Article Text

Download PDFPDF

Mechanical thrombectomy with the penumbra system for treatment of venous sinus thrombosis
  1. Armen Choulakian,
  2. Michael J Alexander
  1. Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
  1. Correspondence to Professor Michael J Alexander, Department of Neurosurgery, Cedars-Sinai Medical Center, 8631 W. Third St., Suite 800E, Los Angeles, CA 90048, USA

Abstract

Objective Venous sinus thrombosis can be a fatal condition. When systemic anticoagulation therapy fails or is high risk, endovascular chemical thrombolysis or mechanical thrombectomy may be necessary. We report our experience using the Penumbra system (PS; Penumbra, Alameda, California, USA) in a series of four patients with venous sinus thrombosis.

Methods Four patients were treated with mechanical thrombectomy using the PS for venous sinus thrombosis. Three of these patients also underwent balloon angioplasty following the PS device. Utility of this technique was evaluated by procedural success, improvement in neurological condition, avoidance of complications and follow-up imaging.

Results Technical success was achieved in all four patients with restoration of flow in the occluded sinuses without the use of chemical thrombolysis. No complications were encountered during the procedure and no postprocedural complications were attributable to the thrombectomy. One patient with glioblastoma died 6 weeks after the procedure. No new intracerebral hemorrhages were caused and there was no exacerbation of pretreatment intracerebral hemorrhages. Follow-up imaging was available in all but one patient to documented continued sinus patency. Neurologic improvement was seen in all patients after thrombectomy. Two patients have returned for outpatient follow-up and both are doing well.

Conclusion Endovascular treatment for venous sinus thrombosis with the PS is a safe and efficacious alternative to the other forms of mechanical thrombectomy reported in the literature. Good clinical and radiographic results can be obtained without the need for chemical thrombolysis.

  • Penumbra system
  • thrombectomy
  • venous sinus occlusion

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

Although rare, venous sinus thrombosis is a potentially fatal condition. Endovascular intervention may become necessary when treatment with systemic anticoagulation fails or is considered high risk. Both chemical thrombolysis and mechanical thrombectomy have previously been reported in the literature. We present the novel use of the Penumbra System (PS; Penumbra, Alameda, California, USA) for the treatment of venous sinus thrombosis.

Methods

A retrospective review was conducted of four patients who underwent thrombectomy for venous sinus thrombosis with the PS. Utility of this technique was evaluated by procedural success, improvement in neurological condition, avoidance of complications and follow-up imaging. Cases are summarized below (table 1).

Table 1

Summary of Venous Sinus Thrombectomy cases with Penumbra System

Case 1 (illustrative case)

History and presentation

Patient 1 was found to have an anterior left parasagittal meningioma after presenting with nausea, vomiting, confusion and balance difficulty. The patient underwent a bifrontal craniotomy for tumor resection with ligation of the anterior third of the superior sagittal sinus (SSS). There were no immediate postoperative defecits. Then on postoperative day 3, the patient had a sudden decrease in level of consciousness to coma and head CT showed a right frontal intracerebral hematoma (ICH) with surrounding edema which necessitated a return to the operating room for hematoma evacuation. A CT venogram showed occlusion in the middle and posterior thirds of the SSS despite being on 5000 units of subcutaneous heparin twice a day. The patient was subsequently found to have heparin-induced thrombocytopenia (HIT) as the etiology of the delayed venous sinus thrombosis.

Procedure

The patient was taken to the angiography suite and placed under general endotracheal anesthesia. Cerebral angiography was performed and showed occlusion of the SSS beginning at the posterior aspect of the craniotomy. The middle one-third of the SSS was not visualized and multiple cortical veins were also not filling (figure 1a). The posterior one-third of the SSS was filling but there was a filling defect near the transverse sinus and confluence of sinuses that was not flow limiting.

Figure 1

(a) Preprocedure lateral right internal carotid artery angiogram demonstrates thrombosis of the middle one-third of the superior sagittal sinus. (b) Cerebral venogram after treatment with the Penumbra system showing reopening of the occlusion with some residual thrombosis. (c) Postprocedure lateral right internal carotid artery angiogram after Penumbra and balloon angioplasty demonstrating patency of the superior sagittal sinus with satisfactory flow.

A 6-French Neuron guide catheter (Penumbra, Alameda, California, USA) was advanced into the right transverse sinus and under roadmap guidance a 0.41-inch Penumbra thrombectomy catheter was introduced into the occluded SSS. The thrombus from the SSS was aspirated over a total of 18 min (figure 2). Cerebral venogram showed reopening of the occlusion with some residual partial occlusion (figure 1b). The Penumbra catheter was removed and a 4 mm×20 mm Hyperglide balloon (ev3, Irvine, California, USA) was used to perform angioplasty of the SSS for residual stenosis. Follow-up angiography showed patency of the SSS with satisfactory flow (figure 1c).

Figure 2

Thrombus removed with the Penumbra System.

Postoperative course

The patient was extubated, moved all extremities purposefully and was able to communicate with improved cognition. Because of the HIT, the patient was treated with intravenous lepirudin followed by conversion to coumadin. Follow-up CT venogram showed stable appearance of the SSS. The patient was transferred to a rehabilitation facility with improved neurologic function.

Case 2

Patient 2, with a history of a large left cerebellar-pontine (CP) angle meningioma, presented after a seizure following 1 week of headache, nausea and vomiting. The patient's neurologic exam was normal with the exception of stable left facial numbness and left-sided hearing loss due to the tumor. CT and MR imaging of the head showed a 3.7 cm×1.8 cm left CP angle meningioma, right mastoiditis and venous sinus thrombosis. Antibiotics were started for the mastoiditis along with a heparin drip; however, the headaches increased and visual obscurations began to develop. The patient was taken to the angiography suite where the SSS, right transverse/sigmoid sinus and right jugular vein were found to be occluded with the progression of the sinus thrombosis. Thrombectomy with the PS followed by balloon angioplasty resulted in reopening of all the occlusions, except for the anterior SSS, and good antegrade venous flow was established. The patient was transferred to the intensive care unit (ICU) and eventually to the ward. Oral anticoagulation with coumadin was started along with continued antibiotics for the mastoiditis. Subsequent MRI/MRV showed stable appearance of the venous sinuses and the patient was eventually discharged home at baseline neurologic state. At 3-month follow-up the patient was doing well with only occasional mild headache and MRV showing no evidence of venous sinus thrombosis.

Case 3

Patient 3, with biopsy-proven right frontoparietal glioblastoma, underwent craniotomy for tumor resection at which time there was injury to the SSS requiring sinus repair. Further resection of the tumor was aborted and MRI/MRV showed occlusion of the posterior third of the SSS extending to the right transverse sinus (figure 3a). The patient was taken to the angiography suite and the PS was used to reopen the occluded sinuses and establish antegrade venous flow. Heparin was given during the procedure but was not continued postoperatively in light of the recent craniotomy. The patient remained neurologically stable until the following day at which time there was a decline in mental status and new seizure activity. Head CT showed increased cerebral edema but repeat angiography revealed patency of the venous sinuses, so the increasing edema was presumed secondary to the glioblastoma. The patient remained neurologically stable with an improving MRV postprocedure day 1 (figure 3b), but died 6 weeks later of cardiopulmonary arrest.

Figure 3

(a) Preprocedure magnetic resonance venogram demonstrating the segmental venous sinus occlusion in the superior sagittal sinus. (b) Repeat magnetic resonance venogram performed postprocedure day 1 demonstrated persistent patency of the superior sagittal sinus following thrombectomy with the Penumbra System.

Case 4

Patient 4, with previous history of birth control pill use and seizure disorder was admitted to an outside medical facility after presenting with generalized seizures and decreased level of consciousness. Initial CT and MRI of the brain showed bilateral cerebral edema and a 2-cm left posterior frontal lobe ICH. Work-up continued over the course of a week with a MRV that revealed thrombosis of the SSS. The patient was transferred to our facility for further treatment and on arrival had no movement in the right upper extremity or bilateral lower extremities with 2/5 grip strength in the left hand and severe impairment in cognition and speech. No anticoagulation had been initiated prior to arrival because of concern of the ICH. The patient was taken to the angiography suite and placed under general endotracheal anesthesia. Preprocedural Duplex revealed occlusion of the femoral venous systems bilaterally and so a 6-French sheath was placed in the right internal jugular vein. Cerebral angiography showed thrombosis of the anterior and middle thirds of the SSS and extending posteriorly. Thrombectomy with PS was performed followed by balloon angioplasty. Follow-up angiography showed no occlusion and satisfactory flow through the SSS. An inferior vena cava filter was placed at the end of the procedure via right jugular access in light of the extensive femoral vein thrombosis. The patient was maintained on systemic anticoagulation with an intravenous heparin drip and transferred to the ICU. In the ICU rapid neurologic improvement was seen in extremity strength and mental status. Subsequently the patient was transferred to the ward and eventually to a rehabilitation facility. Heparin was transitioned to oral Coumadin prior to discharge. At 3-month follow-up clinic visit the patient was neurologically normal and had resumed all regular daily activities.

Discussion

Venous sinus thrombosis is a rare but potentially life threatening condition. One large multicenter prospective observational study found an 8.3% overall mortality rate.1 Intravenous anticoagulation with heparin or subcutaneous anticoagulation with low-molecular-weight heparin followed by oral anticoagulation is the first-line treatment for symptomatic dural sinus thrombosis. These therapies have shown improved outcomes over placebo in prospective randomized controlled trials, even in the presence of pretreatment ICH.2 3

When the clinical condition fails to improve or deteriorates despite systemic anticoagulation, endovascular intervention must be undertaken to recanalize the affected sinuses. Initially, endovascular treatment utilized urokinase infusion at the thrombus site for chemical thrombolysis.4–7 More recently recombinant tissue plasminogen activator (rtPA) has been utilized as it appears to restore flow more quickly and because urokinase is no longer commercially available.8 In the setting of pretreatment ICH the use of local chemical thrombolysis is cautioned for concern of exacerbating the hemorrhage. A retrospective review of four treatment strategies at a single institution found a 37.5% hemorrhagic complication rate in the chemical thrombolysis group versus 25% in the mechanical thrombectomy group.9

Mechanical thrombectomy has been reported with multiple devices, with or without concurrent chemical thrombolysis. Coronary angioplasty balloons, the AngioJet Rheolytic catheter (Possis Medical, Minneapolis, Minnesota, USA) and the Merci Retriever device (Concentric Medical, Mountain View, California, USA) have all been successfully used to treat dural venous sinus thrombosis yet each have their limitations.9–17 Coronary angioplasty balloons can be difficult to navigate to intracranial locations such as the straight sinus and balloon angioplasty can rupture or dissect the dural sinus and adjacent cortical veins. In a recent report, a compliant occlusion balloon (Hyperform; ev3) was used to treat a case of post-traumatic venous sinus thrombosis.18 The AngioJet catheter, a device that uses high velocity saline jets to evacuate the thrombus, was initially designed for use in the peripheral vasculature.15 Its size and rigidity make it at times difficult to navigate to certain intracranial locations. Case reports have shown the feasibility of direct insertion of the device into the venous sinus thrombus via a transcranial approach, though this can be challenging in patients who are systemically anticoagulated.19 The Merci device is a valuable tool in the neurointerventional armamentarium for treating acute thromboembolic stroke. Recently its successful use in a case of venous sinus thrombosis was reported.20 The inability of the Merci device to remove large amounts of clot, as frequently encountered in severe cases of venous sinus thrombosis, may manifest as a limitation as more experience is gained with its use in this disease process.

We report here the first case series using the PS for mechanical venous sinus thrombectomy. The PS has shown safety and efficacy in the mechanical treatment of acute ischemic stroke due to thromboembolism.21 It is composed of a reperfusion catheter and a separator.21 The reperfusion catheter is used in parallel with the separator designed to macerate the thrombus and remove the pieces via an aspiration source.21 Its design for use in the cerebral vasculature makes navigation through the cerebral venous sinuses quite easy. The separator is thin and atraumatic to the vessel walls and the aspiration catheter allows for continual suction of thrombus debris. Balloon angioplasty can be used in conjunction with the PS for further sinus recanalization.

We used the PS in four patients with venous sinus thrombosis. We did not use chemical thrombolysis in any of the patients treated with the PS and three of the four patients were continued on systemic intravenous anticoagulation followed by conversion to oral anticoagulation. Heparin was chosen for intravenous anticoagulation and coumadin for oral anticoagulation as these agents have shown improved outcomes in randomized controlled trials.2 3 In one patient however, lepirudin was substituted for heparin prior to conversion to coumadin because the patient was found to have HIT. Balloon angioplasty was used in addition to the PS in three patients to augment the thrombectomy. A 4-mm Hyperglide balloon was chosen for angioplasty because of its compliance and ease of navigation. Balloon angioplasty augmentation was used in cases where the PS separator did not macerate the clot sufficiently to allow for optimal aspiration with the reperfusion catheter. All cases were performed with the 0.41-inch PS which was the largest catheter available at the time; however, the need for balloon angioplasty may become obviated with the recent availability of the 0.54-inch catheter.

We achieved acceptable recanalization with good venous flow in all affected sinuses. There were no intraprocedural complications and no procedure-related complications postoperatively. Specifically, there was no development of new ICH and no enlargement of preprocedural ICH. One patient, who had glioblastoma, died 6 weeks after undergoing thrombectomy. Continued sinus patency was documented in all but one patient with either non-invasive imaging or catheter angiography. Neurologic improvement was seen in all patients postprocedurally and no patient had a recurrence of symptoms.

Limitations of this study include its small sample size of only four patients. Also, there is a lack of long-term follow-up with only two of the three patients who are still alive returning for their 3-month follow-up visits. One patient has returned to a normal neurologic baseline and resumed all premorbid activities. The other patient is also doing well with only occasional mild headaches. Finally, the use of balloon angioplasty in three of the four cases did not allow for evaluation of PS thrombectomy as a stand-alone treatment for venous sinus thrombosis.

Conclusion

The PS appears to be a safe alternative to the previously reported forms of thrombectomy in venous sinus occlusive disease and is efficacious without the need for concurrent chemical thrombolysis. We recommend consideration of this technique in refractory or deteriorating patients with venous sinus thrombosis, especially in patients with ICH. The need for systemic anticoagulation is not obviated by the PS.

References

Footnotes

  • Competing interests MJA is an institutional principal investigator in the PICS (Penumbra Imaging Collaborative Study) registry.

  • Provenance and peer review Not commissioned; externally peer reviewed.