Tahsin Benlice

Background: Dural venous sinus thrombosis (DVST) is an uncommon but potentially life-threatening cerebrovascular disorder requiring early diagnosis to prevent serious complications. Although CE-MRV is the reference standard, routine brain MRI is often the first imaging study in patients with nonspecific neurological symptoms, and the sinus-specific diagnostic performance of individual sequences remains incompletely defined. Purpose: To evaluate the diagnostic performance and inter-reader agreement of routine brain MRI sequences for DVST detection using a sinus-specific framework. Methods: This retrospective case–control study included 140 patients (34 with DVST, 106 age-matched controls) imaged on 1.5 T and 3.0 T scanners. Two blinded neuroradiologists evaluated six unenhanced sequences (sagittal/axial T1WI, T2WI, FLAIR, DWI [b = 1000 s/mm²], and SWI) across four dural sinuses, using CE-MRV and CE-3D T1WI as the reference standards. Logistic regression and Cohen’s κ assessed diagnostic performance and inter-reader agreement, respectively. Results: Globally, DWI with FLAIR achieved 97.9% accuracy, 91.2% sensitivity, and 100% specificity (AUC = 0.997). Optimal sequences varied by sinus: sagittal T1WI with SWI for the superior sagittal sinus (accuracy = 99.3%), DWI with SWI for the transverse sinus (97.9%), DWI with FLAIR and T2WI for the sigmoid sinus (98.6%), and SWI with axial T1 for the straight sinus (100%). Inter-reader agreement was substantial to almost perfect for routine sequences (mean κ = 0.874) and almost perfect for CE-MRV and CE-3D T1WI (κ = 0.98). Conclusions: Routine brain MRI provides reliable DVST detection with a sinus-tailored multisequence strategy. DWI and FLAIR offer robust diagnostic performance in global evaluation, while T1WI, SWI and T2WI add segment-specific value, reserving CE-MRV and CE-3D T1WI for equivocal or clinically suspicious cases.

Purpose To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility. Methods In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen’s kappa statistics, interobserver agreement was assessed. Results In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39). Conclusion The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.