Eclipse balloon-assisted straight sinus thrombectomy: A novel technique

Abstract

Cerebral venous sinus thrombosis comprises 0.5% of all strokes and usually affects young adults. Straight sinus involvement is relatively rare, and it is associated with poor prognosis. Intravenous anticoagulation is considered the first line of treatment. Endovascular approaches such as direct catheter thrombolysis, balloon-assisted thrombolysis, and mechanical thrombectomy may be more efficient and should be considered in cases in which there is involvement of the deep venous system, declining neurological status, or less invasive treatment options have failed. In this work, we describe a novel technique of ECLIPSE 2L balloon (Balt, Irvine, CA) assisted mechanical thrombectomy for straight sinus thrombosis and a review of dural sinus thrombosis management.

Introduction

Cerebral venous sinus thrombosis (CVST) comprises 0.5% of all strokes and usually affects young adults.^1,2 Its annual incidence is approximated at 4 per 1,000,000 individuals and carries up to an 8.3% mortality rate. ¹ The possible etiologies for CVST include coagulation disorders, inflammatory bowel disease, pregnancy, dehydration, infection, medications such as oral contraceptives, substance abuse, trauma, and iatrogenic causes.^3,4

Intravenous anticoagulation is considered the first line of treatment. ³ Endovascular approaches, such as direct catheter thrombolysis, balloon-assisted thrombolysis, and mechanical thrombectomy (MT) may be more efficient in the acute setting and should be considered in cases with involvement of the deep venous system, declining neurological status, or when less invasive treatment options have failed.^2,5–8

In this report, we present the case of a patient in their late 60s who presented with altered mental status due to straight and left lateral venous sinus thrombosis. We performed a MT using an ECLIPSE 2L balloon (Balt, Irvine, CA) with good clinical outcome.

Case report

A 69-year-old male with past medical history of anxiety, depression, and opioid abuse presented to our institution with symptoms of intracranial hypertension, altered mental status, somnolence, and confusion. Glasgow Coma Scale (GCS) score was 12. Initial computed tomography (CT) showed an acute left temporal lobe infarct with hemorrhagic transformation and CT venogram revealed extensive dural venous sinus thrombosis involving the left transverse and sigmoid sinuses, straight sinus, and vein of Galen (Figure 1(a)). Due to his poor neurological status, the patient was taken for emergent MT.

Figure 1.

(a) Pre-procedure CT angiography (CTA) showing thrombosis of the straight sinus. (b) Post-procedure CTA showing near complete recanalization of the straight sinus. (c) Three-month follow-up CTA showing complete recanalization of the straight sinus.

Under general anesthesia, six-vessel angiography was performed via a transfemoral arterial approach which redemonstrated thrombosis of the straight, transverse, and sigmoid sinuses (Figure 2(a)). An 8 French long sheath was then inserted into the femoral vein for subsequent venography: An Esperance 0.071″ catheter (Wallaby, Laguna Hills, CA) was advanced over a Headway 27 microcatheter (MicroVention, Aliso Viejo, CA) into the straight sinus. The Headway microcatheter was removed and a 6  ×  9 mm ECLIPSE 2L balloon was advanced into the proximal straight sinus over a Hi-Torque Balance Heavyweight 0.014″ microwire (Abbott) (Figure 2(b)). The balloon was inflated and withdrawn gently while applying suction to the Esperance aspiration catheter using a Penumbra (Penumbra, Alamada, CA) aspiration pump. This was performed in segments, several times throughout the straight sinus, left transverse, and sigmoid sinuses to generate slow, controlled, suction and aspiration for removal of the large venous clot burden.

Figure 2.

(a) Carotid artery angiogram (CAG) revealing venous flow defect of the straight sinus (StS). (b) Mechanical thrombectomy through combined use of an aspiration catheter and Eclipse balloon. (c) Post-thrombectomy CAG revealing partial recanalization of the StS.

Post-thrombectomy angiography demonstrated satisfactory recanalization of the straight, left transverse, and sigmoid sinuses (Figure 2(c)). Post-procedurally, the patient presented GCS of 15 without focal neurological deficit. The patient was placed on intravenous heparin drip (aPTT goal of 80–100 s). On post-operative day one, CT angiography confirmed recanalization of the straight sinus (Figure 1(b)). The patient was discharged home on post-operative day 12 on Eliquis 5 mg twice daily. Hypercoagulability work-up was negative and the CVST was attributed to dehydration and substance abuse. At three-month follow-up, he remained intact without any neurological deficit with persistently patent venous sinuses on CT angiography (Figure 1(c)).

Discussion

CVST carries a 4.3% mortality rate and an estimated 18.9% risk of subsequent functional dependence. ¹ Older age, female sex, poor mental status on admission, hemorrhage on initial CT, concomitant central nervous system infection, and cancer are all predictors of poor functional outcomes in CVST patients.^1,8 Clinical symptoms of CVST are typically sequelae of the global intracranial hypertension from impaired venous drainage or from focal cerebral insults due to venous stasis or hemorrhage. ¹ Headache, nausea, vomiting, papilledema, diplopia caused by sixth nerve palsy, hemiparesis, aphasia, sensory disturbance, and psychosis, are just a few of the clinical symptoms that have been previously described in CVST patients. ⁵

According to the International Study on Cerebral Vein and Dural Sinus Thrombosis from 2021, CVST occurs most often in the superior sagittal sinus (72%), followed by the lateral sinuses (70%), and a third of patients present with multiple sinus occlusion. ⁶ A small number of patients, approximately 16%, present with thrombosis of the deep cerebral venous system—involving the straight sinus, internal cerebral vein, or vein of Galen which can be particularly hazardous due to the inherently poor collateral outflow of the deep venous system and the risk of bilateral thalamic or basal ganglia infarction.^1,4 Approximately 30–40% of these patients with deep venous thrombosis present initially with intracranial hemorrhage. ³ Straight sinus involvement, in particular, is relatively rare and is associated with an especially poor prognosis. ⁷ Consistent with our case in which there was concomitant straight, transverse, and sigmoid sinus thrombosis, straight sinus thrombosis is thought to develop primarily as a result of transverse sinus clot propagation.

Noninvasive modalities to diagnose CVST include CT and MRI. ¹ CT arteriography (CTA) and venography (CTV) are rapid and reliable modalities for detecting CVST and in some series are known to provide complete visualization of the superficial dural sinus venous system and straight sinus in all cases. ⁸ In our case, CTA/CTV provided accurate and rapid diagnosis of straight, transverse, and sigmoid sinus thrombosis as confirmed by invasive venography. Nonetheless, some studies report that MRI is not only more sensitive than CT for the detection of CVST but also offers additional and more detailed information on related parenchymal injury and associated focal edema, ischemia, or hemorrhage. ⁵ Invasive modalities, including cerebral angiography, not typically needed to establish the diagnosis of CVST, but can be useful when CT and MRI results are inconclusive or if an endovascular treatment (MT or direct thrombolysis) is being considered. ⁵

In terms of treatment, intravenous heparin with aPTT goal of 80–100 s is considered first-line management of CVST. ¹ Previous studies have demonstrated that the venous sinus recanalization rates after anticoagulation therapy alone are as high as 83–85%. Death or permanent neurological deficit, however, can be observed in approximately 13% of patients despite therapeutic anticoagulation. ³ Cerebral infarction with hemorrhagic transformation at the time of diagnosis of CVST can also complicate management as the risk of potentially expanding hemorrhage has to be balanced with the benefit of the thrombolytic effect of anticoagulation; a landmark randomized, blinded study by Einhäupl et al. 1991 demonstrated that hemorrhagic transformation should not be a contraindication to aggressive heparinization in these patients. ⁹

Despite medical treatment, refractory and/or extensive CVST can rapidly progress to cause venous stasis and ischemia followed by hemorrhagic strokes, cerebral edema, mass effect, and death. ¹⁰ These patients may benefit from early endovascular procedures, such catheter chemical thrombolysis or MT with or without thrombolysis. ¹¹ An early retrospective study of CVST patients in which therapeutic anticoagulation alone was insufficient for dural venous sinus recanalization, subsequent direct catheter chemical thrombolysis was effective in 26 out of 27 patients. ¹ Balloon-assisted thrombolysis may be even more effective since inflating the balloon can reduce local washout of fibrinolytic agents at the site of the clot. ¹² In patients in which thrombosis persists despite systemic and local administration of a fibrinolytic agent, MT and thrombus aspiration may be considered.^13,14 In a recent series, Jedi et al. described 20 patients who underwent MT for management of their CVST ether due to progression of neurological decline despite anticoagulation or due to extensive venous thrombosis burden causing intracranial hypertension. ¹⁰ In their series, direct aspiration was performed with a VacLok (Merit, South Jordan, UT) syringe and balloon-assisted stent retriever MT and venoplasty involved a 6  ×  30 mm Solitaire (Medtronic, Santa Rosa, CA) or Catch Maxi (Balt, Morrisville, NC) stent. Recanalization was achieved in 85.7% and clinical improvement was observed postoperatively in 13 of 21 cases (61.9%). ¹⁰ Five patients continued to decline post-procedurally and four died. The etiology of death was severe traumatic brain injury in two patients, malignant middle cerebral artery infarction, unrelated to the procedure in one patient, and severe bleeding in one patient diagnosed with rhabdomyosarcoma. At six-month follow-up, all surviving patients demonstrated clinical improvement compared to their initial presentation. ¹⁰

In our case, due to the patient's poor neurological status and extension of thrombus from the sigmoid sinus into the vein of Galen, the patient was acutely managed with endovascular balloon-assisted MT. This technique, using a 3- or 4-French Fogarty balloon catheter, has been previously reported for CVST but with a notable incidence of balloon perforations resulting in epidural or subdural hematomas. ¹² In our case, the Eclipse 2L balloon was inventively substituted for the Fogarty balloon because of its well-described compliance to venous sinus anatomy and therefore likely carries a reduced risk of venous rupture in this context. Additionally, with a nominal diameter of 6 mm, it is well-suited to entrap large clots and more efficiently manage venous sinus clot burdens than conventional aspiration catheters. Furthermore, deformation of the profile of this hyper-compliant balloon while it is being withdrawn may identify areas of more organized thrombus and guide the interventionalist to utilize more aggressive devices if needed. The Eclipse balloon is less likely to “hang” on stenotic segments and require subsequent deflation and re-inflation to maintain its profile. This patient made a complete recovery with complete venous sinus recanalization and was without neurological deficits both at discharge and at three-month follow up. While the overall safety and efficacy of acute MT in CVST with extension into the deep venous system has yet to be formally established in large series, this technical note provides a strong basis for further study, especially with the use of the Eclipse balloon catheter.

Conclusion

Balloon-assisted MT is a potentially safe and effective treatment option for patients with extensive CVST or acutely poor neurological status on presentation. The use of a hyper-compliant balloon, such as the Eclipse 2L balloon, may decrease the intraprocedural risk of venous sinus perforation. This is a single institution isolated report of a novel application for the Eclipse 2L balloon and larger prospective studies are warranted.