Cerebral Venous Thrombosis

Abstract

Background and Purpose —We chose to evaluate the safety and efficacy of combined intrathrombus rtPA and intravenous heparin in cerebral venous thrombosis (CVT). Methods —We treated 12 patients with symptoms of 1 to 40 days’ duration (eg, headache, somnolence, focal deficits, seizures, and nausea and vomiting). Pretreatment MRI disclosed subtle hemorrhagic venous infarction in 4 patients, obvious hemorrhagic infarction in 2, small parenchymal hemorrhage from recent pallidotomy in 1, and no focal lesion in 5. Magnetic resonance venography and contrast venography identified thrombi in the superior sagittal sinus (SSS) in 3 patients; transverse/sigmoid sinus (TS/SS) in 2; SSS and both TS/SS in 1; SSS and 1 TS/SS in 5; and SSS, 1 TS/SS, and straight sinus in 1 patient. A loading dose of rtPA was instilled throughout the clot at 1 mg/cm, followed by continuous intrathrombus infusion at 1 to 2 mg/h. Intravenous heparin was infused concomitantly. Results —Flow was restored completely in 6 patients and partially in 3, with a mean rtPA dose of 46 mg (range, 23 to 128 mg) at a mean time of 29 hours (range, 13 to 77 hours). Symptoms improved in these 9 patients concomitantly with flow restoration. Flow could not be restored in 3 patients. In 1 of them, treatment was stopped when little progress had been made, and fibrinogen level dropped to 118 mg/dL. In the other 2 patients, hemorrhagic worsening occurred, and treatment was abbreviated after initial rtPA dosing. In 1 of these, the hematoma was evacuated. Conclusions —Our experience with intrathrombus rtPA in conjunction with intravenous heparin in patients with CVT is encouraging. This therapy should probably be regarded as unsafe in patients with obvious hemorrhage. Time to restore flow may be faster than with urokinase (an average of 71 hours has been reported for 29 documented patients). Further evaluation of rtPA with heparin in CVT is warranted.

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

“…To better elucidate the role of this methodology, several trials and case studies have been conducted (Table 1), 3 of which are particularly notable. 32,67,72 Frey et al 32 treated 12 consecutive patients with combined tissue plasminogen activator and heparin. All 12 patients had significant symptoms without evidence of convalescence, and there was MR imaging evidence of hemorrhage in 7.…”

Cerebral Venous Thrombosis Associated with Thyrotoxicosis: Report of Two Cases

“…The treating physician considered the risk of anticoagulation excessive in our first case. Preliminary reports 17,18 of local thrombolysis in the treatment of CVT suggest that it is more hazardous than anticoagulation and should be used only when seriously ill patients are not responding to anticoagulant therapy. 1,7 In presenting this rare association of CVT and thyrotoxicosis, we wish to alert physicians that young patients presenting with strokes, papilloedema, and tachycardia or atrial fibrillation may require investigation for thyrotoxicosis.…”

Interventional neuroradiology

“…74 ICH with clinical worsening has been reported in two patients. 75 In both cases the thrombolysis had to be terminated but both patients made a good recovery at one and two months.…”