Endovascular Thrombectomy and Thrombolysis for Severe Cerebral Sinus Thrombosis

Abstract

Background and Purpose— Most patients with cerebral sinus thrombosis (CST) recover after treatment with heparin, but a subgroup has a poor prognosis. Those patients may benefit from endovascular thrombolysis. Methods— Prospective case series. Patients with sinus thrombosis were selected for thrombolysis if they had an altered mental status, coma, straight sinus thrombosis, or large space-occupying lesions. Urokinase was infused into the sinuses (bolus 120 to 600×10 3 U; then 100×10 3 U/h) via a jugular catheter, in 15 cases combined with mechanical thrombus disruption or removal. Results— We treated 20 patients (16 women), mean age 32 years. Twelve patients were comatose and 14 had hemorrhagic infarcts before thrombolysis. Twelve patients recovered (Rankin score 0 to 2), 2 survived with handicaps, and 6 died. Factors associated with a fatal outcome were leukemia (3/6 versus 0/14, P =0.02) and large hemorrhagic infarcts (4/6 versus 2/14, P =0.04). Seizures were less frequent in the fatal cases ( P =0.05). Patients who died had a larger mean lesion surface than survivors (30.5 versus 13.6 cm 2 ; P =0.03), larger midline shift (5.2 versus 1.7 mm; P =0.02), and a more rapid course (2.7 versus 8.2 days; P =0.01). Five patients who died had large hemispheric infarcts and edema before thrombolysis, causing herniation. Five patients had increased cerebral hemorrhage (3 minor, 2 major) after thrombolysis. Conclusions— Thrombolysis can be effective for severe sinus thrombosis, but patients may deteriorate because of increased cerebral hemorrhage. Patients with large infarcts and impending herniation did not benefit.

Diagnosis and management of cerebral venous thrombosis

“…Therefore, LP should be reserved for suspected severe raised ICP, including with threat to vision, when other definitive neurosurgical measures might also need to be considered. If anticoagulation is contraindicated, or in cases of severe CVT not responding to anticoagulants, endovascular thrombolysis or mechanical thrombectomy might be an option, 27,28 although evidence to support this approach is currently lacking. Steroids are not recommended and are linked to a poorer prognosis in CVT, even with the presence of parenchymal lesions, unless indicated by an underlying condition, such as meningitis or malignancy.…”

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

“…While these studies were encouraging, a subsequent prospective trial by Stam et al 67 demonstrated less positive results. These authors chose 20 patients whose disease was presumed to have a poor prognosis; 14 had hemorrhagic infarcts at the time of enrollment, and the average initial Glasgow Coma Scale score for the entire group was 7.6.…”

“…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.…”

“…1). 6,17,37,43,45,52,59 Coutinho and colleagues, 17 driven by the limited success of other modalities in the setting of impending hernation, 67 adopted a strategy of hemicraniectomy in this population. They describe 3 cases in which hemicraniectomy was implemented, 2 of which had excellent clinical outcomes.…”

Venous Thrombosis and the Eye

“…This is generally reserved for patients with poorer prognoses (Stam 2005), as there is the potential that thrombolysis may cause death or dependency in up to 40% of patients with CVT (Stam, Majoie et al 2008). However, in critically ill patients, thrombolysis may reduce death compared to other treatments or no treatment at all (Canhao, Falcao et al 2003).…”