Severe Cerebral Venous Sinus Thrombosis Research Articles

Case Reports: Endovascular Treatment of Cerebral Venous Sinus Thrombosis

Background: The causes of cerebral venous sinus thrombosis (CVST) are diverse, and headache is the only symptom in mild cases. However, in severe cases, perfusion disorders may concomitantly cause intracerebral hemorrhage, resulting in serious complications. Herein, we report two severe CVST cases in which good outcomes were obtained following endovascular treatment. Patients and Methods: Case 1. A 42-year-old man consulted an ophthalmologist with a chief complaint of decreased vision. The patient had a considerably high intraocular pressure and papilledema. However, due to unknown etiology, he was only prescribed eye drops. He subsequently developed headaches and experienced an alteration in his. An urgent surgery was performed with using the pull-back technique using a suction catheter, following which, the patient’s neurological symptoms improved. Case 2. A 50-year-old man was transferred to our hospital with a chief complaint of generalized clonic convulsions. The patient was diagnosed with venous sinus thrombosis. Attempts were made to crush the thrombus with a percutaneous transluminal angioplasty balloon and aspirate the thrombus with an aspiration catheter. However, thrombus removal and recanalization could not be achieved. Subsequently, a thrombectomy was performed using the FilterWire technique with a distal embolic protection device. Anterograde blood flow was restored, and the convulsive seizures disappeared. Conclusion: Venous perfusion injury should be avoided in severe cases of CVST, and endovascular treatment using various devices is a therapeutic option in such cases.

Real-time analysis of a mass vaccination effort confirms the safety of FDA-authorized mRNA COVID-19 vaccines

BackgroundAs the coronavirus disease 2019 (COVID-19) vaccination campaign unfolds, it is important to continuously assess the real-world safety of Food and Drug Administration (FDA)-authorized vaccines. Curation of large-scale electronic health records (EHRs) enables near-real-time safety evaluations that were not previously possible.MethodsIn this retrospective study, we deployed deep neural networks over a large EHR system to automatically curate the adverse effects mentioned by physicians in over 1.2 million clinical notes between December 1, 2020 and April 20, 2021. We compared notes from 68,266 individuals who received at least one dose of BNT162b2 (n = 51,795) or mRNA-1273 (n = 16,471) to notes from 68,266 unvaccinated individuals who were matched by demographic, geographic, and clinical features.FindingsIndividuals vaccinated with BNT162b2 or mRNA-1273 had a higher rate of return to the clinic, but not the emergency department, after both doses compared to unvaccinated controls. The most frequently documented adverse effects within 7 days of each vaccine dose included myalgia, headache, and fatigue, but the rates of EHR documentation for each side effect were remarkably low compared to those derived from active solicitation during clinical trials. Severe events, including anaphylaxis, facial paralysis, and cerebral venous sinus thrombosis, were rare and occurred at similar frequencies in vaccinated and unvaccinated individuals.ConclusionsThis analysis of vaccine-related adverse effects from over 1.2 million EHR notes of more than 130,000 individuals reaffirms the safety and tolerability of the FDA-authorized mRNA COVID-19 vaccines in practice.FundingThis study was funded by nference.

Local thrombolysis combined with balloon dilation for patients with severe cerebral venous sinus thrombosis.

Local thrombolysis combined with balloon dilation for patients with severe cerebral venous sinus thrombosis.

Stent retriever thrombectomy combined with long-term local thrombolysis for severe hemorrhagic cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is a rare disease associated with high disability and mortality rates. A subset of patients do not respond to standard anticoagulation therapy, leading to the progression of CVST with hemorrhagic stroke, which represents a major challenge for its treatment. Severe hemorrhagic (SH)-CVST is life-threatening due to large hematoma, edema and/or cerebral hernia. Anticoagulation or thrombolytic therapy alone may lead to further aggravation of the hematoma. Stent retriever thrombectomy combined with long-term local thrombolysis (SRT-LLT) has been used in certain centers for those refractory cases or patients with new intracranial hemorrhage. However, to date, no studies on SRT-LLT treatment specifically for SH-CVST have been performed. The aim of the present retrospective study was to specifically evaluate the effectiveness of SRT-LLT in SH-CVST. Between December 2013 and November 2018, SRT-LLT was performed at our center in 8 patients with hemorrhagic CVST who did not respond to intravenous anticoagulation. The clinical characteristics, results of the radiological evaluation, details on the surgical procedure and clinical outcomes were assessed. The patients were administered systemic intravenous anticoagulation as the initial treatment following admission. SRT-LLT was performed when their condition deteriorated with a high risk of a fatal outcome within a short time period. SRT-LLT was performed in 8 patients, with successful recanalization confirmed by angiography. In 4 of the patients, complete recanalization was achieved, whereas in the remaining 4, recanalization was partial. There were no intraoperative complications. Two patients developed rebleeding after surgery, but they all gradually recovered. There were no treatment-associated fatalities. Therefore, SRT-LLT appears to be a feasible, safe and effective option for SH-CVST and it may be used as rescue therapy for carefully selected patients with SH-CVST.

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

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.

Predictors of successful endovascular treatment in severe cerebral venous sinus thrombosis.

ObjectiveThe objective of this study was to evaluate the thrombus characteristics affecting the extent of recanalization to identify patients with severe cerebral venous sinus thrombus (CVT) more likely to benefit from endovascular therapy.MethodsSevere CVT patients scheduled for endovascular treatment were prospectively recruited into the study. Each thrombosed venous segment was evaluated regarding complete or partial recanalization based on digital subtraction angiography (DSA) after treatment. Magnetic resonance black‐blood thrombus imaging (MRBTI) was performed 1 day before endovascular treatment. The signal‐to‐noise ratio (SNR) of the clot, age of the clot, and baseline volume of the clot were compared between the complete and partial recanalization groups. A logistic regression analysis was performed to identify the association between these clot characteristics and recanalization status.ResultsTwenty‐one CVT patients undergoing endovascular therapy were prospectively included. There were 110 thrombosed segments, 54 of these segments were completely recanalized after endovascular treatment. An acute clot sign (ACS) was found in 39 segments and a subacute clot sign (SCS) was found in 71 segments. There was no significant difference on baseline volume of the clot (1638.8 ± 1432.2 mm3 vs. 1957.5 ± 2056.1 mm3, P > 0.05) between the complete and partial recanalization groups. Logistic regression analysis showed that ACS on MRBTI was associated with complete recanalization (P < 0.001, odds ratio = 3.937, 95% confidence interval, 1.6–9.5).Interpretation ACS can be used to predict complete recanalization in patients undergoing endovascular treatment. MRBTI provides a robust method to define clot composition and is potentially useful in selecting the most appropriate CVT patients for endovascular treatment.

Severe Cerebral Venous and Sinus Thrombosis: Clinical Course, Imaging Correlates, and Prognosis.

Severe cerebral venous-sinus thrombosis (CVT) is a rare disease, and its clinical course, imaging correlates, as well as long-term prognosis have not yet been investigated systematically. Multicenter retrospective study. Inclusion criteria were CVT, Glasgow coma scale ≤9, and treatment in the intensive care unit. Primary outcome was death or dependency, assessed by a modified Rankin Score (mRS) >2 at last follow-up. 114 patients were included. At last follow-up (median 2.5years), 38 patients (33.3%) showed no or minor residual symptoms (mRS=0 or 1), 12 (10.5%) had a mild (mRS=2), 13 (11.4%) a moderate (mRS=3), 12 (10.5%) a severe disability (mRS=4 or 5), and 39 (34.2%) had died. In bivariate analysis, predictors of poor outcome were any signs of mass effect on imaging, clinical deterioration after admission, and age. In contrast, clinical symptoms on admission and parenchymal lesions per se, such as edema, infarction, or hemorrhage were not predictive. Multivariate predictors of poor outcome were an increase in National Institutes of Health Stroke Scale ≥3 after admission [odds ratio (OR) 6.7], bilateral motor signs in the further course (OR 9.2), and midline shift (OR 5.1). The outcome of severe CVT is almost equally divided between severe impairment or death and survival with no or only mild handicap. Specifically, space-occupying mass effect and associated neurologic deterioration seem to determine a poor outcome. Therefore, early detection and treatment of mass effect should be the focus of critical care.

Mechanical thrombectomy combined with recombinant tissue plasminogen activator thrombolysis in the venous sinus for the treatment of severe cerebral venous sinus thrombosis.

The aim of the present study was to assess the effectiveness and safety of endovascular interventional therapy, which is mechanical clot disruption combined with intrasinus thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA), for severe cerebral venous sinus thrombosis (CVST). The records of eight patients with CVST confirmed by computed tomography, magnetic resonance imaging (MRI), magnetic resonance venography (MRV) and/or digital subtraction angiography were analyzed. Of the eight cases, the Glasgow Coma Scale (GCS) scores were between 4 and 9 with a mean value of 8.3±2.7. All the patients had venous infarction and two cases had intracranial hemorrhagic infarcts. Mechanical clot destruction combined with intrasinus thrombolytic therapy with rt-PA was performed under general anesthesia. Intravenous heparin therapy and intracerebral pressure control were applied during this period. One patient succumbed and the other seven patients showed good treatment efficacy. The GCS scores of the seven patients reverted to 15 upon discharge from the Northern Jiangsu People’s Hospital (Yangzhou, China). With regard to the modified Rankin score of the seven patients three months following surgery, six patients scored 0 and one patient scored 1. MRI and MRV follow-up examinations were performed for 3–15 months. Complete recanalization of the criminal sinus, which refer to the sinus attributable to the infarction or hemorrhage, was observed in five cases and partial recanalization was observed in two cases. Symptoms were monitored for 3–24 months and no recurrence was observed. Therefore, mechanical thrombectomy combined with intrasinus thrombolytic therapy with rt-PA is safe and effective for patients with severe CVST.

Abstract WP19: Safety and Validity of mechanical Thrombectomy and Thrombolysis on Severe Cerebral Venous Sinus Thrombosis

BACKGROUND: Although the vast majority of patients suffering from cerebral venous sinus thrombosis (CVST) obtain an optimistic clinical outcome after heparin or warfarin treatment, nevertheless, there remains a subgroup of patients that do not respond to the conventional anticoagulation treatment. These patients, especially the younger people as documented by hospital based studies, have a high morbidity and mortality rate. While the wide spectrum of clinical presentation in most CVST patients makes the diagnosis difficult at an earlier time, endovascular thrombolysis offers an aggressive option to treat CVST. OBJECTIVE: To verify the safety and validity of mechanical thrombectomy combined with thrombolysis in patients with severe CVST. METHODS: A total of 52 patients diagnosed with CVST from January 2007 to December 2010 were enrolled and treated with mechanical thrombectomy combined with thrombolysis. Patients underwent urokinase 100 ~1500×10 3 IU intravenous sinus injection via a jugular catheter after confirming CVST diagnoses by magnetic resonance imaging (MRI)/magnetic resonance venography (MRV) or digital subtraction angiography (DSA). Information obtained on the patients included recanalization status of venous sinuses as evaluated by MRV or DSA, at admission, during operation and 3 and 6 months follow-up after treatment. RESULTS: The percent of patients that showed complete and partial recanalization were 86% and 6% respectively after the mechanical thrombectomy combined with thrombolysis treatment, while 8% of the patients showed no recanilization. The modified Rankin Scale (mRS) scores were 1.0±0.9, 0.85±0.63 and 0.37±0.53 at discharge and at 3 and 6 months follow-up respectively. A total of 6 patients died despite receiving aggressive treatment. No relapsed cases were seen after 3 to 6 months of follow-up. CONCLUSION: Thrombectomy combined with thrombolysis is safe and valid to use in severe cases of CVST. However, a large scale multicenter clinical trial is warranted.

Safety and Validity of Mechanical Thrombectomy and Thrombolysis on Severe Cerebral Venous Sinus Thrombosis

Although the majority of patients with cerebral venous sinus thrombosis (CVST) obtain an optimistic clinical outcome after heparin or warfarin treatment, there remains a subgroup of patients who do not respond to conventional anticoagulation treatment. These patients, especially younger people, as documented by hospital-based studies, have a high morbidity and mortality rate. To verify the safety and efficacy of a dual mechanical thrombectomy with thrombolysis treatment modality option in patients with severe CVST. Fifty-two patients diagnosed with CVST were enrolled and treated with mechanical thrombectomy combined with thrombolysis. Patients underwent urokinase 100 to 1500 × 10 IU intravenous sinus injection via a jugular catheter after confirming diagnoses of CVST by using either magnetic resonance imaging/magnetic resonance venography or digital subtract angiography. Information obtained on the patients included recanalization status of venous sinuses as evaluated by magnetic resonance venography or digital subtract angiography at admission, during operation, and at 3- and 6-month follow-up after treatment. The percentage of patients that showed complete and partial recanalization were 87% and 6%, respectively, after mechanical thrombectomy combined with thrombolysis treatment; 8% of the patients showed no recanalization. The modified Rankin Scale scores were 1.0 ± 0.9, 0.85 ± 0.63, and 0.37 ± 0.53 for discharge, and 3- and 6-month follow-up, respectively. A total of 6 patients died despite receiving aggressive treatment. No cases of relapse occurred after 3 to 6 months of follow-up. Thrombectomy combined with thrombolysis is a safe and valid treatment modality to use in severe CVST cases or in intractable patients that have shown no adequate response to antithrombotic drugs.

Super-selective catheterization of cerebral venous sinus together with mechanical thrombectomy and thrombolysis for severe cerebral venous sinus thrombosis

Super-selective catheterization of cerebral venous sinus together with mechanical thrombectomy and thrombolysis for severe cerebral venous sinus thrombosis

Local thrombolysis for patients of severe cerebral venous sinus thrombosis during puerperium

ObjectiveTo explore and evaluate the efficacy of intrasinus thrombolysis (IST) in patients with cerebral venous sinus thrombosis (CVST) during postpartum period. Methods11 patients during postpartum period with CVST who received IST during July 2007–November 2011 were included. Urokinase was infused into the sinuses via a microcatheter. Magnetic resonance venography (MRV) was performed to assess the recanalization of venous sinuses. ResultsBefore discharge, the intracranial pressure in 11 patients was under 200 mmH2O. MRV confirmed that venous sinus of 9 patients were smooth. The cortex venous and deep venous recovered to normal. Venous sinus of 2 patients recanalized partly, and cortex venous and deep venous had compensation. 9 patients had good outcome and 2 patients had only mild deficits. ConclusionIntrasinus thrombolysis is safe and effective in patients with severe cerebral venous sinus thrombosis during postpartum period.

Local Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Local Thrombolysis for Severe Cerebral Venous Sinus ThrombosisJan Stam, Susanna M. Zuurbier and Jonathan M. CoutinhoAudio Available | Share

Mechanical thrombectomy for intractable cerebral venous sinus thrombosis

Objective Evaluate the safety and efficacy of mechanical throbectomy for severe and uncontrolled cerebral venous sinus thrombosis patients.Method We treated 23 patients with severe and uncontrolled cerebral venous sinus thrombosis by mechanical throbectomy,of which 5 patients were treated by the single mechanical throbectomy, 18 patients by mechanical throbectomy combined with local thrombolysis. In 12 months after the operation the patients should took anticoagulant therapy,etiopathogenisis screening,and appropriate treatment.3months,6 months,and 1 year after operation,we assessed the outcome at follow -up which includes the optic fundus examination,GCS score,mRS score,lumbar puncture,and MRV or DSA.Results Rapid after treatment,the occluded sinus was recanalized.when patients discharged,the mRS (2.1 ± 1.1vs3.7 ± 1.2,P ＜0.05 )and the GCS( 11.5 ±4.6vs10.5± 3.4,P ＜ 0.05 ) are better than that of pre - treated,of which the results of mRS show 9 patients got 0 ～1,6 patients 2 scores,7 patients 3 or more scores,and 1 died in hospital.4 patients died after discharging.3 months after operation,retinal optic disc edema disappeared and the press of lumbar puncture back to normal in all patients.14 patients got 0 ～ 1 with mRS,3 patients came out with 2 ; 1 had 3.There was no recurrence 1 year after operation,17 patients got 0 or 1,and 1got 2.Condusious Mechanical throbectomy for intractable cerebral venous sinus thrombosis is safe and effective.We suggest that for patients especially who are not response to antithrombotic druga take it as soon as possible. Key words: Venous sinus; Thrombosis; Mechanical throbectomy

Local Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Cerebral venous thrombosis is a rare entity that can be difficult to manage. Most patients with cerebral sinus thrombosis recover after treatment with heparin, but a subgroup of severe cerebral venous sinus thrombosis has a poor prognosis. Those patients may benefit from intrasinus thrombolysis. The purpose of this research was to carry out a retrospective analysis of patients with severe cerebral venous sinus thrombosis, and to study the safety and efficacy of intrasinus thrombolysis in patients with cerebral venous sinus thrombosis unresponsive to conventional heparin therapy. Thirty-seven patients with cerebral venous sinus thrombosis who received intrasinus thrombolysis during a 3-year period (January 2007 to December 2009) were included in this study. Urokinase was infused into the sinus via a microcatheter. Data regarding demographic, clinical, and radiologic features were collected. Follow-up data were obtained at 6 months. MRV was repeated to assess the recanalization of the venous sinus. Twenty-seven patients (73%) had good outcome and 7 patients (19%) who were independent for activities of daily life had only mild deficits. One patient survived with severe neurologic deficits and 2 patients died. Complete recanalization of the superior sagittal sinus was seen in 35 patients (97%). At a follow-up of 6 months, 34 patients (92%) were either asymptomatic or had only minor subjective symptoms. Intrasinus thrombolysis is safe and effective in patients with severe cerebral venous sinus thrombosis. However, the subgroup of patients that is likely to benefit the most from this procedure is not clear from our data. Large randomized controlled trials are required to further clarify this issue.

Plasma Biomarker may Help to Distinguish Acute CVST from Non-Thrombotic CVSS in Emergency

Cerebral venous sinus thrombosis (CVST) is one of the important causes of stroke in young people and a lethal event (1). Acute CVST is overlapped with non-thrombotic cerebral venous sinus stenosis (CVSS) in both clinical presentation and brain imaging (2); both of them are predominantly involved in young women, and have severely non-explained headache with vomiting and the imaging feature of non-integrity venous sinus in magnetic resonance venography (MRV) (2). However, the treatment option and the clinical outcomes are entirely different, CVST is typically treated with anticoagulants, whereas non-thrombotic CVSS is treated with dehydration and stenting (3,4). Although CVST can be distinguished from CVSS by digital subtraction angiography (DSA), it is unfeasible in the emergency department (ED). Moreover, thrombolysis should be performed emergently to some intractable and severe CVST. Thus, distinguishing these two diseases in hyperacute stage is crucial. Report showed that D-dimer may helpful in supporting CVST (5), but the result in CVSS is not clear. We compared the levels of plasma biomarkers (D-dimer and fibrinogen) between 34 cases of acute CVST (symptom onset within seven-days) and 34 synchronal cases of age- and gender-matched non-thrombotic CVSS; all of them are confirmed the final diagnosis with DSA. The results revealed significant difference of the two biomarkers in the two groups; 94·1% (32/34) cases in acute CVST group and 5·9% (2/34) in non-thrombotic CVSS group had abnormally elevated D-dimer; 73·5% (25/34) in acute CVST group and 17·6% (6/34) in non-thrombotic CVSS group had abnormally elevated fibrinogen (χ2 = 52·941 and 18·285, all P < 0·001). More importantly, D-dimer and fibrinogen can easily be performed at real time in ED. The results can be obtained within 30 mins after the patient arrives, which is quicker than obtaining the magnetic resonance imaging or DSA imaging. So, these two biomarkers may be helpful and feasible in ED to predict acute CVST in patients with equivocal clinical symptoms, or to distinguish CVST from CVSS when the imaging of MRI/MRV is equivocal.

The Role of VWF In BBB Permeability Associated with Hypoxia/Reoxygenation

AbstractAbstract 2102Aberrant blood brain barrier (BBB) permeability is a hallmark pathology in many diseases of the central nervous system (CNS) including hypoxia, epilepsy, multiple sclerosis and ischemic stroke. Generalized hypoxia is a pathological condition in which the body as a whole is deprived of adequate oxygen supply. Hypoxia occurs in healthy people when they ascend to high altitudes, where it can cause altitude sickness, often manifested by headache, leading to potentially fatal complications such as high altitude cerebral edema (HACE). Hypoxia followed by reoxygenation (H/R) is also commonly used as a model to investigate pathology associated with ischemia/reperfusion as the latter condition is present in several disease states including stroke. In animal models, H/R has been shown to cause tight junction protein abnormalities, increased BBB paracellular permeability and edema. von Willebrand Factor (VWF) is a glycoprotein that is synthesized exclusively by endothelial cells and megakaryocytes. Endothelial cell-derived VWF is secreted constitutively and stored in Weibel-Palade bodies (WPB) from where it is released by regulated secretion into the plasma and subendothelium in response to endothelial activation. It has been demonstrated in vitro that exposure of cultured endothelial cells to hypoxia results in WPB exocytosis and VWF secretion. While it is known that VWF is expressed abundantly by cerebral endothelial cells, very little is known about the role of VWF in endothelial biology, particularly, in regulation of the BBB under stressful conditions. Several studies have shown that VWF protein is up regulated in plasma of patients with several neurological conditions involving BBB disruption such as stroke, severe head injury, cerebral malaria and cerebral venous sinus thrombosis. As it is known that C57BL/6 (wild-type) mice have increased BBB permeability induced by H/R, we investigated the status of BBB integrity in VWF-deficient mice (also on the C57BL/6 background). For these experiments, we used a mouse model of normobaric hypoxia (24 hours of 6% oxygen) followed by reoxygenation (1 hour ~21% oxygen). VWF antigen levels were measured by ELISA and BBB permeability was assessed by quantification of Evan's blue dye leakage into the brain. Our data indicate that plasma VWF levels in wild-type mice are significantly increased after hypoxia when compared to normoxic controls. Upon comparison with wild-type mice, we have determined that VWF-deficient mice have significantly less BBB permeability after H/R suggesting that VWF plays a role in BBB integrity under stressful conditions. We have previously reported that VWF-deficient mice have a defect in regulated P-selectin secretion (Denis et al., PNAS, 2001). To determine if the maintenance of BBB integrity found in VWF-deficient mice was due to lack of P-selectin we utilized an aptamer which inhibits P-selectin (Archemix). Inhibition of P-selectin in wild-type animals resulted in similar BBB permeability when compared to controls. Our findings suggest a critical role for VWF in BBB permeability after hypoxia/reoxygenation that is independent of P-selectin. Disclosures:No relevant conflicts of interest to declare.

Decompressive surgery for severe cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) is one of the common causes of stroke in young people. Mortality in CVST, in addition to progressive thrombosis, is related to elevated intracranial pressure causing transtentorial herniation. The role of decompressive surgery in CVST is not well established. We report our experience with decompressive surgery in CVST and review the literature. This is a retrospective study carried out in the Stroke Unit of a multispeciality tertiary care hospital in south India. The medical records of patients admitted with the diagnosis of CVST between December 2003 and July 2009 were reviewed. The clinical presentation, etiology, medical management, indications for surgery and outcomes were assessed for patients undergoing decompressive surgery. The sensorium was assessed using the Glasgow Coma Scale (GCS), while the outcome was assessed using the modified Rankin scale (mRS). Descriptive statistics were used as appropriate. One hundred and six patients were admitted with the diagnosis of CVST during the study period. Eleven patients (10%) underwent decompressive surgical procedure. Indications for surgery included a low GCS at admission with large infarct on the computed tomography scan, mass effect and midline shift, clinical and radiological signs of transtentorial herniation, deterioration in the sensorium in spite of anti-edema measures and postthrombolysis hematoma. Eight patients (73%) had a good outcome while three patients (27%) died. Of the patients who died, two had a low GCS and bilaterally nonreactive pupils before the surgery while one had thrombosis of the deep venous system. Decompressive surgery for patients with large cerebral venous infarcts is a life-saving procedure. Patients with CVST who develop clinical and radiological features of transtentorial herniation either at presentation or during the course of medical management may benefit from decompressive surgery.

Decompressive surgery for severe cerebral venous sinus thrombosis

Decompressive surgery for severe cerebral venous sinus thrombosis

Combined intraarterial and intravenous thrombolysis for severe cerebral venous sinus thrombosis

To investigate the safety and efficacy of endovascular therapy with combined intra-arterial and intravenous thrombolysis for severe cerebral venous sinus thrombosis. Of the 28 consecutive patients with cerebral venous sinus thrombosis admitted to our hospital in recent 3 years, six patients underwent combined intra-arterial and intravenous thrombolysis. For each patient, local contact thrombolysis was performed with balloon catheter to break clot and urokinase infused for thrombolysis in sinus. At the same time, urokinase (100,000 IU/h) was infused intra-arterially via internal carotid artery to dissolve the venous thrombi. Neurologic outcomes, Glasgow coma scale (GCS), neuroimaging results and modified Rankin Scale score (mRS) were recorded. Of the six treated patients, two were males and four females. Their mean age was 38 +/- 13 (range from 22 to 57) years. Completely recanalization was observed in five patients, whose clinical symptoms recovered completely (mRS score 0). One patient in whom thrombolysis was delayed died the day after the procedure. Endovascular treatment with combined intra-arterial and intravenous thrombolysis may improve neurological outcomes of severe cerebral venous sinus thrombosis.