Loco-regional thrombolysis in the treatment of cerebral venous and sinus thrombosis: report of two cases

Local thrombolysis for severe cerebral venous sinus thrombosis

BACKGROUND AND PURPOSE

Cerebral venous thrombosis is a rare entity that can be difficult to manage. Most patients with cerebral sinus thrombosis recover after treatment with heparin, but a subgroup of severe cerebral venous sinus thrombosis has a poor prognosis. Those patients may benefit from intrasinus thrombolysis. The purpose of this research was to carry out a retrospective analysis of patients with severe cerebral venous sinus thrombosis, and to study the safety and efficacy of intrasinus thrombolysis in patients with cerebral venous sinus thrombosis unresponsive to conventional heparin therapy.

MATERIALS AND METHODS

Thirty-seven patients with cerebral venous sinus thrombosis who received intrasinus thrombolysis during a 3-year period (January 2007 to December 2009) were included in this study. Urokinase was infused into the sinus via a microcatheter. Data regarding demographic, clinical, and radiologic features were collected. Follow-up data were obtained at 6 months. MRV was repeated to assess the recanalization of the venous sinus.

RESULTS

Twenty-seven patients (73%) had good outcome and 7 patients (19%) who were independent for activities of daily life had only mild deficits. One patient survived with severe neurologic deficits and 2 patients died. Complete recanalization of the superior sagittal sinus was seen in 35 patients (97%). At a follow-up of 6 months, 34 patients (92%) were either asymptomatic or had only minor subjective symptoms.

CONCLUSIONS

Intrasinus thrombolysis is safe and effective in patients with severe cerebral venous sinus thrombosis. However, the subgroup of patients that is likely to benefit the most from this procedure is not clear from our data. Large randomized controlled trials are required to further clarify this issue.

Cerebral venous sinus thrombosis associated with bulimia nervosa

Central venous sinus thrombosis (CVST) is a rare cause of headache and stroke but has a wide clinical spectrum of presentations, including headache, seizures, focal neurological signs and alteration in consciousness, which can present in isolation or in various combinations. CVST is a difficult diagnosis to make in clinical practice but advances in neuroimaging allows for faster and more precise diagnosis, but it can still prove elusive. Non-infectious CVST are now more common that post-infectious, for which there are a variety of causes and risk factors in the clinical history that can suggest the diagnosis. The authors present a case that highlights the difficulty in diagnosis and identifies an association with a common eating disorder. A literature review discusses the complexities of presentation, aetiology, imaging and the current evidence on management.

Continuous thrombolysis and repeated thrombectomy with the Penumbra System in a child with hemorrhagic sinus thrombosis: technical note

Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially lethal event. When showing a malignant clinical course despite anticoagulant therapy, new endovascular techniques and technology allow the possibility of more aggressive thrombolysis and thrombectomy. The authors present a case of recanalization of an extensive cerebral thrombosis using a new endovascular thromboaspiration device, the Penumbra System.

BACKGROUND AND PURPOSE

CVST in children is a rare but potentially lethal disorder. When showing a malignant progression despite anticoagulant therapy, the use of local thrombolytics and thrombectomy procedures might provide therapeutic solution.

METHODS

A 16-year-old girl presented with signs and symptoms of a hemorrhagic cerebral sinus thrombosis and showed progression despite full dose anticoagulant therapy. The evolution being attributed to increasing mass effect, decompressive surgery was performed without clinical improvement. Further brain imaging demonstrated progression of the sinus thrombosis. Repeated local thrombectomy with the Penumbra thrombectomy system and continuous, relatively low dose local thrombolysis was performed during a period of 60 h, resulting in recanalization and clinical improvement. The methodology of combined thromboaspiration and thrombolysis is described.

CONCLUSIONS

We present a novel method for revascularization using the Penumbra System in combination with long-term, relatively low dose thrombolysis, in the setting of both clinically and morphologically progressive, hemorrhagic sinus thrombosis. The procedure proved to be both safe and effective and may be considered in the future for patients with progressive sinovenous thrombosis despite adequate medical therapy.

Direct thrombolysis for cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) is an increasingly diagnosed disease with a wide range of symptoms, ranging from a mild headache to cerebral herniation. A potentially devastating syndrome, CVST has been associated with a mortality rate of 6-10%. In prospective studies, the overall rate of death and dependency from CVST ranges from 8.8 to 44.4%. Systemic anticoagulation remains the first-line treatment. However, a percentage of patients deteriorate despite medical therapy. These cases have resulted in the development of thrombolysis or endovascular treatment for CVST. Initial reports of the use of endovascular treatment of CVST have been promising. However, enthusiasm for the use of endovascular thrombolysis and thrombectomy should be tempered by an understanding of possible risks such as intracerebral hemorrhage and/or vessel dissection. The authors review the literature regarding endovascular treatment of CVST with a description of the chemical and mechanical thrombolytic techniques.

Management of stroke in cancer

Cerebrovascular disorders, including brain infarction, brain hemorrhage, and cerebral venous thrombosis, can occur as an early sign of cancer, but typically occur late in the clinical course. These disorders are due to a variety of pathogenic mechanisms, including coagulation disorders associated with the cancer, invasion or compression of vessels from tumor in or adjacent to the brain, and the adverse effects of cancer therapy. The appropriate therapy for these cerebrovascular disorders is empiric in most instances, because as yet there are no prospective treatment trials for them. A review of the existing literature reveals that improvement in patient quality of life and prevention of further cerebrovascular events can be obtained in some clinical situations.

Neurological and cognitive long-term outcome in patients with cerebral venous sinus thrombosis

OBJECTIVES

The main aim of the present study was to assess long-term neurological and cognitive outcome in patients with cerebral venous sinus thrombosis (CVST).

METHODS

We re-investigated by means of a face to face interview all patients with a confirmed diagnosis of CVST, collected at our Department over the years 1990-2000. During the interview the presence of headache, epileptic seizures, visual deficits and a new episode following the first occurrence of CVST were checked. Moreover all patients underwent a neurological examination, a functional evaluation, a cognitive assessment to rule out aphasia, apraxia and working memory deficits. Depression of mood was also investigated.

RESULTS

On the whole 34 patients entered the study: 10 patients referred episodic headache following the disease. In three cases epileptic seizures were present. A new event occurred in only one patient. Four patients showed pyramidal signs, in two cases visual deficits were present. All patients had no functional disability. We found a mild non-fluent aphasia in three patients, working memory deficits in six patients and depression of mood in six cases.

CONCLUSION

The present study demonstrates a good neurological and cognitive long-term outcome in patients with CVST.

[Serious cerebral venous thrombosis: can we use fibrinolytic?]

We report a case of thrombosis of superior sagittal and cavernous sinuses treated by direct instillation of fibrinolytic agents via selective catheterization. Despite risk of bleeding related to the pathology and treatment, no adverse side-effect occurred. This report is unusual regarding the poor initial clinical patient's condition with dilated and unreactive pupil. The good neurologic outcome warrants aggressive treatment in the most severe forms of cerebral venous thrombosis.

Cerebral Sinovenous Thrombosis

Cranial sinovenous disorders comprise a disparate group of illnesses affecting one or more intracranial venous sinuses and cerebral veins, alone or in combination, due to a variety of causes. As medical knowledge advances, fewer and fewer patients have an "idiopathic" diagnosis, with causes clarified in an ever-increasing number of patients. These not only include the long-known puerperal, marantic, infective, and traumatic causes, but in recent years, also a variety of congenital and acquired coagulation disorders, such as protein S, protein C, and antithrombin III deficiency. Certain sinuses are preferentially involved with certain causative entities; for example, cavernous and lateral sinuses are more frequently occluded in relation to infectious processes, either directly or as a parameningeal focus, whereas the superior sagittal sinus is most often occluded by trauma, tumor, or coagulopathy. The optimal treatment of sinovenous occlusion depends on establishing the cause with alacrity, because delays in diagnosis may lead to life-threatening hyperpyrexia, elevations in intracranial pressure, venous infarctions, seizures, coma, and death. However, because up to a third of patients with nonseptic occlusions may survive untreated, with few residua, controversy persists regarding optimal management. There has been a dearth of randomized, prospective treatment trials in this group of disorders. The little data that exist suggest that rapid control of infection, seizure prophylaxis, and anticoagulation must be achieved early so as to prevent progression of thrombosis and intracranial venous hypertension. In recent years, direct retrograde venous thrombolysis has become increasingly available, and has produced such remarkable results that it is likely soon to become the primary treatment of choice for the nontraumatic or nontumoral occlusions.