Objective:
While hydration and anticoagulation is typically the standard of care for cerebral venous sinus thrombosis, some patients remain refractory to medical management and continue to deteriorate. In these instances a number of more aggressive endovascular techniques have been reported to remove clots and restore blood flow in the venous sinuses. These techniques include direct thrombolysis, angioplasty, and various methods to disrupt and aspirate clot. Here we present the technique of endovascular transvenous manual aspiration thrombectomy (MAT) in five patients.
Methods:
We reviewed the records of five patients with medically refractory cerebral venous sinus thrombosis who received transvenous MAT. Presentation, technique, and outcome were evaluated.
Results:
Out of the five cases reviewed presentation included vomiting, dehydration, mental status changes, headaches, and acute motor deficits. On imaging three of the five patients had hemorrhage, edema, and mass effect present before treatment, while two had edema only. All of the patients reviewed were treated with anticoagulation therapy, intravenous heparin or subcutaneous lovenox, for a minimum of 24 hours. However, all of the patients continued to deteriorate despite early and aggressive medical anticoagulation therapy. All of the patients demonstrated rapid and progressive worsening of their neurological exam pre-operatively, including lack of arousal, pathological posturing, and expansion of secondary hemorrhages. This rapid deterioration warranted aggressive intervention, making the patients candidates for endovascular therapy. Direct thrombolysis with tPA was utilized with MAT via a distal access catheter(DAC) in all but one patient in which tPA was not used due to concern for hemorrhage. Aspiration of the superior sagittal sinus, transverse sinuses, straight sinus, and internal jugular were all included in this series. Catheters included the 0.070, 0.057, and 0.044 DAC and the 0.054 Penumbra microcatheter. Revascularization was achieved in all instances. One patient presented and remained neurologically devastated. She died 5 days after treatment. All other patients experienced improvement in their neurological examinations and were eventually discharged from the hospital in stable condition.
Conclusions:
Endovascular transvenous MAT is a feasible and effective revascularization technique to treat patients with cerebral venous sinus thrombosis.
Cerebral venous sinus thrombosis complicated by subdural hematomas: Case series and literature review
