Venous infarction mimicking brain tumour: recognition of the sulcal tram-track appearance and gyriform diffusion restriction, a retrospective study

Purpose Venous infarctions can demonstrate varied imaging appearances and in certain cases, they may mimic intracranial tumors/space occupying lesions, leading to diagnostic confusion and potentially unnecessary invasive procedures. The purpose of this study was to describe the neuroimaging features of venous infarction presenting as tumor-like cortical lesions and to highlight a distinctive imaging appearance termed the Sulcal Tram-Track Sign. Methods A retrospective review was performed of patients with venous infarcts presenting as focal cortical lesions suggestive of space-occupying pathology on MRI. Imaging features were analyzed on conventional MRI sequences, diffusion-weighted imaging (DWI), and susceptibility-weighted imaging (SWI). Particular attention was given to lesion morphology, relationship to cortical sulci, diffusion characteristics, susceptibility findings, and enhancement patterns. Results Eleven patients were identified with venous infarction where the lesions were predominantly cortically based and mimicked space occupying lesions. T2-weighted imaging demonstrated paired linear hyperintensities along opposing banks of the affected sulcus in all cases, producing a tram-track appearance. Gyriform diffusion restriction was present in most patients, and susceptibility-weighted imaging demonstrated cord sign corresponding to thrombosed cortical veins in the majority of cases. Contrast enhancement was minimal or absent. Conclusion Venous infarction due to cortical vein thrombosis may mimic intracranial tumors on MRI. Recognition of the Sulcal Tram-Track Sign, along with associated diffusion restriction and susceptibility changes, may facilitate early diagnosis and help avoid unnecessary invasive interventions.