Endovascular management of cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) is characterized by formation of widespread thrombus within the cerebral venous sinus system. CVST can cause venous hypertension, venous infarcts, hemorrhage and seizures. It is managed in most cases with systemic anticoagulation through the use of heparin to resolve the thrombus. Patients that demonstrate clinical deterioration while on heparin are often treated with endovascular strategies to recanalize the sinuses. We present the case of a patient with widespread CVST, involving his superior sagittal sinuses and bilateral transverse sigmoid sinuses, who was treated with a combination of endovascular therapies.The video can be found here: http://youtu.be/w3wAGlT7h8c.

Download Full-text

Safety and efficacy of the use of large bore intermediate suction catheters alone or in combination for the treatment of acute cerebral venous sinus thrombosis: A multicenter experience

Interventional Neuroradiology ◽

10.1177/1591019919865957 ◽

2019 ◽

Vol 26 (1) ◽

pp. 26-32 ◽

Cited By ~ 1

Author(s):

Sudeepta Dandapat ◽

Edgar A Samaniego ◽

Viktor Szeder ◽

Fazeel M Siddiqui ◽

Gary R Duckwiler ◽

...

Keyword(s):

Sinus Thrombosis ◽

Clinical Status ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Suction Catheter ◽

Aspiration Thrombectomy ◽

Venous Sinus Thrombosis ◽

Procedural Complications ◽

Systemic Anticoagulation ◽

New Generation

Background and purpose Systemic anticoagulation is the standard treatment for cerebral venous sinus thrombosis (CVST). Several endovascular techniques have been described as salvage therapy for anticoagulation refractory CVST cases. We aim to evaluate the safety and feasibility of endovascular aspiration thrombectomy using the new generation, large bore suction catheters alone or in combination with stentriever devices for the treatment of CVST. Methods We collected data on 16 consecutive patients with CVST who received endovascular aspiration thrombectomy at three large academic centers. Second generation reperfusion catheters were used as a large bore suction catheter and advanced to the affected sinus using a coaxial technique. Suction was performed using pump suction. At times, a stentriever was used as an anchor to facilitate advancing the suction catheter and to increase thrombectomy capabilities. Results Median decade of age was the 50s and nine patients were women. Fifty percent of the patients had multiple sinuses involved. All patients received systemic anticoagulation prior to endovascular aspiration thrombectomy. The most common reason to pursue endovascular aspiration thrombectomy in CVST patients was deterioration of initial clinical status (10/16). The mean time from admission to endovascular aspiration thrombectomy was 1.5 days (range 0–6 days). Good recanalization was obtained in all patients. There were no major peri-procedural complications. Most patients were discharged to either home or a rehabilitation facility. Conclusion Endovascular aspiration treatment using large bore suction catheters for CVST is a safe and feasible approach for the treatment of anticoagulation refractory CVST. Heterogeneity of the clinical and radiological presentation requires further investigation to optimize patient selection before evaluating the efficacy of this technique in larger prospective studies.

Download Full-text

A review of therapeutic strategies for the management of cerebral venous sinus thrombosis

Neurosurgical FOCUS ◽

10.3171/2009.8.focus09154 ◽

2009 ◽

Vol 27 (5) ◽

pp. E6 ◽

Cited By ~ 24

Author(s):

Ricky Medel ◽

Stephen J. Monteith ◽

R. Webster Crowley ◽

Aaron S. Dumont

Keyword(s):

Intracranial Hemorrhage ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Case Reports ◽

Case Series ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Level Of Evidence ◽

Venous Sinus Thrombosis ◽

Systemic Anticoagulation

Object Although initially described in the 19th century, cerebral venous sinus thrombosis (CVST) remains a diagnostic and therapeutic dilemma. It has an unpredictable course, and the propensity for hemorrhagic infarction produces significant consternation among clinicians when considering anticoagulation. It is the purpose of this review to analyze the evidence available on the management of CVST and to provide appropriate recommendations. Methods A thorough literature search was conducted through MEDLINE and PubMed, with additional sources identified through cross-referencing. A classification and level of evidence assignment is provided for recommendations based on the American Heart Association methodologies for guideline composition. Results Of the publications identified, the majority were isolated case reports or small case series. Few prospective trials have been conducted. Existing data support the use of systemic anticoagulation as an initial therapy in all patients even in the presence of intracranial hemorrhage. Chemical and/or mechanical thrombectomy, in conjunction with systemic anticoagulation, is an alternative strategy in patients with progressive deterioration on heparin therapy or in those who are moribund on presentation. Mechanical thrombectomy is probably preferred in patients with preexisting intracranial hemorrhage. Conclusions Effective treatments exist for the management of CVST, and overall outcomes are more favorable than those for arterial stroke. Further research is necessary to determine the role of individual therapies; however, the rarity of the condition poses a significant limitation.

Download Full-text

Heparin Resistance and Anticoagulation Failure in a Challenging Case of Cerebral Venous Sinus Thrombosis

The Neurohospitalist ◽

10.1177/1941874415591500 ◽

2015 ◽

Vol 6 (3) ◽

pp. 118-121 ◽

Cited By ~ 6

Author(s):

Adam B. King ◽

Anne E. O’Duffy ◽

Avinash B. Kumar

Keyword(s):

Sinus Thrombosis ◽

Ventilatory Support ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Intensive Care Unit Care ◽

Factor X ◽

Jugular Veins ◽

Venous Sinus Thrombosis ◽

Heparin Resistance ◽

Systemic Anticoagulation

We report a challenging case of cerebral venous sinus thrombosis (multiple etiologic factors) that was complicated by heparin resistance secondary to suspected antithrombin III (ATIII) deficiency. A 20-year-old female previously healthy and currently 8 weeks pregnant presented with worsening headaches, nausea, and decreasing Glasgow Coma Scale/Score (GCS), necessitating mechanical ventilatory support. Imaging showed extensive clots in multiple cerebral venous sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and the straight sinus. She was started on systemic anticoagulation and underwent mechanical clot removal and catheter-directed endovascular thrombolysis with limited success. Complicating the intensive care unit care was the development of heparin resistance, with an inability to reach the target partial thomboplastin time (PTT) of 60 to 80 seconds. At her peak heparin dose, she was receiving >35 000 units/24 h, and her PTT was subtherapeutic at <50 seconds. Deficiency of ATIII was suspected as a possible etiology of her heparin resistance. Fresh frozen plasma was administered for ATIII level repletion. Given her high thrombogenic risk and challenges with conventional anticoagulation regimens, we transitioned to argatroban for systemic anticoagulation. Heparin produces its major anticoagulant effect by inactivating thrombin and factor X through an AT-dependent mechanism. For inhibition of thrombin, heparin must bind to both the coagulation enzyme and the AT. A deficiency of AT leads to a hypercoagulable state and decreased efficacy of heparin that places patients at high risk of thromboembolism. Heparin resistance, especially in the setting of critical illness, should raise the index of suspicion for AT deficiency. Argatroban is an alternate agent for systemic anticoagulation in the setting of heparin resistance.

Download Full-text

Endovascular Interventional Management of Cerebral Venous Sinus Thrombosis

Journal of Stroke Medicine ◽

10.1177/2516608518774211 ◽

2018 ◽

Vol 1 (1) ◽

pp. 28-33

Author(s):

Sunil K. Narayan ◽

Arunmozhimaran Elavarasi

Keyword(s):

Risk Factors ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Endovascular Management ◽

Venous Sinus Thrombosis ◽

Endovascular Interventions ◽

Poor Outcomes

Cerebral venous sinus thrombosis (CVST) is relatively a rare cause of stroke and can have protean manifestations ranging from headache, seizures, diplopia, focal deficits or coma. It is usually managed with anticoagulation. However, various studies have shown a mortality of 13% to 30% and have elucidated certain risk factors such as poor sensorium at presentation and rapid deterioration in spite of anticoagulation, for poor outcomes. In these situations, it has been postulated that endovascular management using thrombolysis or mechanical thrombectomy can give better outcomes. This review tries to address the role of endovascular interventions in CVST.

Download Full-text

Balloon-Assisted Thrombectomy and Intrasinus Urokinase Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Frontiers in Neurology ◽

10.3389/fneur.2021.735540 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jiansheng Yang ◽

Hongyang Wang ◽

Yanxing Chen ◽

Minjian Qiu ◽

Baorong Zhang ◽

...

Keyword(s):

Sinus Thrombosis ◽

Case Series ◽

Cerebral Venous Sinus Thrombosis ◽

Outcome Data ◽

Venous Sinus ◽

Technical Success ◽

Venous Sinus Thrombosis ◽

Contrast Enhanced ◽

Systemic Anticoagulation

Background: Current clinical guidelines recommend systemic anticoagulation as the initial treatment for severe cerebral venous sinus thrombosis (CVST). However, anticoagulation alone does not always dissolve large and extensive CVSTs in some patients. Here, we investigated the effectiveness and safety of balloon-assisted thrombectomy and intrasinus urokinase thrombolysis in our retrospective study of a series of 23 patients with CVST.Methods: We reviewed the clinical, radiological, and outcome data of all patients. Complete recanalization was defined as all the occluded sinuses were recanalized on digital subtraction angiography or Contrast-enhanced magnetic resonance venography. Partial recanalization was defined as the complete recanalization of one sinus but persistent occlusion of other sinuses, or partial recanalization of one or more sinuses. The modified Rankin Scale (mRS) was used to represent the clinical outcome.Results: From May 2017 to November 2019, a total of 23 patients were treated with balloon-assisted thrombectomy and intrasinus urokinase thrombolysis. A total of 84 venous sinuses were involved, ≥3 sinuses were involved in 20 (87%) patients. Among them, 21 (91%) patients achieved technical success. Complete and partial recanalization were obtained in 17 (81%) and 4 (19%) patients at 6 months follow-up, respectively. All 21 patients had mRS scores of 0 (18) or 1 (3).Conclusions: Our case series shows that balloon-assisted thrombectomy combined with intrasinus urokinase thrombolysis and activated partial thromboplastin time-regulated systemic anticoagulation is safe and effective in treating severe CVST.

Download Full-text

Republished: Reversible changes in diffusion- and perfusion-based imaging in cerebral venous sinus thrombosis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2014-011447.rep ◽

2015 ◽

Vol 8 (2) ◽

pp. e6-e6 ◽

Cited By ~ 1

Author(s):

Ning Lin ◽

Andrew K Wong ◽

Lindsay J Lipinski ◽

Maxim Mokin ◽

Adnan H Siddiqui

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Prognostic Value ◽

Ct Perfusion ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Imaging Studies ◽

Venous Sinus Thrombosis ◽

Systemic Anticoagulation

Diffusion- and perfusion-based imaging studies are regularly used in patients with ischemic stroke. Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is primarily treated by systemic anticoagulation. Endovascular intervention can be considered in cases of failed medical therapy, yet the prognostic value of diffusion- and perfusion-based imaging for CVST has not been clearly established. We present a patient with CVST whose abnormal findings on MRI and CT perfusion images were largely reversed after endovascular treatment.

Download Full-text