Cerebral venous sinus thrombosis is a rare disease with a mortality rate of 5% to 70%. We treated 13 cases of venous sinus thrombosis with local thrombolysis and achieved good results.
Materials and methods.
Clinical data From September 2002 to December 2009, 13 patients with cerebral venous sinus thrombosis were treated with local thrombolysis, including 6 males and 7 females with an average age of 40.7±12.9 years.
METHODS: All patients were cannulated through the femoral artery, whole brain angiography was performed, and after a clear diagnosis, the femoral vein was cannulated and the microcatheter was superselected into the thrombus. 12 cases applied urokinase thrombolysis at a dose of 500-2.6 million U, 1 case applied rt-PA 40 mg thrombolysis, and some patients were treated with local thrombolysis via indwelling catheter after surgery, and postoperative heparin anticoagulation. Oral warfarin anticoagulation was administered for at least six months. Author Affiliation: Department of Interventional Medicine, First Affiliated Hospital of Dalian Medical University, 116011, Dalian, China Yongsheng Liu Email: [email protected] Corresponding author: Feng Wang Email: [email protected] Follow-up: All patients were followed up for 18.8±17.7 months (3 to 62 months) with modified Rankin score ( mRS), and 5 routine MRI follow-ups.
Results.
The imaging showed a significantly prolonged cerebral arteriovenous circulation, cerebral venous occlusion or filling defect, and multiple venous sinus involvement in most cases (see Table 1).
RESULTS: The preoperative mRS score was 3 in 7 cases, 4 in 3 cases, and 5 in 3 cases. At discharge, the mRS score was 0 in 2 cases, 1 in 8 cases, 2 in 1 case, 3 in 1 case, and 6 in 1 case. All patients had partial dissolution of thrombus by contrast review. 1 case was in preoperative coma, recovered consciousness and could move the limbs 4 days after surgery, was in coma and had difficulty in breathing 7 days after surgery, and gave up treatment and died 11 days after surgery. The other postoperative symptoms were relieved or disappeared. 3 patients underwent preoperative and postoperative lumbar puncture, and the preoperative pressure was 366±133 mmH2O, and the postoperative pressure was 250±36 mmH2O. 3 cases had complications, (see Table 2).
Follow-up: 8 cases with mRS score 0, 4 cases with score 1, and 1 case with score 6. MRI follow-up: 1 case improved after recurrence and local thrombolysis again after 10 months, 2 cases had partial dissolution of the thrombus, and 2 cases had most of the thrombus dissolved.
Discussion.
Cerebral venous sinus thrombosis is a rare disease with an incidence of 3-4/1000,000 and a mortality rate of 5%-70%. The main etiologies include infection, pregnancy, oral contraceptives, dehydration, cardiac disease, trauma, tumor, cerebral infarction and cerebral hemorrhage, systemic lupus erythematosus, and leukoaraiosis. 20%-35% of the cases have no identified etiology. Treatment includes heparin anticoagulation, local thrombolysis, and expectoration (1-4). Microscopic parenchymal lesions secondary to venous sinus occlusion are characterized by extravasated plasma in the form of large lakes, marked spongiosis without neuronal necrosis, and hemorrhage in the perivascular and brain parenchyma (5). Interventional approaches can rapidly remove thrombus, promote venous return, reduce the risk of venous infarction, and facilitate patient recovery (2,6).
The etiology of this group included thrombocytosis (2 cases) and nephrotic syndrome (1 case). The difference from the main etiology reported in the literature may be related to the small number of cases.
Most patients had multiple venous sinus involvement and 3 patients had straight sinus involvement. Patients with straight sinus involvement were relatively symptomatic, prone to recurrence, and had relatively poor outcomes.
All patients had partial dissolution of the thrombus and significant improvement in symptoms or intracranial pressure, indicating that the imaging performance is not the main indicator for judging the efficacy, but the change of symptoms and intracranial pressure is the main indicator for judging the efficacy. Intraoperative and postoperative anticoagulation should be performed, with heparin anticoagulation for 2-3 days after the end of thrombolysis and warfarin orally for at least six months, with dose adjustment according to INR, with no recurrence in most patients (92.3%).
Infarction can occur in about 10% to 50% of patients with cerebral venous thrombosis due to increased capillary and venous pressure caused by intravenous thrombosis (7). Two patients in this group developed cerebral infarction or cerebral hemorrhage, and satisfactory results were achieved after local thrombolysis. One case had cerebral hemorrhage and gastrointestinal hemorrhage after thrombolysis, which was considered to be related to the higher dose of thrombolytic drugs applied and shorter duration. one case had infarct hemorrhage before surgery, but the catheter was left in place after surgery for continuous thrombolysis, and although the dose of thrombolysis was higher, good results were achieved. In one case, although the preoperative infarctive hemorrhage had occurred, the postoperative catheter was left in place for continuous thrombolysis, and although the thrombolytic dose was high, a good outcome was achieved. In five patients, partial dissolution of the thrombus was seen on postoperative MRV (5 to 12 months after surgery).
In one patient, the catheter and guidewire damaged the vein intraoperatively, resulting in venous rupture. The patient had a slight headache, and contrast spillage was seen on CT, and thrombolysis and anticoagulation were temporarily stopped. Due to the low pressure in the vein, no serious consequences were caused.
All patients in this group were diagnosed preoperatively by MRI. It indicates that most patients can be diagnosed by MRI, which can clarify the cumulative extent of thrombus and the degree and scope of brain tissue damage. mri shows abnormal signal in the venous sinus, cerebral infarction, cerebral edema or cerebral hemorrhage. In this group, 2 cases showed brain parenchymal changes and 11 patients had normal brain parenchyma.
The MRI follow-up results of our cases showed that venous sinus thrombosis was difficult to disappear completely, but most patients had no related symptoms, which may be due to the establishment of venous collateral circulation and the basic restoration of normal cerebral venous return.
The literature reports that 13% of patients with venous sinus thrombosis (mainly treated with anticoagulation and only 2.1% with local thrombolysis) have a poor prognosis (mRS 3-6) (8). In our group, 18.8±17.7 months of follow-up, one patient relapsed and was treated with thrombolysis again, most patients recovered normal brain function, and 7.7% had a poor prognosis with satisfactory outcome (mRS 3-6). Even for patients with cerebral infarction or cerebral hemorrhage the recovery of cerebral function at mid-term follow-up was satisfactory. This suggests that local thrombolytic therapy combined with anticoagulation may achieve better outcomes compared with anticoagulation alone.
As the thrombus in the venous sinus was not completely eliminated, symptomatic recurrence may occur in some cases and the thrombus may be further eliminated in some cases, and the long-term efficacy needs to be further studied due to the short follow-up period and the small number of cases.
Conclusion.
According to our experience, local thrombolysis for cerebral venous sinus thrombosis is a relatively safe and effective method, with a mean follow-up of 18.8 months and satisfactory results in most patients. Local thrombolytic therapy combined with anticoagulation may achieve better results compared with anticoagulation alone.MRI follow-up showed that venous sinus thrombosis was difficult to disappear completely, but most patients had no associated symptoms.