Successful Endovascular Treatment of Cerebral Venous Thrombosis with a Novel, Larger Aspiration Catheter (REACT): A Case Report

Endovascular management of cerebral venous thrombosis: a tertiary-centre experience

Background

Stroke related to cerebral venous thrombosis (CVT) is uncommon, with untoward lethal outcomes. Systemic anticoagulation is the treatment of choice. However, some patients can be resistant to this treatment. Endovascular management with thrombolysis and mechanical thrombectomy can be a viable option in such cases.

Material and methods

We retrospectively reviewed the endovascular management used for CVT in 8 patients who failed to respond to standard anticoagulation therapy between December 2017 and December 2022 in our institute. Clinical profile, imaging parameters, endovascular procedure details, and outcomes in terms of angiographic findings and clinical follow-up were analysed.

Results

In this period, a total of 8 patients underwent mechanical thrombectomy. The procedure was successful in all cases (8/8 = 100%), and 50% of them showed near total/complete recanalization; Perforation of the cortical veins was noted in 2 cases (~25%). Among the 8 patients, one died (1/8 = 12.5%) due to cardiac aetiology; the remaining 7 patients (87.5%) showed good clinical outcome with a modified Rankin Scale score 0 to 2.

Conclusion

Catheter-directed thrombolysis with mechanical thromboaspiration is a safe and effective treatment for cerebral venous sinus thrombosis not responding to anticoagulation.

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.

Practical use and underlying physics of the BENCHMARK™ BMX™ 96 for large-bore aspiration thrombectomy: Case report of initial institutional experience

Endovascular thrombectomy (EVT) is part of first-line intervention for acute ischemic stroke management. Recent technological advances have demonstrated that large-bore catheters are an attractive approach for EVT. A multitude of approaches such as A Direct Aspiration first Pass Technique (ADAPT) or in conjunction with stent retrieval (Solumbra technique) have been developed with increasingly large-bore catheters, demonstrating safety and efficacy. Furthermore, these techniques have demonstrated promise for the intervention of cerebral venous thrombosis as well as posterior circulation ischemic events. Recently, advances in neurointerventional catheters have focused on improved maneuverability to navigate the neurovasculature, as well as larger inner diameters for improved procedural versatility, including aspiration. We describe a case report highlighting our early institutional experience with the recently developed large-bore catheter, the BENCHMARK™ BMX™ 96. The case report entails near complete occlusion of the internal carotid artery from acute thrombus and the utility of the BMX™ 96 catheter for treatment of such extensive clot burden. The applicability of large-bore aspiration catheters, with an emphasis on recent advances, for mechanical thrombectomy in arterial as well as venous systems is discussed. To our knowledge, this is the first reported case of use of the BENCHMARK™ BMX™ 96 access system for EVT in acute ischemic stroke. Such new-generation large-bore catheters are a promising advance in neurointervention, and our early institution experience highlights the ease of use and versatility for neurointerventional procedures such as EVT.

Endovascular Mechanical Thrombectomy with a Large-Bore Aspiration Catheter and Stent Retriever for Cerebral Venous Sinus Thrombosis in Pregnancy: A Case Report

Objective

A case of cerebral venous sinus thrombosis (CVST) during pregnancy effectively recanalized by endovascular mechanical thrombectomy with the combined use of an aspiration catheter and a stent retriever is reported.

Case Presentation

A 27-year-old woman at eight weeks' gestation developed sudden onset of right hemiparalysis and seizures and was referred to our hospital. Her National Institutes of Health Stroke Scale score on admission was 23. On MRI, diffusion-weighted imaging showed a hyperintensity area in the left frontal lobe, and T2* imaging showed hemorrhagic infarction in the same area. MR venography showed obstruction of the anterior two-thirds of the superior sagittal sinus (SSS). Anticoagulant therapy with heparin was started, but since the venous return was expected to be severely impaired, mechanical thrombectomy by endovascular surgery was selected, hoping to resolve symptoms early. Using a large-bore aspiration catheter in combination with a stent retriever, it was possible to safely guide the aspiration catheter into the anterior half of the SSS. The use of a large-bore aspiration catheter enabled retrieval of a large amount of thrombus in a short time, and complete recanalization was achieved. The patient's hemiplegia and aphasia improved significantly within a week after the procedure, and she was discharged without sequelae.

Conclusion

Mechanical endovascular therapy of CVST performed with a combination of a large-bore aspiration catheter and a stent retriever should be considered particularly for patients with severe neurological symptoms or intracranial hemorrhage and for those who do not respond to anticoagulation therapy.