A study performed at an academic center revealed a high rate of misdiagnoses for acute cerebral venous thrombosis (CVT) cases evaluated by imaging in an emergency setting. Findings of this study were recently reported in the Polish Journal of Radiology.
“Because patients with CVT usually develop acute neurological symptoms, the first imaging modality is computed tomography (CT) of the brain in an emergency department,” the study investigators explained in their report. They set out to determine the rate of misdiagnosis in emergency CT evaluations of CVT and prominent issues with interpreting lesions.
The study was a retrospective analysis of emergency CT examinations of the brain performed at the Wroclaw University Hospital in Wroclaw, Poland, from 2015 through 2019. Emergency CT examinations that were included this analysis were those in which follow-up studies had confirmed a CVT diagnosis through CT venography, magnetic resonance imaging with contrast, or digital subtracted angiography.
The researchers analyzed 31 emergency CT examinations involving patients with a mean age of 42.6 years (range, 4-94). From these, 9 had included contrast injections, while 22 had not. Most (77.4%) cases showed thrombosed dural sinuses, while thrombosed veins were seen in 22.6% of cases. In 6.5% of cases, there were no lesions seen within vessels. Nearly half (48.4%) of the cases did not show parenchymal lesions, while hemorrhagic brain lesions were present in 29%, hypodense edema was visible in 19.6%, and brain swelling was present in 3.2%.
The rate of correct diagnosis of CVT was 48.4%, reflecting 15 cases. Among the 16 cases receiving incorrect diagnoses, half (50%) involved vascular and parenchymal lesions that were determined to be overlooked. Another 31.3% involved only vascular lesions, and these were misinterpreted or missed by either being overlooked or obscured by artifacts. Another 12.5% of misdiagnosed cases involved only parenchymal lesions, and these were misinterpreted. Lesions were not present in the emergency CT scan in 6.2% of misdiagnosed cases, reflecting 1 patient.
The authors explained in their report these findings suggested more than 50% of acute CVT cases had received incorrect diagnoses even in a specialized university center, implying the rate of misdiagnosis could be higher in other types of centers. They determined that the primary sources of error in this study were related to overlooking thrombosed hyperdense vessels and misinterpreting parenchymal brain lesions.
“We hope that this analysis will raise the awareness of CVT among emergency doctors, especially general radiologists and neurologists, and help to reduce the rate of delayed diagnoses of CVT, which may cause serious complications to patients,” the investigators concluded.
Jacków-Nowicka J, Jagiełło J, Dziadkowiak E, Bladowska J, Sąsiadek M, Zimny A. Acute cerebral venous thrombosis – still an underdiagnosed pathology in emergency computed tomography of the brain. Pol J Radiol. 2021;86:e574-e582. doi:10.5114/pjr.2021.109490