A novel combined approach using a Penumbra catheter and balloon catheter for cerebral venous sinus thrombosis

Abstract

Cerebral venous sinus thrombosis is sometimes fatal. We describe a case of sinus thrombosis in a 43-year-old woman presenting with generalized seizure, delirium, and a 2 week history of headache and nausea. The patient underwent mechanical thrombectomy using a novel combined approach, in which a Shouryu HR balloon catheter (Kaneka) was anchored in the right transverse sinus (TS), sigmoid sinus (SS), and superior sagittal sinus (SSS), while a Penumbra 5 MAX ACE (Penumbra) catheter was moved back and forth between the right TS, SS, and SSS. Additionally, back and forth movement of the inflated balloon with aspiration—the so-called ‘dental floss technique’—was performed. Partial recanalization was eventually obtained. Follow-up angiography on postoperative day 7 showed a dramatic improvement in venous outflow. The patient was transferred to a rehabilitation hospital on postoperative day 42. We describe our combined approach using aspiration, and Penumbra and balloon catheters, to achieve mechanical thrombectomy for sinus thrombosis.

Background

Cerebral venous sinus thrombosis is a rare but life threatening event. Anticoagulation therapy is the standard medical treatment. However, endovascular treatment is considered in cases refractory to anticoagulation therapy. This patient was treated with mechanical thrombectomy combining a novel technique and the previously reported dental floss technique.¹

Case presentation

The patient was a 43-year-old woman. She presented with a 2 week history of headache and nausea. She was admitted to our hospital for generalized seizure. Her neurological examination in the emergency room showed a delirious state but an ability to follow commands, and no motor paresis. Body temperature was 37.5°C. Other vital signs were within normal limits.

Investigations

Laboratory data demonstrated elevation of her white blood cell count (15 300 cells/µl) and C reactive protein (3.07 mg/dL) and reduction of hemoglobin (7.7 g/dL). A lumber puncture showed a cell count of 23/µl, protein 85 mg/dL, glucose 81 mg/dL, and a negative gram stain. MRI revealed a right temporo-occipital subarachnoid hemorrhage and a left occipital and bilateral frontal venous infarct with slight left frontal hemorrhage (figure 1). Diagnostic angiography (figure 2) showed occlusion of the superior sagittal sinus (SSS), right transverse (TS), and sigmoid sinus (SS).

Figure 1.

MRI images. FLAIR image shows right temporo-occipital subarachnoid hemorrhage and left occipital infarction with edema (A). FLAIR image shows bilateral frontal infarction with edema (B). Diffusion weighted image (DWI) shows left occipital infarction (C). DWI shows bilateral frontal infarction with left frontal small hemorrhage (D).

Figure 2.

Digital subtraction angiography. Anteroposterior venous phase injection from the right internal carotid artery shows occlusion of the superior sagittal sinus (SSS), transverse sinus, and sigmoid sinus (A). Lateral view shows occlusion of the entire SSS (B).

Treatment

Systemic heparinization was administered after angiography. The activated partial thromboplastin time was kept about twice that on admission. MR venography, performed the day after admission, showed occlusion of the SSS, right TS, and SS (figure 3). Right hemiparesis continued to gradually deteriorate; at 6 days after admission, the SSS, right TS, and SS were still occluded on MR venography while MRI revealed progression of left frontal hemorrhage. Therefore, the patient was brought to the angiography suite for mechanical thrombectomy. A 4 F and 6 F sheath were placed in the left common femoral artery and right common femoral vein, respectively. A 4 F diagnostic catheter was placed in the left internal carotid artery. A 6 F shuttle sheath (Cook, Bloomington, Indiana, USA) was advanced into the right jugular vein. A Penumbra ACE reperfusion catheter (Penumbra, Alameda, California, USA) was advanced into the right transverse sinus over a Shouryu HR 4×7 balloon catheter (Kaneka, Osaka, Osaka, Japan) and CHIKAI microguidewire (Asahi Intecc, Nagoya, Aichi, Japan).

Figure 3.

MR venography images. Anteroposterior MR venography on day 1 shows occlusion of the superior sagittal sinus, transverse sinus, and sigmoid sinus (A). Lateral image shows occlusion of the entire superior sagittal sinus (B).

Direct aspiration using the Penumbra under continuous pump aspiration and angioplasty using a Shouryu HR with aspiration was attempted without successful recanalization of the right TS and SS. Therefore, the Shouryu HR was advanced over the CHIKAI into the right TS through the Penumbra catheter. Direct aspiration by the Penumbra and angioplasty failed to recanalize the sinus. Both the method of moving the inflated balloon back and forth (‘dental floss technique’), as reported previously,¹ and that of moving the Penumbra back and forth with a balloon anchor (‘balloon anchor with mobile aspiration technique’) were tried. However, angiography showed no recanalization of the TS and SS followed by thrombectomy for SSS; we guessed that the lack of venous circulation from the SSS contributed to the difficulty in recanalizing the right TS and SS.

The Penumbra was advanced over the Shouryu HR and CHIKAI into the posterior SSS. Although direct aspiration and angioplasty with continuous aspiration were attempted without successful recanalization, ‘balloon anchor with mobile aspiration technique’ from the SSS to confluence resulted in partial recanalization (figure 4). Subsequently, although attempts to navigate the Penumbra into the anterior SSS failed, the Shouryu HR was successfully advanced over the CHIKAI black wire (Asahi Intecc) into the most anterior SSS. The dental floss technique was performed without moving the wire. Angiography showed no recanalization of the anterior SSS, but the Penumbra could be navigated into the anterior SSS while the balloon was anchored in the most anterior SSS. ‘Balloon anchor with mobile aspiration technique’ was then successfully performed to improve partial venous outflow (figure 5A). Many thrombi were obtained through the Penumbra (figure 6A, B).

Figure 4.

Digital subtraction angiography. Unsubtracted lateral view shows the ‘balloon anchor with mobile aspiration’ technique. A Shouryu HR is anchored in the posterior superior sagittal sinus (SSS) while the 5 MAX ACE is moved back and forth (arrows) from the SSS to the confluence, with continuous aspiration.

Figure 5.

Digital subtraction angiography. Lateral (A) injection from the left internal carotid artery (ICA), lateral (B), and anteroposterior (C) injection from the right ICA. Partial recanalization of the superior sagittal sinus (SSS) is seen after the procedure (arrows) (A). Lateral image at the 1 week follow-up angiography shows improvement of venous circulation for the SSS (B). Anterolateral image shows significant improvement of venous outflow for the SSS, right transverse sinus, and sigmoid sinus at 1 week (C).

Figure 6.

Aspirated thrombi. Thrombi obtained by direct aspiration are shown (A). Many thrombi can be seen in the canister (B).

Outcome and follow-up

Systematic heparin was re-administered after the procedure. The 1 week follow-up angiography demonstrated significant improvement of venous outflow for the SSS, and right TS and SS (figure 5B, C). Histopathology of the aspirated thrombus showed many neutrophils in the specimen, indicating a septic thrombus. Moreover, the culture of blood obtained on the day of admission revealed coagulase negative Staphylococci. As a result, this patient was diagnosed with sinus thrombosis induced by sepsis and treated with antibiotics for 2 weeks. The patient gradually showed improvement of her right hemiparesis after the procedure. She was given a factor Xa inhibitor after her hemiparesis improved. Finally, she was transferred to a rehabilitation hospital 42 days after the procedure with mild aphasia and no motor weakness.

Discussion

Medical treatment with anticoagulation therapy has been the gold standard for cerebral sinus thrombosis.² However, endovascular treatment is a good alternative in refractory cases. In this case, we selected mechanical thrombectomy because there was a possibility that thrombolysis would increase the hemorrhage. Several methods for mechanical thrombectomy have been reported.^3–5 Recently, methods using a stent retriever⁶ or Penumbra catheter,⁷ or a combination of the two,⁸ have been reported. Mascitelli et al reported a ‘stent anchor with mobile aspiration’ technique, in which the stent retriever was anchored in the SSS while the Penumbra catheter was moved back and forth.⁸ We modified this method and tried to use a balloon catheter instead of a stent retriever. This is the first report of a ‘balloon anchor with mobile aspiration’ technique. One advantage of this method could be that the anchoring ability of the balloon is stronger than that of the stent retriever so that the Penumbra could be advanced into the more distal portion, even if the vessel became more elongated. It is a helpful combination use of the Penumbra and balloon catheter for the surgeon to use at his or her discretion, depending on the details of the case. The disadvantage is that the aspiration ability of the balloon catheter is less than that of the stent retriever because the diameter of the balloon catheter is larger than that of the delivery wire of the stent retriever. In addition, any worsening of periprocedural complications, such as hemorrhage, infarctions, or pulmonary emboli, may require modification of the anticoagulation strategy.

We performed four methods, combining the Penumbra and balloon catheters, in this case: a direct aspiration technique, angioplasty under aspiration, a dental floss technique, and balloon anchor with mobile aspiration technique. The dental floss technique, moving the inflated balloon back and forth under continuous aspiration,¹ was performed because it was difficult to advance the Penumbra into the anterior SSS the first time. This case has demonstrated that various methods, combining the Penumbra and balloon catheters, resulted in a favorable outcome.

Learning points.

• We introduced the ‘balloon anchor with mobile aspiration’ technique for cerebral sinus thrombosis.

• A combined approach, using both Penumbra and balloon catheters, allows various methods for mechanical thrombectomy.

• The thrombi aspirated by the Penumbra can be useful for diagnosis.