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Ye J, Yang Y, Wan W, Ma X, Liu L, Liu Y, He Z, Yuan Z. Mechanical Thrombectomy for Refractory Cerebral Venous Sinus Thrombosis in a Child with Nephrotic Syndrome : A Case Report. J Korean Neurosurg Soc 2023; 66:735-742. [PMID: 36919228 PMCID: PMC10641426 DOI: 10.3340/jkns.2022.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/28/2023] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
Nephrotic syndrome (NS) is associated with cerebral venous sinus thrombosis (CVST), which is a rare cerebrovascular disorder in children. Systemic anticoagulation with heparin is the standard therapy for CVST, and mechanical thrombectomy (MT) has been described as a salvage treatment for adult anticoagulant refractory CVST, However, it has never been reported in children. We describe a case of MT for refractory CVST in a child with NS. A 13-year-old boy with newly diagnosed NS presented to an emergency department with acute headache. A head computed tomography showed acute thrombus in the superior sagittal sinus, straight sinus and transverse sinus. The child was started on heparin therapy, but clinically deteriorated and became unresponsive. In view of the rapid deterioration of the condition after anticoagulation treatment, the patient received intravascular treatment. Several endovascular technologies, such as stent retriever and large bore suction catheter have been adopted. After endovascular treatment, the patient's neurological condition was improved within 24 hours, and magnetic resonance venography of the head demonstrated that the CVST was reduced. The child recovered with normal neurological function at discharge. This case highlights the importance of considering MT for refractory CVST, and we suggest that MT may be considered for refractory CVST with NS in children.
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Affiliation(s)
- Jing Ye
- Department of Neurology, The Sixth People’s Hospital of Chengdu, Chengdu, China
| | - Yuan Yang
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Weifeng Wan
- Department of Neurosurgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xuntai Ma
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Lei Liu
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Yong Liu
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Zhongchun He
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Zhengzhou Yuan
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
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2
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Nepal G, Kharel S, Bhagat R, Coghlan MA, Yadav JK, Goeschl S, Lamichhane R, Phuyal S, Ojha R, Shrestha GS. Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis. J Cent Nerv Syst Dis 2022; 14:11795735221131736. [PMID: 36204279 PMCID: PMC9530583 DOI: 10.1177/11795735221131736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Background Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally
treated with anti-coagulation therapy. Subsets of patients with severe CVT have been
treated with endovascular thrombectomy (EVT). Despite the high estimated mortality
associated with severe CVT, there has been only one randomized control trial done
regarding safety and efficacy of EVT in severe CVT compared to standard medical
management. Evidence in this area is lacking. Objective The aim of this systematic review is to analyze all existing literature and generate
robust information regarding the role of EVT in the management of patients with severe
CVT. Methods This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase,
Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety
and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good
functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a
95% confidence interval was derived from a meta-analysis of various outcomes (CI). Results A total of 33 studies comprising 610 patients treated with EVT were included for
analysis which comprised one randomized control trial, one prospective study and 31
retrospective studies. Based on pooled data, 85% of patients had good functional
outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had
catheter related complications. The efficacy outcomes in this analysis had a significant
heterogeneity and a subgroup analysis was also done to explain these findings. The
minimum time of follow up was 3 months and varied EVT techniques were used across the
studies. Conclusion This meta-analysis suggests EVT may be safe and efficacious in treating patients with
severe CVT. Registration Our protocol was registered with PROSPERO: International prospective register of
systematic reviews with the registration number CRD42021254760.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Megan A Coghlan
- Department of Neurology, University of Louisville School of
Medicine, Louisville, KY, USA
| | - Jayant K Yadav
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Stella Goeschl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Rajan Lamichhane
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Subash Phuyal
- Department of Neuroimaging and
Interventional Neuroradiology, Upendra Devkota Memorial National Institute of
Neurological and Allied Sciences, Bansbari, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal,Gentle S Shrestha, Department of Critical Care
Medicine, Tribhuvan University Teaching Hospital, Maharajgunj 44600, Kathmandu, Nepal.
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Mera Romo WC, Ariza-Varón M, Escobar FN, Castillo AL. Cerebral venous sinus thrombosis treated with vacuum aspiration thrombectomy without thrombolysis: A descriptive and retrospective study of 5 years' experience at a single center. J Vasc Interv Radiol 2022; 33:1173-1183.e1. [PMID: 35835358 DOI: 10.1016/j.jvir.2022.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 06/11/2022] [Accepted: 06/30/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Cerebral venous sinus thrombosis (CVST) is a rare but life-threatening condition. Mechanical thrombectomy is a treatment option for patients who deteriorate or do not improve despite anticoagulation treatment or who have a major contraindication to anticoagulation. The purpose of this study was to describe our 5 years of experience in treating CVST with vacuum aspiration thrombectomy without thrombolysis. MATERIALS AND METHODS For this retrospective study, data were collected from consecutive patients with CVST who received anticoagulation as initial medical treatment and then were treated with vacuum aspiration thrombectomy without thrombolysis. Patients were followed up at 3 months and after 1 year. RESULTS The 9 patients included in the study had a median age of 37 years, and 5 were female. All 9 patients had headache at presentation; 7 had focal neurologic deficits and 7 had intracranial hypertension. Risk factors for CVST were identified in 8 patients, and poor prognostic factors were identified in 7 patients. In the 9 patients, a total of 24 CVST locations were treated; complete (70.8%) or partial (29.2%) recanalization was achieved in all CVST locations. No procedure-related complications occurred. One patient died of parenchymal hemorrhagic transformation of CVST and vasogenic edema, at 6 hours after the procedure. Two patients required neurosurgical intervention. After 1 year (range, 13-30 months), all 8 surviving patients had good functional outcome (modified Rankin Scale score 0-2). CONCLUSIONS For appropriately selected patients with cerebral venous sinus thrombosis, vacuum aspiration thrombectomy without thrombolysis appears to be an effective therapy.
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Affiliation(s)
- Walter Camilo Mera Romo
- Department of Diagnostic Imaging, Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogotá, Colombia; Radiology Resident of Department of Diagnostic Imaging, Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogotá, Colombia.
| | - Michael Ariza-Varón
- Department of Clinical Neurology, Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogotá, Colombia; Research Group NeuroUnal, Department of Clinical Neurology, Universidad Nacional de Colombia, Bogotá, Colombia; Clinical Neurology Resident, Department Clinical Neurology of Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogotá, D.C. Colombia
| | - Fabian Neira Escobar
- Department of Diagnostic Imaging, Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogotá, Colombia; Radiology Specialist, Universidad Nacional de Colombia, Bogotá, Colombia; Subspecialty in Oncological Radiology, Pontificia Universidad Javeriana, Interventional Radiologist, Hospital Universitario Nacional, Bogotá, D.C. Colombia; Subspecialty in Endovascular Neurointerventionism, Hospital General de Catalunya, Cataluña, Spain
| | - Alfonso Lozano Castillo
- Department of Diagnostic Imaging, Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogotá, Colombia; Radiology Specialist, Universidad Nacional de Colombia, Bogotá, Colombia
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Manoukian MAC, Panigrahi AR, Tzimenatos L. Headache and changes in artwork as a presentation of central venous sinus thrombosis in a child with acute lymphoblastic leukemia. Am J Emerg Med 2022; 59:217.e1-217.e3. [PMID: 35717352 DOI: 10.1016/j.ajem.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 10/18/2022] Open
Abstract
Acute lymphocytic leukemia (ALL) is a common pediatric cancer diagnosis with excellent survival outcomes but significant morbidity, particularly during the induction phase of chemotherapy. Central venous sinus thrombosis (CVST) is a known potential complication of induction therapy; however, it occurs rarely and may be difficult to diagnose, particularly in young children who have limited verbal skills. Herein, we report a case of CVST in a child with B-cell ALL undergoing induction chemotherapy whose main symptoms were headache and a change in the appearance of his artwork noticed by his parents. This astute observation by the child's parents played a critical role in his diagnosis, allowing prompt treatment and eventual recovery.
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Affiliation(s)
| | - Arun R Panigrahi
- Department of Pediatrics, Division of Hematology and Oncology, UC Davis, Sacramento, CA, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, UC Davis, Sacramento, CA, USA
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Gadgil N, Aldave G, Whitehead WE, Dmytriw AA, Chen K, Orbach D, Maier I, Behme D, Fargen KM, Elijovich L, Dornbos D, Spiotta A, Kan P. Endovascular Intervention for Refractory Pediatric Cerebral Venous Sinus Thrombosis. Pediatr Neurol 2021; 121:45-50. [PMID: 34147818 DOI: 10.1016/j.pediatrneurol.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/18/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) is a rare but potentially morbid disease in the pediatric population, and the optimal treatment is not fully understood. Endovascular intervention for this condition has been rarely reported. METHODS The Stroke Thrombectomy and Aneurysm Registry was queried for patients aged less than or equal to 18 years undergoing endovascular treatment for CVST in the past 10 years. Clinical charts and radiographic data were retrospectively reviewed. Modified Rankin Score (mRS) at 90 days postprocedure was determined as the primary outcome. RESULTS A total of seven patients across five pediatric centers ranging from 7 to 16 years of age were identified with a mean follow-up of 28 months. All had underlying conditions predisposing to CVST. Endovascular intervention was undertaken due to neurological deterioration despite systemic anticoagulation; venous infarct was evident preoperatively in six of seven patients. Mechanical venous thrombectomy was attempted in all individuals, and intrasinus thrombolytic therapy was also performed in three cases. Six patients had favorable outcome with mRS 0 or 1 at 90 days postprocedure; one remained neurologically devastated. CONCLUSIONS Endovascular treatment by an experienced interventionalist may be safe and effective in severe cases of CVST in children failing frontline therapy. Children with radiographic or clinical progression despite anticoagulation may be considered for endovascular intervention in a timely manner.
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Affiliation(s)
- Nisha Gadgil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Guillermo Aldave
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Adam A Dmytriw
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Karen Chen
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Darren Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Caroline
| | - Lucas Elijovich
- Department of Neurology and Neurosurgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - David Dornbos
- Department of Neurological Surgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas.
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Woods GM, Kim DW, Paden ML, Viamonte HK. Thrombolysis in Children: A Case Report and Review of the Literature. Front Pediatr 2021; 9:814033. [PMID: 35141182 PMCID: PMC8818955 DOI: 10.3389/fped.2021.814033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/23/2021] [Indexed: 12/24/2022] Open
Abstract
Thromboembolism (TE), including venous thromboembolism (VTE), arterial TE, arterial ischemic stroke (AIS), and myocardial infarction (MI), is considered a relatively rare complication in the pediatric population. Yet, the incidence is rising, especially in hospitalized children. The vast majority of pediatric TE occurs in the setting of at least one identifiable risk factor. Most recently, acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have demonstrated an increased risk for TE development. The mainstay for the management pediatric TE has been anticoagulation. Thrombolytic therapy is employed more frequently in adult patients with ample data supporting its use. The data for thrombolysis in pediatric patients is more limited, but the utilization of this therapy is becoming more commonplace in tertiary care pediatric hospitals. Understanding the data on thrombolysis use in pediatric TE and the involved risks is critical before initiating one of these therapies. In this paper, we present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to MIS-C requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children.
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Affiliation(s)
- Gary M Woods
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Dennis W Kim
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Heather K Viamonte
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
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7
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Shlobin NA, LoPresti MA, Beestrum M, Lam S. Treatment of pediatric cerebral venous sinus thromboses: the role of anticoagulation. Childs Nerv Syst 2020; 36:2621-2633. [PMID: 32743709 DOI: 10.1007/s00381-020-04829-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/22/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cerebral venous sinus thromboses (CVST) occur in children with a variety of etiologies. However, no standard treatment paradigm is established. We sought to identify what treatments have been applied, their outcomes, and the role of anticoagulation in pediatric patients with CVST. METHODS A systematic review was conducted exploring all treatments of pediatric CVSTs using PubMed, Embase, Scopus, and Cochrane Library and Cochrane Central Register of Controlled Trials. Studies meeting inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes. RESULTS Of 2946 resultant articles, 51 full-text articles were included. Management of infectious CVST included broad-spectrum antibiotics, surgery, and anticoagulation. Neoplastic and traumatic CVST treatment included anticoagulation. Treatment of CVSTs associated with metabolic abnormalities centered on correction of metabolic derangements, or supplementation where appropriate, and anticoagulation. Autoimmune, congenital, and thrombotic pathway CVSTs were treated with anticoagulation and treatment of the underlying disorder. Unfractionated heparin and low molecular weight heparin were most commonly used and seen to be effective and safe. Uncommonly, endovascular interventions including venous thrombectomy and intravenous injection of thrombolytic therapy were used with varying success. CONCLUSIONS While conservative, medical, thombolytic, endovascular, and surgical treatment all have a role in in the treatment of pediatric CVSTs, anticoagulation is commonly applied and found to be safe and effective in pediatrics. Risks and benefits of anticoagulation must be considered on an individual basis as no randomized trials have established a standard of care. Based on our findings, we propose an approach to CVST treatment and look to future study aimed at more clearly delineating treatment dose, duration, and timing of re-evaluation in these patients.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Anne and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA
| | - Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Molly Beestrum
- Department of Library Services, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandi Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Anne and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA.
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Wang Y, Zhao C, Huang D, Sun B, Wang Z. Stent retriever thrombectomy combined with long-term local thrombolysis for severe hemorrhagic cerebral venous sinus thrombosis. Exp Ther Med 2020; 20:66. [PMID: 32963596 PMCID: PMC7490800 DOI: 10.3892/etm.2020.9194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 03/10/2020] [Indexed: 01/21/2023] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is a rare disease associated with high disability and mortality rates. A subset of patients do not respond to standard anticoagulation therapy, leading to the progression of CVST with hemorrhagic stroke, which represents a major challenge for its treatment. Severe hemorrhagic (SH)-CVST is life-threatening due to large hematoma, edema and/or cerebral hernia. Anticoagulation or thrombolytic therapy alone may lead to further aggravation of the hematoma. Stent retriever thrombectomy combined with long-term local thrombolysis (SRT-LLT) has been used in certain centers for those refractory cases or patients with new intracranial hemorrhage. However, to date, no studies on SRT-LLT treatment specifically for SH-CVST have been performed. The aim of the present retrospective study was to specifically evaluate the effectiveness of SRT-LLT in SH-CVST. Between December 2013 and November 2018, SRT-LLT was performed at our center in 8 patients with hemorrhagic CVST who did not respond to intravenous anticoagulation. The clinical characteristics, results of the radiological evaluation, details on the surgical procedure and clinical outcomes were assessed. The patients were administered systemic intravenous anticoagulation as the initial treatment following admission. SRT-LLT was performed when their condition deteriorated with a high risk of a fatal outcome within a short time period. SRT-LLT was performed in 8 patients, with successful recanalization confirmed by angiography. In 4 of the patients, complete recanalization was achieved, whereas in the remaining 4, recanalization was partial. There were no intraoperative complications. Two patients developed rebleeding after surgery, but they all gradually recovered. There were no treatment-associated fatalities. Therefore, SRT-LLT appears to be a feasible, safe and effective option for SH-CVST and it may be used as rescue therapy for carefully selected patients with SH-CVST.
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Affiliation(s)
- Yihua Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Qingdao, Shandong 266035, P.R. China
| | - Cuiping Zhao
- Department of Neurology, Qilu Hospital of Shandong University, Qingdao, Shandong 266035, P.R. China
| | - Dezhang Huang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Qingdao, Shandong 266035, P.R. China
| | - Bin Sun
- Department of Neurosurgery, Qilu Hospital of Shandong University, Qingdao, Shandong 266035, P.R. China
| | - Zhigang Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Qingdao, Shandong 266035, P.R. China
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Cellerini M, Francavilla R, Testoni C, Maffei M, Zucchelli M, Ghizzi C. Dural sinus mechanical thrombectomy and continuous local rt-PA infusion in a child with refractory intracranial hypertension and progressive visual loss: A case report. Surg Neurol Int 2020; 11:253. [PMID: 33024591 PMCID: PMC7533100 DOI: 10.25259/sni_236_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/05/2020] [Indexed: 11/04/2022] Open
Abstract
Background Children with intracranial hypertension are at risk for visual loss and their visual function must be closely monitored. Surgery with the insertion of a ventriculoperitoneal shunt is imperative when vision is threatened. Case Description Herein, we report a case of a 5-year-old boy whose refractory intracranial hypertension and severe, progressive visual loss (secondary to a chronic, otogenic, right sigmoid sinus thrombosis, and a contralateral sinus tight stenosis) were resolved by a combination of continuous (6 h), locoregional, infusion of recombinant tissue plasminogen activator (rt-PA), and mechanical thrombectomy. Conclusion The association of in loco and continuous infusion of recombinant tissue plasminogen activator (rt- PA) with mechanical thrombectomy resulted in effective in partially reopening the occluded sinus and facilitating a good clinical recovery. This combined endovascular approach may represent an alternative, less invasive, therapeutic option to surgery in children with intracranial hypertension caused by chronic cerebral venous sinus thrombosis.
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Affiliation(s)
- Martino Cellerini
- Department of Neuroradiology, ISNB - IRCCS, Bologna, Emilia-Romagna, Italy
| | - Rosa Francavilla
- Department of Pediatrics, Maggiore Hospital, ISNB - IRCCS, Bologna, Emilia-Romagna, Italy
| | - Caterina Testoni
- Departments of Anaesthesiology ISNB - IRCCS, Bologna, Emilia-Romagna, Italy
| | - Monica Maffei
- Department of Neuroradiology, ISNB - IRCCS, Bologna, Emilia-Romagna, Italy
| | - Mino Zucchelli
- Departments of Neurosurgery, ISNB - IRCCS, Bologna, Emilia-Romagna, Italy
| | - Chiara Ghizzi
- Department of Pediatrics, Maggiore Hospital, ISNB - IRCCS, Bologna, Emilia-Romagna, Italy
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Cerebrovascular Complications of Pediatric Blunt Trauma. Pediatr Neurol 2020; 108:5-12. [PMID: 32111560 PMCID: PMC7306436 DOI: 10.1016/j.pediatrneurol.2019.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/02/2019] [Accepted: 12/08/2019] [Indexed: 12/13/2022]
Abstract
Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.
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Gervelis WL, Golomb MR. Mechanical Thrombectomy in Pediatric Stroke: Report of Three New Cases. J Stroke Cerebrovasc Dis 2019; 29:104551. [PMID: 31843352 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/01/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy for treatment of arterial ischemic stroke (AIS) and cerebral venous thrombosis (CVT) is well-studied in adult populations, but not in children. METHODS We report 3 new cases of pediatric stroke treated using mechanical thrombectomy. Two cases of AIS and 1 case of CVT were identified from 2018 pediatric stroke clinic records. RESULTS Thrombectomy was successful in 1 of the 2 AIS cases and in the CVT case. None of the children were asymptomatic after thrombectomy. One AIS case had good recovery than developed dystonia which responded to treatment; the second AIS case had residual hemiplegia; and the child with CVT had mild school problems. CONCLUSIONS Mechanical thrombectomy is being increasingly used for pediatric stroke treatment. This study and recent literature reviews suggest thrombectomy holds promise as a treatment for selected pediatric stroke patients. Questions remain about the safety and efficacy of thrombectomy in children with stroke since large randomized controlled studies are not yet feasible.
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Affiliation(s)
- Whitney L Gervelis
- Division of Child Neurology, Department of Neurology, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
| | - Meredith R Golomb
- Division of Child Neurology, Department of Neurology, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana.
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12
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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13
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Omoto K, Nakagawa I, Park HS, Wada T, Motoyama Y, Kichikawa K, Nakase H. Successful Emergent Endovascular Mechanical Thrombectomy for Pediatric and Young Adult Cerebral Venous Sinus Thrombosis in Coma. World Neurosurg 2019; 122:203-208. [DOI: 10.1016/j.wneu.2018.10.189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/23/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022]
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Mechanical Thrombectomy with Intraoperative Local Thrombolysis Versus Mechanical Thrombectomy with Continuous Thrombolysis for Treatment of Cerebral Venous Sinus Thrombosis: A Systematic Review of 82 Cases. World Neurosurg 2019; 125:489-497.e14. [PMID: 30659973 DOI: 10.1016/j.wneu.2018.12.193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/20/2018] [Accepted: 12/23/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The first-line treatment of cerebral venous sinus thrombosis (CVST) is systemic anticoagulation. However, patients with severe or a clinically worsening condition might benefit from mechanical thrombectomy (MT) combined with intraoperative thrombolysis (IOT) or MT with continuous thrombolytic infusion (CTI). The present study compared the efficacy and safety of these 2 endovascular therapeutic methods by performing a systematic review of the literature. METHODS The present systematic review was conducted to identify all cases of CVST treated with MT+IOT or MT+CTI/MT+IOT+CTI reported in PubMed and Ovid. The recanalization rates, outcomes, operation-related complications, sequelae, and postoperative hemorrhage rates were evaluated. RESULTS A total of 28 studies, including 82 patients, met the inclusion criteria. Alone, MT+IOT was performed in 42 patients (51%), and MT+CTI/MT+IOT+CTI was performed in 40 patients (49%). Overall, outcomes data were available for 69 patients, of whom 57 (82%) had had a good outcome and 12 (18%) had had a poor outcome or had died. Recanalization data were available for 68 patients. Of these patients, 28 (41%) had had complete recanalization, 40 (59%) had had partial, and no patient had had no recanalization. Operation-related complications occurred in 5 patients (6%), and 3 patients (4%) developed postoperative intracerebral hemorrhage. However, no significant differences were found in the recanalization rate or prognosis between the MT+IOT and MT+CTI/MT+IOT+CTI groups. CONCLUSIONS The results from our review suggest that MT with local thrombolysis is relatively safe, with no significant differences in efficacy and safety between MT+IOT alone and MT+CTI/MT+IOT+CTI. However, randomized controlled studies are required to provide a definitive answer on its use for CVST.
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15
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Gatto LAM, De Souza TFS, Naves de Lima Alves G, Padilha Miranda T, Koppe GL, Demartini Z. Endovascular Treatment of a Dural Arteriovenous Fistula after Cerebral Sinovenous Thrombosis in a Child. Pediatr Neurosurg 2019; 54:66-70. [PMID: 30481758 DOI: 10.1159/000494563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Dural arteriovenous fistula (DAVF) is rare in children. Development theories postulate a response to cerebral sinovenous thrombosis (CSVT) or to venous hypertension. The symptoms are highly nonspecific and depend on lesion location. Standard treatment of thrombosis is based on antithrombotic therapy, while the main therapy for DAVF is embolization. CASE REPORT An 8-year-old boy presented with headache was diagnosed with CSVT and treated with anticoagulant. He developed tinnitus, mental confusion, and lowering of consciousness. Magnetic resonance imaging showed a DAVF draining through a single stenotic venous sinus. Successful endovascular treatment was performed with arterial embolization of multiple feeders and stent and balloon sinus angioplasty. CONCLUSION Risk factors associated with sinus thrombosis must be always investigated; endovascular treatment is safe and reasonable in a clinical deterioration scenario.
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Affiliation(s)
- Luana Antunes Maranha Gatto
- Neurosurgery and Interventional Neuroradiology, Cajuru University Hospital of Pontifical Catholic University (HUC-PUC), Curitiba, Brazil,
| | | | | | - Tayna Padilha Miranda
- Cajuru University Hospital of Pontifical Catholic University (HUC-PUC), Curitiba, Brazil
| | | | - Zeferino Demartini
- Neurosurgery and Interventional Neuroradiology, Cajuru University Hospital of Pontifical Catholic University (HUC-PUC), Curitiba, Brazil
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Chen C, Wang Q, Li X, Lu Z, He J, Fang Q, Ke X, Duan C, Li T. Stent retriever thrombectomy combined with local thrombolytic therapy for cerebral venous sinus thrombosis: A case report. Exp Ther Med 2017; 14:3961-3970. [PMID: 29067093 PMCID: PMC5647711 DOI: 10.3892/etm.2017.5043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 02/01/2017] [Indexed: 11/21/2022] Open
Abstract
The present study reports the effect of successful treatment of cerebral venous sinus thrombosis (CVST) with stent retriever thrombectomy combined with local thrombolytic therapy. Medical records of 29 patients were retrospectively analyzed following a diagnosis of CVST with magnetic resonance venography (MRV) or digital subtraction angiography (DSA). Systemic anticoagulation was the initial treatment in all patients following admission. In group A, stent retriever thrombectomy combined with local thrombolytic therapy was performed on 14 patients who met the criteria of endovascular therapy. Stent-assisted angioplasty was also performed when patients presented with venous sinus stenosis. A total of 15 patients in group B received systemic anticoagulant treatment. Subsequently, warfarin was administered orally for 3 to 12 months as a continuous anticoagulant therapy. International normalized ratio was monitored when patients were receiving anticoagulant therapy. Additionally, clinical presentation, decision to escalate therapy, recanalization, Glasgow Coma Scale, modified Rankin Scale (mRS) and the clinical outcome was assessed. A total of 14 patients (9 female patients, 5 male patients), with ages ranging from 17 to 57 years, met the criteria of endovascular therapy. The clinical symptoms of 12 patients had improved after receiving endovascular therapy and only 2 patients suffered from intracranial hemorrhage following the procedure. Complete recanalization of venous sinus was exhibited in 10/14 (71.4%) patients in group A when compared with 1/15 (6.7%) patients in group B. mRS were improved in the 12-month follow-up in groups A and B when compared with that at admission. In the present study, patients with acute CVST treated with stent retriever thrombectomy combined with local thrombolytic therapy had a favorable outcome. To conclude, the present study provides a treatment option in treating CVST, particularly for patients that present with evident cortical venous outflow stasis or deteriorate neurology, despite appropriate anticoagulant therapy.
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Affiliation(s)
- Chengwei Chen
- Department of Neurosurgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310006, P.R. China.,The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
| | - Qiujing Wang
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China.,Department of Neurosurgery, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong 518000, P.R. China
| | - Xifeng Li
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
| | - Ziming Lu
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
| | - Jian He
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
| | - Qinrui Fang
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
| | - Xunchang Ke
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
| | - Chuanzhi Duan
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
| | - Tielin Li
- The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China
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17
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How I treat pediatric venous thromboembolism. Blood 2017; 130:1402-1408. [PMID: 28774877 DOI: 10.1182/blood-2017-04-742320] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023] Open
Abstract
The incidence of pediatric venous thromboembolism (VTE) has been increasing significantly over the past decade in part as a result of increased recognition of this serious disorder but more so because of the increased use of central venous catheters and other technological advancements involved in the care of ill children. Management of pediatric VTE is a complex undertaking, considering that the vast majority of children who develop this complication have serious underlying medical disorders. Although the incidence is rising, in comparison with adults, this remains a relatively rare disorder, and as such, large-scale clinical trials have not been completed, rendering management decisions to be based on extrapolation from adult data and the experience of the treating physician. Clearly, both are fraught with problems. Thus, day-to-day management remains more art than science until such time that the results from clinical trials (many of which are under way) become available. This edition of "How I Treat" describes the author's experience in managing 3 common scenarios that one may encounter in pediatric thrombosis and suggests a logical approach to such situations. Furthermore, the author provides 3 algorithms to help guide management decisions.
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Konakondla S, Schirmer CM, Li F, Geng X, Ding Y. New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments. Aging Dis 2017; 8:136-148. [PMID: 28400981 PMCID: PMC5362174 DOI: 10.14336/ad.2016.0915] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 09/15/2016] [Indexed: 12/28/2022] Open
Abstract
Dural venous sinus thrombosis (DVST) is a rare cause of stroke, which typically affects young women. The importance of identifying pre-disposing factors that lead to venous stasis lies in the foundation of understanding the etiology, pathophysiology and clinical presentation. The precise therapeutic role of interventional therapies is not fully understood though the current data do suggest potential applications. The aim of the study was to perform a systematic review and meta-analysis to evaluate the utility of and short-term 30-day survival after endovascular therapy for patients with DVST. Standard PRISMA guidelines were followed. Data sources included PubMed keywords and phrases, which were also incorporated into a MeSH search to yield articles indexed in Medline over a 5-year period. All RCTs, observational cohort studies, and administrative registries comparing or reporting DVST were included. Sixty-six studies met inclusion criteria. 35 articles investigating treatment in a summation of 10,285 patients were eligible for data extraction and included in the review of treatment modalities. A total of 312 patients were included for statistical analysis. All patients included received endovascular intervention with direct thrombolysis, mechanical thrombectomy or both. 133 (42.6%) patients were documented to have a neurologic decline, which prompted endovascular intervention. All patients who had endovascular interventions were those who were started on and failed systemic anticoagulation. 44 patients were reported to have intracranial hemorrhages after intervention. Regardless of systemic anticoagulation, patients were still reported to have complications of VTE and PE. Primary outcome at 3-6 month follow up revealed mRS<1 in 224 patients. DVST presents with many diagnostic and therapeutic challenges. The utility of invasive interventions such as local thrombolysis and mechanical thrombectomy is not fully understood. It is exceedingly difficult to conduct large randomized trials for this low incidence disease process with large pathophysiological heterogeneity.
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Affiliation(s)
- Sanjay Konakondla
- 1 Department of Neurosurgery, Geisinger Health System, Danville, PA 17822, USA
| | - Clemens M Schirmer
- 1 Department of Neurosurgery, Geisinger Health System, Danville, PA 17822, USA
| | - Fengwu Li
- 2 Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaogun Geng
- 2 Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China; 3 Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Yuchuan Ding
- 3 Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
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Ilyas A, Chen CJ, Raper DM, Ding D, Buell T, Mastorakos P, Liu KC. Endovascular mechanical thrombectomy for cerebral venous sinus thrombosis: a systematic review. J Neurointerv Surg 2017; 9:1086-1092. [DOI: 10.1136/neurintsurg-2016-012938] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 12/26/2022]
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20
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Tarango C, Manco-Johnson MJ. Pediatric Thrombolysis: A Practical Approach. Front Pediatr 2017; 5:260. [PMID: 29270396 PMCID: PMC5723643 DOI: 10.3389/fped.2017.00260] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/20/2017] [Indexed: 01/07/2023] Open
Abstract
The incidence of pediatric venous thromboembolic disease is increasing in hospitalized children. While the mainstay of treatment of pediatric thrombosis is anticoagulation, reports on the use of systemic thrombolysis, endovascular thrombolysis, and mechanical thrombectomy have steadily been increasing in this population. Thrombolysis is indicated in the setting of life- or limb-threatening thrombosis. Thrombolysis can rapidly improve venous patency thereby quickly ameliorating acute signs and symptoms of thrombosis and may improve long-term outcomes such as postthrombotic syndrome. Systemic and endovascular thrombolysis can result in an increase in minor bleeding in pediatric patients, compared with anticoagulation alone, and major bleeding events are a continued concern. Also, endovascular treatment is invasive and requires technical expertise by interventional radiology or vascular surgery, and such expertise may be lacking at many pediatric centers. The goal of this mini-review is to summarize the current state of knowledge of thrombolysis/thrombectomy techniques, benefits, and challenges in pediatric thrombosis.
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Affiliation(s)
- Cristina Tarango
- Division of Hematology, Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center Cincinnati, University of Cincinnati, Cincinnati, OH, United States
| | - Marilyn J Manco-Johnson
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplantation, University of Colorado Anschutz Medical Campus, Children's Hospital, Aurora, CO, United States
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Abstract
Cerebral sinovenous thrombosis (CSVT) is a rare but serious cerebrovascular disorder affecting children from the newborn period through childhood and adolescence. The incidence is estimated at 0.6/100,000/year, with 30-50% occurring in newborns. Causes are diverse and are highly age dependent. Acute systemic illness is the dominant risk factor among newborns. In childhood CSVT, acute infections of the head and neck such as mastoiditis are most common, followed by chronic underlying diseases such as nephrotic syndrome, cancer, and inflammatory bowel disease. Signs and symptoms are also age related. Seizures and altered mental status are the commonest manifestations in newborns. Headache, vomiting, and lethargy, sometimes with 6th nerve palsy, are the most common symptoms in children and adolescents. Recent multicenter cohort studies from North America and Europe have provided updated information on risk factors, clinical presentations, treatment practices, and outcomes. While systemic anticoagulation is the most common specific treatment used, there are wide variations and many uncertainties even among experts concerning best practice. The treatment dilemma is especially pronounced for neonatal CSVT. This is due in part to the higher prevalence of intracranial hemorrhage among newborns on the one hand, and the clear evidence that newborns suffer greater long-term neurologic morbidity on the other hand. With the advent of widespread availability and acceptance of acute endovascular therapy for arterial ischemic stroke, there is renewed interest in this therapy for children with CSVT. Limited published evidence exists regarding the benefits and risks of these invasive therapies. Therefore, the authors of current guidelines advise reserving this therapy for children with progressive and severe disease who have failed optimal medical management. As research focused on childhood cerebrovascular disease continues to grow rapidly, the future prospects for improving knowledge about this disorder should be good.
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Affiliation(s)
- Rebecca Ichord
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, United States
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22
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Farias-Moeller R, Avery R, Diab Y, Carpenter J, Murnick J. Contralateral Hypoplastic Venous Draining Sinuses Are Associated with Elevated Intracranial Pressure in Unilateral Cerebral Sinovenous Thrombosis. AJNR Am J Neuroradiol 2016; 37:2392-2395. [PMID: 27469210 DOI: 10.3174/ajnr.a4899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/13/2016] [Indexed: 11/07/2022]
Abstract
Variations in cerebral venous development can influence the ability to regulate drainage. In cerebral sinovenous thrombosis, these variations can be associated with elevated intracranial pressure. We present a series of pediatric patients with unilateral cerebral sinovenous thrombosis and investigate whether the contralateral venous sinus size increases the risk of developing elevated intracranial pressure. Patients diagnosed with a unilateral cerebral sinovenous thrombosis were identified by querying our institutional radiology data base. The difference in the occurrence of elevated intracranial pressure in patients with cerebral sinovenous thrombosis with and without hypoplastic venous sinuses was studied. Twelve cases of unilateral cerebral sinovenous thrombosis met the inclusion criteria and had sufficient images. Six patients had hypoplastic contralateral venous sinuses. The presence of hypoplastic contralateral venous sinus in the setting of thrombosis of a dominant sinus was associated with elevation of intracranial pressure (83% versus 0%, P = .015). Patients with cerebral sinovenous thrombosis and contralateral hypoplastic venous sinuses are at higher risk of developing elevated ICP and may benefit from screening with an ophthalmologic examination.
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Affiliation(s)
| | - R Avery
- From the Divisions of Child Neurology (R.F.-M., R.A., J.C.).,Ophthalmology (R.A.)
| | - Y Diab
- Pediatric Hematology (Y.D.)
| | - J Carpenter
- From the Divisions of Child Neurology (R.F.-M., R.A., J.C.)
| | - J Murnick
- Diagnostic Imaging and Radiology (J.M.), Children's National Health System, Washington, DC.
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Abstract
Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially fatal condition. CVST usually occurs young adults with a female predominance. The current mainstay for treating CVST is anticoagulation with heparin. However, more aggressive interventions, endovascular treatment as an example, may be indicated in selected patients who are non-responsive to heparin and other anticoagulants. Endovascular approaches include catheter-based local chemical thrombolysis, balloon angioplasty and mechanical thrombectomy, all of which may rapidly recanalize the occluded venous sinus, restore the blood flow, reduce the increased intracranial pressure, and subsequently relieve the corresponding symptoms. However, as an invasive strategy, endovascular procedures per se may cause complications, such as intracranial hemorrhage, vessel dissection and pulmonary embolization, which may substantially decrease the benefit-risk ratio of the treatment. Due to the rareness of the condition and the limited indication of this invasive strategy, safety and efficacy of endovascular procedures in treating CVST are less feasible to be evaluated in large randomized clinical trails. Therefore, the evidences for justifying this treatment strategy are largely derived from case reports, cohort studies and clinical observations.
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Shaikh H, Pukenas BA, McIntosh A, Licht D, Hurst RW. Combined use of Solitaire FR and Penumbra devices for endovascular treatment of cerebral venous sinus thrombosis in a child. J Neurointerv Surg 2014; 7:e10. [DOI: 10.1136/neurintsurg-2013-011088.rep] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Shaikh H, Pukenas BA, McIntosh A, Licht D, Hurst RW. Combined use of Solitaire FR and Penumbra devices for endovascular treatment of cerebral venous sinus thrombosis in a child. BMJ Case Rep 2014; 2014:bcr-2013-011088. [PMID: 24554672 DOI: 10.1136/bcr-2013-011088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
A pre-teenager with newly diagnosed ulcerative colitis presented to an emergency department with acute headache, altered mental status and bilateral lower extremity weakness. Head CT demonstrated acute thrombus in the vein of Galen and straight sinus, and the patient was started on a heparin infusion. The patient clinically deteriorated and became unresponsive. In view of the rapid deterioration despite anticoagulation therapy, the patient was taken for endovascular treatment. A novel endovascular approach was performed with combined use of Solitaire FR and Penumbra devices to enhance access to the straight sinus and to limit intraprocedural blood loss. The post-treatment head CT demonstrated a decrease in hyperattenuation within the vein of Galen and straight sinus. The neurologic status improved within 24 h. The patient was discharged home with a normal neurologic examination.
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Affiliation(s)
- Hamza Shaikh
- Department of Neuroradiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Millichap JG. Endovascular Treatment of Cerebral Venous Sinus Thrombosis. Pediatr Neurol Briefs 2013. [DOI: 10.15844/pedneurbriefs-27-12-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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