Intracranial venous sector thrombectomy with endovascular thromboaspiration system

Transcription

1 Intracranial venous sector thrombectomy with endovascular thromboaspiration system Poster No.: C-1191 Congress: ECR 2015 Type: Scientific Exhibit Authors: D. D. J. De la Rosa Porras, E. Castro Reyes, J. A. Guzmán De Villoria, A. García Pastor, M. Paniagua González, M. Urizar Gorosarri, J. M. Jiménez; Madrid/ES Keywords: Neuroradiology brain, Interventional vascular, Catheter arteriography, MR, CT, Recanalisation, Removal DOI: /ecr2015/C-1191 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 22

2 Aims and objectives Cerebral Venous Thrombosis (CVT) is an uncommon form of stroke (0,5-1%), which usually affects young individuals (1,2,3,4). Medical treatment remains as the first management strategy for this entity with full anticoagulation, whether with low molecular weight heparin (LMWH) or IV heparin. However up to 9-13% of these patients have poor outcomes with clinical deterioration in spite of a proper anticoagulation regimen (1). In such cases, other treatment options may be considered. The Penumbra thromboaspiration system (Penumbra, Inc, Alameda, CA) is a newgeneration neuroembolectomy device, originally designed to remove the thrombus in acute ischemic stroke secondary to large vessel thromboembolism. It uses a reperfusion catheter available in different sizes, which aspirates the thrombus, manually or using an aspirating tube connected to a specific designed external pump system. A second device named "separator", may be used for help to break the clot (1,5,6). Nevertheless, the evidence for its efficacy in the treatment of CVT remains anecdotal (1,2,3,4). Our purpose is to introduce our preliminary experience with the Penumbra system (PS) in 2 cases of acute CVT refractory to medical treatment. Methods and materials CASE 1 A 21 years old female patient had a 2 weeks complaint of occipital headache, nausea and emesis. The picture was progressive with worsening headache, vomit and sleepiness. The increasing level of consciousness (LOC) deterioration prompted the family to take the patient to the hospital. A non-enhanced computed tomography (CT) scan of the head was performed in the emergency department, which showed a high density of the torcula and the straight, left transverse and superior longitudinal sinuses, compatible with a CVT. A contrast enhanced CT confirmed the previous findings (Fig. 1 on page 11). Intravenous full anticoagulation regime was inmediately started, however the patient didn't show any signs of improvement after 48 hours, and presented with a lowering of the LOC. The case was then considered for mechanical endovascular treatment. Page 2 of 22

3 Fig. 1: Non-enhanced and Contrast enhanced CT scan of the patient in CASE 1. A and B. On the non enhanced CT scan, there is a focal hyperdensity of the torcula and the left transverse sinus. C and D. After the intravenous contrast administration we can see a filling defect on these venous structures as well as the superior longitudinal sinus. Page 3 of 22

4 References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES A combined double femoral approach was performed, with a 6F long sheath (80 cms Cook.) catheter in the right femoral vein and 5F in the left femoral artery for angiographic control during treatment. The diagnostic angiography showed extensive thrombosis of the major sinuses including the torcula, superior longitudinal, left transverse, left sigmoid, right transverse (up to the origin of the Labbè vein), and straight sinuses (Fig. 2 on page 12). The 5MAX Penumbra catheter was then navigated along a 5MAX device for the intracranial access through the right yugular vein. Combined maneuvers of manual (50cc syringe) and mechanical aspiration were done in both transverse (transtorcular approach for the left size was possible) and superior longitudinal sinus (Fig. 3 on page 12). Due to the big volume of thrombus, mechanical angioplasty with Copernico balloon (8x80) (Balt, France) was performed in the major sinuses in order to increase the rupture rate of thrombus. A big amount of thrombus was aspirated and the final angiographic control, showed partial recanalization of the superior sagital and both transverse sinuses with restoration of arteriovenous flow, previously blocked, through these structures (Fig. 4 on page 13). The straight sinus was not touched. The patient was transferred to the intensive care unit (ICU) after the procedure. Page 4 of 22

5 Fig. 2: CASE 1. Lateral plane digital substraction angiogram, venous phase, confirms thrombosis of the superior longitudinal sinus (arrows). References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES Page 5 of 22

6 Fig. 3: CASE 1. Lateral plane digital substraction venography shows navigation of the Penumbra catheter into the superior longitudinal sinus. A, B and C show a progressive recanalization of the sinus after extensive thrombus extraction. References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES Fig. 4: CASE 1. AP plane digital substraction venography after the thromboaspiration procedure through the Penumbra catheter. A and B show recanalization of the superior longitudinal, torcula and both transverse sinuses. There are residual thrombi inside the sinuses, nonetheless, there is an adequate patency of the venous structures with no significant flow obstruction. References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES This case and images are currently under review for publishing on the Journal of Neurointerventional Surgery. Page 6 of 22

7 CASE 2 A 40 years old male patient, with a prior history of focal epilepsy, treated with a multipharmacological regime, and a one year clinical picture of headache with no other focal symptoms. His last magnetic resonance image (MRI) showed a venous congestion of cerebellar veins, with a dilated right transverse sinus, findings that were suggestive of a possible dural fistula. There was a caudal descent of the cerebellar tonsils into the foramen magnus with secondary hydrocephalus (Fig. 5 on page 13). A former MRI, twelve months prior had no significant findings (not shown). Page 7 of 22

8 Fig. 5: MRI of the patient in CASE 2. A. Coronal T2W TSE images. There is ventricular enlargement and a marked venous dilation on the posterior fossa. B. Axial FLAIR image. Right transverse sinus dilation with associated venous congestion (arrow). C. Sagital T1W TSE image. There is a caudal descent of the cerebellar tonsils. References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES A few weeks after the previously reported MRI, the patient went to the hospital due to a sudden onset of right arm paresis, and confusion. An immediate CT scan showed a high density in the superior longitudinal and left transverse sinuses, besides the already known Page 8 of 22

9 findings (Fig. 6 on page 14). A cerebral angiogram confirmed an acute thrombosis of these sinuses. A dural fistula (Cognard type IIA+B) was present draining in a severely dilated right transverse sinus that remained patent. There were other dural fistulae affecting the torcula, and both the right torn and occipital sinuses (Fig. 7 on page 15). An underlying fistula of the left transverse sinus was also suspected. A full intravenous anticoagulation regime was started immediately, however there was no improvement after 24 hours. Due to the complexity of the dural disease, the patient was considered for endovascular treatment of the acute CVT. Fig. 6: CASE 2. Non-enhanced CT scan. A, B and C. Hiperdensity in the left transverse and the superior longitudinal sinuses, compatible with acute CVT. In A, there is a right transverse sinus dilation (as seen in the previous MRI). B. Ventricular enlargement. References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES Fig. 7: CASE 2. A. AP, intraarterial, digital substraction angiography shows a dural fistula from the right vertebral artery into a severely dilated right transverse sinus. Page 9 of 22

10 There is no passage of contrast material into the superior longitudinal or the left transverse sinuses. B. Similar findings to A in a dural fistula from the external carotid artery into the right transverse and occipital sinuses. C. Lateral digital subtraction, right carotid angiogram, venous phase, shows thrombosis of the posterior third of the superior longitudinal sinus. References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES A combined double femoral approach was performed, with a 6F long sheath (80 cms Cook.) catheter in the right femoral vein and 5F in the left femoral artery for angiographic control during treatment. The 5MAX Penumbra catheter was then navigated along a 5MAX device for the intracranial access through the left yugular vein. Both pump and manual aspiration were used. Mechanical disruption with Copernico 8x80 mm ballon (Balt, France) was used in combination with the aspiration system in the superior longitudinal and the left transverse sinuses, with huge volume of thrombi extracted from them. A partial recanalization of both sinuses was achieved (Fig. 8 on page 15). Treatment of the dural disease was delayed and the patient was moved afterwards to the ICU. Fig. 8: AP digital substraction venography of the patient in CASE 2. A. insertion of the Penumbra catheter through the right transverse into the left transverse sinus (transtorcular approach). B. After extensive thrombi extraction, the angiogram shows recanalization of the left transverse and the superior longitudinal sinuses. An underlying dural fistula is suspected. References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES Page 10 of 22

11 Images for this section: Fig. 1: Non-enhanced and Contrast enhanced CT scan of the patient in CASE 1. A and B. On the non enhanced CT scan, there is a focal hyperdensity of the torcula and the left Page 11 of 22

12 transverse sinus. C and D. After the intravenous contrast administration we can see a filling defect on these venous structures as well as the superior longitudinal sinus. Fig. 2: CASE 1. Lateral plane digital substraction angiogram, venous phase, confirms thrombosis of the superior longitudinal sinus (arrows). Page 12 of 22

13 Fig. 3: CASE 1. Lateral plane digital substraction venography shows navigation of the Penumbra catheter into the superior longitudinal sinus. A, B and C show a progressive recanalization of the sinus after extensive thrombus extraction. Fig. 4: CASE 1. AP plane digital substraction venography after the thromboaspiration procedure through the Penumbra catheter. A and B show recanalization of the superior longitudinal, torcula and both transverse sinuses. There are residual thrombi inside the sinuses, nonetheless, there is an adequate patency of the venous structures with no significant flow obstruction. Page 13 of 22

14 Fig. 5: MRI of the patient in CASE 2. A. Coronal T2W TSE images. There is ventricular enlargement and a marked venous dilation on the posterior fossa. B. Axial FLAIR image. Right transverse sinus dilation with associated venous congestion (arrow). C. Sagital T1W TSE image. There is a caudal descent of the cerebellar tonsils. Page 14 of 22

15 Fig. 6: CASE 2. Non-enhanced CT scan. A, B and C. Hiperdensity in the left transverse and the superior longitudinal sinuses, compatible with acute CVT. In A, there is a right transverse sinus dilation (as seen in the previous MRI). B. Ventricular enlargement. Fig. 7: CASE 2. A. AP, intraarterial, digital substraction angiography shows a dural fistula from the right vertebral artery into a severely dilated right transverse sinus. There is no passage of contrast material into the superior longitudinal or the left transverse sinuses. B. Similar findings to A in a dural fistula from the external carotid artery into the right transverse and occipital sinuses. C. Lateral digital subtraction, right carotid angiogram, venous phase, shows thrombosis of the posterior third of the superior longitudinal sinus. Page 15 of 22

16 Fig. 8: AP digital substraction venography of the patient in CASE 2. A. insertion of the Penumbra catheter through the right transverse into the left transverse sinus (transtorcular approach). B. After extensive thrombi extraction, the angiogram shows recanalization of the left transverse and the superior longitudinal sinuses. An underlying dural fistula is suspected. Page 16 of 22

17 Results In both cases an immediate partial reopening of the major sinuses treated was achieved, with angiographic restoration of blood flow into the venous sectors, previously blocked, with persistence of residual thrombus. Subsequent treatment was maintained with full anticoagulation with LMWH at both the ICU and the neurology department. The first patient quickly recovered, with a marked improvement of her LOC, leaving the ICU after 3 days. She had a mild thrombopenia and anemia, which had a spontaneous resolution. The patient still had some signs of intracranial hypertension, which was managed with a short corticoid regime, with full recovery of the clinical symptoms. She was discharged 10 days later. The second patient stayed at the ICU for few days. He had no seizures during his stay and had a complete recovery of his right arm paresis and confusional state. 10 days after the angiographic procedure a first embolization of his dural disease was performed. The patient was discharged 15 days later with no neurological symptoms whatsoever. No new CVT incidences have occurred since. Both patients undertook a full anticoagulation regime for 6 months. Follow-up imaging shows a complete recovery of the patency of the dural venous sinuses (Fig. 9 on page 19). The second patient was scheduled for further embolization sessions. Page 17 of 22

18 Fig. 9: Maximum Intensity Projections (MIP) in a "time-of-flight" (TOF) venous angio MRI. A and B. Follow up of the patient in CASE 1, 8 months after the event, showed a complete recanalization and adequate patency of the superior longitudinal and both trasnsverse sinuses. C and D. Follow up of the patient in CASE 2, 14 months after the event, showed a complete patency of the venous system, with no residual thrombus. Persistence of the right transverse sinus dilation due to his fistular disease. The study had some minor artifacts from embolization material. References: Radiology, Hospital General Universitarrio Gregorio Marañón - Madrid/ES Page 18 of 22

19 Images for this section: Fig. 9: Maximum Intensity Projections (MIP) in a "time-of-flight" (TOF) venous angio MRI. A and B. Follow up of the patient in CASE 1, 8 months after the event, showed a complete recanalization and adequate patency of the superior longitudinal and both trasnsverse sinuses. C and D. Follow up of the patient in CASE 2, 14 months after the event, showed a complete patency of the venous system, with no residual thrombus. Persistence of Page 19 of 22

20 the right transverse sinus dilation due to his fistular disease. The study had some minor artifacts from embolization material. Page 20 of 22

21 Conclusion Venous thrombosis accounts for approximately 0.5-1% of strokes and mainly affects young adults. This entity has a mortality rate of 8-9%, and there are several risk factors that contribute to the appearance of CVT including prothrombotic conditions (such as antithrombin III deficiency, protein C and S deficiency, factor V Leiden), pregnancy, oral contraception, and infection, among others (1,2). The scientific statement from the AHA / ASA for the diagnosis and management of cerebral venous thrombosis recommend a full dose anticoagulation regime as the initial treatment of choice, which has proven a lowering of the mortality rate and neurological symptoms as well as recanalization of the affected sinuses and veins (1). However, in patients with clinical deterioration despite proper anticoagulation therapy, endovascular treatment may be considered. The use of thrombus aspiration in such cases has only been anecdotally reported in the literature. These therapies include the use of a rheolyitic catheter (AngioJet - MEDRAD, Inc, Warrendale, PA), the Merci retrieval device (Concentric Medical, Mountain View, CA) and the Penumbra System (1,2,4). The evidence for the efficacy of these procedures consists of only a few case reports and series, with a low quantity of patients in which these have been implemented. The risks described for the devices are, as well, very few and consist of perforation of the venous sinus (at an unknown rate), major disabilities (10%), and death (up to 16%) (4). Nevertheless, we must consider that most of these patients had extensive sinus thrombosis and a rapid decline in their clinical condition was to be expected. This being said, all these reports show increasing promise for these procedures in difficult to treat patients. Thus, in selected cases, the removal of large volumes of thrombus by thromboaspiration may help to reestablish the sinus anatomical functionality despite incomplete reopening, contributing, in combination with anticoagulant medication, to improve the final outcome. A multi-institutional, randomized, clinical trial, is needed to completely assess the usefulness of these treatment options. Personal information Page 21 of 22

22 References Saposnik G, et al. Diagnosis and management of cerebral venous thrombosis. A statement for healthcare professionals from the American Heart Association / American Stroke Association. Stroke 2011;42: Velat GJ, et al. Direct thrombectomy using the Penumbra Thromboaspiration Catheter for the treatment of cerebral venous sinus thrombosis. World Neurosurg 2012;77,3/4:591.e e18. Ichiro D, et al. A patient with deep cerebral venous sinus thrombosis in whom neuroendovascular therapy was effective. J Stroke Cerebrovas Dis 2012;21(8):911.e5-911-e8. Haghighi AB, et al. Mechanical Thrombectomy for Cerebral Venous Sinus Thrombosis: A Comprehensive Literature Review. Clin Appl Thromb Hemost 2013 Jan 7;20(5): Bose A, et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol 2008;29: The Penumbra Pivotal Stroke Trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 2009;40: Page 22 of 22