Abstract WP209: Evaluating the Role of Deep Venous Stenosis in Patients with Cryptogenic and Hypertensive Basal Ganglia and Thalamic Hemorrhages

Introduction: The etiology of deep-seated intracranial hemorrhages (ICH), in the absence of identifiable vascular lesions on imaging, has traditionally been considered cryptogenic. With increasing recognition of the role of intracranial veins and venous congestion in brain pathology, we aimed to evaluate the venous anatomy—specifically stenosis of the deep venous system—and assess whether venous congestion in the basal ganglia or thalamic regions is associated with deep ICH. Hypothesis: Stenosis of the deep venous system—including the vein of Galen and straight sinus—can lead to increased venous congestion in the basal ganglia and thalamus, predisposing patients to deep-seated hemorrhages. Methods: We conducted a retrospective, single-arm study of adult patients presenting with spontaneous basal ganglia or thalamic hemorrhages without identifiable vascular etiology on magnetic resonance imaging (MRI) and/or digital subtraction angiography (DSA), and without medication or comorbidity history predisposing to increased bleeding risk. Venous stenosis was assessed using CT venography (CTV) sequences acquired as part of the institutional ischemic stroke CT protocol. Both CTA sequences for perfusion processing and 3D-reconstructed venous-phase images were analyzed to evaluate the presence and severity of deep venous system stenosis. Results: We included 104 patients who met the inclusion criteria, of whom 100 (96%) demonstrated stenosis or occlusion of the deep venous system. The median age was 69 years [IQR: 60–80], with 57% male. Hemorrhage location was nearly evenly distributed between the basal ganglia (49%) and thalamus (51%). Hypertension was identified as the underlying etiology in 28%, while the remainder were classified as cryptogenic. Steno-occlusion most commonly involved the vein of Galen (64%), followed by the straight sinus. Two representative cases are shown in Figures 1 and 2. Conclusion: His study provides a novel indication for deep seated ICH. Identification of such stenoses on imaging provides a potential target for endovascular intervention in patients with deep venous stenosis and concurrent risk factors, such as hypertension, to mitigate the risk of hemorrhage and/or their recurrences.