Mechanical thrombectomy combined with recombinant tissue plasminogen activator thrombolysis in the venous sinus for the treatment of severe cerebral venous sinus thrombosis

Background: Cerebral venous sinus thrombosis (CVST) is a rare and often misdiagnosed condition with mortality rates ranging from 6 to 10%. Diagnosis and monitoring are typically achieved through noninvasive imaging, including computed tomography or magnetic resonance venography. The current standard of treatment is systemic anticoagulation. However, in patients who continue to decline neurologically or do not show sufficient response to or have absolute contraindications to systemic anticoagulation, endovascular treatments are an alternative. Endovascular options are poorly studied and specific devices have not been developed, partially due to the rare nature of the disease. Here, we present a case report detailing the treatment of extensive CVST from the vein of Galen to the sigmoid sinus using mechanical thrombectomy and local infusions of unfractionated heparin (UFH) and tissue plasminogen activator. Case Description: A 53-year-old man presented and was found to have extensive CVST extending from the vein of Galen to the left sigmoid sinus. Systemic UFH was begun; however, his condition continued to decline, and he was taken for endovascular intervention, wherein mechanical thrombectomy was undertaken using combinations of stent retrievers and balloon catheters, which provided acceptable revascularization. Unfortunately, his hospital course was further complicated by a cerebellar hematoma that was surgically evacuated and reocclusion of the sinus for which a microcatheter was placed for infusion of UFH and tissue plasminogen activator. Conclusion: Complicated CVST may require aggressive endovascular management. Local infusions of heparin and thrombolytic agents as well as mechanical thrombectomy are safe alternative options.

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Dural sinus mechanical thrombectomy and continuous local rt-PA infusion in a child with refractory intracranial hypertension and progressive visual loss: A case report

Surgical Neurology International ◽

10.25259/sni_236_2020 ◽

2020 ◽

Vol 11 ◽

pp. 253

Author(s):

Martino Cellerini ◽

Rosa Francavilla ◽

Caterina Testoni ◽

Monica Maffei ◽

Mino Zucchelli ◽

...

Keyword(s):

Intracranial Hypertension ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Visual Loss ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Therapeutic Option ◽

Recombinant Tissue Plasminogen Activator ◽

Dural Sinus ◽

Tissue Plasminogen

Background: Children with intracranial hypertension are at risk for visual loss and their visual function must be closely monitored. Surgery with the insertion of a ventriculoperitoneal shunt is imperative when vision is threatened. Case Description: Herein, we report a case of a 5-year-old boy whose refractory intracranial hypertension and severe, progressive visual loss (secondary to a chronic, otogenic, right sigmoid sinus thrombosis, and a contralateral sinus tight stenosis) were resolved by a combination of continuous (6 h), locoregional, infusion of recombinant tissue plasminogen activator (rt-PA), and mechanical thrombectomy. Conclusion: The association of in loco and continuous infusion of recombinant tissue plasminogen activator (rt- PA) with mechanical thrombectomy resulted in effective in partially reopening the occluded sinus and facilitating a good clinical recovery. This combined endovascular approach may represent an alternative, less invasive, therapeutic option to surgery in children with intracranial hypertension caused by chronic cerebral venous sinus thrombosis.

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Safety and Validity of Mechanical Thrombectomy and Thrombolysis on Severe Cerebral Venous Sinus Thrombosis

Neurosurgery ◽

10.1227/neu.0b013e318285c1d3 ◽

2013 ◽

Vol 72 (5) ◽

pp. 730-738 ◽

Cited By ~ 36

Author(s):

Guangwen Li ◽

Xianwei Zeng ◽

Mohammed Hussain ◽

Ran Meng ◽

Yi Liu ◽

...

Keyword(s):

Magnetic Resonance ◽

Treatment Modality ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Magnetic Resonance Venography ◽

Venous Sinus ◽

Venous Sinus Thrombosis ◽

Digital Subtract Angiography

Abstract BACKGROUND: Although the majority of patients with cerebral venous sinus thrombosis (CVST) obtain an optimistic clinical outcome after heparin or warfarin treatment, there remains a subgroup of patients who do not respond to conventional anticoagulation treatment. These patients, especially younger people, as documented by hospital-based studies, have a high morbidity and mortality rate. OBJECTIVE: To verify the safety and efficacy of a dual mechanical thrombectomy with thrombolysis treatment modality option in patients with severe CVST. METHODS: Fifty-two patients diagnosed with CVST were enrolled and treated with mechanical thrombectomy combined with thrombolysis. Patients underwent urokinase 100 to 1500 × 103 IU intravenous sinus injection via a jugular catheter after confirming diagnoses of CVST by using either magnetic resonance imaging/magnetic resonance venography or digital subtract angiography. Information obtained on the patients included recanalization status of venous sinuses as evaluated by magnetic resonance venography or digital subtract angiography at admission, during operation, and at 3- and 6-month follow-up after treatment. RESULTS: The percentage of patients that showed complete and partial recanalization were 87% and 6%, respectively, after mechanical thrombectomy combined with thrombolysis treatment; 8% of the patients showed no recanalization. The modified Rankin Scale scores were 1.0 ± 0.9, 0.85 ± 0.63, and 0.37 ± 0.53 for discharge, and 3- and 6-month follow-up, respectively. A total of 6 patients died despite receiving aggressive treatment. No cases of relapse occurred after 3 to 6 months of follow-up. CONCLUSION: Thrombectomy combined with thrombolysis is a safe and valid treatment modality to use in severe CVST cases or in intractable patients that have shown no adequate response to antithrombotic drugs.

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A Case of Oropharyngeal Angioedema Following Intravenous Recombinant Tissue Plasminogen Activator (rt-PA) and Mechanical Thrombectomy

Drug Safety - Case Reports ◽

10.1007/s40800-019-0104-9 ◽

2019 ◽

Vol 6 (1) ◽

Author(s):

Mohamed Shirazy ◽

Anis Chaari ◽

Karim Hakim ◽

Kamel Bousselmi ◽

Vipin Kauts

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Mechanical Thrombectomy ◽

Recombinant Tissue Plasminogen Activator ◽

Tissue Plasminogen

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Endovascular Mechanical Thrombectomy for Cerebral Venous Sinus Thrombosis: A Single-Center Experience

World Neurosurgery ◽

10.1016/j.wneu.2019.04.049 ◽

2019 ◽

Vol 127 ◽

pp. e1097-e1103 ◽

Cited By ~ 1

Author(s):

Hanna Styczen ◽

Ioannis Tsogkas ◽

Jan Liman ◽

Volker Maus ◽

Marios Nikos Psychogios

Keyword(s):

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Single Center ◽

Venous Sinus Thrombosis ◽

Single Center Experience ◽

Endovascular Mechanical Thrombectomy

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Efficacy of Tissue Plasminogen Activator in the Lysis of Thrombosis of the Cerebral Venous Sinus

Neurosurgery ◽

10.1227/00006123-199004000-00001 ◽

1990 ◽

Vol 26 (4) ◽

pp. 559-564 ◽

Cited By ~ 27

Author(s):

Lon F. Alexander ◽

Yoshihiro Yamamoto ◽

Samer Ayoubi ◽

Ossama Al-Mefty ◽

Robert R. Smith

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Sinus Thrombosis ◽

Occlusive Disease ◽

Venous Sinus ◽

Pathological Examination ◽

Clot Lysis ◽

Venous Sinuses ◽

Tissue Plasminogen ◽

Cerebral Sinus

Abstract Therapy for thrombo-occlusive disease of the cerebral venous sinuses remains controversial. Although several thrombolytic agents, such as urokinase and anticoagulants, are recommended for treatment, major significant risks include cerebral hemorrhage, especially in patients with venous infarction. Tissue plasminogen activator (tPA) has shown a high affinity for fibrin-bound plasminogen, while exhibiting a low affinity for circulating plasminogen. The purpose of this study was to evaluate this drug for use in cerebral sinus thrombo-occlusive disease. Eleven adult male rabbits were chosen as experimental animals. All animals underwent microsurgical dissection of their major dural venous sinuses. Direct compression was used to form a thrombus within the sinus. The presence of significant venous thrombosis was confirmed radiographically by iohexol sinography. Subsequently. tPA was delivered systemically via the marginal ear vein at a dose of 3000 units/h; the result was total lysis of the clot documented by a sinogram 1 hour after the drug was administered. Postmortem pathological examination confirmed total lysis in seven of eight animals. One animal showed partial retained clot fragments. No significant coagulopathic state was observed. In three control animals, saline was infused without clot lysis. We conclude that tPA is a highly effective agent for the lysis of acute induced venous sinus thrombosis in an experimental model.

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Association Between Recombinant Tissue Plasminogen Activator and In-Hospital Mortality/30-Day Readmission Among Mechanical Thrombectomy Patients: A Retrospective Cohort Study

Value in Health ◽

10.1016/j.jval.2018.04.405 ◽

2018 ◽

Vol 21 ◽

pp. S68

Author(s):

A Sarayani ◽

J Brown ◽

P Pham ◽

T Youn ◽

H Xiao

Keyword(s):

Cohort Study ◽

Hospital Mortality ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Mechanical Thrombectomy ◽

Recombinant Tissue Plasminogen Activator ◽

Tissue Plasminogen

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Successful mechanical thrombectomy in a comatose patient with cerebral venous sinus thrombosis: A case report

Interventional Neuroradiology ◽

10.1177/1591019917706051 ◽

2017 ◽

Vol 23 (4) ◽

pp. 437-440 ◽

Cited By ~ 1

Author(s):

Merel JJ Verhagen ◽

Adriaan CGM van Es ◽

Geert J Lycklama à Nijeholt ◽

Korné Jellema ◽

Jonathan Coutinho ◽

...

Keyword(s):

Case Report ◽

Alternative Treatment ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Comatose Patient ◽

Unfavourable Outcome ◽

Treatment Methods ◽

Venous Sinus Thrombosis

Cerebral venous sinus thrombosis is a rare cause of stroke, which is routinely treated with systemic heparin. Unfavourable outcome is often seen in severe cases. Therefore alternative treatment methods should be explored in these patients. Due to the risk of haemorrhagic complications, treatment without administration of thrombolytics is of particular interest. This report presents a case of successful mechanical thrombectomy, without the use of thrombolytics, in a comatose patient with cerebral venous sinus thrombosis.

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First off Label Endovascular Clinical Experience to Treat Diffuse Cerebral Venous Sinus Thrombosis Using the INARI FlowTriever System: Case Report

Frontiers in Neurology ◽

10.3389/fneur.2021.778842 ◽

2021 ◽

Vol 12 ◽

Author(s):

Saif Bushnaq ◽

Samer Abdul Kareem ◽

Nicholas Liaw ◽

Bader Alenzi ◽

Muhammad Khaleeq Ahmed ◽

...

Keyword(s):

Case Report ◽

Clinical Experience ◽

Mechanical Thrombectomy ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Safety And Efficacy ◽

Venous Sinus Thrombosis ◽

Off Label ◽

Aggressive Interventions

Anticoagulation with heparin is the current mainstay treatment for Cerebral Venous Sinus Thrombosis (CVST). Endovascular treatment is increasingly being used to treat patients with CVST who are non-responsive to anticoagulation. These more aggressive interventions include catheter-based local chemical thrombolysis, balloon angioplasty and mechanical thrombectomy with uncertain safety and efficacy. Here we describe the first reported clinical experience using the INARI FlowTriever system to treat a patient presented with focal weakness and found to have diffuse CVST.

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