E-043 Novel use of the Penumbra Aspiration System in three cases of severe dural venous sinus thrombosis

Abstract

IntroductionDural sinus venous thrombosis is a rare but potentially devastating disease. Current therapies include intravenous heparin, direct mechanical thrombectomy and local chemical thrombolysis. Despite aggressive management of this disease with these therapeutic interventions there are treatment failures that may be amenable to endovascular intervention. To date there is no endovascular device made specifically for this purpose.MethodsThree patients presented with neurological symptoms related to increased intracranial pressure. Non-invasive imaging demonstrated cerebral sinus occlusion. All patients were initially treated with intravenous heparin. The first patient had bilateral transverse and sigmoid sinus and superior sagittal sinus thrombosis, the second had left transverse and sigmoid sinus thrombosis and the third patient had thrombosis of the left transverse sinus which extended into the sigmoid sinus and internal jugular vein. All patients were neurologically deteriorating at the time of intervention and had developed hemorrhagic strokes despite aggressive heparinization.ResultsAll of the patients were successfully revascularized angiographically with the Penumbra Aspiration System in combination with local chemical thrombolysis. The first patient had end stage renal disease and significant comorbidities and eventually succumbed to multiorgan failure secondary to her pre-existing disease. The second patient developed leg weakness prior to the thrombolysis which progressed to paraplegia post-thrombectomy. Her leg strength was improving at discharge (4/5) and she was able to ambulate with assistive devices. She lives at home 2 months post-thrombectomy and ambulates without assistance. The third patient required hemicraniectomy for left parietal hemorrhage. She was discharged to rehab and returned for follow-up at 6 months with minimal word finding difficulties and otherwise neurologically intact. Both survivors were converted to warfarin therapy on discharge.ConclusionSuccessful revascularization was achieved in all three patients using a combination of thrombectomy with the Penumbra Aspiration System and local thrombolysis. All patients were severely injured secondary to sinus thrombosis related strokes; however, aggressive escalation of therapy along with successful revascularization resulted in very good long term outcomes in two patients. To our knowledge these are the first of such cases reported to use the Penumbra Mechanical thrombectomy device to re-canalize the dural venous sinus system.