Endovascular Mechanical Thrombectomy and On-Site Chemical Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Abstract

chen 5,11 , Hung-Chieh chen 5,6 , chiung-chyi Shen 2,7,9,10* , Shun-Fa Yang 1,8* & Yuang-Seng tsuei 1,2,7* cerebral venous sinus thrombosis (cVSt) is a rare cause of cerebral infarction. once patients survive the acute phase, long-term prognosis is generally satisfactory. CVST patients who harbored risk factors known for poor prognosis (e.g., deterioration of consciousness/neurological functions and seizures) were oftentimes unresponsive to systemic heparin treatment. The advantage of combined endovascular mechanical thrombectomy (eMt) and on-site chemical thrombolysis (oct) plus systemic heparin for CVST over the heparin treatment alone has not been proved. A retrospective study was conducted to analyze consecutive patients with CVST from 2005 to 2015. Patients having clinical improvement or stable disease after heparin treatment were in I/S group; patients having continuous deterioration of consciousness/neurological functions and refractory seizures (despite the use of multiple anti-epileptic drugs) after heparin treatment were in D group. EMT and OCT were indicated for patients in D group. Imaging studies and medical records were reviewed for statistical analysis. Safety issues included new-onset/progression of symptomatic intracerebral hemorrhages (ICH) or procedurerelated complications. Total thirty patients were included (I/S group = 16; D group = 14). In D group, the mean time frame from the start of heparin treatment to the endovascular treatment was 3.2 days. Compared with I/S group, all patients in D group had complete stenosis of the sinuses, with higher initial mRS, lower initial GCS, and more seizures (p = 0.006, 0.007, and 0.031, respectively), but no significant differences in the mRS at discharge (p = 0.504). Shorter length of thrombosis and lower initial mRS were associated with better outcomes (p = 0.009 and 0.003, respectively). Thrombosis involving the superior sagittal sinus (SSS) was associated with bad outcomes (p = 0.026). There were two patients (6.7%) with worsening symptomatic ICH, one in each group, managed surgically. The overall mortality of the study was 6.7% (2/30). Combined EMT and OCT after heparin treatment for severe CVST were reasonably safe, which might be considered as a salvage treatment in severe CVST patients who are unresponsive to heparin with heavy clot burden involving SSS in the acute phase. However, further studies are needed to confirm its efficacy and validity. Cerebral venous sinus thrombosis (CVST) is a rare disease. The diagnosis could easily be missed if the initial presentation is non-specific headaches. Heparin (unfractionated heparin or low-molecular-weight heparin) is the first-line treatment. Concomitant intracerebral hemorrhage related to CVST is not a contraindication to heparin

Successful Endovascular Treatment of Cerebral Venous Thrombosis with a Novel, Larger Aspiration Catheter (REACT): A Case Report

“…The major indications for endovascular therapy in CVT include a) clinical deterioration or progression of intracerebral hemorrhage/venous infarction despite anticoagulation, b) severe stupor, comatose presentation, c) deep CVT, d) posterior fossa involvement, and e) major contraindication to anticoagulation such as bleeding disorders, thrombocytopenia (<100×10 9 /L) or recent gastrointestinal hemorrhages [ 6 ]. Recently, a group of authors classified the configuration of CVT into 4 types: a) Type A: partial thrombosis of a sinus, b) Type B: complete thrombosis of the sinus without cortical vein involvement, c) Type C: cortical vein thrombosis only, and d) Type D: complete thrombosis of the sinus with cortical vein involvement [ 7 ]. Applying this classification, our patient had a Type D configuration CVT.…”

“…According to this study, Type D patients have greater disease severity and poorer outcomes and mortality in the acute phase. Endovascular treatment as a salvage treatment was recommended for these patients [ 7 ]. When endovascular therapy is considered for CVT, 3 major treatment approaches have been followed: a) mechanical thrombectomy (using distal access catheter, thrombectomy devices, stent retrievers, or balloons), b) intravascular thrombolysis, or c) a combination of both.…”

“…Although there are newer stent retrievers that are available for acute ischemic stroke, the use of these devices for CVT has not significantly affected outcomes or complete recanalization rates [ 13 ]. For diffuse CVT involving venous channels of different diameters, with varying lengths of occlusion, stent retrievers would not be an ideal device for thrombectomy [ 7 ]. In addition, deploying stent retrievers across each of the occluded sinuses, at various distances, and then retrieving them would significantly increase the intraoperative procedure time.…”

Impacts on Thrombus and Chordae Willisii During Mechanical Thrombectomy in the Superior Sagittal Sinus

“…MT has become a very effective treatment for serious cerebral venous sinus thrombosis ( 26 ). MT destroys and cuts off the thrombus through physical force, makes the thrombus loose in the venous sinus, thus recanalizes sinus blood flow.…”

Diagnostic and treatment recommendations from the FACME ad-hoc expert working group on the management of cerebral venous sinus thrombosis associated with COVID-19 vaccination

“…There is limited evidence to recommend systematic endovascular or surgical treatment. 90 , 91 , 92 , 93 These treatments may be considered in patients presenting poor response to pharmacological treatment at centres with experience in their use. 56 , 57 , 94 …”