Abstract
Purpose
To carry out a retrospective analysis of patients with acute dural sinus thrombosis, and the role of cerebral venous congestion in patient management.
Methods
Twenty-five patients were identified with the clinical and imaging diagnosis of acute dural sinus thrombosis. The imaging diagnosis was by magnetic resonance (MR) and/or computed tomography (CT) venography. There was a female predominance with a female to male ratio of 1.5 to 1 (16 women, 9 men). The age range was from 19 to 64 years old with an average age of 37 years. The first 10 patients, who ranged in age from 21 to 64 years old (average 37 years), received only anticoagulation therapy with heparin and warfarin for periods ranging from 5 days to 2 months. The remaining 15 patients ranged in age from 19 to 57 years old (average 38 years). They either underwent subsequent thrombectomy after a trial of anticoagulation therapy, or went straight to thrombectomy. These latter 15 patients had initial evidence of cerebral venous congestion, either clinically by severe or worsening symptoms despite anticoagulation therapy, or on initial or subsequent CT or MR imaging. In our experience, the cerebral venous congestion imaging findings included intracranial hemorrhage, a hematoma, or edema. The thrombolytic treatment technique consisted of the advancement of a 6 Fr guiding catheter to the jugular bulb or sigmoid sinus from a transfemoral approach. A microcatheter was then advanced to the proximal portion of the thrombus and then either tissue plasminogen activator (tPA) or urokinase was injected to prevent clot propagation. A balloon catheter was used to perform thrombectomy since the thrombolytic agents can be injected via the inner lumen with an inflated balloon. The inflated balloon helped to keep the venous flow from washing out the thrombolytic agent, thus facilitating the agent’s effect.
Results
The first 10 patients received only anticoagulation therapy with heparin and warfarin for periods ranging from 5 days to 2 months. Eight of these were diagnosed with dural sinus thrombosis only, and had a stable hospital course without worsening of symptoms. These patients also did not have imaging evidence of cerebral venous congestion. The remaining 2 patients had cerebral edema on the CT scan. One had only a small amount of edema in the right cerebellum, but the other had severe edema in the bilateral basal ganglia and thalamic areas. Nine of these patients had a stable hospitalization course and experienced a symptom-free recovery, but 1 died with severe cerebral edema and hemorrhage. Seven of the remaining 15 patients were initially treated with anticoagulation therapy for periods ranging from 2 days to 2 months (average 11 days). These 7 patients were considered to have failed anticoagulation therapy since they had worsening symptoms, and 5 of these had developed hemorrhage on subsequent CT or MR imaging scans. Five of the 7 then underwent thrombectomy with the administration of tPA. Of the remaining 2, 1 underwent thrombectomy alone without the administration of tPA, and the other was given 1 million units of urokinase instead of tPA. Three of these patients had a symptom-free recovery, but 2 had residual left-sided weakness, 1 patient had a minimal gait disturbance, and another patient developed a transverse sinus arteriovenous fistula 7 months after thrombolytic therapy. The remaining 8 patients did not receive anticoagulation therapy, and went straight to treatment with thrombectomy and administration of tPA. All of these presented with worsening clinical symptoms. Six had hemorrhage on their imaging studies, 1 had new edema on a subsequent CT scan, and 1 had edema along with the dural sinus thrombosis, but experienced worsening clinical symptoms consisting of headache and atypical dystonia. Five of these 8 patients experienced a symptom-free recovery, and 3 patients had mild residual weakness.
Conclusion
In patients with acute dural sinus thrombosis, an indication for thrombectomy or thrombolytic therapy may be the development of cerebral venous congestion which appears to include (1) worsening or severe clinical symptoms, and/or (2) CT or MR imaging findings including intracranial hemorrhage, a hematoma, or edema. It appears that anticoagulation therapy alone is not adequate in patients with acute dural sinus thrombosis when they develop cerebral venous congestion. This may be due to a lack of sufficient collateral flow. Those patients who went straight to thrombectomy because of worsening symptoms, or the imaging findings of cerebral vascular congestion, survived with either a symptom-free recovery or only mild residual neurologic deficit. The patient with evidence of cerebral venous congestion died while on anticoagulation therapy. Thus, the presence of cerebral venous congestion in patients with dural sinus thrombosis, even while on anticoagulation therapy, appears to be an indication for thrombectomy and infusion of thrombolytic agent through a balloon catheter to the site of thrombosis. Our experience suggests that this approach appears to improve the chance of survival, with either a symptom-free recovery or a recovery with only mild residual neurologic deficit.
Similar content being viewed by others
References
Vogl TJ, Bergmann C, Villringer A, et al. (1994) Dural sinus thrombosis: Value of venous MR angiography for diagnosis and follow-up. AJR Am J Roentgenol 162:1191–1198
Casey SO, Alberico RA, Patel M, et al. (1996) Cerebral CT venography. Radiology 198:163–170
Rother J, Waggie K, vanBruggen N (1996) Experimental cerebral venous thrombosis: Evaluation using magnetic resonance imaging. J Cereb Blood Flow Metab 16:1353–1361
Majore CBLM, VanStraten M, Venema HW, et al. (2004) Multisection CT Venography of dural sinuses and cerebral veins by using matched mask bone elimination. AJNR Am J Neuroradiol 25:787–791
Ayanzen RH, Bird CR, Keller PJ, et al. (2005) MR Cerebral venography: Normal anatomy and potential diagnostic pitfalls. AJNR Am J Neuroradiol 21:74–78
Einhaupl KM, Villringer A, Meister W, et al. (1991) Heparin treatment in sinus venous thrombosis. Lancet 338:597–600
Bousser MG, Chiras J, Bories J, Castaigne P (1996) Cerebral venous thrombosis: A review of 38 cases. Stroke 16:199–213
Brucker AB, Vollert-Rogenhofer H, Wagner M, et al. (1998) Heparin treatment in acute cerebral sinus venous thrombosis: A retrospective clinical and MR analysis of 42 cases. Cerebrovasc Dis 8:331–337
Lewis MB, Bousser MG (1999) Cerebral venous thrombosis: Nothing, heparin, or local thrombolysis? Stroke 30:1729
DeBruijn SFT, deHaan RJ, Stam J, for the Cerebral Venous Sinus Thrombosis Study Group (2001) Clinical features and prognostic factors of cerebral venous sinus thrombosis in a prospective series of 59 patients. J Neurol Neurosurg Psychiatry 70:105–108
Stolz E, GerrietsT, Bodeker RH, et al. (2002) Intracranial venous hemodynamics is a factor related to a favorable outcome in cerebral venous thrombosis. Stroke 33:1645–1650
Ferro JM, Lopes MG, Rosas MJ, et al. (2002) Cerebral Venous Thrombosis Portuguese Collaborative Study Group (VENOPORT). Long-term prognosis of cerebral vein and dural sinus thrombosis: Result of the VENOPORT study. Cerebrovasc Dis 13:272–278
Ferro JM, Canhao P, Stam J, et al. (2004) Prognosis of cerebral vein and dural sinus thrombosis: Result of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 35:664–677
Barnwell SL, Higashida RT, Halbach VV, et al. (1991) Direct endovascular thrombolytic therapy for dural sinus thrombosis. Neurosurgery 28:135–142
Horowitz M, Purdy P, Unwin H (1995) Treatment of treatment of dural sinus thrombosis using selective catheterization and urokinase. Ann Neurol 38:58–67
Smith TP, Higashida RT, Barnwell SL, et al. (1994) Treatment of dural sinus thrombosis by urokinase infusion. AJNR Am J Neuroradiol 15:801–807
Tsai FY, Higashida RT, Matovich VB, et al. (1992) Acute thrombosis of the intracranial dural sinus: Direct thrombolytic treatment. AJNR Am J Neuroradiol 13:1137–1141
Tsai FY, Wang AM, Matovich VB, et al. (1995) Correlation of venous pressure with MR brain parenchymal changes associated with acute dural sinus thrombosis. AJNR Am J Neuroradiol 16:1021–1029
Canhao P, Falcao F, Ferro JM (2003) Thrombolytics for cerebral sinus thrombosis: A systematic review. Cerebrovasc Dis 15:159–166
Keller E, Flacke S, Urbach H, Schild HH (1999) Diffusion and perfusion-weighted magnetic resonance imaging in deep cerebral venous thrombosis. Stroke 30:1114–1116
Manzione J, Newman GC, Shapiro A, Santo-Ocampo R (2000) Diffusion- and perfusion-weighted MR imaging of dural sinus thrombosis. AJNR Am J Neuroradiol 21:68–73
Forbes KPN, Pipe JG, Heiserman JE (2001) Evidence for cytotoxic edema in the pathogenesis of cerebral venous infarction. AJNR Am J Neuroradiol 22:450–455
Terada T, Higashida RT, Halbach VV, et al. (1994) Development of acquired arteriovenous fistulas in the rats due to venous hypertension. J Neurosurg 80:884–889
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Tsai, F.Y., Kostanian, V., Rivera, M. et al. Cerebral Venous Congestion as Indication for Thrombolytic Treatment. Cardiovasc Intervent Radiol 30, 675–687 (2007). https://doi.org/10.1007/s00270-007-9046-1
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00270-007-9046-1