Endovascular Treatment of Cerebral Vein Thrombosis A review of 16 cases Diogo M, Silva AA, Azevedo A, Nunes AP, Roque RF, Sousa C, BaEsta T, Fragata I, Ribeiro C, Alcântara J, Reis J E-‐mail address:
[email protected]
INTRODUCTION & PURPOSE
RESULTS
Cerebral Venous Thrombosis (CVT) is an uncommon cause of stroke with high associated mortality and disability1. Coma at presentation and involvement of the deep venous system are the most consistent predictors of poor outcome2. There is no definite evidence for the best treatment approach for CVT1,3. Hypocoagulation with unfractionated or low-molecular-weight heparin is the only modality with reasonable evidence to support its use in CVT3. Endovascular treatment (ET) with either thrombolysis and/or mechanical thrombectomy may be an option in selected patients whose condition worsens despite adequate hypocoagulation or whose initial clinical presentation is such that they are at high risk for an unfavorable outcome4. Although to our knowledge no randomized controlled studies have been published to date, ET may allow a more rapid and effective restoration of venous drainage, improving the prognosis5. Our aim was to evaluate venous recanalization and functional outcome in a series of CVT patients submitted to ET.
METHODS We retrospectively analysed 16 consecutive CVT patients treated with endovascular chemical (alteplase) ± mechanical thrombolysis in our institution between October 1st 2003 and December 31st 2011. CVT diagnosis was made with CT/MRI. All patients were treated with heparin. Pretreatment neurological status and Glasgow Coma Scale Score (GCS) were assessed. The degree of repermeabilization was evaluated with digital subtraction angiography (DSA) immediately after thrombolysis and was classified as null, partial or complete. Functional outcome was evaluated at discharge using the modified Rankin Scale (mRS) score and was considered good when mRS score was ≤2.
A
B
A total of 16 patients were treated in the timeframe given – 4 male, 12 female, with a median age of 39 years (ranging from 18 to 72 years old). Decision to perform ET was based on depression of consciousness at admission in 5 cases (GCS 6-8) and on clinical worsening in 11. At the time of procedure average GCSs was 10. Local alteplase was administered to all patients (mean dose: 11mg intraarterial, 9mg intrasinus) and additional mechanical thrombectomy was performed in 12 cases, with stenting of the right lateral sinus in one patient. Immediate partial dural sinus repermeabilization was achieved in all patients and total repermeabilization in one. No serious complications related to the technique were recorded in our series. There were 2 cases of transient hematuria and one patient developed a puncture site haematoma, none of which had systemic repercussions. Mean hospitalization time in our unit was 18 days. Despite treatment two patients (12,5%) died as a consequence of disease progression, both of which had presented with coma. At discharge there was a good functional outcome in 56% patients, with a median mRS score of 2 in the surviving patients.
C
Fig.1 – Diagnostic imaging pre-treatment (A) Veno CT showing absence of filling of the lateral sinuses, with dilated posterior fossa veins; (B) and (C) PC2D MRI (sagital and axial projections) of the same patient showing no filling of the superior sagital sinus (SSS) and faint filling of the deep venous system (DVS)
Table 1 – Demographic characteristics, presentation, reason for the decision to treat with endovascular treatment, type of treatment used, degree of repermeabilization of the occluded sinus and modified Ranking Scale score at discharge of the 16 patients in the study. GCS- Glasgow Coma Scale score; ET – Endovascular treatment; mRS – Modified Ranking Scale score; HP – hemiparesis; rtPA - alteplase
CONCLUSION
A
B
CVT is an uncommon but potentially fatal condition that remains a diagnostic and therapeutic challenge1. As described in previous publications, ET seems to be a good therapeutical option in selected patients with severe presentation or progressive deterioration despite hypocoagulation5. In our experience, ET led to partial venous repermeabilization with clinical and functional improvement in 81,2% of patients. Despite the promising results, randomized controlled trials are needed to confirm the efficacy and safety of this invasive therapeutic approach.
BIBLIOGRAFIC REFERENCES
C
D
Figure 2 – Different endovascular aproaches to CVT (A) pre-treatment lateral view showing absence of filling of the proximal 2/3 of the SSS and lateral sinuses (LS) (B) lateral view showing angioplasty baloon inside the SSS (C) pre-stenting and (D) post-stenting lateral viewes showing improvement in the right LS drainage.
Contacts: Mariana Cardoso Diogo, Department of Neuroradiology , CHLC, Lisbon, Portugal
1–Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarramenteria F and for the ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT), Stroke 2004;35:664–70. 2-Canhão P, Ferro JM, Lindgren AG, Bousser M, Stam J, Barinagarrementeria F, Causes and Predictors of Death in Cerebral Venous Thrombosis, Stroke, 2005;36:1720-1725 3-Einhäupl K, Bousser MG, de Bruijn SF, Ferro JM, Martinelli I, Mashur F, et al, EFNS guideline on the treatment of cerebral venous and sinus thrombosis, Eur J Neurol 13:553–559, 2006 4-Stam J: Thrombosis of the cerebral veins and sinuses. N Engl J Med 352:1791–1798, 2005 5-Newman BC, Pakbaz RS, Nguyen AD, Kerber, CW, Endovascular treatement of extensive cerebral sinus thrombosis, J Neurosurg 110:442-445, 2009
e-mail:
[email protected]
