
FLAIR
DTI
n (%) 1
iso
hyper
variable
normal/restricted
14 (18%) 2 3
13 (17%) 4
hypo
10 (13%) 5
9 (12%) 6
4 (5%) 7
3 (4%) 8
2 (3%) 9
For 6 thrombi (7%) no pattern could be defined; hyper, hyperintense; hypo, hypointense; iso, isointense

17. Results 7: Statistics Age of thrombus  hyperintense signal on T1w:
p=0.002 for thrombus age <1 day vs. 1-8 days
p=0.036 for thrombus age <1 day vs. >8 days
No statistically significant correlation age of thrombus  signal on T2w, FLAIR, and DTI

18. Example 1
11-year-old male with early subacute thrombosis (7 days to diagnosis) of the superior sagittal sinus
A: Isointense clot on sagittal T1w (arrow)
B: Hyperintense clot on axial T2w (arrow)
C: Isointense clot on
axial FLAIR image
D: Trace of diffusion and E: matching ADC map: restricted diffusion (bright on D, dark on E) within clot in the superior sagittal sinus (arrows)

19. Example 2
6-year-old female with hyperacute thrombosis (hours to diagnosis) of the right jugular vein
A: Hyperintense clot on sagittal T1w (arrow)
B: Hyperintense clot on axial T2w (arrow)
C: Hyperintense clot on axial FLAIR (arrow)
D: Trace of diffusion and E: matching ADC map: normal diffusion in right jugular vein (arrows)

20. Example 3
7-month-old female with hyperacute thrombosis (hours to diagnosis) of the right sigmoid sinus A: Hyperintense clot on axial T2w (arrow)
B: Matching axial minimum intensity projection (minIP)-SWI image: isointense signal in same location (arrow)
6-year-old female with hyperacute thrombosis (hours to diagnosis) of the right transverse sinus
C: Isointense clot on axial T2w (arrow)
D: Matching axial minIP-SWI image shows hypointense signal at corresponding level (arrow)

21. Conclusions Diagnosis of CSVT in children = CHALLENGING
MR sequences individually not sensitive enough for an accurate diagnosis of pediatric CSVT
DTI + SWI = no complementary value
Correlation between thrombus age and signal intensity on different MR sequences:
Only age <1 day  hyperintense signal on T1w