We wish to share our experience of a patient with cerebral venous and sinus thrombosis (CVST) in whom endovascular stenting resulted in a good clinical outcome as recently reported by Adachi et al.1
A 44-year-old woman presented with headache and right arm weakness. Magnetic resonance imaging (MRI) revealed brain edema at the left temporal lobe (Figure 1(a)). T1-weighted MRI with gadolinium demonstrated an ‘empty delta sign’ in the cerebral sinus (Figure 1(b)). Digital subtraction angiography (DSA) revealed occlusion of the superior sagittal sinus (SSS) and venous congestion in the left temporal lobe (Figure 1(c)). We attempted thrombolysis. Throughout the procedure, heparin was administered to maintain an activated clotting time of 250 to 300 seconds. A 7 French (F) guiding catheter was placed in the right internal jugular vein. We placed a microcatheter into SSS and injected 120,000 units of urokinase. However, this was totally ineffective. Subsequently, we attempted balloon angioplasty, introducing a Gateway 2.5 mm × 3.0 mm and 3.5 mm × 3.0 mm (Stryker, Kalamazoo, MI, USA), but this did not improve venous flow. We then placed three intracranial stents (4.5 × 37 mm, 4.5 × 28 mm, 4.5 × 28 mm) (ENTERPRISE Vascular Reconstruction Device: Codman & Shurtleff, Johnson & Johnson), which restored the patency of the SSS. There was an immediate improvement in the patient’s headache after recanalization. Following the intervention, the patient was given anticoagulation therapy for 3 months. Three months later, DSA demonstrated SSS patency (Figure 1(d)). Postoperatively, she has not experienced a recurrence of CSVT for 3 years.
Figure 1.
(a) The lesion demonstrated by hyper intensity in T2-weighted MRI. (b) Contrast-enhanced magnetic resonance imaging showing an ‘empty delta sign’ in the superior sagittal sinus. (c) Angiography demonstrating SSS occlusion and left parietal venous congestion. (d) Three months after endovascular treatment, the angiography showed a good result of the recanalization.
The standard therapy for CVST is anticoagulation therapy. However, good outcomes have been reported following thrombolytic therapy and mechanical clot disruption. Reports describe urokinase2 as thrombolytic therapy, and percutaneous transluminal angioplasty balloon3 as angioplasty.
In our case, immediate intravascular treatment reduced hemorrhagic risk and prevented a worsening of the patient’s clinical symptoms, which improved after recanalization. Endovascular stenting was successful, in our case, in treating CVST, suggesting that stenting can be considered as a viable treatment option for CVST.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
References
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