Mechanical Thrombectomy versus Intrasinus Thrombolysis for Cerebral Venous Sinus Thrombosis: A Non-Randomized Comparison

Abstract

<jats:p> Small retrospective studies have shown the benefit of endovascular treatment with intrasinus thrombolysis (IST) or mechanical thrombectomy (MT) with/without IST (MT+/−IST) in cases of multifocal cerebral venous thrombosis (CVT). </jats:p><jats:p> Our study compares the mortality, functional outcome and periprocedural complications among patients treated with MT +/– IST versus IST alone. </jats:p><jats:p> We reviewed clinical and angiographic findings of 63 patients with CVT who received endovascular treatment at three tertiary care centers. Primary outcome variables were discharge mortality and neurological dysfunction, and intermediate (three months) and long-term (&gt;six months) morbidity. The modified Rankin scale (mRS) was used to assess morbidity. mRS ≤1 was considered a good recovery. Neurological dysfunction was rated as neuroscore: 0, normal; 1, mild (ambulatory, communicative); 2, moderate (non-ambulatory, communicative); and 3, severe (non-ambulatory, non-communicative/comatose). </jats:p><jats:p> In patients who received IST alone, presenting neurological deficits were comparatively minor (p&lt;0.001). When the two groups were adjusted for admission neuroscore, there was no statistical significance between discharge mortality [7(21%) versus 4(14%), p=0.228], neurological dysfunction (p=0.442), intermediate (p=0.336) and long-term morbidity (p=0.988). Patients who received MT +/- IST had a higher percentage of periprocedural complications without reaching statistical significance. </jats:p><jats:p> Compared to IST, MT was performed in severe cases with extensive sinus involvement. When adjusted for admission neurological dysfunction, both groups had similar mortality and discharge neurological dysfunction and similar intermediate and long-term morbidity. </jats:p>

Endovascular mechanical thrombectomy for cerebral venous sinus thrombosis: a systematic review

“…Most of the evidence for the use of EMT in patients with CVST is limited to small case series 2 10–12 18 21 22. Additionally, variations in endovascular techniques, as well as heterogeneity in patient selection criteria, follow-up, and outcome reporting methods confound the assessment of the risk to benefit profile of EMT 10 12–14 16 18 22 23. The Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis (TO-ACT) trial is currently in the recruitment process (ClinicalTrials.gov NCT01204333) to investigate the functional outcomes of patients with severe CVST treated with endovascular thrombolysis 4 24.…”

“…EMT can be achieved by various modalities including catheter-mediated clot maceration, balloon dilatation, rheolytic systems (eg, AngioJet), micro-snaring (eg, Merci retriever), aspiration systems (eg, Penumbra aspiration pump), and stent retrievers (eg, Solitaire and Trevo). In small series, these have been associated with improvements in recanalization rates 7 12 13 16 18 20 32. Siddiqui et al 16 found a tendency toward increased direct, catheter-related complications in the EMT group compared with the local thrombolysis group; however, they point out that bulkier devices such as the AngioJet (which was used in 82% of cases) probably require more manipulation than smaller devices such as the Penumbra system.…”

“…Neurological deficit was categorized as mild, moderate, or severe, which corresponded to a modified Rankin Scale (mRS) score of 1–2, 3–4, and 5, respectively. When the mRS score was not available, mild neurological deficit corresponded to an independently communicative and ambulatory patient with mild weakness; moderate deficit corresponded to a patient with impaired ambulation and moderate weakness; and severe deficit corresponded to a patient who required assistance in activities of daily living 15 16. A good outcome was defined as an mRS score of 0–2, whereas a poor outcome was defined as an mRS score of 3–5.…”

“…A good outcome was defined as an mRS score of 0–2, whereas a poor outcome was defined as an mRS score of 3–5. Recurrence was defined as the presence of both clinical (new or relapse of previous symptoms) and radiologic evidence of re-thrombosis during follow-up after complete or partial recanalization 16 17…”

Surgical Superior Sagittal Sinus Thrombectomy in Refractory Thrombosis: A Technical Note

“…Methods include both mechanical thrombectomy with stent retriever devices and catheter infusion of thrombolytic agents. These techniques have been increasing in their application, but literature supporting their use is limited [5, 14]. A recent meta-analysis has shown high mortality and periprocedural complications, but this is likely strongly biased by their reserved use for the most severe or refractory cases [5].…”