Endovascular Mechanical Thrombectomy and On-Site Chemical Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Chih-Hsiang Liao,Nien-Chen Liao,Hung-Chieh Chen,Yuang-Seng Tsuei,Wen-Hsien Chen,Chiung-Chyi Shen,Shun-Fa Yang

doi:10.1038/s41598-020-61884-5

Abstract

Cerebral venous sinus thrombosis (CVST) is a rare cause of cerebral infarction. Once patients survive the acute phase, long-term prognosis is generally satisfactory. CVST patients who harbored risk factors known for poor prognosis (e.g., deterioration of consciousness/neurological functions and seizures) were oftentimes unresponsive to systemic heparin treatment. The advantage of combined endovascular mechanical thrombectomy (EMT) and on-site chemical thrombolysis (OCT) plus systemic heparin for CVST over the heparin treatment alone has not been proved. A retrospective study was conducted to analyze consecutive patients with CVST from 2005 to 2015. Patients having clinical improvement or stable disease after heparin treatment were in I/S group; patients having continuous deterioration of consciousness/neurological functions and refractory seizures (despite the use of multiple anti-epileptic drugs) after heparin treatment were in D group. EMT and OCT were indicated for patients in D group. Imaging studies and medical records were reviewed for statistical analysis. Safety issues included new-onset/progression of symptomatic intracerebral hemorrhages (ICH) or procedure-related complications. Total thirty patients were included (I/S group = 16; D group = 14). In D group, the mean time frame from the start of heparin treatment to the endovascular treatment was 3.2 days. Compared with I/S group, all patients in D group had complete stenosis of the sinuses, with higher initial mRS, lower initial GCS, and more seizures (p = 0.006, 0.007, and 0.031, respectively), but no significant differences in the mRS at discharge (p = 0.504). Shorter length of thrombosis and lower initial mRS were associated with better outcomes (p = 0.009 and 0.003, respectively). Thrombosis involving the superior sagittal sinus (SSS) was associated with bad outcomes (p = 0.026). There were two patients (6.7%) with worsening symptomatic ICH, one in each group, managed surgically. The overall mortality of the study was 6.7% (2/30). Combined EMT and OCT after heparin treatment for severe CVST were reasonably safe, which might be considered as a salvage treatment in severe CVST patients who are unresponsive to heparin with heavy clot burden involving SSS in the acute phase. However, further studies are needed to confirm its efficacy and validity.

Highlights

Therapy[1,2,3]
Decompressive craniectomy was performed in Cerebral venous sinus thrombosis (CVST) patients with life-threatening conditions after repeated imaging studies
Sixteen patients (8 males and 8 females) were in I/S group; fourteen patients (6 males and 8 females) belonged to D group. (Of note, among patients in D group, none of the patient/parent/guardian/ of kin refused the endovascular therapy as a salvage treatment.) All of the patients received heparin treatment after the confirmation of CVST diagnosis: two patients received UFH, and the rest received LMWH

Summary

Introduction

Therapy[1,2,3]. Once the patient survived the acute phase, long-term prognosis was generally satisfactory[4]. The authors compared the heparin responders with the heparin non-responders, who received additional endovascular treatment, and analyzed their clinical characteristics and outcomes in the acute phase. After the diagnosis of CVST was confirmed, all of the patients received heparin treatment (adjusted-dose UFH or weight-based LMWH), regardless of the presence of intracerebral hemorrhage (ICH)[1,2,3]. Patients having (1) continuous deterioration of consciousness, (2) progression of neurological deficits (e.g. muscle power), or (3) worsening seizures (generalized tonic-clonic seizures, epilepsia partialis continua, etc., despite the use of multiple anti-epileptic drugs) after heparin treatment, which were poor prognostic factors in CVST patients according to the literature[5,6,7,8,9], were defined as clinical deteriorating patients (D group). All of the radiological studies were reviewed and agreed upon by the senior authors (YST and WHC)

Results

Discussion

Conclusion