Activated partial thromboplastin time as a predictor of hyperdense thrombus on non-contrast CT in acute cerebral venous sinus thrombosis
Keywords:
Cerebral venous sinus thrombosis, Activated partial thromboplastin time, Hounsfield unit , Thrombus density, Coagulation biomarkersAbstract
Background and Aim: Cerebral venous sinus thrombosis (CVST) is an uncommon yet potentially serious cerebrovascular disorder that demands rapid diagnosis and timely treatment. Non-contrast computed tomography (NCCT) frequently shows increased thrombus attenuation, expressed in Hounsfield Units (HU), which mirrors clot composition. Activated partial thromboplastin time (APTT), a marker reflecting intrinsic coagulation pathway activity, may modulate thrombus formation dynamics. The relationship between APTT and thrombus density in acute CVST, however, has not been well characterized. We aimed to evaluate the association between APTT and HU-based thrombus density in patients with acute CVST.
Methods: We conducted a retrospective cohort study at a tertiary referral center between January 2022 and December 2023. Adult patients with acute CVST who underwent NCCT within 7 days of symptom onset and had APTT measured within 24 hours of imaging were included. Thrombus density was measured in HU using standardized region-of-interest assessment. Spearman’s rank correlation was used to examine the APTT–HU relationship, and receiver operating characteristic (ROC) analysis was used to define the optimal APTT threshold for predicting higher thrombus density (HU ≥ 70).
Results: Ninety-three patients were analyzed. A moderate negative correlation was observed between APTT and thrombus density (r = –0.408, p < 0.001). ROC analysis identified an APTT threshold of ≤21.6 seconds for predicting HU ≥ 70, with sensitivity 72.9%, specificity 91.1%, and an area under the curve of 0.769 (p < 0.001).
Conclusion: Shorter APTT values are associated with denser thrombi on NCCT in acute CVST. Combining coagulation parameters with quantitative CT measurement may strengthen early evaluation and clinical decision-making, especially in centers with limited access to advanced venous imaging.
References
1. Ranjan R, Ken-Dror G, Sharma P. Pathophysiology, diagnosis and management of cerebral venous thrombosis: A comprehensive review. Medicine (Baltimore). 2023;102(48):e36366. doi:10.1097/MD.0000000000036366
2. Gaur U, Gadkari C, Pundkar A. Cerebral venous sinus thrombosis (CVST): a clinically significant neurological condition. Cureus. 2024;16(6):e62692. doi:10.7759/cureus.62692
3. Maghbooli M, Kermani M, Sany SNT, Arfaei M. Determining the diagnostic value of venous sinus density indices in non-contrast brain CT scan for early diagnosis of cerebral venous sinus thrombosis. Brain Behav. 2025;15(2):e70324. doi:10.1002/brb3.70324
4. Honig A, Eliahou R, Simaan N, et al. Admission hyperdense sinus sign predicts poorer outcomes in cerebral venous sinus thrombosis. J Neurol. 2026;273(2):120. doi:10.1007/s00415-025-12950-3
5. Ratnaparkhi C, Dhok A, Gupta A, et al. Diagnostic accuracy of Hounsfield Unit value and Hounsfield Unit to hematocrit ratio in predicting cerebral venous sinus thrombosis: a retrospective case-control study. Cureus. 2024;16(4):e57567. doi:10.7759/cureus.57567
6. Amran MY, Hidayah MF, Akbar M, Bintang AK, Hawari I. Hounsfield unit-to-hematocrit ratio as a quantitative marker for cerebral venous sinus thrombosis: a retrospective diagnostic study. Acta Biomed. 2025;96(4):16843. doi:10.23750/abm.v96i4.16843
7. Vellema J, Munckhof AV, Coutinho JM. Cerebral venous thrombosis: Current management, recent advances and future directions. Int J Stroke. 2025 Dec;20(10):1177-1187. doi: 10.1177/17474930251393311.
8. Miraclin AT, Bal D, Sebastian I, Shanmugasundaram S, Aaron S, Pandian JD. Cerebral venous sinus thrombosis: current updates in the Asian context. Cerebrovasc Dis Extra. 2024;14(1):177–184. doi:10.1159/000541615
9. Almegren MO. Cerebral venous thrombosis: a comprehensive narrative review. Brain Circ. 2025;11(3):178–186. doi:10.4103/bc.bc_120_24
10. Grover SP, Mackman N. Intrinsic pathway of coagulation and thrombosis: insights from animal models. Arterioscler Thromb Vasc Biol. 2019;39(3):331–338. doi:10.1161/ATVBAHA.118.312130
11. Starikova EA, Mammedova JT, Rubinstein AA, Sokolov AV, Kudryavtsev IV. Activation of the coagulation cascade as a universal danger sign. Curr Issues Mol Biol. 2025;47(2):108. doi:10.3390/cimb47020108
12. Tan CW, Cheen MHH, Wong WH, et al. Elevated activated partial thromboplastin time-based clot waveform analysis markers have strong positive association with acute venous thromboembolism. Biochem Med (Zagreb). 2019 Jun 15;29(2):020710. doi: 10.11613/BM.2019.020710.
13. Erhard A, Freuer D, Peters A, et al. Blood coagulation factors and risk of venous thromboembolism: a population-based study. Eur J Med Res. 2026;31(1):248. doi:10.1186/s40001-025-02428-w
14. Tripodi A. Thrombin generation: a global coagulation procedure to investigate hypo- and hyper-coagulability. Haematologica. 2020;105(9):2196–2199. doi:10.3324/haematol.2020.253591
15. Amran MY, Hidayah MF, Hawari I. Hematocrit, platelets, and Hounsfield units: a case-control study in non-contrast computed tomography imaging of cerebral venous sinus thrombosis. J Neurosci Rural Pract. 2025;16(2):248–255. doi:10.25259/JNRP_453_2024
16. Rodriguez-Granillo GA, Cirio J, Morales C, et al. Thrombus discrimination with electron density: potential implications for non-contrast computed tomography imaging. Cardiovasc Diagn Ther. 2024;14(2):304–310. doi:10.21037/cdt-23-388
17. Abdrabou A, Osman AM, Taha NM, Darwish EAF. Attenuation measurements on non-contrast-enhanced CT brain: a re-visit of their role in the diagnosis of cerebral venous thrombosis. Jpn J Radiol. 2025;43(6):940–948. doi:10.1007/s11604-024-01710-4
18. Alharbi OA, Alahmadi KO. The diagnostic utility of unenhanced computed tomography of the brain and D-dimer levels in acute cerebral venous sinus thrombosis: A quantitative study. J Clin Imaging Sci. 2022 Apr 16;12:15. doi: 10.25259/JCIS_76_2021.
19. Tayyebi S, Akhavan R, Shams M, et al. Diagnostic value of non-contrast brain computed tomography in the evaluation of acute cerebral venous thrombosis. Sci Rep. 2020;10(1):883. doi:10.1038/s41598-020-57810-4
20. Mu S, Lin Y, Xu Y, et al. A novel rat model for cerebral venous sinus thrombosis: verification of similarity to human disease via clinical analysis and experimental validation. J Transl Med. 2022;20(1):174. doi:10.1186/s12967-022-03387-7
21. Sadik JC, Jianu DC, Sadik R, et al. Imaging of cerebral venous thrombosis. Life (Basel). 2022;12(8):1215. doi:10.3390/life12081215
22. Oliveira IM, Duarte JÁ, Dalaqua M, Jarry VM, Pereira FV, Reis F. Cerebral venous thrombosis: imaging patterns. Radiol Bras. 2022;55(1):54–61. doi:10.1590/0100-3984.2021.0019
23. Yang Y, Cheng J, Peng Y, et al. Clinical features of patients with cerebral venous sinus thrombosis at plateau areas. Brain Behav. 2023;13(6):e2998. doi:10.1002/brb3.2998
24. Amran MY, Fitrah YA. Crescent-shaped intracranial hemorrhage in cerebral venous sinus thrombosis: a case report and review of literature. J Neurosci Rural Pract. 2025;16(1):144–149. doi:10.25259/JNRP_585_2024
Downloads
How to Cite
Issue
Section
License
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.
How to Cite
