Thrombus In Sinus Research Articles

Acute Coronary Syndromes Associated With Thrombus in the Sinus of Valsalva and Normal Coronary Arteriography: The Pivotal Role of Transesophageal Echocardiography in the Intensive Care Unit

We describe 4 patients with thrombus in nonaneurysmal sinus of Valsalva. The diagnosis was made with transesophageal echocardiography performed in the Intensive care unit, in the setting of acute coronary syndromes. Coronary arterlography showed normal coronary arteries in each patient. In 3 patients, conservative medical therapy resulted in full recovery. Two patients had previously undergone aortic valve surgery.

Sinus of Valsalva Thrombosis Causing Renal Infarction

A 72-year-old man was admitted to our hospital with a renal infarction. On admission, computed tomography (CT) of the abdomen revealed total occlusion of the right renal artery, which was found to be recanalized with residual thrombus 7 days later. Transesophageal echocardiography and chest CT demonstrated crescent-shaped thrombus in the non-coronary sinus of Valsalva without evidence of aneurysm. After coumadin treatment the patient did not experience recurrent episodes of systemic embolization. Five months after the initiation of anticoagulation, transesophageal echocardiography and chest CT demonstrated disappearance of the thrombus. This is a rare case of renal infarction caused by a thrombus in the non-coronary sinus of Valsalva without aneurysm.

Direct Endovascular Thrombolytic Therapy for Dural Sinus Thrombosis

PURPOSE To evaluate the efficacy, safety, and results of direct thrombolytic therapy in intracranial dural sinus thrombosis by infusion of alteplase (recombinant tissue plasminogen activator). METHODS Nine patients were treated during a 2-year period for intracranial dural sinus thrombosis. A microcatheter was placed directly into the thrombus in the dural sinus via the transfemoral route. Thrombolysis was initiated with a rapid injection of 10 mg of alteplase over 10 minutes, followed in 3 hours by a continuous infusion of 50 mg, then a continuous infusion at 5 mg per hour until complete thrombolysis or a total dose of 100 mg per day had been reached. Repeat thrombolysis was tried the following day if complete recanalization did not occur at 100 mg per day. RESULTS Successful recanalization with improvement of symptoms was achieved in all cases. Time required for complete thrombolysis was between 8 and 43 hours. The total dose of alteplase ranged from 50 to 300 mg. Complications of a small intrapelvic hemorrhage and oozing at a femoral puncture site occurred in separate cases, but were not related to the amount of infused alteplase. MR venograms obtained 1 to 4 weeks after the procedure showed no evidence of reocclusion of the dural sinuses. CONCLUSION Direct fibrinolytic therapy with alteplase is safe, fast, and effective in treating dural sinus thrombosis. However, to prevent hemorrhagic complications, further studies are required to determine its optimal dose and proper rate of administration.

Histopathological aspects of dural arteriovenous fistulas in the transverse-sigmoid sinus region in nine patients.

In recent years, dural arteriovenous fistulas (DAVFs) have been primarily thought to be acquired lesions, formed after sinus thrombosis. The pathogenesis of DAVF, however, is still controversial. We have studied histopathological aspects of DAVFs in resected specimens obtained from nine patients, to obtain clues to the pathogenesis of DAVFs. Histological comparison was made among nine DAVF cases and five control cases without venous sinus disease. In addition, the relationship between the clinical course and histological aspects was investigated. The essential abnormality found was a connection between the dural arteries and the dural veins within the venous sinus wall, through small vessels averaging approximately 30 microns in diameter. By using several staining methods, we confirmed that the vessels were part of the venous system; we named these dilated venules "crack-like vessels." The development of abnormal communications between dural arteries and dural veins (crack-like vessels) is regarded as the essential part of the pathogenesis of DAVFs, and sinus thrombus is not thought to be an essential lesion of DAVFs. It might be postulated that sinus hypertension caused by stenocclusive disease of the venous sinuses triggers the development of fistulous connections between arteries and veins in the dural wall, which may result in increasingly dilated venules and the formation of DAVFs.

Feasibility of radiofrequency powered, thermal balloon ablation of atrioventricular bypass tracts via the coronary sinus: in vivo canine studies.

Radiofrequency catheter ablation of left-sided accessory pathways is technically demanding and usually requires left heart catheterization. The feasibility of creating lesions from within the coronary sinus of sufficient size to ablate accessory pathways in humans using a thermal balloon catheter was studied in 20 dogs. In group 1 (n = 14), 17 thermal inflations were performed in 12 dogs at either 70 degrees, 80 degrees, or 90 degrees C each for 30 or 60 seconds (in 2 dogs two non-thermal control inflations were performed). Animals were sacrificed 6.3 +/- 1.6 days later. In group 2 (n = 6), seven thermal inflations were performed at 90 degrees C each for 180, 300, or 360 seconds. Group 2 animals received antiplatelet and anticoagulant therapy for 1 week and were sacrificed at 13 +/- 10.7 days. In both groups, hemodynamic, angiographic, and electrocardiographic studies were performed at baseline, 1 hour after inflation, and prior to sacrifice. All dogs remained clinically stable throughout the procedure and no complications were attributed to the effect of thermal inflation. Thermal lesions measured 14.4 +/- 4.4 mm in length and extended from the coronary sinus intima to a mean depth of 2.9 +/- 1.2 mm (range 1.4-6.5 mm). Group 2 lesions were significantly deeper than group 1 lesions (P = 0.03). Of the 24 thermal lesions created, atrial necrosis was present in 23 and ventricular necrosis in 11. In all lesions there was some degree of either atrial necrosis, ventricular necrosis, or both. A variable degree of coronary sinus thrombus was present in 18 dogs without clinical sequelae. It is concluded that radiofrequency balloon heating via the coronary sinus can create thermal lesions in the atrioventricular sulcus of dogs that may be of sufficient size to ablate accessory left-sided pathways in humans.

Magnetic resonance imaging of thrombosed dural sinuses.

Magnetic resonance imaging should have the potential to replace angiography in the diagnosis of dural sinus thrombosis. Concerning time-dependent signal changes of the thrombus, we intended to develop a standardized examination protocol for routine use in suspected dural sinus thrombosis. The time-dependent signal changes of thrombosed dural sinuses were studied in 23 consecutive patients by multiplanar spin-echo and flow-sensitive sequences. Signal intensities and thrombus homogeneity were graded and related to the time after clinical onset and the results of the magnetic resonance angiography. Four stages of the thrombus evolution could be observed. The acute thrombosis (days 1 to 5) appeared strongly hypointense in T2-weighted images and isointense in spin density- and T1-weighted images. In the subacute stage (up to day 15) the thrombus signal was strongly hyperintense in T1- and T2-weighted images. The third stage began in the third week after clinical onset. The thrombus signal was decreased in all sequences and showed an increasing inhomogeneity. The fourth (late) stage was characterized by either the restitution of blood flow or the persistence of a residual thrombus. Each stage requires a different diagnostic approach. With the combined use of spin-echo and gradient-echo sequences, it is possible to make the diagnosis of acute thrombosis; in the second stage, multiplanar spin-echo sequences are sufficient. Diagnosis of dural sinus thrombosis can be established accurately with magnetic resonance imaging in the first two stages. However, the diagnosis of the later stages is difficult because of inhomogeneous signs of recanalization and flow phenomena. Therefore, a suspected older dural sinus thrombus still requires intra-arterial angiography as the primary diagnostic tool.

Radiofrequency catheter ablation of left lateral accessory pathways via the coronary sinus.

The purpose of this study was to describe a new technique for catheter ablation of left lateral accessory pathways (APs) by radiofrequency energy applied at the epicardium through the coronary sinus wall using a unipolar configuration. In an overall group of 212 patients with left lateral APs, multiple endocardial ablation attempts of the AP were unsuccessful in eight patients. The mean +/- SD cumulative duration of previous attempts was 12 +/- 9 hours, using DC shocks and/or radiofrequency energy applied both at the atrial and/or ventricular AP insertions. Epicardial AP insertion was determined by bipolar and unipolar unfiltered distal electrograms by scanning the coronary sinus with a steerable 6F or 7F catheter with a 4-mm distal electrode. The local atrial to ventricular electrogram amplitude ratio was 0.3-1.6. At the ablation site, the catheter tip was slightly deflected toward the annulus to increase both the ventricular component of electrograms and contact with the epicardium. In four patients, epicardial electrogram timings were earlier than endocardial ones. The AP was ablated in seven of the eight patients with 20-30 W applied for 10-60 seconds. No complications occurred except a marked nonspecific pain during radiofrequency energy application; however, the catheter remained adherent to the coronary sinus wall, and its withdrawal was performed during a new radiofrequency application to decrease the risk of coronary sinus rupture. After ablation, echocardiograms, coronary artery angiograms, and levophase coronary sinus angiograms showed no abnormality in all patients except two who had a probable mural thrombus in the coronary sinus. AP conduction remained abolished for 1-10 months of follow-up in seven patients. Radiofrequency catheter ablation of left lateral APs can be achieved effectively and relatively safely via the mid or distal coronary sinus when endocardial approaches are unsuccessful.

Catheter ablation of accessory pathways using radiofrequency energy in the canine coronary sinus

Ablation of a left-sided accessory pathway with high energy direct-current shocks delivered by an electrode catheter in the coronary sinus is associated with the risk of coronary sinus rupture. The safety and effectiveness of closed chest catheter desiccation in the coronary sinus with use of radiofrequency energy was studied. Radiofrequency energy (174 ± 74 J) was applied between the distal electrode of a standard electrode catheter placed 3 to 6 cm inside the coronary sinus and a large posterior chest wall patch in 16 dogs.No arrhythmias or hemodynamic changes were observed. Three dogs were killed approximately 1 h after ablation and 13 after 2 to 4 weeks. Lesions in the atrioventricular (AV) sulcus were observed in 14 of 16 dogs. Lesions were 11.6 ± 6 mm in length, 4.3 ± 2.3 mm in width and 2.8 ± 1.4 mm in depth. Microscopic examination showed well circumscribed areas of necrosis and fibrosis in the fat of the AV sulcus. The media and intima of the circumflex coronary artery were not involved nor was the endocardium or mitral apparatus damaged in any dog. Coronary sinus thrombus was present in 3 of 16 dogs.Large amounts of radiofrequency energy can be safely applied to the coronary sinus. The size and location of the lesions produced suggest that this technique may be useful for the interruption of left-sided accessory AV connections in humans.

Thrombosis of the superior longitudinal sinusduring infancy: Report of two cases

Early diagnosis of thrombosis of the superior longitudinal sinus during life is possible ifconsidered in infants with severe infection and dehydration who develop the sudden onset of central nervous system manifestations. The finding of blood-tinged xanthochromic spinal fluid with elevated protein content and increased pressure suggests the presence of superior longitudinal sinus thrombosis. Two instances of this lesion in infants are presented. Pulmonary arterial emboli, probably dislodged from the sinus thrombus, were found in the second patient.

THE PATHOLOGY OF HYDROCEPHALUS

Erasmus Wilson Demonstration delivered at the Royal College of Surgeons of England on 23rd October 1958 by K. M. Laurence, M.A., M.B., Ch.B. Department of Morbid Anatomy, The Hospital for Sick Children, Great Ormond Street* ERASMUS WILSON, APART from being an eminent dermatologist of the latter end of the last century, and a past President of this College, was also a keen Egyptologist. I am sure that had he been fortunate enough to discover the hydrocephalic mummy of the Roman period reported by Douglas Derry in 1913, his interest in hydrocephalus might well have been aroused. Today, I would like to discuss the naked eye pathology of hydrocephalus, and shall base this talk on post-mortem material obtained during my tenure of the Hydrocephalus Research Fellowship at The Hospital for Sick Children, Great Ormond Street. Most of these cases were examined using a special technique first described by Martin (1952) which was later modified (Laurence and Martin, 1959) whereby the brain is allowed to fix in situ within the skull several weeks before a dissection is made. This not only permits grossly hydrocephalic brains to be examined without danger of distortion, but it enables minor degrees of malformation and abnormality to be recognised. some of which would undoubtedly have been missed if conventional methods of removing the brain from the bony cage were employed. Most important of all, this method allows the careful examination of the extra-cerebral cerebro-spinal fluid pathways, such as the basal cisterns, almost impossible by any other method. Hydrocephalus is best defined as the excessive accumulation of cerebrospinal fluid within the cranial cavity. I wish, however, to exclude hydrocephalus e vacuo where an excessive amount of cerebro-spinal fluid replaces volume lost through primary atrophy of the brain. Theoretically, hydrocephalus may be brought about in three separate ways (see Table I). TABLE I CAUSES OF HYDROCEPHALUS Over-production of C.S.F. Choroid plexus papilloma and villous hypertrophy. Defective absorption of C.S.F. .. ? ? Venous sinus thrombus. Within ventricular system: Foramina of Monro Aqueduct Exit foramina Obstruction to the C.S.F. pathway Subarachnoid space: Arnold-Chiari malformation Basal cistern block Outside C.N.S.: Skull abnormalities Over-production of cerebro-spin al fluid That over-production of cerebro-spinal fluid occurs is now conceded by most authorities (Russell, 1954). The choroid plexus papillomata, in which