P.074 Management, timing of anticoagulation and outcomes of patients with
                        cerebral venous sinus thrombosis: a single centre chart review

Background: Cerebral venous sinus thrombosis (CVST) accounts for <1% of all strokes. Our objectives were to describe the clinical features and examine the association between timing of anticoagulation therapy and outcomes in CVST patients. Methods: We conducted a retrospective chart review of patients admitted to Hamilton Health Sciences from 2015 – 2020 with imaging confirmed CVST. Results: We included 96 patients, mean age of 47.9 (SD 18.1). The most common clinical presentation was headache (43.8%). Brain trauma was the most common identified risk factor (15.6%), while 27% of individuals had no identified cause. Most patients (57.3%) received anticoagulation within 24hrs of identified CVST, while 26% had a delay (≥48hrs) and 16.7% were not anti-coagulated. The rationale for delaying or not starting anticoagulation included traumatic brain injury (31.8%), neurosurgical procedure (9.1%), presence of venous infarct and/or haemorrhage (27.1%) and unclear rationale (31.8%). At a median of 8 days, more patients without clear indications for delayed or no anticoagulation were disabled (defined by modified Rankin Scale, mRS, score ≥ 2) or dead (mRS 6), compared to those anti-coagulated in 24hrs (87.5% versus 31.8%; RR 2.75; 95% CI 1.74 – 4.35). Conclusions: Unjustified delay in anticoagulation may result in poorer clinical outcomes in CVST patients.

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Abstract 3070: Assessment of Manual Aspiration Therapy for the Treatment of Sinus Thrombosis

Stroke ◽

10.1161/str.43.suppl_1.a3070 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Lance Bodily ◽

Mouhammad Jumaa ◽

Syed Zaidi ◽

Tudor Jovin ◽

Brian Jankowitz

Keyword(s):

Sinus Thrombosis ◽

Anticoagulation Therapy ◽

Stable Condition ◽

Standard Of Care ◽

Mass Effect ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Motor Deficits ◽

Aspiration Thrombectomy ◽

Venous Sinus Thrombosis

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.

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Intensive care resources required to care for critically ill children with focal intracranial infections

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.4.peds17715 ◽

2018 ◽

Vol 22 (4) ◽

pp. 453-461 ◽

Cited By ~ 1

Author(s):

Marlina E. Lovett ◽

Zubin S. Shah ◽

Melissa Moore-Clingenpeel ◽

Eric Sribnick ◽

Adam Ostendorf ◽

...

Keyword(s):

Mechanical Ventilation ◽

Chart Review ◽

Sinus Thrombosis ◽

Invasive Mechanical Ventilation ◽

Retrospective Chart Review ◽

Cerebral Venous Sinus Thrombosis ◽

Critically Ill Children ◽

Venous Sinus Thrombosis ◽

Intracranial Infections ◽

Vasoactive Medications

OBJECTIVEFocal intracranial infections such as intraparenchymal abscesses or localized infections in the epidural or subdural spaces are relatively rare infections associated with both morbidity and mortality in children. Although children with these infections frequently require surgical intervention, there is a paucity of literature describing the critical care resources required to manage these cases. This retrospective chart review was performed to evaluate the resources necessary to care for critically ill children with focal intracranial infections at the authors’ institution.METHODSThe authors performed a retrospective chart review of cases at their institution by using ICD-9/10 codes to identify children admitted to the pediatric intensive care unit (PICU) for either intracranial abscess or extradural and subdural abscess between 2006 and 2016. All notes, medication administration records, laboratory/imaging results, vital signs, microbiological data, and electroencephalogram results were reviewed. Data were extracted to determine the utilization of the following resources: mechanical ventilation, vasoactive medications, and intracranial pressure (ICP) monitoring. The presence of intracranial hypertension, cerebral edema, seizure, and cerebral venous sinus thrombosis were noted. Pediatric cerebral performance category (PCPC) score was determined based upon the neurological exam at discharge.RESULTSA total of 45 children met the inclusion criteria. Their median age was 9 years (IQR 3–14 years). The incidence of focal intracranial infections in children admitted to the PICU was 0.68/1000 PICU admissions in 2006 and 2.81/1000 admissions in 2016. Thirty-nine children (86.7%) underwent neurosurgical intervention. Twenty patients (44%) required invasive mechanical ventilation, 7 (15.6%) received vasoactive medications, and 11 (24%) had an ICP monitor. Clinical seizures were detected in 12 children, including 2 who had both clinical and subclinical seizures; 1 child had subclinical seizures only. Eight children (17.8%) developed cerebral venous sinus thrombosis. The median PCPC score was 1 (interquartile range [IQR] 1–3). The median PICU length of stay was 6.4 days (IQR 2.2–10.2 days). Children with seizures had a significantly longer hospital LOS than children without seizure.CONCLUSIONSIn this single-center, retrospective study, critical care needs for children with focal intracranial infections varied. Most frequently, patients required close neurological monitoring, and almost half required invasive mechanical ventilation. Future studies should focus on further elucidating the resources required to care for these children as well as detecting factors to identify those children most at risk for complications.

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Combined use of stent-retriever and aspiration thrombectomy for cerebral venous sinus thrombosis involving the straight sinus: A case report

Interventional Neuroradiology ◽

10.1177/1591019917730335 ◽

2017 ◽

Vol 23 (6) ◽

pp. 605-608 ◽

Cited By ~ 5

Author(s):

Syunsuke Taniguchi ◽

Kei Harada ◽

Masahito Kajihara ◽

Kozo Fukuyama

Keyword(s):

Sinus Thrombosis ◽

Anticoagulation Therapy ◽

Cerebral Venous Sinus Thrombosis ◽

Stent Retriever ◽

Venous Sinus ◽

Aspiration Thrombectomy ◽

Venous Sinus Thrombosis ◽

Straight Sinus ◽

Combined Use ◽

Level Of Consciousness

Cerebral venous sinus thrombosis (CVST) is generally treated with anticoagulation therapy, however, endovascular therapy is considered for refractory cases. A 42-year-old woman presented with a progressive disturbance in consciousness, and diagnosed CVST in the straight sinus (SS). Recanalization of SS was achieved by emergent thrombectomy using aspiration catheter and stent-retriever system, and her level of consciousness improved immediately. The combined use of them aided the removal of the thrombus located in the SS.

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Management and outcome of spontaneous cerebral venous sinus thrombosis in a 5-year consecutive single-institution cohort

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012237 ◽

2016 ◽

Vol 9 (1) ◽

pp. 34-38 ◽

Cited By ~ 22

Author(s):

Darrin J Lee ◽

Arjang Ahmadpour ◽

Tamar Binyamin ◽

Brian C Dahlin ◽

Kiarash Shahlaie ◽

...

Keyword(s):

Superior Sagittal Sinus ◽

Sinus Thrombosis ◽

Anticoagulation Therapy ◽

Transverse Sinus ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Dural Sinus ◽

Venous Sinus Thrombosis ◽

Sagittal Sinus ◽

The Impact

BackgroundCerebral venous sinus thrombosis (CVST) is an uncommon form of stroke with a variable presentation, ranging from headaches, to coma and death. Although the American Stroke Association has developed guidelines for the treatment of CVST, data are sparse on the outcome after treatment with anticoagulation, thrombolysis, and thrombectomy.MethodsIn this retrospective review, we describe the 5-year UC Davis experience with spontaneous CVST.ResultsForty-one patients (mean age 37.5±23.1, range 0–96 years; 29 female) were identified with CVST. The majority of cases involved the transverse sinus (75.6%), sigmoid sinus (58.5%), and superior sagittal sinus (29.3%). The most common form of treatment was anticoagulation or antiplatelet therapy (n=35), while six patients were managed by observation alone. The overall 1-year modified Rankin score (mRS) was 1.4±1.5. Male patients and patients with a poor admission mRS had a worse outcome. Outcome was unaffected by hypercoagulable state, number of dural sinuses involved, the presence of intracranial hemorrhage, or seizures. Two patients who underwent anticoagulation therapy also required endovascular thrombectomy; both patients had a 1-year mRS of ≤2. Two patients underwent direct open surgical canalization of the superior sagittal sinus with varying outcomes (mRS 2 vs mRS 6).ConclusionsIn our series, the majority (92.9%) of patients with spontaneous dural sinus thrombosis had a favorable clinical outcome as defined by a mRS ≤2. Further prospective studies are needed to study the impact of anticoagulation on the clinical course of the disease.

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Cerebral venous sinus thrombosis after vestibular schwannoma surgery: a call for evidence-based management guidelines

Neurosurgical FOCUS ◽

10.3171/2018.4.focus18112 ◽

2018 ◽

Vol 45 (1) ◽

pp. E4 ◽

Cited By ~ 6

Author(s):

Hussam Abou-Al-Shaar ◽

Yair M. Gozal ◽

Gmaan Alzhrani ◽

Michael Karsy ◽

Clough Shelton ◽

...

Keyword(s):

Vestibular Schwannoma ◽

Sinus Thrombosis ◽

Anticoagulation Therapy ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Evidence Based ◽

Posterior Fossa Surgery ◽

Venous Sinus Thrombosis ◽

True Incidence

OBJECTIVEPostoperative cerebral venous sinus thrombosis (CVST) is an uncommon complication of posterior fossa surgery. The true incidence of and optimal management strategy for this entity are largely unknown. Herein, the authors report their institutional incidence and management experience of postoperative CVST after vestibular schwannoma surgery.METHODSThe authors undertook a retrospective review of all vestibular schwannoma cases that had been treated with microsurgical resection at a single institution from December 2011 to September 2017. Patient and tumor characteristics, risk factors, length of stay, surgical approaches, sinus characteristics, CVST management, complications, and follow-up were analyzed.RESULTSA total of 116 patients underwent resection of vestibular schwannoma. The incidence of postoperative CVST was 6.0% (7 patients). All 7 patients developed lateral CVST ipsilateral to the lesion. Four cases occurred after translabyrinthine approaches, 3 occurred after retrosigmoid approaches, and none occurred following middle cranial fossa approaches. Patients were managed with anticoagulation or antiplatelet therapy. Although patients were generally asymptomatic, one patient experienced intraparenchymal hemorrhage, epidural hemorrhage, and obstructive hydrocephalus, likely as a result of the anticoagulation therapy. However, all 7 patients had a modified Rankin scale score of 1 at the last follow-up.CONCLUSIONSPostoperative CVST is an infrequent complication, with an incidence of 6.0% among 116 patients who had undergone vestibular schwannoma surgery at one institution. Moreover, the management of postoperative CVST with anticoagulation therapy poses a serious dilemma to neurosurgeons. Given the paucity of reports in the literature and the low incidence of CVST, additional studies are needed to better understand the cause of thrombus formation and help to establish evidence-based guidelines for CVST management and prevention.

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