Enlarged Cortical Veins

James D. Eastwood, MD

DIFFERENTIAL DIAGNOSIS

Common

Less Common

Rare but Important

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Helpful Clues for Common Diagnoses

Normal
- Major anastomotic cortical veins (Trolard, Labbe, SMCV) can be very prominent
Developmental Venous Anomaly
- Central vein of DVA can drain cortically
- “Medusa head” configuration
Arteriovenous Malformation
- Prominent cortical veins tend to be regional, geographically related to nidus
- Look for varices, stenoses, stagnant flow
- Caution: Prominent veins may persist even if no residual AV shunting present
Dural A-V Fistula
- Chronic dural sinus thrombosis (vascularized thrombus) common precursor
- Cognard type IIB shows reflux into cortical veins; types III-IV have direct cortical drainage
  - Hemorrhage risk ↑

Helpful Clues for Less Common Diagnoses

Thrombosis, Dural Sinus
- Thrombosis/stenosis causes increased back pressure
- T2* (clot “blooms”), CECT or T1 C+ MR (“empty delta” sign) helpful
Thrombosis, Cortical Venous
- Can occur without dural sinus occlusion
- Hyperdense on NECT (“cord sign”)
- T2* most useful (“blooms”)

Helpful Clues for Rare Diagnoses

Venous Varix
- Usually with AVM or dAVF
- Isolated venous varices are rare
Vein of Galen Malformation
- Deep veins but cortical may ↑ if large
Sinus Pericranii
- Transcalvarial communication between dural venous sinus, extracranial (scalp) veins
- Sometimes associated with DVA