Doppler Imaging of Superior Sagittal Sinus Thrombosis Albert H. Lam, MB, FRACR, DDU Three cases of neonatal superior sagittal sinus throm bosis diagnosed by Doppler imaging and confirmed ‘with either computed tomography, magnetic reso- ‘ence imaging, or digital subtraction angiography fare described. One infant died and the others had ‘uneventful recovery. Young infants with superior sagittal sinus thrombosis rarely are seen for diag- nostic imaging: the nonspecicty ofthe clinical pre- entation of this disorder and the difficulties with fis investigation owing to the invasiveness of the Magnetic resonance imaging i a sensitive, noninva sive diagnostic modality, but itis nat always avall- able and practical forthe very sick infants in the ert- foal extent In the cnoae desrbed her, Doppler imaging proved to be diagnostic and useful inthe management of superior sagital sinus thrombosis tnd should be used in te initial assessment ofthe condition, ait isthe most convenient and least tau ‘matic dlagnostc modality. Ke worDs: Doppler sono- graphy; Superior sagittal sinus thrombosis; Throm- radiologic procedures lead to its undendingnosi. bons reba venous sinus thrombosis is» com= plication in the sick neonate; ts found in 57% of cerebral angiograms in infants and clallren. Before 198) it was described only in autop- SY stds of aophyxiated newbors® Despite the 5 Supt pt na SS, Super ata ina tomy EGG Gitte ats peel Compo ‘Snwpopiy; EEK Dip son spinon See T rurederercrage ANE Roy Ac Hputeeher Rese My 2194, he Degen of adele Roa Alenia Hopi or Chan Cetera, Sydney. esa even man ape plcion Rage 1 ant ‘Mane emafoniece aad mp ups tA. Lae MB, [REACH Dw Doon a any, apt Aland ep [erchaien 80 Boxe Comperow NSW 280 Aaa ‘numerous publieations describing CVST in adults and older Infants,> imaging diagnosis of neonatal CCVST is limited. A iterature review revealed only a fer recent case reports in newborn infants. The con- dition is underdingnosed because of its nonspecific clinical presenation® In addition, the various able diagnostic procedures, suchas carotid anglogra- phy, DSA, CT.and MR imaging all have their ita Hons. These tess elther are t00 invasive, carry in twinsc hazard, or are not relly avaiable forte ick and ventilated infants in the intensive care wards Sonography with color Doppler facility is an accept- ed, readily available facility in the neonatal ICU and proved tobe effective in both defining the anatomy fn eying ow i he intracranial vers ye fem of the newborn. We present three cases of SSST liagnosed by Doppler sonography. The only previ= ‘ous reports were fwo cases of SSST detected with igray seale Bode sonography® and two cases pre ented atthe 3éth Annual Meeting ofthe Society for Paediatric Radiology.” (©1995 bythe American Instat of Ulrasound in Maicne «J Utrascund Med VA-6, 1995 + 0278-4297/95/535042 SUPERIOR SAGITTALSINUS THROMBOSIS. Utasound Med 16-46, 195 ‘igure Color Doppler images of the 55 of case 1m corn (A and idling sata () sections show absence of low Color ‘Seagal te cot tenis rat) ae even ot sets MATERIALS AND METHODS, ‘Bxaminations were performed with an Acuson 1EXP (Mountain View, CA) unit using 7 Miz sector and lnear transducers capable of allowing. color Doppler and duplex sonographic evaluation” A pre- ‘minary gray scale sonogram was obtained to detect ‘abnormal intracranial morphology; this was fol- ‘owed by the color Doppler nd duplex studies. The ‘olor Doppler images were magnified lectronically ‘and the Golorsensitive volume was restricted {0 ‘maximize color sensitivity and frame rate. Color per- ‘Selence was sot at maximum setting, and the color ‘Seale was set atthe minimum, Color gain was set to maximize vascular signal without affecting tssue ‘maoticn artifacts. The intracranial veins were exam ined through the anterior fontanelle witha combina- tion cf sagittal, parasagital and angled coronal sec- tions with both Secor and linear transducers. As the ‘cours ofthe superior sagittal sinus is nearly perpen ‘dicular to the transducer fooplate, the vestel is best imaged with linear transducer and electronic beam steering fo maximize te angle of isonation Fg.) Exceive pressure withthe linear aray transducer over ‘he SSS is avoided asthe slowr venous flow of the superficially located sinus immediately below the anterior fontanlle is compressible by pressure or molding’ The presence and pattem of the duplex ‘Sonographic waveform of the venous flow are then ‘Sssested, espacially when absence of low is demon ‘Strate withthe color Doppler imaging. establish the diagnosis ofa complete occlusion hy thrembus, "Three neonates with a cinial dagnosis of SST treated in he neonatal ICU ofthe FAHC were selec: fc Meheal records were reviewed and information concerning their hospitalization and investigations was recorded, case ‘A newborn male infant was transfered to RAHC ‘with cyanosis and tachypnea. Echocardiography re vealed a double-outlet right ventricle, complete ati al sepial defect, patent ductus arteriosus, and an obstrcted infracardiac total anomalous pulmonsry ‘venous retum, Teal correction ofthe cardiac nom ly with ligation of the dicks arteriosus and band: ing ofthe pulmonary arteries was performed on day 2'Intermittent pulmonary. arterial hypertension ‘ocurred during the immediate postoperative perl fo. Acute renal failure develope on day 5, which required peritoneal dialysis. Sepicemia developed fubsequently and Escher co wae cultured from the ETT aspirate. Four eplodes of ton fea setae of the let orarm and neck were observed on day 9 ‘which were controlled with phenobarbitone Bulging ofthe anterior fontanele was noted, Cranial sonog- raphy performed on the same day revealed a hypoe hole enlarged 555, which appeared ovoid in tans verse section. A Doppler study ofthe SSS revealed Absence of flow in both color and duplex Imaging. (ig. 1). A CT scan with contrast showed a linea,J Uluasoune Med Hest, 1885 nodular filling defect within the humen ofthe poste- flor aspect of the $55 (Fig. 2). Follow-up cranial Doppler sonography revealed’ progressive sinus ‘hrombosls with involvement of the lft transverse Sinn EchogenicIksione were preset in both thal mi and a complex echogenic lesion was observed in the eft parietal subcortical region suggestive of hemt- corshagie infarcts, The patient died on day 17 sith septicemia and persistent renal failure case 'A.4 seek old male term infant was referred to RAHC for investigation of seizure. The infant had a ‘normal perinatal Nstory. He developed otis media, ‘which vas treated with antibiotics. A generalized truncal rash and diarrhea developed subsequently. A focal seizure with twitching of both eyes and pallor ‘was observed by the primary physician and the i fant was admitted to 2 base hospital where pheno- burbitone was given. A CT scan performed in the bse hospital prior to transfer to RAHC revealed a left IVE. Cranial sonography with Doppler per- formed alter admission to RAH revealed in addi tion tothe lft IVH, an echogenic S55 with loss of the normal concavity of the inferior borders. Absence ‘of venous flow vas demonstrated with both color (Fig. 3) and duples imaging. MR imaging performed 2 days later revealed a hyperintense $35 in both TI- Weighted and long TR sequences (Fig. 4). The focal ‘seizure was well controlled with medication and the Figure 2 Aaa conrastenhanced CTscan incase ho the lnc nodular ling defects rote) ie caudal al of ‘he SS consent wth thrombus Infant was discharged on day 4. Follow-up cranial sonography and. Doppler 1 month later revealed recanalization ofthe S85 with normal venous flow. ‘The left IVH had also resolved. case ‘Az week old infant was refered tothe neonatal ICU Figure 3 Color Doppler sonography trough the atror onan in case 2 n coronal (A) nd mide sil () sectors Shews absence of color-coded low signal i the S85, i contrat tothe adpcen coral aerial ow. Note te Bposchae ‘large SES with nf normal cons of he ont boners rahe)|W SUPEuOR SAGITTAL SINUS THROMEOSIS. ‘of RAHC for management ofa generalized seizure He had been delivered by cesarean section at 37 ‘weeks’ gestation because of complications arising {om preslampsia. Bulging of the anterior fontanlle was seen. Cranial sonography with Doppler imaging, performed on day 1 after admission revealed bate AI IVH. and mild. ventriculomegaly: The $55 ap- ‘peared hypoechoic and prominent in size, Color and ‘Suplex Doppler images showed absence of venous slg (Fig. 5), DSA performed on day 3 failed to show ‘opacification of the 555 onthe delayed lms (Fig, 6) inthe venous phase. The seizure wos controlled with ‘medication and the infant was discharged home on day 6 Follow-up cranial sonography with Doppler studies 4 weeks later revealed recanalization of the thrombosed sagittal sinus with reestabishment of ‘enous flow. The IVH and venticulomegaly also had resolved party DISCUSSION CCVSF inthe neonate difers from the adult disorder 8nd is alfeted by a unique set of isk actors and con- ditions. Sepsis, dehydration, and shock are well. kanown predisposing factors CVST i also reported 138.2 complication of jugular venous catherzation © The S55 i the most commonly ivolved sinas be cause it a unique low -pressre,valveless system with an acutely angled cerebral vein draining into Jel! The venous drainage ofthe brain i though the extemal and internal veins into the lange dural sins 6, which return the Blood tp the heat via the inter- nal jugular veins. The dorsal superior veins drain the dorsal convexty of the cerebral hemisphere and ‘ross the subdural space ae bridging veins before ‘hey enter the SSS. The medial superior veins drain ‘most ofthe medial aspect ofthe cerebral hemisphere find connect dectly with the SS. If venous otfow fs ostructed by venous or sinus thrombosis, capil- Taris andl venles in the involved drainage territory ‘become congested, and multiple small er a ingle large hemorshagicinfaretdevelopsin gray and white ‘matter lending to necrosis and ecema of adjacent tis- ‘ses. In view ofthe extensive network of venows col Interal, its not surprising that thrombosis Timited to sinus isnot assolted| with cerebral infarction and ‘ears a good prognosis, asin our cases 2 and 3. For an infart to occur, its necessary forthe vein to be thrombosed a it ite of entry into sinus, Throm- bosis ofthe dorsal superior cerebral veins causes a Inemorthagic infarct in the dorsal portion ofthe cere- bral hemisphere, 25 was chserved incase 1. Throm- bosis ofthe medial superior veins causes infarction 1 Utrasund Med 1481-46, 1985 Figure 4 Min sail (T-weghted (TR, 620° TE, 2) MR lmogeot case 2 demonstrates hgh sig ines in the x al fall of S55 orm, content th thrombene ‘Thalumichemorage a is noted Figure 5 Color Doppler sonography with duplex study through the sate foal ncn 3 mine sagital scion shows absence of etlorcde! flow signal tthe ‘larged SS Grants corr the aceon coral ‘Stel flows The absence of venous fw i coded wth the duplex Doppler ting bow ‘nthe medial aspect ofthe cerebral hemisphere, adj cont to the fabs corr, From the ist pathologie study by Bailey and Has {in 1881" the present time there have been fev lin kcal reports of CVST, despite its frequent occurrence ‘in some autopsy studies of asphydated newborns?1 Utrasound Med 1841-465, 1955 Figure 6 Lateral view ofthe ne venous phase of the verte tl DSA in ase 3 shows complete nonin of S55 ra Ie) consistent wth orbs ‘The diagsis of CVST is ten dificult clinically ax wal a adlogiily. Clinical findings may be sub> Ueand fetures may mimic other conionss CVST represen an important and underecognized cause Cf nconatal seizure in tere infant. ‘The definitive diagnosis has traitonally raed on conventional angiography, which revealed ling de. fees o lack of venous sis opacification (Fig. In Scion to the oceasiona lack of specie. angog. raphy or DSA san invasive technique ad carries inherent ris, eopeclly in neonates CT provides ‘method for det imaging ofthe intracranial con: tents and allows the diagnosis of CVST tobe nonin- ‘sive Direct sign on CT include the denae tangle Sen the cord sign, and empty dela sign Fig. 2) in contrast CT scans! The CT findings are not ll spe ic for S55, and false-positive mets were report ed.1415 Radionuclide angiography provides non- invasive physiologic Now information, Locsin! dluced parison in the expected distribution of he {volved venous channel implies ccluson; ower. false pontive and false-negative signs signcont Iy limit the usefsness of the modality. Recently, ‘AR imaging has become the modality of choice for the diagnosis” Aside from it limited avait, MR imaging has disadvantages related to transport ane seanning of ck neonates who require ie sop: port when cles survelane isindicte, as incase raphy with a mobile color Doppler fait is vO0NE 1 most neonatal ICUS tas been sccopled asthe modal of choice fo the imaging of neonatal intracranial sess, In our study ts role ‘Son be expanded to inci teu as noninvasive method forthe diagnosis and follow-ap of SST With this modal crc wsslzation othe trom tus (ig 3,3) an the absence of ow (ig 33 canbe demonarated inthe noninvasive wa. Daring ‘ubcoria, thalamic ae aca gargs hemectoge Subori hla and sal gay ‘which ae characteristic of SS. Recaalzaton of the thromboned sins with retablichment of owt slsocanbedocimented Although SS, nena eee tral vein and vein of Galen ae visualized consis tel with color Dopperimaging ther some line {atom with regard fo the Inorior saga in, transverse snus a basal veins of Rosenthal? Mk tmoging or Mik angiogrophy i incatd i theese Common type of dural sins tombe is cially sepeced ‘CONCLUSION ‘The cost effectiveness, ease of application, avail- ability, and noninvasiveness of color Doppler imag ing offer a distinct advantage forthe imaging ding nosis of SSST in neonates ts use can be recon ‘mended in neonates with multiple seizures that are not related to metabolic disorders. Color Doppler sonography is indicated particularly when known, predieposing factors of S6ST are present. The ine Ereased application ofthe modality may add signifi fant information conceming changes In cerebral hemodynamics associated ‘with various clinical problems and may provide insights for neonates ‘vith transient seizure disorder, Owing tothe limita tions of complete Doppler imaging of the deeper cerebral venous system, MR imaging or MR angiog- raphy is recommended when Doppler results are negative yet there is a strong cinial suspicion of (CVST ofthe deeper system or sonographic evidence ‘of unexplained cerebral hemorrhage infarcts. [REFERENCES 1. Scot LN, Goldman RL, Haedman OR, ota: Venous Thromb in infant and children” Radiology 113353, 2 Towbin A: Cowbell venous system damage in haan [strand newton tit} Diss 18559, 1990 3. Bowser MG, Chins J, Boss Je a Cobra! enous hrombori—a review of caees Soke 16198, 188, 4. Shovell Ml SverK OGorman Meta Neostl dua Taylor GA: srcanial venous sytem in the newbore0. 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Ulyasound Med 14146 1955, Bae OF Hass GM: Darl sins trombone Bic “Te scl manitstion and extent of rain ny esis thrombon Ped 17551951 Bannnno FS, Moody DM, Bll MR ts: Compute cecil Tomegapie Adings in cretral snoweno.s ‘edwin | Comput Assi Tomo 281, 1978 VinapongeC Cazenave C, Quin. a The empty ‘dhs agi Fraguencyand signin oenor ot ‘Stes Womb Waogy 10277? Davies RF Shvatine PF: Tneenc oferty eka sig in ‘onputed tomography im passa 968 group. Ris Stiaaee (Ghungs, Harwood NsehD: Vasu occhaive dese: Sean dural ss br Teas Fe T(E Tatldogy! Diprore, eging,iewonton, Yo Prinaepha fo Upc Dons ‘Meco, Grossman Gomer Mea: igh id MR Engig of crcl venoe roma] Comp A ‘Topo es