Rheolytic catheter thrombectomy, balloon angioplasty, and direct recombinant tissue plasminogen activator thrombolysis of dural sinus thrombosis with preexisting hemorrhagic infarctions

Abstract

We describe the case of a 28-year-old obtunded woman who presented with bilateral anterior parietal lobe cortical hemorrhages associated with thrombosis of the superior sagittal sinus, both transverse and sigmoid sinuses, and multiple cortical veins draining into the sagittal sinus. Initial heparin therapy was not effective. A combination of AngioJet rheolytic catheter thrombectomy, balloon angioplasty, and continuous direct superior sagittal sinus recombinant tissue plasminogen activator infusion led to venous recanalization with a successful clinical outcome, without worsening of the preexisting intracranial hemorrhages.

Fig 1.

Lateral projection skull radiograph shows the tip of the guidewire (arrowhead) extending distal to the tip of the AngioJet catheter (arrow). From this location, the AngioJet catheter was withdrawn over the guidewire to the right jugular bulb (open arrow) while engaged in rheolytic thrombectomy.

Fig 2.

Anteroposterior projection superior sagittal sinus venogram obtained via the AngioJet catheter port shows considerable improvement with sinus patency. Extensive filling defects from residual thrombus are present in the superior sagittal, right transverse, and right sigmoid sinuses (arrows). In real time, the antegrade flow was subjectively slow. Transosseous collateral veins are also seen (arrowhead).

Fig 3.

Anteroposterior projection venogram obtained after rheolytic thrombectomy and while the AngioJet catheter was withdrawn from the left to the right jugular bulb. Multiple filling defects, representing considerable residual thrombus, are seen in both transverse and sigmoid sinuses (arrows). Prominent collateral veins (arrowheads) in the posterior neck are seen aiding venous drainage of the posterior fossa.

Fig 4.

Final anteroposterior venogram obtained on day 3 of endovascular therapy, following completion of mechanical intervention and rtPA infusion shows satisfactory antegrade flow and patency of the superior sagittal sinus, right transverse, and sigmoid sinuses. The nondominant left transverse and sigmoid sinuses remain occluded.