[Infectious aneurysms of the cavernous carotid artery]

We describe 3 patients who developed infectious aneurysms of the cavernous carotid artery. The aneurysms were due to sphenoidal sinusitis in two patients and due to endocarditis in one. The acute and septic onset of the cavernous sinus syndrome, suggested thrombophlebitis of the cavernous sinus in all 3 patients. The diagnosis was established by magnetic resonance imaging and magnetic resonance angiography. Therapeutic internal carotid artery occlusion was indicated for a fissuration of their aneurysm manifested (n=3) by an episode of epistaxis (n=2) and blood in sphenoid sinus (depicted by MRI) in one case. We discuss the pathophysiology and management of bacterial aneurysms of the cavernous carotid artery. Close clinical and imaging follow-up should be performed for patients under antibiotherapy. Selective angiography with therapeutic occlusion of the carotid artery is discussed in patients with persistence of symptoms or if clinical findings are suggestive of fissuration or if aneurysmal sac diameter increases on follow-up imaging studies.

Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis

BACKGROUND AND PURPOSE

Cerebral venous thrombosis is a rare entity that can be difficult to manage. Intrasinus thrombolysis is an increasingly applied intervention, but this modality carries an increased risk of hemorrhage. We describe for the first time an option with a potentially lower incidence of intracranial bleeding, the combination of the AngioJet rheolytic thrombectomy catheter with intra-arterial thrombolysis, in 2 patients with extensive dural sinus thromboses, preexisting intracranial hemorrhage, and severe progressive neurological deficits despite heparin therapy.

METHODS

Four procedures were performed in 2 patients with thromboses in the superior sagittal and transverse sinuses (right in 1 patient and bilateral in 1 patient) and cortical veins. Rheolytic thrombectomy was performed in the sigmoid, transverse, straight, and superior sagittal sinuses; this technique involves the use of the Bernoulli effect to create a vacuum that fragments and aspirates thrombus. For associated persistent cortical vein thromboses, low-dose intra-arterial thrombolysis was used.

RESULTS

Both patients had excellent angiographic results with sinus reopening after rheolytic thrombectomy and cortical vein reopening after intra-arterial thrombolysis. Follow-up CT showed no change in 1 patient and increased preexisting intracranial hemorrhage in the other. One patient had a negative hypercoagulable workup, and the other patient had probable anti-phospholipid antibody syndrome. At 6 months, both patients had excellent clinical outcome with no neurological deficits except mild short-term memory loss in 1 patient.

CONCLUSIONS

The combination of rheolytic thrombectomy with intra-arterial thrombolysis is a treatment modality that allows accelerated recanalization of occluded dural sinuses and cerebral veins with lower doses of thrombolytic agents.

Posttraumatic dural sinus thrombosis in children

Posttraumatic dural sinus thrombosis (DST) in children has rarely been described in the literature. Over a period of two years (1994-1996) we treated 131 children (n=131) with minor or severe head injury requiring a cranial computed tomography (CT) scan. DST was found in eight patients (6.1%), five with mild and three with severe cranial trauma. Diagnosis was suspected either because of a skull fracture crossing over a dural sinus or because of a hyperdensity at a dural sinus in the noncontrast CT scan. Enhanced CT scan was used to confirm DST. No specific symptoms related to DST were observed. DST was managed conservatively in all patients and recovery was uneventful. Recanalization of the sinus was documented to occur within three weeks to six months in six children. One patient showed a residual clot after five months and another did not have a follow-up CT scan. Based on our data we conclude that neither surgical nor medical intervention is indicated in traumatic DST in children.

Endovascular treatment of a grade IV transverse sinus dural arteriovenous fistula by sinus recanalization, angioplasty, and stent placement: technical case report

OBJECTIVE AND IMPORTANCE

The frequent association of dural arteriovenous fistulae (DAVFs) and dural sinus thrombosis may render the treatment of these complex lesions difficult. We report a case of DAVF eradicated by recanalization of the chronically thrombosed transverse sinus (TS) and sigmoid sinus followed by balloon angioplasty and stent deployment at the site of the fistula.

CLINICAL PRESENTATION

A 52-year-old man presented with a Type IV DAVF of the left TS with widespread white matter changes secondary to venous hypertension. Arterial feeders arose from the left internal carotid, external carotid, and vertebral arteries. The distal segment of the left TS, the left sigmoid sinus, and the proximal segment of the right TS were occluded. Reverse flow was observed in the deep venous system and in the superior sagittal sinus.

INTERVENTION

Endovascular access was gained through the left internal jugular vein. Mechanical recanalization of the thrombosed left TS and sigmoid sinus was followed by balloon angioplasty and placement of six overlapping stents extending from the TS to the proximal internal jugular vein. Angiograms performed after surgery showed resaturation of antegrade venous drainage as well as complete eradication of the fistulous connections. The patient was discharged with an improving clinical

CONCLUSION

Recanalization of a chronically occluded dural venous sinus through a jugular approach is feasible. In addition to eradicating cerebral venous hypertension by reestablishing antegrade venous drainage, balloon angioplasty and stent deployment at the DAVF site produced complete closure of the fistula. This may prove to be a new therapeutic strategy for management of DAVF.

[Otitic hydrocephalus. A report of two cases]

Otitic hydrocephalus is one the less common intracranial complications of infectious ear disease, consisting of elevated intracranial pressure without focal neurologic abnormalities other than those due to the elevated pressure. Two representatives cases is discussed in this report, followed by a review of the literature. The clinical course, diagnosis, treatment, and prognosis are outlined. The etiology and the association with lateral sinus thrombosis remains obscure.

Power Doppler ultrasound imaging in neonatal cerebral venous sinus thrombosis

Neonatal sinus thrombosis is a rare occurrence in sick neonates. Because of its nonspecific manifestations, the incidence is underestimated. This disease may not be demonstrated by conventional color Doppler and is diagnosed by computed tomography or magnetic resonance imaging. The authors report a neonate with neonatal sinus thrombosis diagnosed by power Doppler and suggest that the technique may be used as a less expensive and more available screening and follow-up method in high-risk neonates.

Features of dural sinus thrombosis simulating pseudotumor cerebri

To characterize dural sinus thrombosis (DST) patients presenting with a syndrome simulating pseudotumor cerebri (PTC), medical records of patients initially diagnosed as having PTC between 1980 and 1995 were analysed. Inclusion criteria were intracranial hypertension (IH) and a normal initial computed tomography (CT) scan. All patients underwent angiography or magnetic resonance imaging (MRI) and magnetic resonance venography (MRV). Patients with IH secondary to a determined disorder were excluded from the study. Forty-six patients were included, 12 patients had MRI/MRV or angiography findings compatible with DST and the remaining 34 patients had no vascular pathology on neuroimaging studies and were considered to have PTC. No clinical or auxiliary findings differed between the two groups except for younger age, which delineated the PTC patients. Two patients with DST died during the study. Both were agitated, had a relatively rapid course of symptom progression, and a CSF pressure of over 40 cm water. We conclude that DST can be identified in 26% of patients presenting with symptoms and signs typical of PTC. It may be impossible to differentiate between patients with and without DST if MRI/MRV or angiography are not performed in this scenario.

Effect of echo contrast media on the visualization of transverse sinus thrombosis with transcranial 3-D duplex sonography

Transcranial duplex sonography has the capacity of detecting venous flow as in the transverse sinus. During a 6-month period, 28 consecutive patients (mean age 55 y) with a clinically suspected diagnosis of cerebral sinus thrombosis were included in the study. All patients were examined using 3-D ultrasound equipment within 24 h of having undergone either venous computerized tomography (CT), venous magnetic resonance imaging (MRI) or cerebral angiography. A total of 22 healthy patients had a normal venous CT, venous MRI or cerebral angiography of both transverse sinuses. Before echo contrast enhancement, the transverse sinus could be visualized in only 2 of these 44 sinuses (22 patients). A total of 6 patients with an unilaterally missed transverse sinus in 3-D ultrasound suffered from sinus thrombosis (n = 3), hypoplasia (n = 2) or aplasia (n = 1) of the unilateral transverse sinus in neuroradiological tests. In none of the patients with an thrombosis of the transverse sinus did ultrasound contrast media application improve the visualization of the affected sinus. Our study confirms that the normal transverse sinus, insonated through the contralateral temporal bone, often cannot be visualized without the use of contrast agents. With transcranial 3-D duplex sonography, a differentiation between thrombosis, hypoplasia and aplasia of the sinus was not possible.

Use of mechanical thrombolysis via microballoon percutaneous transluminal angioplasty for the treatment of acute dural sinus thrombosis: case presentation and technical report

OBJECTIVE AND IMPORTANCE

Although conventional superselective chemical thrombolysis is frequently successful for the treatment of severe acute dural sinus thrombosis, the technique has limitations and risks. This prompted us to develop a supplemental technique for achieving more rapid recanalization, using coronary microballoon percutaneous transluminal angioplasty catheters. We describe a successful application of this technique and technology that has not been previously reported.

CLINICAL PRESENTATION

After several days of severe headaches, photophobia, and vomiting, a 29-year-old woman presented with rapidly progressive neurological deficits secondary to complete occlusion of the superior sagittal sinus (SSS) and right transverse/sigmoid sinus complex. Owing to her rapid neurological decline, she was referred for emergency endovascular intervention.

TECHNIQUE

Initially, superselective chemical thrombolysis of the SSS was performed using urokinase. However, because of the extensive nature of the thrombus and lack of initial therapeutic response, we elected to attempt mechanical thrombolysis with various coronary percutaneous transluminal angioplasty microballoon catheters. This was accomplished by initial coaxial positioning of the device into an occluded segment, followed by gentle inflation and retraction of the device along the course of the right transverse sinus and/or SSS. These maneuvers were repeated with balloons of increasingly large diameter. Near-complete restoration of venous outflow was obtained within the SSS with preferential runoff into the left transverse sinus. The right transverse sinus was only partially recanalized. Despite the patient's rapid neurological decline on presentation, she experienced a dramatic clinical recovery with near-complete reversal of neurological deficits within 24 hours of intervention.

CONCLUSION

This report shows the feasibility of performing safe and effective mechanical thrombolysis with percutaneous transluminal angioplasty coronary balloon microcatheters within the major dural sinuses. This technique can probably accelerate clot disruption and thrombolysis, possibly resulting in a more rapid restoration of venous flow.

Helical CT angiography: dynamic cerebrovascular imaging in children

BACKGROUND AND PURPOSE

The purpose of this study was to assess the feasibility of helical CT cerebrovascular imaging (CTCVI) in children and to make initial comparisons with MR angiography and digital subtraction angiography (DSA).

METHODS

Twenty-six patients, ages 3 days to 17 years, were examined with CTCVI. Patients were scanned with 1-mm collimation and 2:1 pitch 30 seconds after the initiation of a hand injection of 2 mL/kg nonionic contrast material (320 mg/dL iodine) with a maximum dose that did not exceed 80 mL (minimum volume, 5 mL in a 2.5-kg infant). Reconstructions were done using maximum intensity projection and integral rendering algorithms. Four patients had CTCVI, MR angiography, and DSA (42 vessels studied) and nine patients had CTCVI and DSA (136 vessels studied). Scores of 1 (not present) to 3 (present in continuity to the first bifurcation) were assigned independently by two radiologists to 32 vessels in each correlated case for each available technique.

RESULTS

There were no technical failures. CTCVI depicted 18 thrombosed dural sinuses, three vascular malformations, one intracranial aneurysm, and four tumors. Ninety-five percent of the vessels seen with DSA were also seen with CTCVI. CTCVI identified all vessels seen on MR angiography.

CONCLUSION

Helical CTCVI is an effective technique for assessing the intracranial circulation in children. In this initial comparison, CTCVI showed more vascular detail than MR angiography, and had fewer technical limitations.

Superior sagittal sinus thrombosis and transient ischemic attacks: possible mechanism

Clinical manifestations of superior sagittal sinus (SSS) thrombosis are nonspecific but characterized by headache, papilledema, seizures, focal deficits, progressive coma and death. Recurrent transient focal neurologic deficit is an extremely rare manifestation in superior sagittal sinus thrombosis and the mechanism is unknown. A 45-year-old man presented with headache for two weeks and four episodes of transient (5-10 minutes) right or left hemiparesis for two days. Magnetic resonance image and transfemoral cerebral angiography revealed superior sagittal sinus thrombosis with numerous prominent collateral venous channels. There was no parenchymal lesion. After four days of heparinization, no further transient focal neurologic deficits developed. Follow-up angiography showed partial recanalization of the SSS. Possible mechanism of transient ischemic attacks in this patient is thought to be a transient functional disturbance due to a temporal reduction of tissue perfusion in the process of operating fully-enough collateral channels.

Dural-pial arteriovenous malformation after sinus thrombosis

BACKGROUND

We report an unusual case of acquired dural-pial arteriovenous malformation (AVM) following sinus thrombosis.

CASE DESCRIPTION

Initial angiography performed in a 39-year-old man showed thrombosis of the superior sagittal sinus (SSS) and the right transverse sinus (TS) but no vascular malformations. Follow-up angiography 29 months later revealed recanalization of the SSS and the TS, retrograde cortical venous drainage which suggested that thrombosis of the sinuses probably propagated into the adjacent parietal cortical veins, and development of a dural-pial AVM at or near the site of thrombi in more than one cortical vein. Complete surgical excision of the lesion was accomplished without neurological deterioration.

CONCLUSIONS

The present case suggests the possibility that the pial AVM is not only a congenital condition but also may develop as an acquired lesion.

Sagittal sinus thrombosis after closed head injury

Superior sagittal sinus thrombosis (SSST) is an unusual disorder, most often attributed to hematological abnormalities, oral contraceptive use, or association with the puerperium. Although SSST secondary to trauma has been reported, it still remains an extremely rare entity. Antemortem diagnosis of SSST is made by findings on computed tomographic scanning, cerebral angiography, or magnetic resonance imaging. Prognosis is variable and spontaneous resolution has been reported. Successful treatment options of spontaneous cases include systemic anticoagulation and thrombolytic therapy along with supportive measures. There are currently no guidelines for the management of SSST associated with traumatic brain injury. This report describes a case of SSST in a man who sustained a closed head injury.

Venous transcranial Doppler in acute dural sinus thrombosis

The value of conventional transcranial Doppler ultrasound in the diagnosis and monitoring of cerebral vein thrombosis is unclear. Previous studies have suggested the usefulness of this method in two cases with superior sagittal sinus thrombosis that showed increased velocities of deep cerebral veins. The purpose of the present study was to evaluate the deep intracranial venous circulation in patients with that pathology. Venous transcranial Doppler ultrasound was performed with a range-gated 2 MHz transducer in 17 healthy volunteers and in six cases of proven acute superior sagittal sinus thrombosis. Peak systolic, end diastolic and mean blood flow velocities were measured in the basal vein of Rosenthal (BVR) and deep middle cerebral vein (DMCV) through a posterior temporal window. In 16 controls and in one patient, the straight sinus was also studied through an occipital approach. Sex distribution and mean age of controls and patients were similar. Mean blood flow velocities in controls were as follows (mean, SD): DMCV, 10.4, 1.4 cm/s; BVR, 11.3, 1.8 cm/s; straight sinus, 29.5, 9.9 cm/s. Three of the patients with superior sagittal sinus thrombosis showed increased velocities either in the DMCV, the BVR or the straight sinus. One patient showed slightly increased velocities in the BVR, and the other two showed normal venous velocity values. This study confirms the usefulness of conventional transcranial Doppler ultrasound in detecting superior sagittal sinus thrombosis. However, a normal examination does not exclude this diagnosis.

Endovascular treatment of traumatic dural sinus thrombosis: case report

OBJECTIVE

Dural sinus thrombosis has rarely been associated with closed head injury. We present a unique case involving the use of endovascular thrombolysis in the treatment of traumatic dural sinus thrombosis, which has not been reported.

CLINICAL PRESENTATION

A 20-year-old male patient suffered a severe closed head injury while skiing. He developed refractory elevated intracranial pressure requiring barbiturate coma. Angiography demonstrated thrombosis of the dominant right transverse and sigmoid sinuses, with partial thrombosis of the superior sagittal sinus. Urokinase was administered via a microcatheter within the thrombus as a bolus of 250,000 units and then as a continuous infusion of 60,000 to 100,000 units per hour for 48 hours. The patient was maintained in a barbiturate coma and heparinized. Serial angiography was performed to assess the sinus patency and efficacy of thrombolysis.

RESULTS

After 48 hours of thrombolysis, angiography demonstrated normal patency of the superior sagittal, right transverse, and right sigmoid sinuses. The intracranial pressure decreased after thrombolysis and was manageable with conventional techniques. Within 48 hours of the completed thrombolysis, the barbiturates were withdrawn and the patient's neurological status rapidly improved until the time of discharge 2 weeks later.

DISCUSSION AND CONCLUSION

This case documents a rare instance of traumatic dural sinus thrombosis resulting from a closed head injury. In addition, endovascular thrombolysis resulted in subsequent opening of the dural sinuses and effective intracranial pressure management, despite the presence of a hemorrhagic contusion. Heparin was effective in maintaining sinus patency and was used safely in conjunction with urokinase in this setting of head injury.