Transcranial Color-Coded Sonography for the Detection of Cerebral Veins and Sinuses and Diagnosis of Cerebral Venous Sinus Thrombosis

Abstract

This study aimed to determine the detection rate of transcranial color-coded sonography (TCCS) of cerebral veins and sinuses and to explore the diagnostic accuracy of TCCS for straight sinus (SS) and transverse sinus (TS) thromboses. The detection rates of cerebral veins and sinuses using TCCS and contrast-enhanced TCCS (CE-TCCS) were analyzed. The diagnostic accuracy of CE-TCCS was evaluated. Median time from symptoms to CE-TCCS was 10 (range, 1–150) d. The detection rate of bilateral basal veins of Rosenthal was 100% by CE-TCCS, followed by right TS (91.89%), SS (88.12%), left TS (74.59%) and vein of Galen (70.27%). Compared with magnetic resonance imaging/magnetic resonance venography, CE-TCCS showed 100% sensitivity and 96.3% specificity for SS thrombosis, 100% and 100% for right TS thrombosis and 100% and 94.4% for left TS thrombosis. In conclusion, CE-TCCS shows high identification rates of cerebral veins and sinuses and a high diagnostic accuracy for SS and TS thrombosis.

Introduction

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke, characterized by the formation of a blood clot in the dural sinus and/or cerebral veins, involving the superior sagittal sinus in 62% of the cases, the transverse sinus (TS) in 86%, straight sinus (SS) in 18%, cortical veins in 17%, internal jugular in 12% and the deep venous system in 11% (Saposnik et al., 2011, Stam, 2005). The incidence of CVST is low, with 0.5%–3% of all strokes (Bousser and Ferro, 2007, Saposnik et al., 2011) affecting predominantly younger people (Ruiz-Sandoval et al. 2012). The rate of intracranial hemorrhage is high (30%–40%), and the acute-phase mortality is 3%–15% (Piazza, 2012, Saposnik et al., 2011). Nevertheless, the rate of complete recovery is 79% at 16 mo (Ferro et al. 2004). The leading risk factors are pro-thrombotic conditions (either genetic or acquired), oral contraceptives, puerperium and pregnancy, infection and malignancy (Ferro and Canhao 2014).

The clinical manifestations of CVST are highly variable, ranging from headache to coma that mimics other disorders (Aoun et al., 2011, Ruiz-Sandoval et al., 2012). CVST should be suspected in younger patients (<50 y of age) who present with acute, subacute or chronic headache with unusual features, signs of intracranial hypertension, focal neurologic abnormalities in the absence of risk factors or seizure (Piazza 2012). Up to 25% of the patients with CVST may present with an isolated headache without focal neurologic findings (Saposnik et al. 2011). Computed tomography (CT) and magnetic resonance imaging (MRI) are useful for initial evaluation but cannot rule out CVST if they are normal (Bushnell and Saposnik, 2014, Einhaupl et al., 2010, Gulati et al., 2014, Piazza, 2012, Saposnik et al., 2011).

Digital subtraction angiography (DSA) is the traditional gold standard for the diagnosis of CVST, but nowadays MRI/magnetic resonance venography (MRV) is recommended by the European Federation of Neurologic Societies guidelines as the preferred brain image, whereas CT/CT venography (CTV) is an acceptable option when MRI is not available (Bushnell and Saposnik 2014). Nevertheless, neither DSA nor MRV/CTV can provide the hemodynamic status of the cerebral veins and sinuses (Shin et al. 2018). Back in 1987, Furuhata et al. showed that blood flow in several cerebral veins can be depicted by transcranial color-coded sonography (TCCS) for the exact placement of the Doppler sample volume (Schreiber et al. 2002). Then, in the mid-1990s, the first-generation ultrasound contrast agent (SHU 508 A) helped the identification of venous blood flow within the cerebral deep venous system and the diagnosis of CVST (Becker et al., 1995, Delcker et al., 1999, Ries et al., 1997, Stolz et al., 1999). Nevertheless, because of the skull and the low flow velocities of intracranial veins, the diagnostic value of the transcranial ultrasound procedures in the cerebral venous system is limited (Shin et al. 2018). With the development of ultrasound systems and the advent of the second-generation ultrasound contrast agents, ultrasound diagnosis of intracranial venous diseases is possible.

Therefore, the primary aim of this study was to explore the diagnostic accuracy of TCCS for SS and TS thromboses. The secondary aim of the study was to determine the detection rate of TCCS of cerebral veins and sinuses.