The clinical analysis and treatment strategy of endovascular treatment for cerebral venous sinus thrombosis combined with intracerebral hemorrhage

AbstractCerebral venous sinus thrombosis (CVST) combined with intracerebral hemorrhage(ICH) is a special subgroup, and whether intrasinus thrombolysis (IST) or mechanical thrombectomy (MT) therapy should be carried out is controversial because of previous hemorrhage and possible delayed hemorrhage.The aim of this study was to analyze the safety and effectiveness of endovascular treatment of CVST with ICH and further discuss the treatment strategy. This is a retrospective study of 56 cases admitted from January 2010 to June 2019 diagnosed with CVST combined with ICH, and all were treated with endovascular treatment including IST with or without MT. We reviewed the clinical, radiological, and outcome data of all patients. The percentage of cases that showed complete and partial recanalization were 67.8% and 26.9% after endovascular treatment. ICH exacerbation occurred in 5 cases during thrombolysis. The percentage of cases with good outcome was 87.5% at discharge. 51 cases were followed up at sixth month. 49 cases had a mRS score of 0–2,and 2 cases had a mRS score of 3–4 at sixth month.Our data suggest that endovascular treatment may improve clinical and radiological outcome in most patients of CVST with ICH, but confirmation in prospective, controlled studies is warranted.

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Endovascular treatment for vaccine-induced cerebral venous sinus thrombosis and thrombocytopenia following ChAdOx1 nCoV-19 vaccination: a report of three cases

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018238 ◽

2021 ◽

pp. neurintsurg-2021-018238

Author(s):

Jonathan Cleaver ◽

Richard Ibitoye ◽

Hamish Morrison ◽

Richard Flood ◽

Kate Crewdson ◽

...

Keyword(s):

Endovascular Treatment ◽

Sinus Thrombosis ◽

Rare Complication ◽

Cerebral Venous Sinus Thrombosis ◽

Outcome Data ◽

Venous Sinus ◽

Dural Sinus ◽

Patient Records ◽

Venous Sinus Thrombosis ◽

Poor Outcomes

BackgroundVaccine-induced thrombosis and thrombocytopenia (VITT) is a rare complication following ChAdOx1 nCoV-19 vaccination. Cerebral venous sinus thrombosis (CVST) is overrepresented in VITT and is often associated with multifocal venous thromboses, concomitant hemorrhage and poor outcomes. Hitherto, endovascular treatments have not been reviewed in VITT-related CVST.MethodsPatient records from a tertiary neurosciences center were reviewed to identify patients who had endovascular treatment for CVST in VITT.ResultsPatient records from 1 January 2021 to 20 July 2021 identified three patients who underwent endovascular treatment for CVST in the context of VITT. All were female and the median age was 52 years. The location of the CVST was highly variable. Two-thirds of the patients had multifocal dural sinus thromboses (sigmoid, transverse, straight and superior sagittal) as well as internal jugular vein thromboses. Intracerebral hemorrhage occurred in all patients; subarachnoid blood was noted in two of them, and intraparenchymal hemorrhage occurred in all. There was one periprocedural parenchymal extravasation which abated on temporary cessation of anticoagulation. Outcome data revealed a 90-day modified Rankin Scale (mRS) score of 2 in all cases.ConclusionsWe demonstrate that endovascular treatment for VITT-associated CVST is feasible and can be safe in cases that deteriorate despite medical therapy. Extensive clot burden, concomitant hemorrhage, rapid clinical progression and persistent rises in intracranial pressure should initiate multidisciplinary team discussion for endovascular treatment in appropriate cases.

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Abstract 1122‐000212: INARI FlowTriever system: First Endovascular Clinical Experience to Treat Diffuse Cerebral Venous Sinus Thrombosis

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000212 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Samer Abdul Kareem ◽

Saif Bushnaq ◽

Nicholas Liaw ◽

Bader Alenzi ◽

Muhammad Khaleeq ◽

...

Keyword(s):

Endovascular Treatment ◽

Superior Sagittal Sinus ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Endovascular Techniques ◽

Venous Thrombectomy ◽

Venous Sinus Thrombosis ◽

Sagittal Sinus ◽

Clot Burden

Introduction : Cerebral Venous Sinus Thrombosis (CVST) is a rare stroke with a wide range of symptomatology at presentation ranging from headache, focal weakness, and coma. Anticoagulation remains the mainstay of treatment. However, in a subset of patients endovascular treatment can be potentially beneficial. Here we describe the first clinical experience using the INARI FlowTriever system to treat a patient presented with focal weakness and found to have diffuse cerebral venous sinus thrombosis. Methods : Case report of CSVT treated with INARI FlowTriever system. Results : A 78‐year‐old female with past medical history of Autoimmune hepatitis and hypothyroidism, was brought to the hospital with left arm weakness. CT head revealed left temporoparietal intraparenchymal hemorrhage and right frontal subarachnoid hemorrhage. CTA of the head and neck revealed extensive CVST involving superior sagittal sinus, bilateral transverse and sigmoid sinuses. She was started on heparin drip. Patient was taken for venous thrombectomy due to persistent left‐sided weakness and multicompartment bleeding while being on anticoagulation for 48 hours. She underwent successful endovascular venous thrombectomy using the INARI FlowTriever system with large clot burden extracted. She was switched to novel oral anticoagulation prior to discharge. During the 3 months follow‐up–MRI brain with and without contrast revealed near complete resolution of the clot burden in the superior sagittal sinus and left transverse/sigmoid complex and her modified Rankin score was at 0. Conclusions : Here we discussed a case of diffuse CVST who was treated initially with heparin drip then underwent endovascular venous thrombectomy using INARI FlowTriever system with large clot burden aspirated with a reasonable safety profile. The INARI medical FlowTriever system is the only mechanical thrombectomy system indicated for the treatment of pulmonary embolism. It is specifically designed for venous clots. It is composed of a trackable large bore aspiration catheter. The INARI FlowTriever Catheter; has 3 expanding nitinol mesh disks; designed to engage and disrupt venous clots and subsequently deliver it to the large bore aspiration catheter. Its larger size makes it an attractive candidate for venous sinus clot retrieval. This study illustrates the first clinical use of INARI thrombectomy device in CVST with a reasonable safety profile. Anticoagulation is the mainstay first line treatment for CVST. However, a small subset of patients would potentially benefit from endovascular treatment but it still uncertain how to select these patients and what is the best timeline to offer early endovascular treatment. Various neuro endovascular techniques has been attempted to treat cerebral venous sinus thrombosis. However; it is unclear which approach and device provides the optimal restoration of venous blood flow. Current neuro endovascular techniques and devices are not particularly designed for CVST pathology treatment and there is need for further innovation and new devices.

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Cerebral venous sinuses thrombosis in both transverse sinus and torcula: Multistep endovascular treatment and stenting

Interventional Neuroradiology ◽

10.1177/1591019916674917 ◽

2016 ◽

Vol 23 (1) ◽

pp. 84-89 ◽

Cited By ~ 6

Author(s):

G Cabral de Andrade ◽

A Lesczynsky ◽

VM Clímaco ◽

ER Pereira ◽

PO Marcelino ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Endovascular Treatment ◽

Clinical Symptoms ◽

Sinus Thrombosis ◽

Transverse Sinus ◽

Cerebral Venous Sinus Thrombosis ◽

Severe Form ◽

Venous Sinus ◽

Lateral Sinus ◽

Mechanical Thrombolysis

Purpose Cerebral venous sinus thrombosis (CVST) is an unusual and potentially life-threatening condition with variable and nonspecific clinical symptoms and high morbimortality rates. Standard therapy consists of systemic anticoagulation; although there is no clear evidence about the best choice for treatment, intravenous heparin is used as the first-line treatment modality. Intravenous sinus thrombolysis can be an effective and relatively safe treatment for acutely deteriorating patients who have not responded to conventional therapy. This case report presents the possibility of endovascular treatment in multiple steps with mechanical thrombolysis with balloon, local pharmacological thrombolysis and stenting, in a patient with a severe form of CVST. Case summary A 67-year-old woman presented severe headache, agitation and confusion with diagnosis of venous sinus dural thrombosis in both lateral sinus and torcula. After 24 h there was neurological worsening evolving with seizures and numbness even after starting heparin, without sinus recanalization; CT scan showed left temporal intracerebral hemorrhage. We decided to take an endovascular approach in multiple steps. The first step was mechanical static thrombolysis with balloon; the second step was dynamic mechanical thrombolysis with a balloon partially deflated and “pulled”; the third step was local thrombolysis with Actilyse™; finally, the fourth step was angioplasty and reconstruction of the sinuses using multiple carotid stents and complete angiographic recanalization of both sinuses and torcula. After 24 h of endovascular treatment there was full clinical recovery and no tomographic complications. Conclusion This result shows that mechanical clot disruption, intrasinus thrombolysis and reconstruction of wall sinuses with stenting can be an endovascular option in the severe form of CVST with intracerebral hemorrhage and rapid worsening of neurological symptoms. Although this type of treatment can re-channel the occluded sinuses, further comparative and randomized studies are needed to clarify its efficacy versus other therapeutic modalities.

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Pearls & Oy-sters: Delayed traumatic intracerebral hemorrhage caused by cerebral venous sinus thrombosis

Neurology ◽

10.1212/wnl.0000000000000836 ◽

2014 ◽

Vol 83 (14) ◽

pp. e135-e137 ◽

Cited By ~ 5

Author(s):

P.-J. Hsu ◽

C.-W. Lee ◽

S.-C. Tang ◽

J.-S. Jeng

Keyword(s):

Intracerebral Hemorrhage ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Venous Sinus Thrombosis

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Direct thrombolysis for cerebral venous sinus thrombosis

Neurosurgical FOCUS ◽

10.3171/2009.7.focus09146 ◽

2009 ◽

Vol 27 (5) ◽

pp. E7 ◽

Cited By ~ 37

Author(s):

Maryam Rahman ◽

Gregory J. Velat ◽

Brian L. Hoh ◽

J Mocco

Keyword(s):

Endovascular Treatment ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

First Line ◽

Venous Sinus Thrombosis ◽

Cerebral Herniation ◽

Wide Range ◽

Vessel Dissection ◽

Mild Headache

Cerebral venous sinus thrombosis (CVST) is an increasingly diagnosed disease with a wide range of symptoms, ranging from a mild headache to cerebral herniation. A potentially devastating syndrome, CVST has been associated with a mortality rate of 6–10%. In prospective studies, the overall rate of death and dependency from CVST ranges from 8.8 to 44.4%. Systemic anticoagulation remains the first-line treatment. However, a percentage of patients deteriorate despite medical therapy. These cases have resulted in the development of thrombolysis or endovascular treatment for CVST. Initial reports of the use of endovascular treatment of CVST have been promising. However, enthusiasm for the use of endovascular thrombolysis and thrombectomy should be tempered by an understanding of possible risks such as intracerebral hemorrhage and/or vessel dissection. The authors review the literature regarding endovascular treatment of CVST with a description of the chemical and mechanical thrombolytic techniques.

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Stenting for acute cerebral venous sinus thrombosis in the superior sagittal sinus

Interventional Neuroradiology ◽

10.1177/1591019915609120 ◽

2015 ◽

Vol 21 (6) ◽

pp. 719-723 ◽

Cited By ~ 15

Author(s):

Hidemitsu Adachi ◽

Yohei Mineharu ◽

Tatsuya Ishikawa ◽

Hirotoshi Imamura ◽

Shiro Yamamoto ◽

...

Keyword(s):

Endovascular Treatment ◽

Balloon Angioplasty ◽

Superior Sagittal Sinus ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Digital Subtraction ◽

Thrombus Aspiration ◽

Venous Sinus Thrombosis ◽

Sagittal Sinus

Endovascular treatment for superior sagittal sinus (SSS) thrombosis is not always successful because of difficult access and long thrombus lesions. We report the first two cases of patients with acute cerebral venous sinus thrombosis at the SSS that was not recanalized by anticoagulation, mechanical thrombectomy, or thrombolysis, but was successfully treated by stent placement. Case 1 was a 37-year-old woman with bilateral subdural hematomas. Digital subtraction angiography showed obstruction of the sinus from the SSS to the right transverse sinus. Recanalization was achieved by selective thrombolysis using urokinase followed by balloon angioplasty, but re-occlusion occurred on the next day of treatment. Repeated endovascular treatment including balloon angioplasty, thrombus aspiration and thrombolysis using recombinant tissue plasminogen activator failed to achieve recanalization. We thus placed intracranial stents in the SSS, which did achieve recanalization. Case 2 was a 69-year-old woman with a small infarction in the left parietal lobe. Digital subtraction angiography showed sinus obliteration from the SSS to the bilateral transverse sinuses. Recanalization was not achieved by balloon angioplasty, thrombus aspiration and selective thrombolysis. We thus placed intracranial stents in the SSS, which did achieve recanalization. Postoperative course was uneventful in both cases and venous sinus patency was confirmed by venography >1.5 years after treatment. When conventional endovascular strategies have been unsuccessful, placement of intracranial stents, which can easily gain access to the distal part of the SSS as compared with carotid stents, may be a useful treatment option for the acute sinus thrombosis in this region.

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