Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis. Case report

Drag-out technique using a large balloon fixed with an aspiration catheter for retrieving residual thrombus on the wall of the superior sagittal sinus: illustrative case

BACKGROUND

The authors report a patient with sagittal sinus thrombosis that was resistant to reported endovascular treatments but successfully recanalized by dragging out the thrombus using a large balloon fixed with an aspiration catheter.

OBSERVATIONS

A 57-year-old man presented with the persistent headache and a simple partial seizure. Diagnostic study with computed tomography and angiography demonstrated the superior sagittal sinus (SSS) thrombosis. Due to the neurological worsening even after systemic heparinization, the patient underwent mechanical thrombectomy. Despite six passes of stent retrievers and a large-bore aspiration catheter, functional recanalization was not achieved. Therefore, the so-called dental floss technique was attempted using a large compliant balloon catheter (Transform 7 × 7 mm). However, the balloon catheter just wobbled along the lesion without recanalization. To restrict the movement of the balloon catheter, the distal shaft of the balloon catheter was fixed with the aspiration catheter, and both the balloon and the aspiration catheter were slowly pulled to drag the thrombus out, resulting in recanalization of cortical veins as well as the SSS.

LESSONS

Dragging the thrombus using a large balloon fixed with an aspiration catheter was a useful technique to retrieve sticky thrombus in the patients with the sinus thrombosis.

Successful treatment of cerebral venous sinus thrombosis by balloon venoplasty: a case report

Cerebral venous sinus thrombosis is a special cerebrovascular disease affecting young adult and middle-aged people. The clinical manifestations of cerebral venous sinus thrombosis are diverse and nonspecific; thus, imaging plays an important role in early diagnosis. Anticoagulation with heparin is the preferred treatment for cerebral venous sinus thrombosis. Endovascular treatment is also being increasingly used to achieve recanalization of the cerebral venous sinus. We herein describe a woman in her early 50s who was diagnosed with cerebral venous sinus thrombosis for which anticoagulation with heparin was ineffective. To improve her symptoms and prognosis, we selected balloon venoplasty to treat the right sigmoid sinus thrombosis. Her condition subsequently improved, and no recurrence was observed after several follow-ups.

Brainstem Venous Infarction from Thrombosis on the Jugular Bulb as a Serious Complication of Blunt Head Trauma Injury: A Case Report

The incidence of dural venous sinus thrombosis (DVST) and the cerebral venous infarct have not exactly known, but DVST is closely related to the skull fracture around the venous sinus. A 56-year-old man experienced massive watery discharge after hitting on his face by a falling machine. He was alert and no cerebrospinal fluid discharge on admission. Air-density was shown on the jugular fossa in the brain computed tomography. On the 3th day of trauma, he suddenly had dyspnea and loss of consciousness and became comatose. Acute edema on medulla, pons and right cerebellar hemisphere and focal infarct on right medulla were visualized on the brain magnetic resonance imaging. And the sigmoid sinus and the jugular vein were occluded and venous circulation on the right posterior fossa was diminished on the cerebral angiography. Air-density on the sinus may be an indicator into developing venous thrombosis and brainstem venous infarct could be followed by the DVST round the jugular bulb.

Treatment of pediatric cerebral venous sinus thromboses: the role of anticoagulation

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.

Endovascular treatments for cerebral venous sinus thrombosis

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.

Early Spontaneous Recanalization of Sigmoid Sinus Thrombosis Following a Closed Head Injury in a Pediatric Patient : A Case Report and Review of Literature

Cerebral venous sinus thrombosis (CVST) following a closed head injury in pediatric patients is a rare condition, and an early spontaneous recanalization of this condition is extremely rare. A 10-year-old boy was admitted with a mild, intermittent headache and nausea five days after a bicycle accident. The brain computed tomography showed an epidural hematoma at the right occipital area with pneumocephalus due to a fracture of the occipital skull bone. The brain magnetic resonance imaging and the magnetic resonance venography demonstrated a flow signal loss from the right sigmoid sinus to the right jugular vein. The diagnosis was sigmoid sinus thrombosis, so close observations were selected as a treatment for the patient because of his gradually improving symptoms; however, he complained of vomiting 14 days the after conservative treatment. The patient was readmitted for a further examination of his symptoms. The laboratory and the gastroenterological examinations were normal. Due to concern regarding the worsening of the sigmoid sinus thrombosis, the brain magnetic resonance venography was rechecked and it revealed the recanalization of the venous flow in the sigmoid sinus and in the jugular vein.

Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel combination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique

Intracranial complications of sinusitis are rare but life threatening. We present a case of a 17-year-old woman with sinusitis who deteriorated over the course of 12 days from subdural empyema and global purulent cerebral venous sinus thrombosis. The patient was managed with surgery and mechanical thrombectomy utilizing a novel 'stent anchor with mobile aspiration technique', in which a Trevo stent retriever (Stryker) was anchored in the superior sagittal sinus (SSS) while a 5 MAX ACE reperfusion catheter (Penumbra) was passed back and forth from the SSS to the sigmoid sinus with resultant dramatic improvement in venous outflow. The patient was extubated on postoperative day 3 and was discharged with minimal lower extremity weakness on postoperative day 11. This is the first report using the Trevo stent retriever for sinus thrombosis. It is important to keep these rare complications in mind when evaluating patients with oral and facial infections.

Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel combination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique

Intracranial complications of sinusitis are rare but life threatening. We present a case of a 17-year-old woman with sinusitis who deteriorated over the course of 12 days from subdural empyema and global purulent cerebral venous sinus thrombosis. The patient was managed with surgery and mechanical thrombectomy utilizing a novel 'stent anchor with mobile aspiration technique', in which a Trevo stent retriever (Stryker) was anchored in the superior sagittal sinus (SSS) while a 5 MAX ACE reperfusion catheter (Penumbra) was passed back and forth from the SSS to the sigmoid sinus with resultant dramatic improvement in venous outflow. The patient was extubated on postoperative day 3 and was discharged with minimal lower extremity weakness on postoperative day 11. This is the first report using the Trevo stent retriever for sinus thrombosis. It is important to keep these rare complications in mind when evaluating patients with oral and facial infections.

Cerebral Venous Sinus Thrombosis: Successful Treatment of Two Patients Using the Penumbra System and Review of Endovascular Approaches

Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially life-threatening condition. When showing resistance to treatment or a malignant progression despite anticoagulant therapy, endovascular interventional treatment is of help. The Penumbra System (PS), a novel thrombectomy device specifically designed to remove the thrombus in acute ischemic stroke, also proved to be an effective device for mechanical recanalization of CVST. We first reported two cases successfully treated using the PS in the management of intractable CVST in Asia, and analyzed the technical differences of use of the device through a systematic review of the literature.One patient underwent mechanical thrombectomy of the thrombosed superior sagittal sinus using the 0.054-inch PS catheter when direct pharmacological thrombolysis failed. The other patient underwent mechanical thrombectomy using the 0.041-inch PS catheter with adjuvant local pharmacological thrombolysis. Literature reports on the use of the PS in patients with CVST were reviewed.Successful venous recanalization was achieved using the PS. The patients improved symptomatically following the intervention. Literature reports showed that the PS can be successfully applied for treatment of CVST, though the methods used previously were diverse.The PS has proved to be effective in the rapid recanalization of CVST, but different treatment techniques exist. The solution to these problems depends on more clinical trials as well as further improvements to devices.

Dural sinus and internal jugular vein thrombosis complicating a blunt head injury in a pediatric patient

INTRODUCTION

Cerebral venous sinus thrombosis (CVST) following a blunt head trauma is a rare condition, described in the literature along with the lack of consensus regarding diagnosis and management. We present a case of a pediatric patient with a blunt head injury and epidural hematoma, who developed dural sinus and internal jugular vein thrombosis with fatal outcome.

DISCUSSION

Most of reports show good outcome and recovery, but CVST might be related to poor recovery and even lead to death. The diagnosis and management of this condition are discussed based on a literature review.

CONCLUSION

It is important to keep a high degree of suspicion of CVST since early diagnosis may prevent potentially treatable catastrophic outcomes.

Mechanical thrombectomy for cerebral venous sinus thrombosis: a comprehensive literature review

BACKGROUND

Endovascular treatment of cerebral venous sinus thrombosis (CVST) includes pharmacological and mechanical thrombolysis.

METHODS

The authors searched the English literature on CVST from 1990 to 2012 for all case reports or case series of mechanical thrombectomy.

RESULTS

A total of 64 patients were treated in all published studies. The techniques for mechanical thrombectomy included rheolytic thrombectomy with an AngioJet device (46.9%), clot retraction with the Penumbra system (4.7%), clot retraction with a Fogarty catheter (1.6%), clot retraction with a microsnare (3.1%), balloon venoplasty without stenting (18.7%), balloon venoplasty with stenting (4.7%), and an amalgam of techniques (18.7%). Nine (16.1%) patients died. At the most recent follow-up, 40 (62.5%) patients had no disability or minor disability and 7 (10.9%) patients had major disability.

CONCLUSION

Randomized multiinstitutional clinical trials with larger number of participants are needed to sufficiently compare the effect of intrasinus thrombolysis and mechanical thrombectomy to standard-of-care anticoagulation therapy.

Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion

OBJECT

Intracranial hypertension resulting from compression of the superior sagittal sinus (SSS) by an overlying depressed calvarial fracture is a rare condition. Primary surgical treatment for the symptomatic patient in this setting traditionally involves elevation of the fracture, which often carries significant associated morbidity.

METHODS

The authors report a case involving a 6-year-old boy who suffered a closed, depressed, parietooccipital fracture as the result of an unhelmeted all-terrain vehicle accident. This fracture caused compression and subsequent thrombosis of the SSS, which resulted in CSF malabsorption and progressive intracranial hypertension. Initially headache free following the injury, he had developed severe and unremitting headaches by postinjury Day 7. A CT angiography study of the head obtained at this time exhibited thrombosis of the SSS underlying the depressed calvarial fracture. Subsequent lumbar puncture demonstrated markedly elevated intrathecal pressures. Large volumes of CSF were removed, with temporary improvement in symptoms. After medical management with anticoagulation failed, the decision was made to proceed with image-guided ventriculoperitoneal shunt insertion.

RESULTS

The patient's headaches resolved immediately following the procedure, and anticoagulation therapy was reinstituted. Follow-up images obtained 4 months after the injury demonstrated evidence of resolution of the depressed fracture, with recanalization of the SSS. The anticoagulation therapy was then discontinued. To the authors' knowledge, this report is the first description of ventriculoperitoneal shunt insertion as the primary treatment of this infrequent condition.

CONCLUSIONS

This report demonstrates that select patients with this presentation can undergo CSF diversion in lieu of elevation of the depressed skull fracture-a surgical procedure shown to be associated with increased risks when the depressed fracture overlies the posterior SSS. The literature on this topic is reviewed and management of this condition is discussed.

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.

A review of therapeutic strategies for the management of cerebral venous sinus thrombosis

OBJECT

Although initially described in the 19th century, cerebral venous sinus thrombosis (CVST) remains a diagnostic and therapeutic dilemma. It has an unpredictable course, and the propensity for hemorrhagic infarction produces significant consternation among clinicians when considering anticoagulation. It is the purpose of this review to analyze the evidence available on the management of CVST and to provide appropriate recommendations.

METHODS

A thorough literature search was conducted through MEDLINE and PubMed, with additional sources identified through cross-referencing. A classification and level of evidence assignment is provided for recommendations based on the American Heart Association methodologies for guideline composition.

RESULTS

Of the publications identified, the majority were isolated case reports or small case series. Few prospective trials have been conducted. Existing data support the use of systemic anticoagulation as an initial therapy in all patients even in the presence of intracranial hemorrhage. Chemical and/or mechanical thrombectomy, in conjunction with systemic anticoagulation, is an alternative strategy in patients with progressive deterioration on heparin therapy or in those who are moribund on presentation. Mechanical thrombectomy is probably preferred in patients with preexisting intracranial hemorrhage.

CONCLUSIONS

Effective treatments exist for the management of CVST, and overall outcomes are more favorable than those for arterial stroke. Further research is necessary to determine the role of individual therapies; however, the rarity of the condition poses a significant limitation.