WSC 2026 | Novel imaging biomarkers for the diagnosis and prognosis of CVT

In this session, we discussed several topics relevant in CVT. One of the topics was imaging, imaging biomarkers. So we started by discussing the importance of biomarkers and how biomarkers can help us. So biomarkers, imaging biomarkers specifically, they should help us to identify an association with certain features or prognostic features or certain characteristics of the patients. But then they should help us ultimately to make decisions. And so actually for most of the biomarkers we have in CVT, we are still in this early stage where we can identify certain associations, but not always to have this information whether the biomarker changes the way we manage the patients and the prognosis of the patients. So this was a general reflection. Then, of course, we have different types of biomarkers. We have biomarkers for the diagnosis. Also, then after the diagnosis, we have biomarkers to predict prognosis, to predict certain outcomes of the patients. And we can divide this in at least three main areas. So the ones that are related with the thrombus, the ones that are related with the tissue, with the brain tissue, and also then with the evolution and the response of the patient to treatment. So the collaterals and the recanalization. So going through these different groups of biomarkers, let’s say, for the diagnosis, it is really interesting the use of the attenuation of the sinus. So if the sinus is more hyperdense, then we will suspect the thrombus. However, we know that this is both not very sensitive, nor very specific. And so there were studies looking into the specific attenuation, so the values, and indeed it improved a bit, both the sensitivity and the specificity, but still the values are not good enough to be used in clinical practice, either to rule out or to make the diagnosis. So indeed, this is an interesting field, but we are still not there in terms of using it in clinical practice for this purpose. Then there is a small study, about 250 patients published recently using AI also to detect this attenuation and these signals at baseline to make the diagnosis. It is very interesting. However, again, what is published is values of sensitivity that are still not good enough. And so in terms of translation for clinical practice, although this is a very interesting idea and definitely something to explore in the future, we are still not in the stage that we can use this kind of AI to make the diagnosis, at least according to this first small study.

So then moving to the thrombus, of course, it will be very interesting to have better imaging of the thrombus. The most used is SWI. It is now in clinical practice, we know. And there are even recent studies, again, looking into the capacity of this sequence to improve the diagnosis. And indeed, it improves, especially for cortical vein thrombosis. It is quite good because it is difficult to see even in T1 with gadolinium and indeed for patients that have isolated cortical vein thrombosis it can be even just the way to make the diagnosis. So this is definitely something we have to be aware of and use. However then for other sequences like black blood sequences that there are studies published on CVT, recent studies, it is interesting. I’ve shown a meta-analysis also of the most recent studies and they are mostly retrospective, mostly single center. And also these values that we can compare with the gold standard. So the comparison, whether this can add up to the sequences that we already have in terms of improving diagnosis is sometimes not clear. So we need to improve also the quality of this assessment so that we can have a better understanding of what it adds to what we already have. But it is promising also for measuring the thrombus volume because it suppresses the blood flow signal. And so it creates, let’s say, better imaging of the thrombi. And so it is promising also on this. Also, sequences of vessel wall, let’s say, contrast enhancement can have this value. There’s a study also showing that it can be even used for this calculation of the thrombus volume. And then we also discussed, of course, the collaterals. There are very few studies, the evidence also in different directions. So we still need, again, better evidence on collaterals. Also, in terms of recanalization, we discussed our recent studies on early recanalization, on the possible predictors of early recanalization. Also, in terms of imaging, particularly the susceptibility vessel sign. So this SWI eye point 10 signal may predict early recanalization and also then the association with the evolution of the brain lesions with early recanalization and the recent study we have already presented that shows that recanalization is associated with prognosis, even after controlling for other predictors of prognosis. And we did this study on the DOAC-CVT prospective cohort.

Well, then finally, of course, the tissue is a very big challenge in terms of imaging. And we would like to be able to predict the evolution of the brain injury. And for example, DWI, we have shown this in a study that often is reversible, even if you have diffusion restriction and CVT, it is reversible. But we do need better markers, perfusion, and other techniques that are being explored in order to understand the value of how can we predict the evolution of the brain tissue. So overall, I think this was a very nice session, also with discussions around other topics, and we look forward to future CVT sessions and the next conference.

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