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Central Vein Sign

Summary

  • Radiological finding in multiple sclerosis (MS) characterised by a central vein within white matter lesions
  • Helps differentiate MS from other white matter diseases, particularly small vessel disease
  • Visible on susceptibility-weighted imaging (SWI) and T2*-weighted MRI sequences

Pathophysiology

  • MS lesions typically develop around small veins in the white matter
  • Inflammation and demyelination occur around these central veins
  • The central vein remains visible within the lesion due to:
    • Increased deoxyhaemoglobin content
    • Magnetic susceptibility differences between the vein and surrounding tissue

Demographics

  • Most commonly observed in patients with MS
  • Can be seen in all subtypes of MS:
    • Relapsing-remitting MS
    • Secondary progressive MS
    • Primary progressive MS
  • Less frequently observed in other white matter diseases

Diagnosis

  • Central vein sign is a supportive feature in MS diagnosis
  • Criteria for positive central vein sign:
    • Vein visible in the centre of the lesion
    • Vein runs partially or entirely through the lesion
    • Vein visible in at least two perpendicular planes
  • Proposed diagnostic threshold:

    • 40% of white matter lesions should demonstrate the central vein sign for MS diagnosis

Imaging

  • Best visualised on:
    • Susceptibility-weighted imaging (SWI)
    • T2*-weighted sequences
  • 3T MRI provides better visualisation than 1.5T
  • FLAIR imaging (combination of FLAIR and T2) can improve detection
  • Imaging parameters:
    • High spatial resolution
    • Thin slices (≤3mm)
    • Minimal slice gap
  • Post-processing techniques:
    • Minimum intensity projection (mIP)
    • Segmented-EPI for improved resolution

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  • A patient with a diagnosis of MS had an ovoid lesion in the right frontal subcortical white matter.
  • SWI showed that the lesion was centred on a medullary vein.

Treatment

  • Central vein sign does not directly influence treatment decisions
  • Aids in early and accurate diagnosis of MS, which can lead to:
    • Earlier initiation of disease-modifying therapies
    • Improved long-term outcomes
  • Potential applications in clinical trials:
    • Patient selection
    • Monitoring treatment response
  • Future developments may include:
    • Automated detection algorithms
    • Standardisation of imaging protocols for widespread clinical use

Differential diagnosis

Differential diagnosis Differentiating feature
Multiple Sclerosis Central vein sign present in >40% of lesions
Small Vessel Disease Lesions typically do not have central vein
Neuromyelitis Optica Lesions tend to be larger and follow different distribution
Acute Disseminated Encephalomyelitis Lesions are typically larger and more confluent
Cerebral Vasculitis Lesions often follow vascular territories
Susac Syndrome Characteristic involvement of corpus callosum "snowball" lesions
Migraine with Aura No visible lesions on MRI
CADASIL Characteristic involvement of anterior temporal lobes and external capsule
Lyme Disease Lesions are typically non-specific and may resolve with treatment
Progressive Multifocal Leukoencephalopathy Lesions are typically larger and in subcortical white matter