Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis

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1 J Neurosurg 111:17 21, 2009 Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis Case report Fr a n k S. Bi s h o p, M.D., Mi c h a e l A. Fin n, M.D., Mi c a l Sa m u e l s o n, M.S., a n d Ri c h a r d H. Sc h m i d t, M.D., Ph.D. Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah In severe cases, posttraumatic cerebral sinus thrombosis can result in venous congestion and persistent intracranial hypertension refractory to both conventional medical therapy and surgical decompression. The authors report a unique case of a patient successfully treated with endovascular mechanical thrombolysis using balloon angioplasty for clinically significant posttraumatic venous sinus thrombosis and review the reported treatments for cerebral venous sinus occlusive disease. This 18-year-old man suffered severe closed head injury from a fall while skateboarding. A head CT scan demonstrated basilar skull fractures involving the left jugular foramen. A CT angiogram revealed thrombosis of the left transverse sinus and occlusion of the sigmoid sinus and internal jugular vein. Despite treatment with anticoagulation therapy and decompressive hemi- and suboccipital craniectomies, intracranial hypertension remained refractory. Serial angiography demonstrated progressive sinus occlusion. Endovascular balloon thrombolysis of the left transverse and sigmoid sinuses resulted in immediate reduction of intracranial pressures and improved sinus patency. Intracranial pressure measurements remained low after the procedure. The patient eventually improved neurologically, was able to follow commands and walk, and was discharged to a rehabilitation facility for further recovery. Anticoagulation therapy, surgical decompression, and endovascular thrombolysis have been reported as treatment modalities for clinically significant posttraumatic venous sinus thrombosis. In this case, endovascular mechanical thrombolysis with balloon angioplasty resulted in resolution of thrombus and successful immediate reduction of intracranial pressure. This treatment may be considered in patients with critically elevated intracranial pressure from posttraumatic venous sinus occlusion refractory to other treatment measures. (DOI: / JNS08491) Ke y Wo r d s dural venous sinus thrombosis balloon angioplasty trauma endovascular treatment Th r o m b o s i s of the cerebral venous sinuses caused by trauma is a relatively rare but well-described event, more commonly associated with penetrating head injury but reported to occur in up to 6% of patients with closed head injury. 18 In severe cases, posttraumatic sinus thrombosis can result in venous congestion and persistent intracranial hypertension that are refractory to conventional medical therapy and lead to severe neurological morbidity or death. 13 We report a unique case of a patient treated with endovascular thrombectomy with balloon angioplasty for clinically significant posttraumatic venous sinus thrombosis. Abbreviation used in this paper: ICP = intracranial pressure. Case Report History and Examination. This 18-year-old man suffered a severe closed head injury from a fall while skateboarding. He had a Glasgow Coma Scale score of 7 at the scene of the accident and was transported to the emergency department at another facility. He was intubated after demonstrating deteriorating findings on neurological examination. A CT scan of the head revealed traumatic brain injury, and he was transferred to our facility for treatment. The patient was stable on arrival at our institution, and a repeat head CT scan revealed moderate bifrontal contusions with moderate cerebral edema, diffuse subarachnoid hemorrhage, petechial hemorrhages consistent with diffuse axonal injury, and basilar skull fractures involving the left jugular foramen that were concerning for venous injury. Computed tomography angiography revealed thrombosis of the left transverse sinus and occlusion of the left sigmoid sinus and internal jugular vein (Fig. 1). The opposite transverse sinus and venous system were patent and appeared to be codominant. Medical Treatment. The patient was admitted to the intensive care unit, and his ICP was monitored and found 17

2 F. S. Bishop et al. Fig. 1. Computed tomography angiogram demonstrating thrombosis of the left transverse sinus and occlusion of the sigmoid sinus (left) and occlusion of the left internal jugular vein (right). to be highly elevated, at cm H 2 O. Systemic heparin infusion was started immediately after admission. Cerebral angiography confirmed the sigmoid sinus occlusion (Fig. 2), and the infusion catheter was left in the sinus to allow direct intraluminal heparin infusion at 500 U/hour in addition to systemic infusion of heparin. Despite aggressive medical management, the patient s intracranial hypertension remained refractory to treatment, with ICP measurements of cm H 2 O, and serial CT evaluations revealed worsening cerebral edema, without evidence of significant worsening of associated brain injury. The medically refractory ICP out of proportion to the severity of brain injury, and the increased cerebral edema with associated left-sided sinus thrombosis were consistent with decreased cerebral venous outflow from sinus occlusion. First Operation and Postoperative Course. On the second day after admission, a left decompressive hemicraniectomy was performed for treatment of the patient s severe intracranial hypertension. A wide bone removal was achieved, the dura mater was opened, and an autologous pericranial tissue graft was sutured loosely into place for dural augmentation. Postoperatively, the ICP measurements initially improved to cm H 2 O. Postoperative angiography revealed significantly improved blood flow through a partially thrombosed left sigmoid sinus and contrast agent through the entire sinus from the transverse through the sigmoid sinus and jugular foramen. The improvement in ICP was only temporary, however, and the patient s intracranial hypertension increased substantially over a 2-day period to cm H 2 O. Further CT evaluation revealed marked cerebellar edema with complete effacement of the fourth ventricle (Fig. 3). Second Operation and Postoperative Course. The patient underwent a wide decompressive suboccipital craniectomy with placement of an onlay allograft dural substitute, which decreased the ICP to cm H 2 O. On the following day, despite 2 decompressive surgeries, the patient s ICP continued to elevate to cm H 2 O. An emergency cerebral angiogram revealed reocclusion of the sigmoid sinus. Angioplasty and Postoperative Course. Because of Fig. 2. Cerebral angiogram of the left transverse sinus demonstrating complete occlusion of the left sigmoid sinus. 18

3 Posttraumatic venous sinus thrombosis and balloon angioplasty Fig. 4. Cerebral angiogram demonstrating improved flow of contrast agent through the left sigmoid sinus. Fig. 3. Computed tomography scan demonstrating cerebellar edema and obliteration of the fourth ventricle. persistent sinus thrombosis, microballoon percutaneous transluminal angioplasty of the left transverse and sigmoid sinuses was performed. A 7 7 mm compliant occlusion microballoon catheter (HyperForm, ev3, Inc.) was inserted into the left transverse sinus, expanded, and then retracted through the left transverse and sigmoid sinuses to the left jugular bulb. Multiple passes were performed. Contrast injection after the balloon angioplasty procedure demonstrated significant flow improvement of the left sigmoid sinus (Fig. 4). The patient s ICP was immediately reduced after the procedure to cm H 2 O and remained low throughout the remainder of his hospital stay. He had no hemorrhagic complications after the procedure, and use of the intrasinus heparin infusion catheter was discontinued after 3 days. Systemic anticoagulation therapy was continued with intravenous heparin postprocedure. A follow-up angiogram demonstrated further improvement of blood flow through the venous sinuses. The patient was discharged from the intensive care unit on postangioplasty Day 13. He required a tracheostomy, a gastrostomy, and a ventriculoperitoneal shunt for management of posttraumatic hydrocephalus, but eventually improved neurologically, was able to follow commands and walk, and was discharged on warfarin to a rehabilitation facility for further recovery. Discussion Posttraumatic venous sinus thrombosis is a rare but well-described entity that was first reported in 1934 by Bagley. 13 Cerebral sinus thrombosis can result from either mild or severe closed head injury, and no correlation with the severity of injury has been reported. 18,20 The clinical symptoms are generally nonspecific, range in severity from benign to fatal, and may present in a delayed manner days after the head injury. 21,23 Patients commonly present with symptoms of raised ICP out of proportion to their imaging findings or with an associated fracture over the sinus, 18,20 and such patients should be screened with CT angiography for diagnosis. The management of venous sinus thrombosis from a traumatic cause remains controversial, and numerous anecdotal treatments have been described with varying results. In cases that follow a benign clinical course, close observation with serial imaging without the use of anticoagulation therapy has been reported to have good clinical outcomes. 18,20 Symptoms may rapidly progress, however, to severe neurological morbidity or death. 11,13 In such cases, aggressive medical or surgical management is advocated, as many traumatically injured patients are young and otherwise healthy. Anecdotal reports include medical management of mild symptoms with acetazolamide 21 and serial lumbar punctures 23 to reduce CSF volume and administration of dexamethasone to decrease cerebral edema, 19 but the efficacy of these therapies remains unclear. In life-threatening cases, aggressive medical management of intracranial hypertension and surgical treatment with decompressive craniectomy or surgical thrombectomy have also been reported, with varying results. 13,14,27 Despite initial treatment, there is the potential for sinus reocclusion and symptom recurrence, which may require additional, more aggressive management. 10,14 The use of anticoagulation medication in trauma to prevent thrombus propagation is also controversial, and no consensus exists regarding its use in cerebral sinus thrombosis. 19,27 Furthermore, the use of anticoagulation medication in patients with head injuries remains to be systematically investigated, although this therapy is often 19

4 F. S. Bishop et al. used on a case-by-case basis. In nontraumatic cases, systemic anticoagulation therapy with low-dose intravenous heparin has been shown to be safe and effective when titrated carefully to avoid excessive anticoagulation, even in the presence of pretreatment intracranial hemorrhage, and patients had superior outcomes when compared with those treated without anticoagulation medication. 6,17 The first cases of successful endovascular treatments with thrombolysis were reported by Vines and Davis 24 in Several subsequent reports have shown that direct application of chemical thrombolytic agents into the sinus at or in the thrombus in conjunction with systemic anticoagulation therapy is effective in restoring angiographic patency of the sinuses and can result in dramatic clinical improvement of intracranial hypertension and neurological deficits. 7,8,12,15 Patients treated with thrombolytic agents have also been reported to have better neurological outcomes than patients treated with anticoagulation therapy alone, 25 although not all reports have substantiated this finding. 17 Of note, hemorrhagic complication rates of 10 30% have been reported in association with chemical thrombolysis; these may be intracranial or at remote extracranial locations and may be associated with clinical deterioration. 1,17,25 Because hemorrhage risk is associated with infusion duration and total dosage, modern catheterbased methods use intermittent burst-bolus techniques, which may decrease the frequency of this complication. 7,16 In the setting of trauma with cerebral hemorrhage, however, chemical thrombolytic therapy with either tissue plasminogen activator (tpa) or urokinase would be contraindicated. Endovascular treatment with mechanical thrombectomy using balloon angioplasty has been performed for cerebral sinus occlusive disease since Most thrombectomy procedures are performed in combination with chemical thrombolysis, and the technique is generally associated with good outcomes. 2,4,22,26 More recently, endovascular rheolytic thrombectomy, which uses a catheter to create a localized low-pressure vacuum to disrupt the thrombus and which suctions clot to minimize the circulation of emboli, has been used. Treatment of cerebral sinus thrombosis with this method with and without chemical thrombolysis has been reported with generally good results. 3,9 When mechanical thrombectomy is performed without thrombolysis, a decreased incidence of hemorrhagic complications has been demonstrated. 17 Only 2 cases involving endovascular treatment for posttraumatic cerebral sinus thrombosis have been reported. Kuether et al. 11 reported a case of severe closed head injury with associated thrombosis of the dominant right transverse and sigmoid sinuses. In the case reported by D Alise et al., 5 the patient had thrombosis of the superior sagittal and transverse sinuses and a delayed presentation with progressive headache and papilledema. Both patients were treated with endovascular chemothrombolysis with administration of urokinase, were subsequently treated with systemic anticoagulation therapy, and had good clinical outcomes. Ours is the first reported case of posttraumatic venous sinus thrombosis treated with endovascular mechanical thrombectomy with balloon angioplasty. Our patient had severe refractory intracranial hypertension associated with cerebral and cerebellar edema even though the confluence of sinuses and opposite sinus were radiographically patent. Endovascular mechanical thrombectomy resulted in immediate ICP reduction and continued improvement of venous flow through the sinus on repeat angiographic studies. This is also the first reported case of local intraluminal anticoagulation therapy with heparin administered within the thrombosed sinus. Chemical thrombolysis was not used because of the increased risk of hemorrhagic complications, which may be even greater in the setting of trauma. 1,17,25 No complications were observed with the use of either direct or systemic heparin infusions. This case illustrates several features of posttraumatic venous sinus thrombosis of the transverse and sigmoid sinuses. Venous sinus thrombosis should be suspected in cases involving fractures of the occiput and can be associated with substantial intracranial hypertension and neurological decline. It can be readily detected with CT angiography. A patent codominant transverse sinus may not protect patients from ICP elevation or neurological decline. Systemic anticoagulation is required for treatment of symptomatic sinus thrombosis and can be safely used 6,17 in the setting of trauma if a therapeutic goal of a partial thromboplastin time of seconds is not exceeded. More aggressive therapeutic measures such as intraluminal infusion of heparin and mechanical thrombolysis are indicated if persistent venous hypertension causes refractory cerebral edema and intracranial hypertension. 22 Conclusions Posttraumatic venous sinus thrombosis can be an extremely aggressive disease that can result in venous congestion, persistent intracranial hypertension, or intracranial hemorrhage and may be unresponsive to conventional medical therapy and even surgical decompression. In refractory cases, endovascular mechanical thrombolysis with balloon angioplasty in conjunction with anticoagulation therapy may be an effective and safe alternative for treatment. Disclaimer The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Acknowledgments Dr. Steve Stevens performed the procedure in this patient. The authors thank him for his technical expertise and his discussion with us regarding the procedure. They also thank Kristin Kraus, M.Sc., for her excellent editorial assistance. References 1. Canhao P, Falcao F, Ferro JM: Thrombolytics for cerebral sinus thrombosis: a systematic review. Cerebrovasc Dis 15: , Chaloupka JC, Mangla S, Huddle DC: Use of mechanical 20

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