Abstract 1122‐000044: Endovascular Thrombectomy for Straight Sinus Thrombosis

Introduction : Cerebral venous thrombosis (CVT) is an under‐recognized disease that accounts for roughly 1% of all strokes 1 . It presents a diagnostic challenge due to its varied and ambiguous presentation, which on average, delays diagnosis by 7 days. Pre‐disposing factors include trauma, pregnancy, dehydration, and medications such as oral contraceptives. In one study, 50% of CVT occurred during pregnancy or puerperium 2 . Seven out of 8 cases of CVT presented postpartum among 50,700 deliveries in Canada 3 . Clinical signs and symptoms range from a mild headache to decreased level of consciousness depending on the location of thrombosis. Up to 13% of individuals can have poor outcomes despite anticoagulation therapy. Methods : A 28‐year‐old, 7‐week postpartum female awoke with a headache and difficulty speaking, followed by urinary and bowel incontinence. Her clinical status worsened and was admitted to an outside hospital where CT‐head without contrast revealed right temporal lobe hypodensity. A hyperdense straight sinus sign was present but not recognized at that time. She was transferred to our hospital and MRI brain demonstrated extensive vasogenic edema in the basal ganglia, thalami, and deep white matter with cytotoxic edema in bilateral watershed areas from severe hydrocephalus. MR‐Venography showed extensive cerebral venous thrombosis in the inferior sagittal sinus, vein of Galen, straight sinus, and left transverse and sigmoid sinuses. Upon transfer to our facility, NIHSS was 9 for decreased level of consciousness and aphasia with episodes of left‐sided clonic movements. Despite adequate anticoagulation therapy, she continued to decline with extensor posturing and a comatose state. Results : Since the findings on MRI‐brain were predominantly vasogenic edema, thrombectomy was performed with a stent‐retriever and aspiration, with complete recanalization of her straight sinus. Subsequent MRIs demonstrated improvement and resolution of the edema and hydrocephalus. Hypercoagulable work‐up revealed an elevated protein C and antithrombin III and she was transitioned to enoxaparin and discharged to LTACH. At four‐month follow‐up she was able to speak and walk with physical therapy. Conclusions : We highlight the importance of early recognition of deep venous thrombosis as it commonly affects level of consciousness. A subtle finding, it should be in the differential diagnosis of alteration in level of consciousness without obvious neuroimaging findings. The AAN guidelines for management of CVT do not advocate for thrombectomy in all patients as large randomized controlled trials do not currently exist. However, they recognize that thrombectomy may be considered if deterioration occurs despite intensive anticoagulation treatment. The TO‐ACT trial found no significant difference in mortality between intervention and medical therapy, aggressive intervention with thrombectomy prevented a larger stroke burden in our patient. Therefore, thrombectomy should be considered in patients suffering from CVT, particularly in refractory and extensive cases.

Comparisons of clinical characteristics, brain MRI findings, and responses to epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache: retrospective study

Background Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment. Methods We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus). Results A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02). Conclusions Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

Endovascular management of torcular dural sinus malformations in children: the role of straight sinus occlusion

BackgroundTorcular dural sinus malformations (tDSMs) with arteriovenous shunts are rare congenital intracranial vascular malformations that carry a high rate of neurologic impairment and death in the neonatal, infant and young pediatric population. Their impact on brain venous drainage, especially the deep venous system, is one of the key factors in the clinical prognosis and natural history of the disease. We describe our therapeutic strategy for tDSMs, disconnecting the reflux into the deep venous system by performing an endovascular straight sinus occlusion.MethodsAmong all children with dural sinus malformations seen between 2002 and 2020, we retrospectively reviewed those with tDSM in whom straight sinus occlusion had been performed.ResultsOur databank included nine patients with tDSM that were embolized. Mean age at the clinical onset was 8.9±9.6 months (min–max=0–31). Five patients presented a significant reflux in the straight sinus on digital subtraction angiography. Those patients were initially clinically worse (mean modified Rankin Scale (mRS) 3.8) than those who did not present with reflux (mean mRS 2.25), this reflux being responsible for intraventricular hemorrhage in three patients. The reflux was suppressed by transarterial embolization in one patient and by transvenous straight sinus occlusion in four patients. Staged endovascular treatment resulted in a complete cure in six patients without complications, and clinical improvement in all patients.ConclusionStraight sinus occlusion is a feasible technique that needs to be considered in the treatment strategy for tDSM with deep venous reflux in order to avoid or minimize brain damage.