Balloon-Assisted Thrombectomy and Intrasinus Urokinase Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Sliding balloon-assisted thrombectomy combined with aspiration and intrasinus urokinase thrombolysis for the treatment of hemorrhagic cerebral venous sinus thrombosis: experience of 10 patients

Background

Cerebral venous sinus thrombosis (CVST) is an unusual cause of stroke. Currently, standard anticoagulant therapy does not have satisfactory efficacy for treating some cases of hemorrhagic CVST. Therefore, we explored the efficacy and safety of the combination of sliding balloon-assisted thrombectomy with aspiration and intrasinus urokinase thrombolysis for the treatment of CVST patients with intracranial hemorrhage (ICH).

Methods

We retrospectively analyzed the clinical, imaging and follow-up data of 10 CVST patients with ICH who underwent sliding balloon-assisted thrombectomy combined with aspiration and intrasinus thrombolysis with urokinase from February 2022 to June 2023. Complete recanalization and partial recanalization in the cerebral venous sinus were defined as imaging outcomes, and the modified Rankin score (mRS) at the 3-month and 6-month follow-ups was used to evaluate clinical efficacy.

Results

A total of 10 CVST patients aged 18-68 years were enrolled, including 5 males. All of the patients was diagnosed with ICH by noncontrast CT and with thrombosis at 3 or more venous sinuses by digital subtraction angiography (DSA). After treatment, complete recanalization was achieved in 6 patients, and partial recanalization was achieved in 4 patients. At the 3- and 6-month follow-up, all 10 patients showed neurological independence (mRS score ≤ 2), without any signs of symptom aggravation, cerebral hematoma enlargement, pulmonary embolism or other complications after treatment.

Conclusion

These results indicated that the combination of sliding balloon-assisted thrombectomy, aspiration and intrasinus urokinase thrombolysis may be safe and effective for the treatment of CVST patients with intracranial hemorrhage.

Cranial venous sinus thrombosis following early spontaneous abortion: a case report and literature review

BACKGROUND

Pregnancy/puerperium cranial venous sinus thrombosis (CVST) is rare, mainly occurring in perinatal/late pregnancy, and less frequently in early pregnancy. None has been reported after early spontaneous abortion.

CASE REPORT

This study reports a case of CVST following early pregnancy spontaneous abortion in a patient with no known risk factors such as hypertension, diabetes, coagulopathy, or antiphospholipid syndrome. Following aggressive endovascular thrombectomy and thrombolytic treatment with 300,000 units of urokinase administered through a catheter, the patient experienced marked improvement in headache symptoms, with nausea and vomiting completely resolving. Four days later, a repeat magnetic resonance venography scan demonstrated successful recanalization of the intracranial venous sinuses, accompanied by a notable decrease in D-dimer levels upon reassessment.

CONCLUSION

For young patients with early pregnancy bleeding, comprehensive coagulation function and D-dimer tests could be conducted. Even after a spontaneous abortion, if the patient presents with symptoms such as headache, vomiting, or visual impairment, the possibility of pregnancy-associated CVST should be considered, and an immediate head CT or MRI should be arranged. In cases complicated by cerebral hemorrhage, endovascular thrombectomy and thrombolysis can be performed.

Cohort analysis of carotid artery puncture injection of urokinase combined with warfarin for the treatment of cerebral venous sinus thrombosis

PURPOSE

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular disease with increased intracranial pressure from impaired cerebral venous drainage and absorption of cerebrospinal fluid. There is a lack of evidence to prove the benefits and risks of thrombolytic and anticoagulant therapies. We conducted a retrospective analysis of the therapeutic effect of carotid artery puncture injections of urokinase combined with warfarin in patients with CVST.

METHODS

Thirty-six patients with CVST who received a carotid artery puncture injection of urokinase combined with warfarin were retrospectively analyzed in the urokinase group, while 30 patients with CVST received subcutaneous low-molecular-weight heparin (LMWH) and warfarin, as the control group. Clinical parameters, imaging data, laboratory test data, treatment plans, and follow-up information were collected and compared.

RESULTS

At discharge, the GCS score was higher in the urokinase group than that in the control group. In the urokinase group, no patient died. Recanalization of the venous sinus trunk was observed in 32 patients. While two patients died in the control group, recanalization of the venous sinus trunk was achieved in 20 patients. A follow-up examination showed that recovery in the urokinase group was also better than that in the control group.

CONCLUSION

This study suggests that carotid artery puncture injection of urokinase combined with warfarin is a safe and effective option for CVST, can reduce CVST recurrence. However, this was a retrospective study with a relatively small sample size, and future studies are needed to confirm the procedure's feasibility.

Early Versus Late Initiation of Endovascular Therapy in Patients with Severe Cerebral Venous Sinus Thrombosis

BACKGROUND

Endovascular therapy (EVT) for severe cerebral venous sinus thrombosis (CVST) is controversial in terms of indication and clinical benefit. The impact of delay of EVT on functional recovery is unclear. This study aimed to investigate the effect of early versus late initiation of EVT in severe CVST.

METHODS

From prospective EVT and CVST registries, patients with CVST diagnosed between January 2010 and December 2022 were retrospectively identified for this multicenter collaboration. EVT was considered in severe CVST with features prone to a poor prognosis. We compared early (< 24 h) with late (> 24 h) initiation of EVT after the presentation in the emergency department and subsequent CVST diagnosis. Outcome parameters included functional independence (modified Rankin Scale [mRS] score 0-2) at 90 days, mRS score at discharge, in-hospital mortality, and mortality at 3 months.

RESULTS

Of 363 patients with CVST, 45 (12.4%; 31 [early EVT] vs. 14 [late EVT]) were included in this study. We found a higher proportion of patients with functional independence at 3 months among early versus late EVT (66.7% vs. 27.3%; odds ratio [OR] 5.3; 95% confidence interval 1.02-25; p = 0.036). In multivariate logistic regression, late EVT was inversely correlated with functional independence (OR 0.17 [0.04-0.83]; p = 0.011). The mortality rate was 16.7% versus 36.4% (mRS 6 at 3 months, OR 0.34, 95% confidence interval 0.07-1.75; p = 0.217) at 90 days for early versus late EVT.

CONCLUSIONS

We observed a higher rate of functional independence in patients with early EVT. These preliminary findings must be confirmed in subsequent randomized controlled trials evaluating a "time-is-brain" paradigm for EVT in CVST.

Safety and clinical outcomes in endovascular treatment for symptomatic cerebral venous thrombosis: a single-center experience with meta-analysis

The role of mechanical thrombectomy (MT) in cerebral venous sinus thrombosis (CVT) is ambiguous. This study aims to share our experience with MT in CVT, supplemented by a meta-analysis on this treatment. All patients who had MT for CVT at our institution, between 2016 and 2021, were retrospectively reviewed for treatment indications, the technique used, success and complication rates, and clinical outcomes. A meta-analysis was performed for clinical and safety outcomes from published literature with > 10 patients. A total of 15 patients were included in this study. All had a venous hemorrhage or deteriorating despite anticoagulation. MT was performed using aspiration (with wide bore catheters) in 7 patients: aspiration with stent retriever in 5 and transjugular Fogarty-balloon thrombectomy in 3 patients. Adjunctive intra-sinus thrombolysis (IST) was used in 4 cases and venoplasty in 3. Technical success (restoring antegrade venous flow on arterial injection) was 100% with no procedure-related major complication. The direct transjugular approach was cheaper and faster. At 3-month follow-up, 86% of patients had good outcomes (MRS < 2). Meta-analysis of clinical and safety outcomes from 22 and 20 studies, respectively, demonstrated a positive association between MT and good outcomes as well as no significant association with hazardous periprocedural events. EVT via mechanical means for CVT is feasible in our series and meta-analysis. From our experience, trans-jugular Fogarty balloon embolectomy seems to be a potential cost-saving option, at least in a certain part of the world.

Inflammation and Severe Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is a rare type of venous thromboembolism (VTE). It is an important cause of stroke in young adults and children. Severe CVT, which is characterized by cerebral venous infarction or hemorrhage, seizures, or disturbance of consciousness, has more severe clinical manifestations and a worse prognosis. It is commonly believed that the onset of severe CVT gave credit to venous return disorder, with the underlying pathogenesis remaining unclear. There is increasing evidence suggesting that an inflammatory response is closely associated with the pathophysiology of severe CVT. Preclinical studies have identified the components of neuroinflammation, including microglia, astrocytes, and neutrophils. After CVT occurrence, microglia are activated and secrete cytokines (e.g., interleukin-1β and tumor necrosis factor-α), which result in a series of brain injuries, including blood-brain barrier disruption, brain edema, and cerebral venous infarction. Additionally, astrocytes are activated at the initial CVT stage and may interact with microglia to exacerbate the inflammatory response. The extent of cerebral edema and neutrophil recruitment increases temporally in the acute phase. Further, there are also changes in the morphology of inflammatory cells, expression of inflammatory mediators, and inflammatory pathway molecules with CVT progression. Lately, some clinical research suggested that some inflammation-related biomarkers are of great value in assessing the course, severity, and prognosis of severe CVT. Moreover, basic and clinical research suggested that anti-inflammatory therapy might hold promise in severe CVT. This study reviews the current literature regarding the involvement of inflammation in the pathophysiology and anti-inflammatory interventions of severe CVT, which would contribute to informing the pathophysiology mechanism and laying a foundation for exploring novel severe CVT therapeutic strategies.

Endovascular Treatment of Intracranial Vein and Venous Sinus Thrombosis—A Systematic Review

Background: Cerebral venous sinus or vein thromboses (SVT) are treated with heparin followed by oral anticoagulation. Even after receiving the best medical treatment, numerous patients experience neurological deterioration, intracerebral hemorrhage or brain edema. Debate regarding whether endovascular treatment (EVT) is beneficial in such severe cases remains ongoing. This systematic review summarizes the current evidence supporting the use of EVT for SVT on the basis of case presentations, with a focus on patient selection, treatment strategies and the effects of the COVID-19 pandemic. Methods: This systemic literature review included randomized controlled trials (RCTs) and retrospective observational data analyzing five or more patients. Follow-up information (modified Rankin scale (mRS)) was required to be provided (individual patient data). Results: 21 records (n = 405 patients; 1 RCT, 20 observational studies) were identified. EVT was found to be feasible and safe in a highly selected patient cohort but was not associated with an increase in good functional outcomes (mRS 0–2) in RCT data. In observational data, good functional outcomes were frequently observed despite an anticipated poor prognosis. Conclusion: The current evidence does not support the routine incorporation of EVT in SVT treatment. However, in a patient cohort prone to poor prognosis, EVT might be a reasonable therapeutic option. Further studies determining the patients at risk, choice of methods and devices, and timing of treatment initiation are warranted.