Clinical and Angiographic Imaging Features of Isolated Cortical Venous Thrombosis

Cerebral venous thrombosis usually presents as dural sinus thrombosis. More rarely, it occurs in an isolated form (isolated cortical vein thrombosis; ICoVT). ICoVT is poorly recognized and underdiagnosed, and noninvasive imaging remains nebulous. The digital subtraction angiographic (DSA) patterns of ICoVT are neither well known nor documented. We present clinical and imaging details of the largest series of ICoVT, with all cases demonstrating both noninvasive imaging findings, along with angiographic confirmation. We propose a preliminary compilation of the DSA patterns of ICoVT.

We identified all patients with cerebral venous thrombosis at our institution between January 2013 and June 2019. Only patients in whom ICoVT was diagnosed and/or suspected with computed tomographic venography and/or magnetic resonance imaging/MR venogram with subsequent DSA confirmation were included. DSA imaging was reviewed for direct and indirect signs. Clinical data, outcomes, and follow-up imaging were analyzed.

We identified 109 patients with cerebral venous thrombosis; in 21 patients ICoVT was suspected on noninvasive imaging and eventually had DSA confirmation. Headache and focal neurological deficit were the most common presentations (each 67%). Ten patients (47%) presented with parenchymal changes due to ICoVT and 15 patients (71%) presented with subarachnoid hemorrhage. We identified 5 DSA patterns of ICoVT (3 direct; 2 indirect). Filling defects in cortical veins and the regional absence of cortical veins and decreased subcortical opacification were the most common patterns (52% and 90%, respectively). Sixteen patients (76%) were anticoagulated. Eighteen patients were discharged without disability or minor disability (84%). No deaths occurred.

Catheter angiography/venography may be important in diagnosing ICoVT, especially when magnetic resonance imaging/MR venogram is unclear. The angiographic patterns of ICoVT are presented.