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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

Imaging Appearance

  • Basis of the sign:
    • MS lesions develop around small veins in the white matter, with inflammation and demyelination occurring around the central vein
    • The vein remains visible within the lesion because of its deoxyhaemoglobin content and the magnetic susceptibility difference between the vein and the surrounding tissue
  • Criteria for a 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
  • Sequences:
    • Best visualised on susceptibility-weighted imaging (SWI) and T2*-weighted sequences
    • FLAIR* imaging (a combination of FLAIR and T2*) can improve detection
    • 3T MRI provides better visualisation than 1.5T
  • Technique:
    • High spatial resolution, thin slices (≤3mm) and minimal slice gap
    • Post-processing with minimum intensity projection (mIP); segmented-EPI improves 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.

Clinical Relevance

  • A diagnostic aid, not a treatment target: it improves specificity for MS and helps distinguish it from small vessel disease and other white matter disease mimics
  • Proposed diagnostic threshold: >40% of lesions showing a central vein supports MS; simplified "select-3/select-6" rules count a fixed number of qualifying lesions1
  • Seen in all subtypes of MS — relapsing-remitting, secondary progressive and primary progressive
  • Less frequently observed in other white matter diseases

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

  1. Sati et al. The central vein sign and its clinical evaluation for the diagnosis of multiple sclerosis: a consensus statement from the North American Imaging in Multiple Sclerosis Cooperative. 2016. Nature reviews. Neurology - Open in new tab. ↩