Endovascular management of cerebral venous sinus thrombosis

Elevated Factor VIII Level Associated with Transverse Cerebral Venous Sinus Thrombosis

BACKGROUND Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke. CVST can be caused by systemic conditions as well as mechanical factors that reduce blood flow to promote thrombosis. These can include hormonal therapies, pregnancy, malignancy, genetic conditions. trauma, neurosurgical procedures, and adjacent infections (mostly mastoiditis). This case report describes a patient with right transverse sinus thrombosis with no prior risk factors. CASE REPORT A 50-year-old female with no risk factors presented with complaints of headache associated with diplopia for 2 weeks. She did not have any other neurologic signs or symptoms. The patient initially underwent a cerebral magnetic resonance imaging that revealed right transverse sinus thrombosis. She underwent an extensive procoagulant workup and was found to have an increased factor VIII level. All other workups were negative. The patient was started on heparin infusion and bridged to coumadin to achieve a therapeutic international normalized ratio. The patient had improvement in her headache symptoms and was discharged to be followed as an outpatient. CONCLUSIONS We report a case of right transverse sinus thrombosis in a patient with increased factor VIII levels. It is prudent to promptly diagnose cerebral sinus venous thrombosis and start antithrombotic treatment for complete resolution of symptoms.

Cerebral venous thrombosis: state of the art diagnosis and management

PURPOSE

This review article aims to discuss the pathophysiology, clinical presentation, and neuroimaging of cerebral venous thrombosis (CVT). Different approaches for diagnosis of CVT, including CT/CTV, MRI/MRV, and US will be discussed and the reader will become acquainted with imaging findings as well as limitations of each modality. Lastly, this exhibit will review the standard of care for CVT treatment and emerging endovascular options.

METHODS

A literature search using PubMed and the MEDLINE subengine was completed using the terms "cerebral venous thrombosis," "stroke," and "imaging." Studies reporting on the workup, imaging characteristics, clinical history, and management of patients with CVT were included.

RESULTS

The presentation of CVT is often non-specific and requires a high index of clinical suspicion. Signs of CVT on NECT can be divided into indirect signs (edema, parenchymal hemorrhage, subarachnoid hemorrhage, and rarely subdural hematomas) and less commonly direct signs (visualization of dense thrombus within a vein or within the cerebral venous sinuses). Confirmation is performed with CTV, directly demonstrating the thrombus as a filling defect, or MRI/MRV, which also provides superior characterization of parenchymal abnormalities. General pitfalls and anatomic variants will also be discussed. Lastly, endovascular management options including thrombolysis and mechanical thrombectomy are discussed.

CONCLUSIONS

CVT is a relatively uncommon phenomenon and frequently overlooked at initial presentation. Familiarity with imaging features and diagnostic work-up of CVT will help in providing timely diagnosis and therapy which can significantly improve outcome and diminish the risk of acute and long-term complications, optimizing patient care.

Pediatric Otogenic Sigmoid Sinus Thrombosis: Case Report and Literature Reappraisal

The purpose of this study was to review our experience with a single case of mastoiditis associated with sigmoid sinus thrombosis and increased intracranial pressure, and to review the experience of others through prior publications. We reviewed a case of a 6-year-old boy with an acute otitis media and mastoiditis, with associated ipsilateral sigmoid sinus and contralateral distal transverse sinus thrombosis. Based on the literature and our own experience, we conclude that most children with dural sinus thrombosis from acute otitis media and mastoiditis, in the setting of increased intracranial pressure, attain a good neurological outcome with a conservative neurosurgical approach. The mainstay of treatment seems to be appropriate antibiotic coverage and anticoagulation. Surgeries such as external ventricular drain, serial lumbar punctures, intracranial pressure monitor, and endovascular thrombectomy are reserved for patients with neurological deterioration despite maximal medical treatment.

New Developments in the Pathophysiology, Workup, and Diagnosis of Dural Venous Sinus Thrombosis (DVST) and a Systematic Review of Endovascular Treatments

Dural venous sinus thrombosis (DVST) is a rare cause of stroke, which typically affects young women. The importance of identifying pre-disposing factors that lead to venous stasis lies in the foundation of understanding the etiology, pathophysiology and clinical presentation. The precise therapeutic role of interventional therapies is not fully understood though the current data do suggest potential applications. The aim of the study was to perform a systematic review and meta-analysis to evaluate the utility of and short-term 30-day survival after endovascular therapy for patients with DVST. Standard PRISMA guidelines were followed. Data sources included PubMed keywords and phrases, which were also incorporated into a MeSH search to yield articles indexed in Medline over a 5-year period. All RCTs, observational cohort studies, and administrative registries comparing or reporting DVST were included. Sixty-six studies met inclusion criteria. 35 articles investigating treatment in a summation of 10,285 patients were eligible for data extraction and included in the review of treatment modalities. A total of 312 patients were included for statistical analysis. All patients included received endovascular intervention with direct thrombolysis, mechanical thrombectomy or both. 133 (42.6%) patients were documented to have a neurologic decline, which prompted endovascular intervention. All patients who had endovascular interventions were those who were started on and failed systemic anticoagulation. 44 patients were reported to have intracranial hemorrhages after intervention. Regardless of systemic anticoagulation, patients were still reported to have complications of VTE and PE. Primary outcome at 3-6 month follow up revealed mRS<1 in 224 patients. DVST presents with many diagnostic and therapeutic challenges. The utility of invasive interventions such as local thrombolysis and mechanical thrombectomy is not fully understood. It is exceedingly difficult to conduct large randomized trials for this low incidence disease process with large pathophysiological heterogeneity.

Diffuse Subarachnoid Hemorrhage Secondary to Cerebral Venous Sinus Thrombosis

BACKGROUND

Aneurysmal rupture accounts for the majority of nontraumatic subarachnoid hemorrhage (SAH). Increasingly recognized is the occurrence of nontraumatic convexity SAH unaccounted for by aneurysmal rupture.

CASE REPORT

These presentations require consideration of rare but clinically significant sources of SAH. We report a patient presenting with prolonged mild headaches and acute onset of seizure like activity found to have diffuse subarachnoid hemorrhage and extensive dural venous sinus thrombosis involving the superior sagittal sinus and right transverse-sigmoid sinuses.

CONCLUSIONS

There are few reported cases of SAH secondary to dural sinus thrombosis; however most of these are convexity hemorrhage. Sinus thrombosis presenting as diffuse SAH is extremely rare, as is showcased in this report.