Treatment of progressive cerebral sinuses thrombosis with local thrombolysis

Abstract

Cerebral venous thrombosis (CVT) is a potentially serious disease, with nonspecific clinical symptoms and an unpredictable outcome. Despite adequate anticoagulation, a patient's clinical condition can rapidly deteriorate. The aim of this study was to evaluate the efficacy of local thrombolysis in these patients. Consecutive patients with progressive cerebral venous thrombosis between October 2008 and January 2011 were enrolled prospectively. Progressive CVT was defined as the persistence of neurologic findings (headache, blurred vision, and visual field defects) despite at least four days (or 48 hours in patients with involvement of more than one sinus) on full anticoagulation therapy with heparin and development of focal neurologic deficits or cortical hemorrhage. We excluded patients with large hematomas and predisposing malignancies like leukemia. All patients underwent local thrombolysis with 30 mg recombinant tissue plasminogen activator (rtPA). Overall, 26 patients were enrolled with a mean age of 35.5 years (range 18 to 56 years). Six patients (23%) were male and twenty patients (77%) were female. The most common presenting feature was headache and the most common neurologic finding was papilledema, which was present in all patients. Eighty-five percent of women had a history of oral contraceptive pill consumption. Successful recanalization was achieved in all patients except one (96.2%). Neurological examinations and follow-up assessments were based on a modified Rankin scale (mRS). Favorable outcome and recovery was defined as a mRS score of 0-1. Follow-up assessments at the third week showed that 25 out of 26 recovered, with 18 having a mRS score of 0 and 7 with a mRS score of 1. There were no procedure-related neurological complications. Our results show that local thrombolysis is a safe and effective treatment modality for patients suffering from progressive CVT.

Figure 1

A 35-year-old woman presented with headache and blurred vision secondary to acute thrombosis in the left lateral sinus (left). The microcatheter was advanced up to the distal segment of sinus (middle). Control image 20 min after thrombolysis showed excellent recanalization (right). Further work-up revealed Antitrombin III deficiency.

Figure 2

MRV showed SSS thrombosis secondary to closed head trauma (left) in a 21-year-old male patient. The microcatheter was advanced into the site of thrombosis and 30 mg rtPA was injected (middle). Control MRV showed patent sinus (right).

Figure 3

Right transverse sinus thrombosis in a 45-year-old opium addicted man (left). While the guiding catheter is in the jugular bulb, the microcatheter was advanced into the transverse sinus (middle). The patient showed significant improvement and control MRV showed good recanalization (right).