Background and Purpose: The use of thrombolytics is frequently mentioned in patients with cerebral venous or dural sinus thrombosis (CVDST) who deteriorate despite anticoagulant the

Thrombolytics for cerebral sinus thrombosis: a systematic review.

Background and Purpose —Cerebral venous thrombosis is a rare entity that can be difficult to manage. Intrasinus thrombolysis is an increasingly applied intervention, but this modality carries an increased risk of hemorrhage. We describe for the first time an option with a potentially lower incidence of intracranial bleeding, the combination of the AngioJet rheolytic thrombectomy catheter with intra-arterial thrombolysis, in 2 patients with extensive dural sinus thromboses, preexisting intracranial hemorrhage, and severe progressive neurological deficits despite heparin therapy.

Methods— Four procedures were performed in 2 patients with thromboses in the superior sagittal and transverse sinuses (right in 1 patient and bilateral in 1 patient) and cortical veins. Rheolytic thrombectomy was performed in the sigmoid, transverse, straight, and superior sagittal sinuses; this technique involves the use of the Bernoulli effect to create a vacuum that fragments and aspirates thrombus. For associated persistent cortical vein thromboses, low-dose intra-arterial thrombolysis was used.

Results— Both patients had excellent angiographic results with sinus reopening after rheolytic thrombectomy and cortical vein reopening after intra-arterial thrombolysis. Follow-up CT showed no change in 1 patient and increased preexisting intracranial hemorrhage in the other. One patient had a negative hypercoagulable workup, and the other patient had probable anti-phospholipid antibody syndrome. At 6 months, both patients had excellent clinical outcome with no neurological deficits except mild short-term memory loss in 1 patient.

Conclusions —The combination of rheolytic thrombectomy with intra-arterial thrombolysis is a treatment modality that allows accelerated recanalization of occluded dural sinuses and cerebral veins with lower doses of thrombolytic agents.

https://www.ahajournals.org/doi/pdf/10.1161/01.STR.31.6.1420

Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis.

Background Treatment of cerebral sinus thrombosis with thrombolytics has been reported in cases with a deteriorating clinical course despite anticoagulant therapy. The rationale of this treatment is to promote rapid recanalisation of the occluded sinus. Objectives To review the available evidence on the efficacy and safety of thrombolysis in confirmed cerebral sinus thrombosis. Search strategy We searched the Cochrane Stroke Group trials register (March 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to March 2003), EMBASE (1980 to March 2003), and reference lists of all relevant publications. Selection criteria We aimed to analyse separately unconfounded randomised controlled trials comparing thrombolytic agent with placebo, or thrombolytic agent with antithrombotic therapy, or thrombolytic agent and antithrombotic with antithrombotic alone, in patients with dural sinus thrombosis (confirmed by MR venography, intra-arterial venography or CT venography). Data collection and analysis Two groups of reviewers independently applied the inclusion criteria. Main results No randomised controlled trials were found. Reviewer's conclusions There is currently no available evidence from randomised controlled trials regarding the efficacy or safety of thrombolytic therapy in dural sinus thrombosis. A randomised controlled trial is justified to test this therapy especially in patients predicted to have a poor prognosis.

Thrombolysis for cerebral vein and dural sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is an increasingly diagnosed disease with a wide range of symptoms, ranging from a mild headache to cerebral herniation. A potentially devastating syndrome, CVST has been associated with a mortality rate of 6-10%. In prospective studies, the overall rate of death and dependency from CVST ranges from 8.8 to 44.4%. Systemic anticoagulation remains the first-line treatment. However, a percentage of patients deteriorate despite medical therapy. These cases have resulted in the development of thrombolysis or endovascular treatment for CVST. Initial reports of the use of endovascular treatment of CVST have been promising. However, enthusiasm for the use of endovascular thrombolysis and thrombectomy should be tempered by an understanding of possible risks such as intracerebral hemorrhage and/or vessel dissection. The authors review the literature regarding endovascular treatment of CVST with a description of the chemical and mechanical thrombolytic techniques.

/pdf/direct-thrombolysis-for-cerebral-venous-sinus-thrombosis-2laimp9vvz.pdf

Direct thrombolysis for cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis is often difficult to manage Treatment options include systemically delivered anticoagulation therapy or chemical thrombolysis Targeted endovascular delivery of thrombolytic agents is currently a popular option, but it carries an increased risk of hemorrhage These strategies require significant time to produce thrombolysis, often in a patient with a rapidly deteriorating neurological condition Rapid mechanical recanalization with thrombectomy is therefore very attractive; this procedure provides rapid recanalization with no increased risk of hemorrhage from use of thrombolytic agents Nevertheless, the rheolytic catheter is large and stiff and may not be able to navigate tortuous intracranial vascular anatomy The authors present their experience with direct dural sinus mechanical thrombectomy performed using the rheolytic catheter via a transcranial route Two patients with dural sinus thrombosis and rapidly deteriorating levels of consciousness underwent unsuccessful attempts at mechanical thrombolysis via the usual transfemoral route Through a burr hole over the dural sinus, mechanical thrombectomy was subsequently performed using the thrombectomy catheter Sinus patency was restored following treatment and both patients demonstrated neurological recovery Hemorrhage or a rapidly deteriorating neurological condition may preclude the use of systemic or locally delivered thrombolytic agents for the treatment of cerebral venous sinus thrombosis Mechanical thrombectomy may be the treatment of choice in these circumstances In patients with limited transfemoral access, a transcranial approach may be used to access the cerebral dural sinuses and thrombectomy may be safely and effectively performed Further evaluation of this therapy is warranted

A transcranial approach for direct mechanical thrombectomy of dural sinus thrombosis. Report of two cases.

We recently encountered a patient with thrombosis of the superior sagittal sinus of an idiopathic cause. The patient was treated initially with combined local thrombolytic therapy through the burr hole over the superior sagittal sinus and systemic anticoagulant therapy. Continuous ventricular drainage and hyperbaric oxygenation therapy were used to control the increased intracranial pressure. The superior sagittal sinus was successfully recanalized. Whereas the patient suffered a complication with subacute subdural haematoma, he was successfully treated with the combination of these therapies. The rationale and approach are discussed.

Superior sagittal sinus thrombosis treated with combined local thrombolytic and systemic anticoagulation therapy

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Superior sagittal sinus thrombosis treated with combined local thrombolytic and systemic anticoagulation therapy