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Table of Contents    
ORIGINAL ARTICLE
Year : 2014  |  Volume : 62  |  Issue : 4  |  Page : 371-375

Balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis


Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

Date of Submission03-Mar-2014
Date of Decision25-May-2014
Date of Acceptance24-Aug-2014
Date of Web Publication19-Sep-2014

Correspondence Address:
Shao-Feng Shui
Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou - 450 052
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.141241

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 » Abstract 

Background and Purpose: This study aimed to investigate the efficacy and safety of balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis (CVST). Materials and Methods: Twenty-six cases of digital subtraction angiography-confirmed CVST were treated with balloon dilatation and thrombus extraction. Active treatment of primary disease was carried out after cerebral venous sinus recanalization, and the subsequent anticoagulant therapy lasted for 6 months. Results: Recanalization of the cerebral venous sinus was achieved in all 26 patients, and no endovascular treatment-related complications occurred during or after the procedure. At discharge, the Glasgow Coma Scale (GCS) of the patients had improved from an average of 12.3 points to 15 points, and clinical symptoms were improved in 100% of the patients. Follow-up times ranged from 12-62 months (mean follow-up time of 42.3 months) and no thrombus re-formation or new neurological deficits occurred during that time. Conclusion: Based on our small study population, balloon dilatation and thrombus extraction appears to be a safe and effective treatment for cerebral venous sinus thrombosis. However, further research is needed to confirm this.


Keywords: Balloon dilatation and thrombus extraction, cerebral venous sinus thrombosis, endovascular treatment


How to cite this article:
Shui SF, Li* TF, Han XW, Ma J, Guo D. Balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis. Neurol India 2014;62:371-5

How to cite this URL:
Shui SF, Li* TF, Han XW, Ma J, Guo D. Balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis. Neurol India [serial online] 2014 [cited 2019 Oct 14];62:371-5. Available from: http://www.neurologyindia.com/text.asp?2014/62/4/371/141241

FNx01Shao-Feng Shui and Teng-Fei Li contributed equally to this work and share first authorship



 » Introduction Top


The onset of cerebral venous sinus thrombosis (CVST) is insidious, and its clinical symptoms are varied. Thus, CVST is often misdiagnosed and inappropriately treated, resulting in a high rate of subsequent disability and mortality. [1] Modern diagnostic imaging techniques, such as magnetic resonance venography (MRV) and digital subtraction angiography (DSA), have advanced our neuroradiology capabilities and made diagnosis of CVST possible. Moreover, interventional neuroradiology adds endovascular treatment to the list of effective cures for CVST. This treatment has greatly reduced the disability and mortality rates of this disease. [2],[3],[4]

Due to the diverse etiology and varied clinical course of CVST, and the widely ranging extent of thrombus involvement, a single endovascular treatment (such as transarterial or transvenous thrombolysis, mechanical fragmentation, or venous sinus stenting) would not be effective for all patients. Between October 2006 and June 2012, our department treated CVST with balloon dilatation and thrombus extraction with good clinical effects. We report the patient characteristics, our technique, and the patient outcomes below.


 » Materials and Methods Top


Written informed consent was obtained from all the patients for the publication of this article and any accompanying images. This study was also approved by the Ethics Committee of the Affiliated Hospital of Zhengzhou University. Between October 2006 and June 2012, 26 CVST patients received endovascular treatment at our hospital. All had a history of progressive neurologic symptoms that did not resolve with medical treatment. Of the 26 patients, seven were male and 19 were female, and their ages ranged from 18-46 years with a mean age of 28.9 years. Medical history before endovascular treatment ranged from 2-14 months, with a mean time of 3.6 months. Follow-up times after endovascular treatment ranged from 12-62 months, with a mean follow-up time of 42.3 months. Twenty suffered from superior sagittal sinus thrombi and 14 had simultaneous involvement of the transverse sinus and/or sigmoid sinus [Figure 1] and [Figure 2]. Nerve dysfunction, such as impaired vision, cranial nerve palsy, hemiplegia, altered mental state and progressive stubborn headaches, was present in 12 patients. Among them, eight patients' MRI showed T1WI low signal and T2WI high signal in brain parenchyma, T1WI low signal and T2WI high signal in superior sagittal sinus, and enhancement scanning showed filling defect in superior sagittal sinus, which presented CVST (patchy bleeding in brain parenchyma could be seen in four patients). Four patients' MRI showed T1WI high signal and T2WI low signal in superior sagittal sinus and straight sinus, which was considered to be subacute thrombosis. The other 14 patients had only clearance headaches or epileptic seizures. Four cases of their MRI images showed T1WI high signal and T2WI low signal in superior sagittal sinus and straight sinus, which is subacute thrombosis; abnormal widening Galen vein could be seen in one of the four patients. Ten patients' MRI showed T1WI low signal and T2WI high signal in superior sagittal sinus and straight sinus, which is old thrombosis. Papilledema was obvious in all 26 patients. Preoperative Glasgow Coma Scale (GCS) scores ranged from 6-14 points, with a mean score of 12.3 points. All patients underwent d-dimer tests, CT, MRI, or MRV to confirm CVST.
Figure 1: Cerebral angiography showing a discontinuous image of the superior sagittal sinus with delayed venous circulation and collateral circulation established

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Figure 2: (a-d) Radiographs of the superior sagittal sinus with the microcatheter in place showing that the superior sagittal sinus is obstructed by a large mass causing a fi lling defect within the sinus

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Most of the 26 patients had prior risk factors for CVST. Nine of them were puerperal, four suffered from serious infections, three were dehydrated, and five had hematologic diseases simultaneously. However, the etiological factors underlying the CVST were unclear in five patients. Laboratory examination showed that eight cases had platelet number abnormally increased (340-710 × 10 9 /L), which include five blood disease patients and three for unknown cause. Plasma fibrinogen increased in 20 patients, while others were normal; homocysteine increased in 14 patients, while others were normal; d-dimer increased in all the patients.

Transarterial cerebral angiography was performed to survey the CVST in detail [Figure 1] and [Figure 2]a-d. Balloon dilatation and thrombus extraction were performed via the right femoral vein. Placement of a 6F sheath in the femoral vein allowed passage of a 6F guiding catheter to the basis cranii. The opening of the sigmoid sinus was approached under postero-anterior and lateral projection fluoroscopy with a 300 cm 0.014 inch micro-guide wire and a 0.014 inch microcatheter, which were advanced retrograde into the anterior third of the superior sagittal sinus. After the position of the catheter was confirmed using postero-anterior and lateral projection DSA radiography, the tip of the micro-guide wire was kept in the anterior third of the superior sagittal sinus while the microcatheter was pulled out. To disrupt the thrombus, a 5 mm rapid exchange balloon was then delivered to the anterior third of the superior sagittal sinus along the micro-guide wire. The balloon was dilated and drawn slowly back to the sigmoid sinus, while at the same time we used a syringe to draw the thrombus out through the guiding catheter [Figure 3]a-f. This process was repeated 2-4 times as necessary to sufficiently extract the thrombus. When the balloon dilatation and thrombus extraction were finished, internal carotid angiography was performed again to assess the level of recanalization of the venous sinus [Figure 4].
Figure 3: (a-f) One 5-mm rapid exchange balloon was delivered to the anterior third of superior sagittal sinus along the micro-guide wire. The balloon was dilated and then drawn back slowly to the sigmoid sinus

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Figure 4: Angiograph showing that the fi lling defect in the superior sagittal sinus is signifi cantly reduced after the procedure

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After intracranial venous sinus recanalization, 5,000 U of low molecular weight heparin were injected subcutaneously every 12 h for 3-7 days. In addition, medications such as mannitol, nimodipine and gangliosides were administered to treat dehydration, improve intracranial circulation, and provide brain cell nutrition. Follow-up examinations were performed at 3, 6, and 12 months after discharge and included fundic examination and MRV.


 » Results Top


There were no encephalic or general hemorrhagic complications during or after the procedure in any patient. In all cases, the GCS score returned to 15 points and retinal edema was greatly improved or completely resolved. MRV confirmed that all venous sinus vessels were unobstructed and the cortical veins and venae profundae had returned to normal.

Neurological function improved in all patients after discharge (100%). Over our mean follow-up time of 42.3 months, there were no instances of recurrent thrombosis or neurological deficits.


 » Discussion Top


CVST is a hemodynamic disorder in which the outflow of blood from the brain is blocked. The chief pathophysiological changes associated with this condition include increased cerebral venous pressure, cerebral ischemia caused by insufficient perfusion pressure, and intracranial hypertension. Systemic anticoagulation is effective in preventing the formation of fresh thrombi; however, anticoagulant therapy is not a very effective treatment for thrombi that have already formed. [5] In 2011, a meta-analysis that examined the safety of anticoagulant therapy in 79 cases of CVST reported that the risk of encephalorrhagia in CVST patients treated with anticoagulants rose by 9%. [6] There is still controversy about the use of anticoagulants in CVST patients with evidence of encephalorrhagia.

Recently, transvenous contact thrombolytic therapy has increased the recanalization rate and enhanced the clinical efficacy of CVST treatment. However, because of specific characteristics of the anatomic structure of the intracranial venous system, the long time course of thrombus formation, and the different types of lesions and varied hemodynamic changes, transvenous contact thrombolytic therapy is not always effective and some thrombi treated in this way are likely to re-form. Since anticoagulation and thrombolysis have the possibility to aggravate concurrent intracranial hemorrhage, these therapies are contraindicated in cases of CVST combining intracranial hemorrhage and infarction. In 2008, a prospective study with a small sample size revealed that endovascular thrombolysis has a definite curative effect, but that patients with accompanying hemorrhagic infarcts and imminent cerebral herniation do not benefit from thrombolysis. [7] The recommendations of the European Federation of Neurological Societies (EFNS) (2010) are: [8] 1. Systemic or local thrombolysis is not conventionally recommended for the treatment of CVST (grade D recommendation, level IV evidence); 2. Critical patients for whom systemic anticoagulation is insufficient, and in whom intracranial hemorrhage is not found, could receive local thrombolysis under careful intensive care (grade D recommendation, level IV evidence).

Mechanical fragmentation of CVST is a more direct method of recanalization. Using the catheter and guide wire to repeatedly disrupt the thrombus, coupled with injection of contrast media and thrombolytic agents to assist in breaking down the thrombus, reduces the time to recanalization. Since the first report of the successful application of guide wire mechanical fragmentation combined with intravascular thrombolysis in the 1990s, mechanical fragmentation has been widely used. [9] However, this is a rough intervention and the venous sinus has a thin wall with inelastic arachnoid granulations, thus it is easy to cause iatrogenic hemorrhage. [10] Therefore, in order to avoid inadvertent introduction of the micro-guide wire into the cortical veins and subsequent tearing of vessels, radiography should be repeated during operation. The EFNS 2010 guide recommends: [8] 1. Mechanical fragmentation should be a treatment choice for CVST patients who have intracranial hemorrhage already, or for whom other methods have been unsuccessful (grade D recommendation, level IV evidence); 2. Invasive processes and re-occlusion events limit extensive use of mechanical fragmentation of thrombi (grade D recommendation, level IV evidence).

Balloon dilatation and thrombus extraction is one technique for mechanical fragmentation, but reports of simultaneous dilatation and thrombus extraction using a single balloon are rare. Bishop et al. [11] performed balloon dilatation in 1 case of left transverse sinus and sigmoid sinus thrombosis; this patient's intracranial pressure obviously decreased after the operation, leading to a positive treatment outcome and favorable long-term prognosis. The success of this technique may be due to the ability of balloon dilatation to both flatten the thrombus and to dilate vessels, making previously strictured vessels normal in diameter. Here, we have described a new technique for balloon dilatation and thrombus extraction in which the balloon is dilated and then pulled back to achieve venous sinus recanalization by dredging the venous sinus. This technique can avoid the use of thrombolytics and thereby reduce the risk of re-hemorrhage, an especially important consideration for the treatment of patients with cerebral hemorrhage. The patients in our study had a 100% recanalization rate with improvement of clinical symptoms, and there were no operation-related complications or mortality. Theoretically, balloon dilatation has the potential to push the thrombus into the cortical veins and thus worsen the disease, but in our series of cases this did not occur. Perhaps these complications would have been more evident with a larger sample size. Regardless of our success, there are many issues relating to this technique that require further investigation. These include determining the optimal choice of balloon type, the best operative approach, and the long-term efficacy of the therapy.

The key to successful treatment of CVST is rapid recanalization of the venous sinus. Because of the complex nature of CVST, it is difficult to recanalize the venous sinus quickly using a single method. Balloon dilatation and thrombus extraction is a fast, new, and promising treatment at present. However, in view of the small sample size in our study and the limited number of other reports of this technique, there is still little clinical evidence about the safety of this procedure. Further research is needed to determine if this is the optimal treatment for CVST.


 » Acknowledgments Top


We thank all the patients and their families who participated in this study.

 
 » References Top

1.Kumaravelu BS, Gupta MA, Singh BK. Cerebral venous thrombosis. Med J Armed Forces India  2008;64:355-60.  Back to cited text no. 1
    
2.Stam J. The treatment of cerebral venous sinus thrombosis. Adv Neurol 2003;92:233-40.  Back to cited text no. 2
    
3.Canhao P, Falcao F, Ferro JM. Thromboytics for cerebral sinus thrombosis: A systematic review. Cerebrovasc Dis 2003;15:159-66.  Back to cited text no. 3
    
4.Philips MF, Bagley LJ, Sinson GP, Raps EC, Galetta SL, Zager EL, et al. Endovascular thrombolysis for symptomatic cerebral venous thrombosis. J Neurosurg 1999;90:65-71.  Back to cited text no. 4
    
5.Röttger C, Madlener K, Heil M, Gerriets T, Walberer M, Wessels T, et al. Is heparin treatment the optimal management for cerebral venous thrombosis? Effect of abciximab, recombinant tissue plasminogen activator, and enoxaparin in experimentally induced superior sagittal sinus thrombosis. Stroke 2005;36:841-6.  Back to cited text no. 5
    
6.Fuentes B, Martínez-Sánchez P, Raya PG, Abenza MJ, Tejedor ED. Cerebral venous sinus thrombosis associated with cerebral hemorrhage: Is anticoagulant treatment safe? Neurologist 2011;17:208-10.  Back to cited text no. 6
    
7.Stam J, Majoie CB, van Delden OM, van Lienden KP, Reekers JA. Endovascular thrombectomy and thrombolysis for severe cerebral sinus thrombosis: A prospective study. Stroke 2008;39:1487-90.  Back to cited text no. 7
    
8.Einhupl K, Stam J, Bousser MG, De Bruijn SF, Ferro JM, Martinelli I, et al. European Federation of Neurological Societies. EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. Eur J Neurol 2010;17:1229-35.  Back to cited text no. 8
    
9.Dowd CF, Malek AM, Phatouros CC, Hemphill JC 3 rd . Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis: A new technique. AJNR Am J Neuroradiol 1999;20:568-70.  Back to cited text no. 9
    
10.Chow K, Gobin YP, Saver J, Kidwell C, Dong P, Viñuela F. Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis. Stroke 2000;31:1420-5.  Back to cited text no. 10
    
11.Bishop FS, Finn MA, Samuelson M, Schmidt RH. Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis. Case report. J Neurosurg 2009;111:17-21.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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