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Diffusion-Weighted Magnetic Resonance in Cerebral Venous Thrombosis
Kon Chu, MD;
Dong-Wha Kang, MD, PhD;
Byung-Woo Yoon, MD, PhD;
Jae-Kyu Roh, MD, PhD
Arch Neurol. 2001;58:1569-1576.
ABSTRACT
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Background Cerebral venous thrombosis (CVT) is a cause of stroke with obscure pathophysiologic
properties that differ from arterial stroke. Its main mechanisms of pathophysiology
are the breakdown of the blood-brain barrier and the coexistence of cytotoxic
and vasogenic edema. However, conventional magnetic resonance imaging (MRI)
cannot differentiate between vasogenic and cytotoxic edema.
Objectives To describe the diffusion-weighted imaging (DWI) findings and characterize
the clinical applications of DWI in CVT.
Setting A tertiary referral center, neurology department.
Design and Methods From November 1998 to March 2001, 14 patients (5 men, 9 women; mean
age, 43 ± 10 years) with CVT underwent DWI, conventional MRI, MR venography,
or conventional cerebral angiography. Abnormal findings on DWI and conventional
MRI indicated the necessity of MR venography and conventional angiography
to confirm the diagnosis of CVT. Apparent diffusion coefficient (ADC) values
were measured in all of the abnormal lesions with visual inspection of DWI
and T2-weighted echo planar imaging.
Results Findings on DWI were grouped according to 3 patterns: (1) Heterogeneous
signal intensity (SI) (10 patients) showed mixed bright high SI and low SI
and the corresponding ADC values were inversely correlated to the DWI SI.
The areas of prominent low SI on DWI were reversed with adequate treatment
on follow-up MRI in 1 patient. (2) Multifocal high SI (3 patients) was similar
to that observed in acute arterial stroke. The corresponding ADC values were
decreased and DWI was performed in the acute stages. (3) Intravascular clot
with high SI was found with (1 patient, also in heterogenous SI group) or
without (1 patient) parenchymal lesions. In 1 patient, DWI demonstrated T2-negative
and fluid attenuated inversion recovery–negative lesions without correlative
symptoms.
Conclusions These data suggest that DWI with ADC maps can be used to discriminate
between types of edema for tissue viability and to provide information about
stages and diagnostic clues in CVT.
INTRODUCTION
DIFFUSION-weighted imaging (DWI), first developed by Le Bihan et al,1 can detect changes in water diffusion associated with
cellular dysfunction and can be used to detect ischemic lesions of the brain
within the first few hours of stroke onset.2
The application of DWI in diagnosing arterial stroke is well established and
has been demonstrated by numerous experimental and clinical studies3, 4, 5, 6, 7, 8, 9
to show an early decrease and late increase, or normalization, of the apparent
diffusion coefficient (ADC). It has been well documented that cytotoxic edema,
related to acute infarction, is characterized by markedly decreased diffusion
and that increased interstitial water in vasogenic edema10
demonstrates increased diffusion. Conventional magnetic resonance imaging
(MRI) cannot differentiate between vasogenic and cytotoxic edema.
Cerebral venous thrombosis (CVT) is a cause of stroke with obscure pathophysiologic
properties that differ from arterial occlusion. Röther et al11 summarized the mechanisms: (1) Increased pressure
in the superior sagittal sinus results in reduced capillary perfusion pressure12 and increased cerebral blood volume.13
(2) Obstruction to venous flow leads to increased intracranial pressure and
blood-brain barrier disruption, resulting in decreased cerebral blood flow.14 (3) The net capillary filtration increases, leading
to progressive cerebral edema with (4) intracerebral and subarachnoid hemorrhage
additionally compromising the brain tissue.15
There have been a few case reports on the application of DWI in patients
with CVT.16, 17, 18
These reports revealed that the most striking feature of DWI findings was
that reversible ADC changes (decrease16, 17
or increase18) were evident during the acute
period of CVT. More recently, various DWI results have been reported,19, 20 such as heterogenous findings and
the possibility that cytotoxic edema is a feature of CVT.
We report various DWI findings in CVT and evaluate the prognostic value
of DWI. Furthermore, the mechanisms of venous stroke were characterized by
analyzing ADC maps.
METHODS
From November 1998 to March 2001, 14 consecutive patients (5 men, 9
women; mean age, 43 ± 10 years) with CVT underwent DWI, conventional
MRI, MR venography (MRV), or conventional cerebral angiography. Magnetic resonance
venography and conventional angiography were performed after DWI and conventional
MRI findings strongly suggested CVT. Cerebral venous thrombosis was diagnosed
by abnormal findings on conventional MRI (empty delta, high signal intensity
(SI) in venous sinuses, and parenchymal lesions), MRV (nonvisualization of
venous sinus and cerebral veins other than the asymmetry of transverse sinuses),
or conventional angiography. The time taken from onset of stroke to DWI was
variable (1-30 days). Detailed characteristics of patients and MRI findings
are presented in Table 1 and Table 2. The patients were examined using
a 1.5-T MRI unit (Signa Horizon, Echospeed; General Electric Medical Systems,
Milwaukee, Wis) with echo planar imaging capability. Fast-spin echo T2-weighted
images (T2WI; TR/TE, 4200/112 millisecond; field of view, 21 x 21 cm;
matrix, 256 x 192; and slice thickness, 5 mm with 1.5-mm gap) were obtained.
A DWI was obtained in the transverse plane using single-shot echo planar imaging
(TR/TE, 6500/125 milliseconds; field of view, 24 x 24 cm; matrix, 128
x 128; slice thickness, 5 mm with 2.5-mm gap; and 2 b values, 0 and
1000 mm2/s). The diffusion gradients were applied along 3 axes
(x, y, z) simultaneously. The ADC was calculated
based on the Stejskal-Tanner equation21 as
the negative slope of the linear regression line best fitting the points for
b vs ln SI—the SI from the region of interest within the images acquired
at each b value. Apparent diffusion coefficient maps were created by performing
this calculation on a pixel-by-pixel basis. The respective ADC values are
described (Figure 1, Figure 2, Figure 3, and Figure 4, and Table 2). Normal ADC values of the parenchyma and white matter ranged
from 0.78 to 0.91 x10 -3mm2/s (Chu et al,
unpublished data, 2000). Regions of interest were carefully drawn in the abnormal
areas on calculated average ADC maps as well as in normal-appearing areas
with variable sizes. The selection of regions of interest was made with the
help of T2-weighted echo planar images obtained by the same method of acquisition
as the diffusion images (ie, images generated from the diffusion sequence
with diffusion sensitivity, b = 0); this was to avoid errors in regions of
interest selection caused by spatial distortions leading to discrepancies
between diffusion images and conventional MRIs. The analyses of images and
ADC values were performed by expert neuroradiologists (Kee-Hyun Chang, MD,
PhD, Seoul, Korea) and neurologists (K.C. and D.-W.K.). Perfusion-weighted
MRI was not performed.
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Table 1. Summary of Patient Characteristics
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Table 2. Summary of MRI Findings*
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Figure 1. Patient 1. A, Initial diffusion-weighted
image (DWI), performed 10 days after onset of stroke, shows heterogenous signal
intensity (SI) in left basal ganglia and high SI in the right basal ganglia.
B, Apparent diffusion coefficient map indicates normal values (0.85-0.86 x
10 -3mm2/s) in the area of very bright SI on DWI
(solid arrows), and elevated values (1.74-1.78 x 10 -3mm2/s) in the area of mildly bright SI on DWI (dotted arrows). C, Initial
T2-weighted image shows high SI in the bilateral basal ganglia and left caudate
intracerebral hemorrhage and intraventricular hemorrhage. D, Follow-up T2-weighted
image, performed 1 month later, demonstrates remnant high SI in the previously
very bright area on DWI and otherwise normal findings.
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Figure 2. Patient 9. A, Diffusion-weighted
image (DWI), performed 15 days after onset, indicates high signal intensity
(SI) in the right frontal lobe (dotted arrow) with surrounding low SI (solid
arrow). High SI of the clot in superior sagittal sinus is also seen (dashed
arrow). B, Apparent diffusion coefficient (ADC) map indicates decreased ADC
values (0.51-0.52x10 -3mm2/s) in very bright
SI region on DWI and high ADC values (1.45x10 -3mm2/s) in the surrounding low SI region on DWI. The ADC values of the
clot are decreased (0.32x10 -3mm2/s) C,
T1-weighted sagittal image shows high SI in the superior sagittal sinus. D,
T2-weighted magnetic resonance image shows high SI in right frontal lobe.
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Figure 3. Patient 11. A and B, Diffusion-weighted
images show multiple high signal intensity (SI) lesions in the left hemisphere
and their corresponding apparent diffusion coefficient values are 0.53-0.59x10 -3mm2/s (arrows). C, Initial fluid-attenuated inversion
recovery image shows high SI in the left parieto-occipital lobes. D, Initial
magnetic resonance venograph, performed 12 days after onset, shows filling
defects in superior sagittal sinus (arrow).
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Figure 4. Patient 14. A, Diffusion-weighted
image, performed 20 days after onset, shows clot high signal intensity (SI)
(arrow) in the right internal jugular vein. B, The attenuated inversion recovery
map demonstrates low SI in the clot and its apparent diffusion coefficient
values are 0.43-0.55 x 10 -3mm2/s. C, Fluid-attenuated
inversion recovery image shows high SI in the right internal jugular vein.
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RESULTS
Based on the patterns of SI on DWI and ADC maps, we classified the DWI
findings into 3 groups: heterogeneous SI, multifocal high SI, and high SI
in clots. The characteristics of the groups are described.
HETEROGENEOUS SI GROUP (PATIENTS 1-10)
Heterogeneous SI indicated nonhemorrhagic venous infarcts (patients
1-8). Apparent diffusion coefficient maps showed normal ADC values (0.75-0.86
x 10 -3mm2/s) in the areas of very bright
SI and elevated ADC values (1.64-1.78 x 10 -3mm2/s) in mildly bright SI areas on DWI (eg, patient 1, Figure 1B). Anticoagulation therapy was initiated and the patient's
symptoms and signs were completely normalized. A follow-up MRI of patient
1 was obtained 1 month later. The heterogeneous SI on DWI had disappeared
completely and the ADC values had returned to normal (0.72-0.78 x 10 -3mm2/s). A follow-up T2-weighted image depicted high
SI remaining in a previously very bright lesion on the initial DWI (Figure 1D). Diffusion-weighted imaging results
and ADC maps of the rest of the group (patients 2-8) showed similar findings.
In patient 9, the area of heterogeneous SI had a dark, thin rim surrounded
by low SI (Figure 2). The very bright
SI with a dark rim indicated a hemorrhagic signal. Apparent diffusion coefficient
maps depicted decreased ADC values (0.51-0.52 x 10 -3mm2/s) in the very bright SI region (hemorrhagic cavity) on DWI and high
ADC values (1.45 x 10 -3mm2/s) in the surrounding
low SI region on DWI. The findings of DWI and ADC maps were similar in patient
10.
MULTIFOCAL HIGH SI GROUP (PATIENTS 11-13)
This type of DWI finding (Figure 3)
would be expected for an acute arterial stroke (patient 11). The corresponding
ADC values were decreased (0.53-0.59 x 10 -3mm2/s) on ADC maps. The values were low in all of the multiple lesions
on DWI and similar to those observed for an acute arterial stroke. The diagnosis
of CVT in this patient was confirmed by the visualization of high SI of the
thrombus in the cerebral venous sinus on T1-weighted MRI and nonvisualization
of the right transverse sinus and superior sagittal sinus on MRV. The MRI
findings of patients 12 and 13 were similar. The multiple MRI lesions did
not correlate with clinical symptoms and signs, such as focal neurologic deficits.
After commencing anticoagulation therapy, the symptoms disappeared within
a week and no follow-up MRI was obtained.
HIGH SI IN CLOTS GROUP (PATIENTS 7 AND 14)
High SIs in clots were found in the cerebral veins and sinuses (Figure 4) with (patient 7) or without (patient
14) parenchymal involvement. The corresponding ADC values of the clots were
very low (0.43-0.55 x 10 -3mm2/s) compared
with those of cerebrospinal fluid (3.05-4.75 x 10 -3mm2/s) in patient 14. The ADC values of the clot in patient 7 (Figure 2A and B) were also very low (0.32
x 10 -3mm2/s).
COMMENT
Findings of CVT on DWI have several distinctive aspects compared with
those of arterial stroke. We observed 3 patterns in the DWI findings: heterogeneous
SI, multifocal high SI, and high SI in clots. Conventional MRI images (T2
and fluid-attenuated inversion recovery) depicted similarly high SIs for the
areas of venous congestion and infarct and cannot be used to differentiate
between the types of edema.
HETEROGENOUS SI IN NONHEMORRHAGIC VENOUS INFARCT
The heterogenous SI group included nonhemorrhagic and hemorrhagic venous
infarctions. Nonhemorrhagic venous infarctions (patients 1-8) were indicated
by the combination of cytotoxic and vasogenic edema on DWI, and the SI was
inversely correlated with the corresponding ADC value. The experimental CVT
study reported an early decrease (<48 h), and late increase (>48 h) in
ADC values,10 demonstrating that early cytotoxic
edema preceded late vasogenic edema. Corvol et al16
and Manzione et al17 reported that rapid MRI
scanning during the acute period (within 24 hours) revealed decreased ADC,
which was later reversed by suitable treatment. Keller et al18
reported that DWI findings, obtained 1 day after the onset of symptoms, revealed
high ADC values, which suggested the existence of a predominantly vasogenic
edema. Their DWI findings correlated well with a previous experimental study.10 Diffusion-weighted image results and ADC maps in
this group, performed at the early to late subacute stages (3-30 days), showed
normal to increased ADC values.
Recently, heterogenous SI on DWI was reported.19, 20
It was observed that ADC values decreased up to 16% in the acute stage and
increased or were normalized within 4 days. In 1 patient in the series,19 the ADC values were were very low (0.3-0.4,10 -3mm2/s) and the abnormal region turned out to be hemorrhagic.
Most of the high ADC region disappeared on follow-up images.19
In our study, DWI in the heterogeneous SI group depicted variable and
high SI, very bright, high SI in the normal ADC regions, and high SI in the
high ADC regions. The high SI despite the normal to high ADC values was probably
owing to a T2 shine-through effect. As with T1- and T2-weighted images, DWI
is not a pure map of ADC but contains mixed contributions from spin density
and T2 effects.22, 23 Because of
these shine-through effects, the DWI should be interpreted with reference
to ADC maps. The diagnostic information provided by DWI and ADC maps is not
identical.
The ability to differentiate between the different types of edema is
important because of their relationship with tissue viability. Follow-up DWI
and conventional MRI results in patient 1 depicted an almost complete disappearance
of the multiple lesions in the bilateral basal ganglia, brainstem, and cerebellum,
which had previously shown high ADC values at the onset of clinical improvement.
The multiple high ADC lesions were caused by disruption of the blood-brain
barrier and were not necessarily associated with cellular damage. Preservation
of neuronal tissue was also documented by Hsu et al,24
using proton MR spectroscopy in a case of deep CVT. The authors suggested
that although the tissue was impaired, it was still viable.
HETEROGENOUS SI OF HEMORRHAGIC VENOUS INFARCT
The heterogenous SI group had an additional factor: SI attributed to
hemorrhage (patients 7, 8). The bright SI of the hemorrhagic clot on DWI was
owing to the paramagnetic effect of the intracellular methemoglobin, and the
surrounding low SI with high ADC values was probably caused by vasogenic edema.
Between these, a thin rim of low SI was observed, suggesting the occurrence
of hemosiderin.25, 26 Diffusion-weighted
imaging and ADC measurement of intracranial hematoma were recently reported
by Atlas et al.27 The authors suggested that
the determining factors of ADC values in hematoma may be the paramagnetic
effects of the methemoglobin rather than restriction of water movement. Apparent
diffusion coefficient values suddenly rise in the late subacute stage during
which the red blood cells start to lyse and the intracellular methemoglobin
switches to the extracellular state.27 Our
DWI findings and ADC values of patients 9 and 10 reflected those findings.
MULTIFOCAL HIGH SI OF VENOUS INFARCT
The second type of DWI abnormality was manifested as multifocal high
SI (patients 11-13). The ADC values of the lesions were as low as those observed
for arterial stroke. Cerebral venous thrombosis was diagnosed by the abnormalities
observed with conventional MRI and MRV. Time interval from onset to DWI was
rather short (5 days in patient 11, 2 days in patient 12, 1 day in patient
13); DWI findings of this group may represent the acute stages. Forbes et
al20 reported the initial ADC decrease in patients
with CVT and the ADC decrease returned to normal or increased within 4 days.
Anticoagulation was immediately initiated after the MRI results were obtained.
The clinical symptoms disappeared completely after the anticoagulation therapy.
The mechanisms of multifocal high SI on DWI are not well known. However,
Manzione et al17 reported a similar reversible
ADC decrease in multiple high SI lesions on DWI. They suggested that a variety
of different mechanisms in diffusion abnormalities in CVT probably occur,
resulting in a local increase in transcapillary and interstitial pressure
rather than failure of the tissue energy state.17
The high SIs on DWI and low ADC values do not always indicate irreversibility
but rather the presence of tissue at risk. Dardzinski et al28
reported progressive ADC changes during a period after permanent middle cerebral
artery occlusion and suggested the ranges of ADC values as follows: (1) <0.45
x 10 -3mm2/s, severe ischemia and irreversible
damage will occur; (2) >0.55 x 10 -3mm2/s,
infarction will not occur; (3) 0.45-0.55 x 10 -3mm2/s, potentially reversible. Our results (ADC values, 0.53-0.59 x
10 -3mm2/s) correspond well to the previous reports.
With adequate treatment, DWI abnormalities with low ADC values may be reversible
in CVT as with the cells in ischemic penumbra.
SI OF CLOTS IN SINUSES
Diffusion-weighted imaging also showed high SI of the intravascular
clots, which has not previously been reported (patients 7 and 14). The corresponding
ADC values of the intravascular clots were observed to decrease (0.43-0.55,
10 -3mm2/s), which means that the high SI of the
clot could not be attributed to T2 shine-through effects. Our report is the
first to our knowledge to describe the DWI findings of an intravascular clot
at the early subacute stage with an analysis of corresponding ADC values.
We suggest that the SI of the clot in DWI was owing to the paramagnetic effect
of the clot (intracellular methemoglobin). Furthermore, the DWI of patient
11 depicted abnormality in the clot SI alone without any visible parenchymal
lesion.
The appearances of clots on conventional MRIs and the variable stages
associated therewith have been well described by Bianchi et al.26
The T1, T2, and fluid-attenuated inversion recovery SIs were also high and
our findings are similar to the early subacute stage thrombus described by
Bianchi et al.26 Intraluminal clots evolve
at stages similar to parenchymatous hematomas depending on the paramagnetic
effects of hemoglobin degradation products.29, 30
The evolution of the MRI signal from parenchymal hemorrhages does not differ
markedly from venous thrombosis. However, eventually hemorrhage will show
a peripheral rim of low SI on T1-weighted, T2-weighted, and DWI results, which
is characteristic of hemosiderin. This feature is absent in the venous sinuses,
which are not able to accumulate macrophages containing hemosiderin.25, 26 At the subacute stage, the clots
first become hyperintense on T1 with persisting low SI on T2 images and then
appear hyperintense on both T1 and T2 images.26
Atlas et al27 reported the ADC changes during
the evolution of the hematoma. They suggested that the potential mechanisms
of the ADC decrease in early hematoma may be summarized as follows: (1) a
shrinkage of extracellular space with clot retraction; (2) a change in osmotic
environment; (3) conformational changes of the hemoglobin macromolecule within
the RBC; and (4) contraction of intact red blood cells.27
DETECTION OF THE SUBCLINICAL ABNORMALITIES
Diffusion-weighted imaging findings in patient 3 showed T2-negative
mixed SI in the right high frontal lobe. The location of the lesion also correlated
well with the thrombosed cortical veins and sinuses (high SI on T1- and T2-weighted
MRIs). However, the patient exhibited no specific symptoms. The DWI findings
were thus able to resolve subtle or preclinical venous congestion before visible
lesions appeared on conventional MRI and clinical symptoms became apparent.
This case was reported previously elsewhere29
and Manzione et al17 also reported similar
findings.
There were some limitations to our study. First, the number of patients
was too small from which to extrapolate our findings, especially for the grouping
attempt. Second, the time from the onset of disease to DWI was variable and
not homogenous. This can be attributed to the diverse clinical manifestations
of CVT. It is well known that the course of the disease in humans can progress
over days and weeks.31, 32, 33
We were therefore unable to perform DWI in all of the patients immediately
after the onset of disease as in the previous experimental study.10 This may reflect the more gradual stepwise progression
of CVT that occurs naturally in humans compared with the complete and rapid
thrombosis induced in animal studies. Third, the relative lack of experimental
evidence and the previous experience with DWI in CVT may not fully support
our findings.
Despite these limitations, this article is the first to describe the
various DWI findings in patients with CVT in various stages. It may be difficult
to diagnose CVT by conventional MRI findings alone. To confirm the diagnosis,
further tests, such as MRV or conventional angiography, may be necessary.
Diffusion-weighted imaging can be used to discriminate between different types
of edema, assess tissue viability, detect subclinical abnormalities, deliver
time-saving information for early diagnosis, and facilitate basic imaging
research of the pathophysiology of CVT.
AUTHOR INFORMATION
Accepted for publication June 7, 2001.
This study was supported by the Seoul National University Hospital Research
Fund.
Drs Chu and Kang have equally contributed to this study.
From the Department of Neurology and Clinical Research Institute, Seoul
National University Hospital, Neuroscience Research Institute of Seoul National
University Medical Research Center, Seoul, Korea.
Corresponding author: Byung-Woo Yoon, MD, PhD, Department of Neurology,
Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul 110-744,
South Korea (e-mail: bwyoon{at}snu.ac.kr).
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Potential Utility of Diffusion-Weighted Imaging in Venous Infarction
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