MRI Web Clinic — April 2016

Deep Venous Thrombosis
Stephen F. Quinn, M.D.

Clinical History: A 62 year-old female complains of progressive knee pain that worsens with exercise. What are the findings? What is your diagnosis?

1a
1b
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Figure 1:

Two proton density-weighted fat-suppressed axial images, one just above the level of the tibial tuberosity (1a), and the other more caudal image at the level of the tibial tuberosity (1b), and a proton density-weighted fat suppressed sagittal image (1c) of the proximal lower extremity are provided.

Findings

2a
2b
2c
Figure 2:

The (2a) axial proton density-weighted fat suppressed image demonstrates a distended gastrocnemius vein (arrow) with increased signal in the medial head of the gastrocnemius muscle (asterisks) as well as signal changes in the area of another gastrocnemius vein more posterior and lateral (arrowhead). The (2b) more caudal axial proton density-weighted fat-suppressed image reveals a central area of decreased signal and peripheral increased signal involving the more posterior and lateral gastrocnemius vein (open arrow). The (2c) sagittal proton density weighted image shows distension and increased signal in the more anterior gastrocnemius vein (arrow) and central decreased signal, peripheral increased signal and distension of the more posterior gastrocnemius vein (open arrows).

Diagnosis

Acute thrombosis (thrombophlebitis) of the gastrocnemius veins.

Introduction

Deep venous thrombosis (DVT) of the muscular venous branches within the gastrocnemius and soleus muscles is an important finding sometimes first seen with MR imaging.1  DVT of these muscular veins can be associated with minor trauma to the lower extremity and is often not clinically suspected. 2 Although the true incidence and optimal treatment of DVT of the gastrocnemius and soleus veins is unsettled, the diagnosis is important because of the potential for proximal migration of the thrombosis and resultant pulmonary emboli as well as late term complications of venous insufficiency.3,4,5,6,7 To make this diagnosis with MR imaging, a familiarity of the diagnostic features is necessary. The MR appearance of the calf veins is variable and makes the diagnosis of DVT difficult. The anatomic nuances of the gastrocnemius and soleus veins are generally ignored except for those physicians involved with phlebology. Parellada and others described the diagnostic features of DVT of the gastrocnemius and soleus veins as being marked reactive edema in the surrounding soft tissues and muscles, branching rim-enhancing structures within intramuscular plexuses and vascular distension.1

Anatomy

Various terms have been used for the gastrocnemius and soleus veins including sural veins, muscular veins, soleal veins, sinusoid veins, and saccular veins.8 In this discussion, the terms gastrocnemius and soleus veins will be used.

The anatomy of the gastrocnemius and soleus veins is variable. In one cadaver based series, the number of gastrocnemius veins varied from 2-12 for each muscle head.9 (Fig. 3a) Most of the gastrocnemius veins drained into the popliteal vein (Fig. 4a, 5a). The ability to visualize the gastrocnemius veins with MR is variable due in part the compressibility of the veins. With padding and surface coils, the veins can be compressed and not visible. In other patients, with venous incompetence or muscular development of the gastrocnemius muscles, the veins can be prominent in size.

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Figure 3:

The (3a) axial proton density-weighted image of a 45 year-old male demonstrates normal gastrocnemius veins which are more numerous and larger in the medial head, which is a common finding (arrows). Duplicated popliteal veins are present and the larger and more medial vein has normal intraluminal signal changes, another common finding due to vascular flow (arrowhead).

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Figure 4:

An (4a) axial proton density-weighted fat-suppressed image of a 26 year-old male shows a normal gastrocnemius vein (arrowhead) draining into the popliteal vein (arrow). Between the medial and lateral heads of the gastrocnemius muscle is the small saphenous vein (curved arrow).

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Figure 5:

The (5a) sagittal proton density-weighted fat-suppressed image demonstrates multiple gastrocnemius veins (arrows) draining into the popliteal venous system.

The soleus veins are even more variable and numerous than the gastrocnemius veins and in one cadaver based study the number of veins varied from 7-38 and the length of veins varied from 0.9-2.8 cm.10 The soleus veins drain into posterior tibial, peroneal and communicant veins.11

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Figure 6:

An (6a) axial proton density-weighted fat-suppressed image of a 34 year-old male demonstrates a short thrombosed soleus vein (curved arrow) connected to a thrombosed posterior tibial vein complex (arrow). This example was used because normal soleus veins are not well seen with routine MR imaging. There is soft tissue edema surrounding the thrombosed vessels. The peroneal veins are also thrombosed (arrowhead).

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Figure 7:

The (7a) sagittal proton density-weighted fat- suppressed image reveals a horizontally oriented thrombosed soleus vein (curved arrow) connected to a thrombosed posterior tibial vein (arrows).

Clinical implications

Deep venous thrombosis of the lower extremity affects 1-2% of the population with an annual incidence of 0.5-1 per 1000.12 The risk factors for DVT of the calf veins, including the gastrocnemius and soleus muscles, include malignancy, immobility, previous DVT, trauma, and postoperative status.13 Van Stralen and others reported that DVT of calf veins was strongly associated with minor injuries located in the leg whereas this association was not seen in other anatomic regions. A 50-fold increased risk was found in factor V Leiden carriers with a leg injury compared with non-carriers without injury.2

The gastrocnemius and soleus veins have been shown to be a frequent source of pulmonary emboli.3,14 Most vascular laboratories interrogate only the anterior tibial, posterior tibial, and peroneal veins and only a minority of laboratories interrogate the soleus and gastrocnemius veins. Forty percent of patients with acute isolated calf DVT will have normal duplex sonograms if the muscular veins of the calf are not interrogated.15

Differential diagnosis

Calf pain is a common clinical problem and physical examination is notoriously non-specific including the much maligned Homans’ sign. A long list of possibilities can cause pain in the calf including thrombophlebitis, ruptured/dissecting popliteal cysts, myositis, inflammatory pseudotumor, popliteal artery aneurysm rupture, muscle injuries, and internal derangements of the knee.16 In some patients, more than one of these conditions may co-exist.17

Imaging

Duplex sonography is the mainstay of imaging for DVT of the lower extremities, including the gastrocnemius and soleus veins. Duplex sonography is readily available in most areas, relatively inexpensive, safe, and rapid and can be performed even on unstable patients. Although Duplex sonography is the study of choice for the evaluation of calf DVT, it is also a reliable method to evaluated calf regions soft tissue injuries.18 As previously discussed, if thrombosis of the gastrocnemius and soleus veins is suspected, the vascular laboratory performing the duplex exam should be notified to interrogate these vascular segments.

The MR features of gastrocnemius and soleus DVT include a tubular branching structure with variable intraluminal signal on proton density-weighted fat-suppressed images that most commonly present with decreased signal centrally and peripheral increased signal (Fig. 8a) In other patients the degree of intraluminal increased signal varies from complete (Fig. 2a) to moderate (Fig. 9a) The thrombosed vessels may be distended (Fig. 9b, 9c). On T1-weighted images the intraluminal signal is often increased. Perivascular soft tissue edema and edema in the adjacent musculature is common (Fig. 10a). No prospective studies have been performed to test the specificity, sensitivity and accuracy of these MR findings so it is imperative that duplex sonography is performed for correlation if these MR findings are present.

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Figure 8:

An (8a) axial proton density-weighted fat-suppressed image of a 49 year-old female demonstrates a thrombosed horizontally oriented gastrocnemius vein (arrow) with predominately decreased central intraluminal signal with more peripheral increased signal, including perivascular involvement.

 

 

9a
9b
9c
Figure 9:

An (9a) axial proton density-weighted fat-suppressed image of a 40 year-old male reveals a thrombosed gastrocnemius vein (arrow) with moderate increased signal that is predominately peripheral. The (9b) axial proton density-weighted fat-suppressed image in a 51 year-old male demonstrates a thrombosed soleus vein (arrow) that is distended with predominately decreased intraluminal signal (asterisk). A more cephalad (9c) axial proton density-weighted fat-suppressed axial image reveals a partially thrombosed soleus vein (arrow) connected to a peroneal vein.

 

 

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Figure 10:

A (10a) T1- weighted sagittal image from a 40 year-old male demonstrates a thrombosed gastrocnemius vein (arrow) with increased intraluminal signal.

In a review article, Orbell and others stated that MRI has some advantages over duplex ultrasonography and requires improvements before it is routinely used clinically for the evaluation of venous thrombosis. Venography or CT venography are mentioned as studies that can be helpful when duplex scanning is inadequate.12 MR venography (MRV), which is not routinely used in musculoskeletal MR imaging, in the hands of experienced investigators, has shown to be useful in the evaluation of DVT.19

Treatment and Prognosis

The treatment of gastrocnemius and soleus DVT is controversial. Singh and others advocated not treating asymptomatic patients with isolated DVT of the calf and instead recommended serial duplex exams to evaluate for proximal thrombus extension. The subset of patients after orthopedic procedures, who tend to have greater thrombus extension, did receive a recommendation for anticoagulation.6 Macdonald and others found that the rate of thrombus propagation from gastrocnemius and soleus veins was 3% and suggested follow-up imaging beyond 2 weeks may not be necessary.20 Pangas and others, who reviewed multiple articles on the subject of gastrocnemius and soleus DVT, concluded that serial duplex exams be performed on these patients and treatment “may be deemed beneficial” if there is thrombus propagation.4 Sales and others found that treatment with and without anticoagulation has similar outcomes and recommended a randomized trial be performed.5 Lautz and others found that patients with isolated gastrocnemius and soleus DVT had a “dramatically” lower rate of venous thromboembolism when anticoagulated compared to patients who were not anticoagulated.21

Summary

Deep venous thrombosis (DVT) of the muscular venous branches within the gastrocnemius and soleus muscles is an important finding sometimes first seen with MR imaging. DVT of these muscular veins is associated with minor trauma to the lower extremity and is often not clinically suspected. The diagnosis is important because of the potential for proximal migration of the thrombus and subsequent pulmonary emboli as well as late term complications of venous insufficiency. To make this diagnosis with MR imaging, a familiarity of the diagnostic features is necessary. The proposed MR criteria for venous thrombosis include vessel distension, perivascular edema and signal changes of the vessel. The appearance is variable and most commonly seen as decreased central signal and increased peripheral signal on proton density-weighted fat-suppressed images. If suspected on MR imaging, a venous Duplex examination should be performed and the vascular laboratory needs to be contacted to make sure the gastrocnemius and soleus veins are interrogated during the exam.

References

  1. Parellada AJ, Morrison WB, Reiter SB, Carrino JA, Glickman PL, Kloss LA, et al. Unsuspected lower extremity deep venous thrombosis simulating musculoskeletal pathology. Skeletal radiology. 2006;35(9):659-64.
  2. Van Stralen KJ, Rosendaal FR, Doggen CJ. Minor injuries as a risk factor for venous thrombosis. Archives of internal medicine. 2008;168(1):21-6.
  3. Ohgi S, Tachibana M, Ikebuchi M, Kanaoka Y, Maeda T, Mori T. Pulmonary embolism in patients with isolated soleal vein thrombosis. Angiology. 1998;49(9):759-64.
  4. Pengas I, Nash W, Reed N, Kumar S. Evidence for treatment of muscular vein thrombosis in orthopaedic patients. Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology. 2013;14(3):159-64.
  5. Sales CM, Haq F, Bustami R, Sun F. Management of isolated soleal and gastrocnemius vein thrombosis. Journal of vascular surgery. 2010;52(5):1251-4.
  6. Singh K, Yakoub D, Giangola P, DeCicca M, Patel CA, Marzouk F, et al. Early follow-up and treatment recommendations for isolated calf deep venous thrombosis. Journal of vascular surgery. 2012;55(1):136-40.
  7. Wang CJ, Wang JW, Weng LH, Huang CC, Yu PC. Clinical significance of muscular deep-vein thrombosis after total knee arthroplasty. Chang Gung medical journal. 2007;30(1):41-6.
  8. Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, Partsch H, et al. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. Journal of vascular surgery. 2002;36(2):416-22.
  9. Aragao JA, Reis FP, Pitta GB, Miranda F, Jr., Poli de Figueiredo LF. Anatomical study of the gastrocnemius venous network and proposal for a classification of the veins. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2006;31(4):439-42.
  10. Reis FP, Aragao JA, de Figueiredo LF, Miranda F, Jr., Nunes MA, Feitosa VL. Venous drainage of the soleus muscle. Surgical and radiologic anatomy : SRA. 2008;30(4):341-5.
  11. Sequeira CM, Juliano Y, N.F. N, Mayall RC, Miranda F, Jr. Soleus veins: anatomic basis and their role in the origin of deep venous lower limb thrombosis. Rev Assoc Med Bras 2007;53:305-10.
  12. Orbell JH, Smith A, Burnand KG, Waltham M. Imaging of deep vein thrombosis. The British journal of surgery. 2008;95(2):137-46.
  13. Brian S, Fries Richard B, Bhagwan S. Clinical characteristics of patients with isolated calf vein thrombosis in a large teaching hospital. International journal of vascular medicine. 2011;2011:414093.
  14. Yoshimura N, Hori Y, Horii Y, Takano T, Ishikawa H, Aoyama H. Where is the most common site of DVT? Evaluation by CT venography. Japanese journal of radiology. 2012;30(5):393-7.
  15. Labropoulos N, Webb KM, Kang SS, Mansour MA, Filliung DR, Size GP, et al. Patterns and distribution of isolated calf deep vein thrombosis. Journal of vascular surgery. 1999;30(5):787-91.
  16. Agha A, Dimarcangelo MT, Reginato AJ. Calf pain and swelling (pseudothrombophlebitis) caused by rupture of the plantaris muscle/tendon. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases. 1996;2(3):147-51.
  17. Slawski DP. Deep venous thrombosis complicating rupture of the medial head of the gastrocnemius muscle. Journal of orthopaedic trauma. 1994;8(3):263-4.
  18. Su LY, Guo FJ, Xu G, Han XJ, Sun CK, Zhang Z, et al. Differential diagnosis of isolated calf muscle vein thrombosis and gastrocnemius hematoma by high-frequency ultrasound. Chinese medical journal. 2013;126(23):4448-52.
  19. Spritzer CE. Progress in MR imaging of the venous system. Perspectives in vascular surgery and endovascular therapy. 2009;21(2):105-16.
  20. Macdonald PS, Kahn SR, Miller N, Obrand D. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. Journal of vascular surgery. 2003;37(3):523-7.
  21. Lautz TB, Abbas F, Walsh SJ, Chow C, Amaranto DJ, Wang E, et al. Isolated gastrocnemius and soleal vein thrombosis: should these patients receive therapeutic anticoagulation? Annals of surgery. 2010;251(4):735-42.

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