AUTHOR(S): Medlock, Michael D., M.D.;
Olivero, William C., M.D.;
Hanigan, William C., M.D., Ph.D.;
Wright, Robert M., M.D.; Winek, Sally Jo, M.D.
Department of Neuroscience (MDM, WCO, WCH,
SJW) and Department of Radiology (RMW),
University of Illinois College of Medicine at Peoria,
Peoria, Illinois
Neurosurgery 31; 870-876, 1992
ABSTRACT: FROM 1985 TO 1991, 13 children
were diagnosed at the University of Illinois College
of Medicine at Peoria, Saint Francis Medical Center,
with cerebral venous thrombosis (CVT) by magnetic
resonance imaging scan. Ages ranged from newborn
to 5 years. Six children were premature neonates, five
were term neonates and two were 5 years old. In the
premature neonates, thrombosis was usually
associated with other problems. All the term neonates
had seizures. In all neonates, thrombosis resolved
without any specific treatment. In the two older
children, one presented with pseudotumor cerebri and
one with coma. These children required neurosurgical
intervention. Follow-up magnetic resonance imaging
scans were obtained in 9 of 13 children and showed
thrombus resolution in each case. Three children were
studied in the acute and convalescent stages by
magnetic resonance angiography using time-of-flight
techniques. Each follow-up magnetic resonance
angiogram showed improvement in venous flow
consistent with their clinical course and other
imaging studies. We conclude that 1) CVT in
children encompasses a range of clinical conditions
which may or may not require neurosurgical
intervention; 2) magnetic resonance imaging is
superior to other modalities for the diagnosis of CVT;
and 3) magnetic resonance angiography is an
alternative means to monitor the evolution of CVT
and efficacy of therapeutic intervention.
KEY WORDS: Cerebral venous thrombosis;
Magnetic resonance angiography;
Magnetic resonance imaging; Neonates
Early descriptions from autopsy studies suggested
that cerebral venous thrombosis (CVT) was a grave,
often pre-terminal condition associated with many
diseases (5,9). Angiography, and then computed
tomography, provided progressively less invasive
means for diagnosis and established the association
of CVT with many other diseases. With magnetic
resonance imaging (MRI) and now MR angiography,
the diagnosis can be made even more accurately and
noninvasively. This report describes the risk factors,
clinical presentations, radiological findings, and

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treatment in 13 children with CVT.
PATIENTS AND METHODS
From 1985 to 1991, 13 children were diagnosed
with CVT at the University of Illinois College of
Medicine at Peoria, Saint Francis Medical Center.
The hospital records and cerebral imaging studies of
these children were reviewed. All of the children had
MR imaging, two had arterial digital subtraction (DS)
angiography and three had MR angiography. MRI
scans were done with a 0.5- or 1.5-T Siemens
Magnetom scanner (Erlangen, Germany). MR
angiography was performed on the 1.5-T scanner
using limited flip angle gradient recalled echo (timeof-flight) techniques. Fast low angle shot (FLASH)
sequences were used to study one child and fast
imaging with steady precession (FISP) sequences
were used to study two children. Each child's most
recent developmental outcome was obtained from
office charts and by phone calls to parents or
caretakers. None was lost to follow-up. Three of these
children were included in a previous report by
Hanigan et al. (16).
RESULTS
For comparison purposes, these 13 children were
divided into 3 age groups: 6 premature neonates, 5
full-term neonates, and 2 older children, both 5 years
of age.
Table 1 summarizes the findings in the premature
neonates. In three of these children, MRI scanning
was done because of a questionably abnormal
cerebral sonogram performed routinely to rule out
periventricular hemorrhage (PVH). One child with a
Grade 4 PVH had seizures that were difficult to
control, which prompted MRI scan. One child had
MRI scan because of a questionably abnormal
computed tomographic (CT) scan of the head, and
one child had Escherichia coli meningitis and
seizures. None of the children required any specific
treatment for their CVT. Follow-up MRI was
performed in five of the six children at 8 days, 26
days, 27 days, 47 days, and 8 months after the initial
study. In each case there was complete or near
complete recanalization of the major venous
channels. In the two children in whom follow-up
more than 2 years was available, one child is
developmentally normal and one has mild
psychomotor retardation.
Table 2 summarizes the findings in the term
neonates. All five term infants had seizures or
probable seizures; three had no known risk factors,
one had asphyxia related to abruptio placentae, and
one had hydrocephalus with PVH. Of the three
without any other central nervous system insult, two
have had no further seizures after hospital discharge,
and one has persistent daily seizures. Two of these
children are developmentally normal and three are
developmentally delayed. Again, as in the premature
newborns, none of these children required any
specific treatment for their thrombosis. Follow-up
MRI scan was done in three of these children 43 days,
65 days, and 4 months after the initial study. All
studies showed recanalization of the major sinuses.

Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.

Neurosurgery 1992-98
November 1992, Volume 31, Number 5
870 Children with Cerebral Venous Thrombosis
Diagnosed with Magnetic Resonance Imaging and
Magnetic Resonance Angiography
Clinical Study

CASE REPORTS
Patient 1
A 6-day-old female infant (Patient 6 in Table 1)
was admitted for hypotonia and lethargy. She was
born at 36 weeks estimated gestational age and
weighed 2470 g. Her parents were mentally deficient.
At the time of presentation, she was in respiratory
distress, hypotonic, and hyporeflexic. Cerebrospinal
fluid contained 4450 red blood cells/mm3, 17 white
blood cells/mm3, glucose 2.0 mmol/L (normal, 2.224.44), and protein 1.01 g/L (normal, 0.15-0.45). There
was neither PVH nor seizures. CT scan at 11 days of
age showed superior sagittal sinus hyperdensity
consistent with thrombosis. MRI scan at 14 days of
age showed superior sagittal sinus and right
transverse sinus thrombosis with two small left
frontal lobe hemorrhages. MR angiogram obtained
immediately after the spin-echo images at 14 days of
age showed no flow in multiple intracranial sinuses
and, at 21 days of age, an MR angiogram showed
improved venous flow (Fig. 1). MRI scan at 21 days
of age showed recanalization of both sinuses.
Acquisition time for these images was 6 minutes.
Karyotyping showed a deletion of the short arm of
chromosome 18. She has had no further seizures and
is not taking anticonvulsant medication. At 7 months'
chronological age, her developmental age is
estimated at 4 months.
Patient 2
A 5-year-old boy fell backwards, struck his head
on a coffee table, and suffered a depressed skull
fracture of the left occipital bone. He was followed
without surgery. MRI scan confirmed the presence of
a depressed skull fracture but showed little
underlying parenchymal abnormality and no extraaxial hemorrhage. MR angiography showed
occlusion of the dominant left transverse sinus
(Fig. 2, top). Acquisition time for these images was
9.5 minutes.
Over the next several weeks he had three
admissions for worsening headaches. Lumbar
puncture showed an opening pressure of 400 mm
H2O. Cerebrospinal fluid protein, glucose, and cell
count were normal. Each lumbar puncture provided
him with only temporary relief of headache and
intracranial hypertension. Forty-one days after injury,
DS angiography confirmed the continued occlusion
of the left transverse sinus. He underwent elevation of
the fracture. Postoperative MRI scanning and
angiography showed recanalization of the sinus
(Fig. 2, bottom). One year later, he had no further
headache and was neurologically normal.
Patient 3
A 5-year-old boy presented with increasing
lethargy. He sustained a mild head injury with no loss
of consciousness 1 week before admission. He had
several days' history of headache and malaise. He had

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a generalized tonic-clonic seizure during evaluation
in the emergency room. His family and other
members of the community had atypical pneumonialike infections. A CT scan was interpreted as normal
on images transmitted by phone at night. Review of
the actual films later in the morning revealed a
hyperdense transverse sinus. Lumbar puncture
showed 2250 red blood cells/mm3 and 23 white blood
cells/mm3. The opening pressure was not measured.
He rapidly became comatose and required intubation.
MRI scan showed a right parietal lobe venous infarct
and a left frontal lobe hematoma. MR angiogram
showed extensive thrombosis of the internal and
external venous systems (Fig. 3, top). Acquisition
time for these images was 5.5 minutes.
Acyclovir and antibiotics were begun. An
intracranial pressure (ICP) monitor showed normal or
near normal pressure. Over the next several days, he
was treated with heparin and diuretics; however, his
ICP climbed to 70 torr. Pentobarbital-induced
electroencephalogram burst suppression was
unsuccessful in controlling his ICP. Systemic
urokinase was begun at 60,000 U/hr (Abbokinase,
Abbott Laboratories, North Chicago, IL) and
continued for 4 days. After this, DS angiography
showed sluggish venous flow and persistent
thrombus in the anterior superior sagittal sinus.
Cerebrospinal fluid cultures were negative for
bacteria. His ICP gradually normalized over the next
several days, and he was extubated. Repeat DS
angiography showed normal venous flow and
resolution of all thrombus. Two days after the DS
angiogram, a repeat MR angiogram showed improved
flow in all venous channels (Fig. 3, bottom). At 15
months after illness, he was normal intellectually
with a mild pronator drift.
DISCUSSION
The natural history of cerebral venous thrombosis
is variable. Reports before the use of conventional
angiography were based only on postmortem
examination. In the Byers and Hass (9) autopsy series
of 50 children with CVT, 26 cases were associated
with bacterial infection and 24 cases were not (9).
Even after the advent of angiography, the prognosis
was felt to be poor. Askenasy et al. (2) described three
patients with angiographically confirmed sagittal
sinus thrombosis, all of whom died. Averback (4)
reported seven patients with aseptic CVT, five of
which were fatal. In Bailey and Hass' report (5) of 33
children with pathologically confirmed aseptic CVT,
the majority of children had severe nutritional
disturbances from vomiting and diarrhea and 31 died.
Recent reports suggest a more variable outcome. In a
series by Scotti et al. (32), of eight children with CVT
diagnosed by angiography, six of which were aseptic,
they noted only one child who died. In a series by
Bousser et al. (7), of 38 adult patients, only 4 died.
Since the introduction of high resolution CT and MRI
scans, the diagnosis has been made more frequently,
many times with good outcome, even in comatose
patients (7,17,34). There have been numerous case
reports, but a limited series of children with CVT not
related to contiguous infection.

Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.

Both older children, Patients 2 and 3, required
neurosurgical intervention. Their case histories, along
with the neonate in whom we obtained acute and
convalescent MR angiograms, are presented in detail.

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spin-echo images. Paradoxical enhancement caused
by slow flowing blood can produce high signal on T1weighted images which can be confused with
thrombosis. By changing the imaging plane, the high
signal will become low signal excluding thrombosis
(23,37)
. The diagnosis can be made even without
clinical suspicion (3). In a review of 234 children with
neurological disorders who underwent 261 MRI
scans of the head, 2 showed dural sinus thrombosis
(27)
. Rivkin et al. (28) reported six neonates with MRI
scan-diagnosed CVT who presented with lethargy
and hypotonia and had a benign clinical course
without specific treatment.
MR angiography has been used in the diagnosis of
CVT. The two most useful MR angiographic
techniques are generally classed as limited flip angle
gradient recalled echo (time-of-flight) and phase
contrast images. Phase contrast images require longer
acquisition times, which are more likely to
compromise pediatric imaging. Both techniques
require improvements before small vessel disease can
be adequately imaged. We used two different time-offlight techniques, FISP and FLASH. Our MR
angiograms produced by both of these methods were
consistent with the clinical course of the patients, CT
scans, DS angiography, and T1- and T2-weighted
spin-echo MRI scans. MR angiography has also been
used successfully to study cerebrovascular disease in
neonates and infants with arterial occlusive disease
and stroke from various causes (22,30). To our
knowledge there have been no reports of MR
angiograms performed in children with CVT.
Even with the recent advances in neuroimaging and
earlier diagnosis of sinus occlusion, treatment
remains controversial. The dilemma is whether to use
anticoagulation, usually heparin, to prevent further
thrombosis, to use fibrinolytic therapy such as
urokinase to lyse the clot, and/or to symptomatically
treat the elevated ICP with steroids, mannitol,
acetazolamide, etc. The dilemma persists because the
natural history is not known. DiRocco et al. (12)
treated five patients with a combination of heparin
and systemic urokinase with good results. Several of
the patients had focal neurological deficits and one
was in a coma. In a large series of 38 cases described
by Bousser et al. (7), most patients were treated with
anticoagulation and steroids. Gettelfinger and
Kokmen (15), in treating seven patients with superior
sagittal sinus thrombosis, recommended that
anticoagulation should not be used but recommended
antiedema agents. Higashida et al. (18) treated a
neonate with infusion of urokinase directly into the
superior sagittal sinus with a good outcome.
Thromboplastin has been used in the intracranial
sinuses, subarachnoid space, and brain parenchyma
with good clot lysis and few complications in animal
models (1,21). Although there have been rare case
reports of surgical treatment of aseptic sinus
occlusion, treatment now appears to be primarily
medical (26,32,36). An ICP monitor may be helpful in
the management, although it precludes MRI
scanning. Transfemoral instillation of fibrinolytic
agents by an interventional neuroradiologist may play
a role in selected patients.

Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.

The presenting clinical picture can vary from
asymptomatic to coma with focal neurological
deficits. Confusion, headache, hemiplegia, and
seizures are common symptoms. Papilledema and
focal deficits are also common (7,33). A common
presentation in the newborn period is seizures and
full fontanels. Dural sinus occlusion can also cause
the clinical syndrome of pseudotumor cerebri. Before
the advent of antibiotics, the association of dural
CVT with chronic mastoiditis or chronic otitis was a
common presentation in children. Today, this is
rarely seen.
Other associated conditions include dehydration,
asphyxia, polycythemia, systemic malignancy,
trauma, meningitis, pregnancy, oral contraceptives,
sickle cell trait, and coagulation abnormalities (6,8,14,
20,24,31,32,35,38)
. Little has been written on whether or
not there are any maternal risk factors which
predispose a newborn to CVT. In the mothers of the
premature infants in our series, three had
preeclampsia and two had premature rupture of the
membranes. In the full-term newborn pregnancies,
one mother had preeclampsia, one had
oligohydramnios, one had abruptio placentae, and
one had a history of illicit drug abuse. Of the 11
newborns, 6 mothers were smokers; all of the term
neonates' mothers and one of the premature neonates'
mothers. More data is needed to determine whether
any of these conditions are causally related to CVT.
The diagnosis is confirmed with neuroimaging.
Until recently the modality of choice was intraarterial iodinated contrast angiography. Findings
include nonvisualization of the venous sinuses either
partial or complete, increase in the arteriovenous
circulation time, collateral venous pathways, reversal
of flow in the obstructed sinus, and mass affect from
venous infarct (33,39). We have found angiography
useful only when MRI scanning was not available or
when an ICP monitor precluded the use of MRI
scanning. With the availability of high resolution CT
scanning, a noninvasive diagnosis was made with
increased accuracy. Findings included dural and
tentorial enhancement, dilatation of transcerebral
intermedullary veins, the cord sign, i.e., visualization
of thrombosed veins, and the empty delta sign (13,27).
Brain involvement may show hemorrhagic infarcts,
edema, compression, or enlargement of the ventricles
(15,25,27,29)
. In our series, several CT scans were
interpreted as normal when MRI scans showed
unequivocal CVT.
MRI scanning is superior to CT scanning in the
diagnosis of venous thrombosis. By 1989, MRI was
described as the imaging modality of choice (5,10,11,13,
19,20,24,29,37)
. In high field magnetic resonance, acute
sinus thrombosis is isointense on T1-weighted
images and markedly hypointense on T2-weighted
images. Sinus thrombosis in an intermediate stage has
a high signal intensity on T1- and T2-weighted spinecho images (10,23). Daniels et al. (10) have described a
gradient recall echo MR sequence in which the
normal sinus and veins are hyperintense but lose
signal with complete occlusion. They think this may
be the best method for diagnosis of acute sinus
thrombosis, which can be missed on T2-weighted

ACKNOWLEDGMENT
The authors thank Mrs. JoAnna Gass for assistance
in the preparation of the manuscript.
Received, April 7, 1992.
Accepted, June 12, 1992.
Reprint requests: William C. Olivero, M.D.,
Department of Neuroscience, University of Illinois
College of Medicine at Peoria, P.O. Box 1649, Peoria,
IL 61656.
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Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.

Most of the children in our series received no
treatment specific for CVT. Many of the neonates
have developmental delays; because of their multiple
medical problems, it is impossible to determine the
precise role that CVT played in this delay. Three of
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COMMENTS
The prevailing neurosurgical impression of
cerebral sinus thrombosis is that it is a medical illness
with very limited neurosurgical implications. This
article by Medlock et al. shows us how well this
entity is diagnosed by magnetic resonance imaging
(MRI) angiography in a wide variety of pediatric
patients, and it is clear that some perplexing clinical
problems might be clarified by the use of this
technique. In particular, their Patient 2, who had a
pseudo-tumor syndrome in association with a
depressed fracture obliterating the left transverse
sinus, was particularly instructive. The authors used
excellent clinical judgment in withholding immediate
elevation of this potentially serious fracture, which
was associated with no intracranial pathology. They
confirmed the continued presence of increased
intracranial pressure, demonstrated the occluded
transverse sinus by MRI angiography, and the
reappearance of flow in the sinus after elevation of
the fracture accompanied by resolution of the clinical
problem. This short acquisition time of the MRI
studies suggest that this technique could become
more widely used in the appropriate clinical setting.
R. Michael Scott
Boston, Massachusetts
This article addresses a complex issue of the
occurrence of cerebral venous thrombosis in a myriad
of diseases in childhood. In a retrospective analysis
spanning 6 years, the authors review 13 children with
deep cerebral venous thrombosis as a part of their
clinical syndromes. The diagnosis in each child was
made with MRI scan, and follow-up MRI scans were
obtained in 9 of 13 children. The authors categorize
their children into three groups: premature neonates,
term neonates, and two older children.
This varied clinical spectrum was looked at with
MRI to define the presence of venous thrombosis as a
part of their clinical spectrum. The radiological
findings were consistent in these patients with
various degrees of venous thrombosis. What
association this finding had with any of the clinical
syndromes is difficult to discern. In one case, the
individual with depressed skull fracture, his clinical
syndrome was more than likely the result of venous
occlusion secondary to the bony fragment rather than
thrombosis.
This paper presents an excellent discussion of

Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.

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Microsurgical revascularization with venous
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Tarras S, Gadia C, Meister L, Roldan E,

cerebral venous thrombosis and reviews the literature
as to the use of MRI in its diagnosis. I think it is very
important, and the authors appropriately point out the
fact that the temporal relationship of the diagnostic
tests for cerebral venous thrombosis by no means
proves a causal relationship. This is an interesting
and well written paper and one which brings to our
attention the very common association of cerebral
venous thrombosis and various other primary
diseases. For instance, it is not uncommon in the
neonate with vein of Galen malformation to find
associated cerebral venous thrombosis as a part of the
picture. In fact, deep cerebral venous anomalies and
occlusions we now realize form a part of the
pathological process in the vein of Galen
malformations. Again, it is important to realize this
process (cerebral venous thrombosis) represents a
paraphenomenon of the primary pathological process
although it may contribute to presentation and
outcome.

Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.

J. Parker Mickle
Gainesville, Florida

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Figure 1. MR angiogram at 14 days old (top,
FLASH, TR/TE/flip angle = 31/10/50, unenhanced)
showed diminished flow in the superior sagittal sinus
(arrows) and internal cerebral venous system
(arrowheads) flow. MR angiogram at 21 days old
(bottom, FLASH, TR/TE/flip angle = 31/10/50,
unenhanced) showed recanalization of the superior
sagittal sinus and improved flow in the internal
venous system.

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Figure 2. Preoperative MR angiogram 3 days after
the injury (top, TR/TE/flip angle = 40/7/20,
unenhanced) showed thrombosis of the left transverse
sinus from the torcula to the vein of Labbe.
Postoperative MR angiogram (bottom, TR/TE/flip
angle = 40/7/20, unenhanced) shows restoration of
flow through the sinus.

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Figure 3. MR angiogram on the day of admission
(top, FISP, TR/TE/flip angle = 23/13/20, gadolinium
diethylene-triamine-pentaactic acid-enhanced)
showed extensive thrombosis of the superior sagittal
sinus (arrows) and internal venous system
(arrowheads). Follow-up MR angiogram (bottom,
FISP, TR/TE/flip angle = 23/13/20, unenhanced)
showed improved flow in the internal and external
venous systems even with contrast enhancement on
convalescent study.

Table 2. Term Neonatesa

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Table 1. Premature Neonatesa