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

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

Scientific Reports ◽

10.1038/s41598-020-78570-1 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Xin-bin Guo ◽

Shuo Liu ◽

Sheng Guan

Keyword(s):

Intracerebral Hemorrhage ◽

Endovascular Treatment ◽

Treatment Strategy ◽

Sinus Thrombosis ◽

Clinical Analysis ◽

Cerebral Venous Sinus Thrombosis ◽

Outcome Data ◽

Venous Sinus ◽

Venous Sinus Thrombosis ◽

Clinical And Radiological Outcome

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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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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Prognostic value of systemic immune–inflammation index in acute/subacute patients with cerebral venous sinus thrombosis

Stroke and Vascular Neurology ◽

10.1136/svn-2020-000362 ◽

2020 ◽

Vol 5 (4) ◽

pp. 368-373

Author(s):

Shen Li ◽

Kai Liu ◽

Yuan Gao ◽

Lu Zhao ◽

Rui Zhang ◽

...

Keyword(s):

Regression Analysis ◽

Cox Regression ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Cox Regression Analysis ◽

Venous Sinus Thrombosis ◽

Immune Inflammation ◽

Poor Outcomes

ObjectiveTo evaluate the prognosis values of systemic immune–inflammation index (SII) in non-chronic cerebral venous sinus thrombosis (CVST).Methodspatients with CVST, admitted to the First Affiliated Hospital of Zhengzhou University, were retrospectively identified from January 2013 to December 2018. We selected patients in acute/subacute phase from database. Functional outcomes of patients were evaluated with the modified Rankin Scale (mRS)—mRS 3–6 as poor outcomes and mRS 6 as death. The overall survival time was defined as the date of onset to the date of death or last follow-up date. Survival analysis was described by the Kaplan-Meier curve and Cox regression analysis. Multivariate logistic regression analysis assessed the relationship between SII and poor functional outcome. The area under the Receiver Operating Curve curve (AUC) was estimated to evaluate the ability of SII in prediction.ResultsA total of 270 patients were included and their duration of follow-up was 22 months (6–66 months), of whom 31 patients had poor outcomes and 24 patients dead. Cox regression analysis showed that SII (HR=1.304, 95% CI: 1.101 to 1.703, p=0.001) was a predictor of death in non-chronic CVST. Patients with higher SII presented lower survival rates (p=0.003). The AUC of SII was 0.792 (95% CI: 0.695 to 0.888, p=0.040) with a sensitivity of 69.6% and specificity of 80.1%. Subgroups analysis demonstrated that SII was an important predictor of poor outcomes in male (OR=1.303, 95% CI: 1.102 to 1.501, p=0.011) and pregnancy/puerperium female (OR=1.407, 95% CI: 1.204 to 1.703, p=0.034).ConclusionsSII was a potential predictor in the poor prognosis of patients with acute/subacute CVST, especially in male and pregnancy/puerperium female.

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Cerebral Venous Sinus Thrombosis as a Rare Complication of Systemic Lupus Erythematosus: Subgroup Analysis of the VENOST Study

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2019.104372 ◽

2019 ◽

Vol 28 (12) ◽

pp. 104372 ◽

Cited By ~ 1

Author(s):

Taskın Duman ◽

Seden Demirci ◽

Derya Uluduz ◽

Hasan Hüseyin Kozak ◽

Serkan Demir ◽

...

Keyword(s):

Systemic Lupus Erythematosus ◽

Lupus Erythematosus ◽

Subgroup Analysis ◽

Sinus Thrombosis ◽

Rare Complication ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Systemic Lupus ◽

Venous Sinus Thrombosis

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Cerebral Venous Sinus Thrombosis in a Patient with Ulcerative Colitis Flare

Case Reports in Neurological Medicine ◽

10.1155/2018/5798983 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7

Author(s):

L. M. Conners ◽

R. Ahad ◽

P. H. Janda ◽

Z. Mudasir

Keyword(s):

Ulcerative Colitis ◽

Inflammatory Bowel Disease ◽

Bowel Disease ◽

Sinus Thrombosis ◽

Rare Complication ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Venous Sinus Thrombosis ◽

Increased Risk ◽

Inflammatory Bowel

Inflammatory bowel disease is characterized by a chronic inflammatory state and is therefore associated with abnormalities in coagulation and a hypercoagulable state. Cerebral venous sinus thrombosis is a rare complication of inflammatory bowel disease yet contributes significant morbidity and mortality to those affected. Early diagnosis is critical, as a delay in diagnosis portends a worse prognosis. This paper seeks to highlight the increased risk of venous sinus thrombosis in patients with inflammatory bowel disease. We start by discussing the case of a seventeen-year-old female who presented with ulcerative colitis flare and developed new-onset seizures, found to be caused by a large 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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Headache in cerebral venous sinus thrombosis revisited: Exploring the role of vascular congestion and cortical vein thrombosis

Cephalalgia ◽

10.1177/0333102417698707 ◽

2017 ◽

Vol 38 (3) ◽

pp. 503-510 ◽

Cited By ~ 5

Author(s):

Ravinder-Jeet Singh ◽

Jitender Saini ◽

Shriram Varadharajan ◽

Girish Baburao Kulkarni ◽

Mustare Veerendrakumar

Keyword(s):

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Dural Sinus ◽

Dural Sinus Thrombosis ◽

Venous Sinus Thrombosis ◽

Cortical Vein ◽

Vein Thrombosis ◽

Cortical Vein Thrombosis ◽

Vascular Congestion

Background and purpose Headache constitutes the most common symptom of cerebral venous sinus thrombosis (CVST), but its pathophysiology is unclear. We sought to investigate the potential mechanism for headache genesis in patients with CVST based on its imaging correlates. Methods A subgroup of CVST patients having headache as the predominant symptom without significant parenchymal lesion were retrospectively analysed for imaging features of vascular congestion (VC), in addition to cortical venous (CVT) and dural sinus thrombosis (DST) on magnetic resonance imaging. Headache and imaging patterns were classified into lateralized and nonlateralized phenotypes and their correlation was sought. Results Among 41 patients included, 28 had lateralized headache (LH group; 15 males; mean age 32.25 ± 9.19 years) while 13 had nonlateralized headache (non-LH group; six males; mean age 27.15 ± 8.65 years). Headache characteristics in both the groups were quite similar. Imaging showed VC in 39 of 41 and CVT among 35 of 41 patients, which were lateralized in 23 of 39 and 18 of 35 patients, respectively. Nearly all lateralized imaging patterns (21 of 23 for VC and 17 of 18 for CVT) occurred in the LH group and ipsilateral to (concordant) headache, while the non-LH group showed lateralized VC and CVT in only two and one patient respectively. Sinus thrombosis was lateralized in both groups irrespective of headache laterality. Whole cohort headache-imaging laterality (including patients with nonlateralized headache and nonlateralized imaging) concordance was 31 of 39, 24 of 35 and 18 of 41 for vascular congestion, cortical vein thrombosis and dural sinus thrombosis respectively. Conclusion Co-localization of VC and CVT with overlying headache might provide a possible explanation of headache and its laterality in patients with CVST.

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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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