Evolution and advances in endovascular mechanical thrombectomy of cerebral venous sinus thrombosis

Abstract

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke and standard treatment involves anticoagulation. However, for some special CVST patients who are ineligible for anticoagulation or refractory to conservative treatment, endovascular treatment (EVT) may be an effective option. Mechanical thrombectomy (MT) is a commonly used treatment. Compared with anticoagulation treatment alone, MT may result in additional procedure-related complications, however, many studies have shown that it has a high rate of vessel recanalization and lower incidence of related complications in arterial large vessel occlusion stroke. In addition, the applicability of MT in children, patients with deep cerebral thrombosis, and patients with bleeding before treatment has been reported. MT combined with intravascular thrombolysis (IVT) and other multimodal therapeutic strategies, also has a good curative effect, and further research is needed to compare and optimize different treatment strategies. Owing to the low incidence of CVST, randomized controlled clinical trials with a large sample size to explore the safety and effectiveness of MT are scarce. In addition, devices specifically designed for cerebral venous sinus and effective endovascular therapies are currently not well-established. This article summarizes different endovascular instruments and multimodal therapies for cerebral venous thrombosis. We also discuss the limitations, prospects, prognostic factors, and applications in special cases of interventional thrombectomy.

Keywords: Cerebral venous sinus thrombosis (CVST); Endovascular treatment (EVT); Local intrasinus thrombolysis (LIST); Mechanical thrombectomy (MT); Multimodal treatment strategies; Stent.

Figure 1

Endovascular instruments and multimodal treatment strategies for cerebral venous sinus thrombosis. CVST, cerebral venous sinus thrombosis.

Figure 2

Partial recanalization of a 40-year-old male cerebral venous sinus thrombosis patient underwent endovascular treatment. Subacute clot signs in the superior sagittal sinus (SSS) and straight sinus indicated subacute thrombus (white arrows). Follow-up magnetic resonance black-blood thrombus imaging (MRBTI) image depicted partial recanalization (red arrows). Digital subtraction angiography (DSA) showed partial recanalization of SSS. Reproduced with permission from Wiley publisher (journal citation18). Copyright: © 2019 The Authors.

Figure 3

(A) A 47-year-old male patient presented with a headache and worsened in the next day. The computed tomography (CT) scan revealed right temporal lobe hemorrhage. (B) Stent retriever thrombectomy was performed. The arrow indicates the Solitaire FR stent deployed in the occluded superior sagittal sinus (SSS). The arrowhead indicates the clots that were removed. (C) The 4-month follow-up CT scan was normal, apart from the cranioplasty. (D) The lateral digital subtraction angiography (DSA) sinus phase image of the right side demonstrated extensive severe cerebral venous sinus thrombosis. (E) DSA revealed partial recanalization of the occluded sinus. (F) DSA revealed complete recanalization of the SSS with normal arteriovenous blood flow in the left transverse sinus at the 4-month follow-up. Reproduced with permission from Spandidos publisher (journal citation76). Copyright: © Wang et al.