A transcranial approach for direct mechanical thrombectomy of dural sinus thrombosis

Transcription

1 J Neurosurg 101: , 2004 A transcranial approach for direct mechanical thrombectomy of dural sinus thrombosis Report of two cases ALI CHAHLAVI, M.D., MICHAEL P. STEINMETZ, M.D., THOMAS J. MASARYK, M.D., AND PETER A. RASMUSSEN, M.D. Departments of Neurosurgery and Neuroradiology, Section of Cerebrovascular and Endovascular Neurosurgery, The Cleveland Clinic Foundation, Cleveland, Ohio C Cerebral venous sinus thrombosis is often difficult to manage. Treatment options include systemically delivered anticoagulation therapy or chemical thrombolysis. Targeted endovascular delivery of thrombolytic agents is currently a popular option, but it carries an increased risk of hemorrhage. These strategies require significant time to produce thrombolysis, often in a patient with a rapidly deteriorating neurological condition. Rapid mechanical recanalization with thrombectomy is therefore very attractive; this procedure provides rapid recanalization with no increased risk of hemorrhage from use of thrombolytic agents. Nevertheless, the rheolytic catheter is large and stiff and may not be able to navigate tortuous intracranial vascular anatomy. The authors present their experience with direct dural sinus mechanical thrombectomy performed using the rheolytic catheter via a transcranial route. Two patients with dural sinus thrombosis and rapidly deteriorating levels of consciousness underwent unsuccessful attempts at mechanical thrombolysis via the usual transfemoral route. Through a burr hole over the dural sinus, mechanical thrombectomy was subsequently performed using the thrombectomy catheter. Sinus patency was restored following treatment and both patients demonstrated neurological recovery. Hemorrhage or a rapidly deteriorating neurological condition may preclude the use of systemic or locally delivered thrombolytic agents for the treatment of cerebral venous sinus thrombosis. Mechanical thrombectomy may be the treatment of choice in these circumstances. In patients with limited transfemoral access, a transcranial approach may be used to access the cerebral dural sinuses and thrombectomy may be safely and effectively performed. Further evaluation of this therapy is warranted. KEY WORDS cerebral venous thrombosis venous sinus obstruction thrombectomy prognosis EREBRAL venous thrombosis is relatively uncommon, with mortality rates ranging from 5 to 30%. 1 Cerebral venous thrombosis most often affects young and middle-aged patients and is more common in women than in men. 5,28,50 It is associated with hypercoagulable states secondary to dehydration, meningitis, pregnancy, sickle cell disease, oral contraceptive use, and numerous other conditions. Diagnosis may be difficult because of nonspecific signs and symptoms. This difficulty may lead to a significant delay in diagnosis, which directly affects prognosis. Diagnosis is made based on a high index of suspicion and neuroimaging results. Cerebral venous thrombosis may be recognized because of a venous infarction or a hemorrhage in an atypical location on CT or MR imaging. 8,23,28 Additionally, thrombosis may be seen as a hyperdense area in a dural venous sinus on unenhanced CT scans or as a void in the sinus on enhanced CT scans (this has been referred to as the empty delta sign). 49 Although conventional angiography remains the gold standard for diagnosis, cerebral venous thrombosis may be clearly and accurately visualized using MR imaging and MR venography. 10 The potential for neurological recovery is dependent on Abbreviations used in this paper: CT = computerized tomography; ICH = intracerebral hemorrhage; MR = magnetic resonance; SSS = superior sagittal sinus. early treatment delivered prior to the onset of venous infarction and/or hemorrhage. The optimal treatment is controversial, in part because of the variable nature of the disease process. 9 Systemic anticoagulation therapy is often the firstline treatment. Heparin has been shown to lead to improved outcome following venous sinus thrombosis compared with no treatment. 15 Anticoagulant agents such as heparin only limit propagation of the thrombosis and therefore do not lyse the existing thrombus. Clot propagation and clinical progression may be halted, but if occlusion of the sinus is not tolerated (that is, there is insufficient collateralization), restoration of venous sinus patency is required. Reports on the use of peripheral and direct delivery of thrombolytic agents have been published. Intravenous delivery has resulted in various outcomes and a significant amount of time is required for thrombolysis (that is, days). 13,27 Direct endovascular delivery of thrombolytic drugs to the site of thrombosis has yielded favorable results. 2,3,17 22,24,27,35,37,38,40,42,45,47 Despite these promising findings, the use of thrombolytic agents is still associated with an increased incidence of hemorrhage and significant time is required for recanalizaiton. Mechanical thrombectomy with the rheolytic catheter (Angiojet Xpeedior 100; Possis Medical, Minneapolis, MN) is an exciting option for dural sinus thrombosis (Fig. 1). This device has been used successfully in the treatment 347

2 A. Chahlavi, et al. FIG. 3. Intraoperative photograph obtained after midline incision over the inion showing a small craniotomy turned over the torcular herophili. The torcular herophili was directly punctured and No. 6 French sheath was placed. of occluded coronary, pulmonary, and other peripheral vessels, 31 33,41 and also in the management of cerebral venous thrombosis. 9,14,34,39 The Angiojet catheter is relatively large and stiff; these properties may make peripheral access and intracranial navigation difficult and at times impossible in the face of tortuous vessels or venous sinus stenosis. In these situations a direct transcranial approach to the cerebral venous sinus compartment is desirable. We present our initial experience with direct mechanical thrombolysis of cerebral venous thrombosis, for which we used a transcranial approach. FIG. 1. A: Depiction of the Angiojet. B: Depiction of the catheter in the thrombus. This mechanical device forces a very highspeed jet of saline down the body of the instrument. At the end of the device the saline makes a 180 U-turn and is exposed over a very short distance. This high-speed saline jet creates a suction or a vacuum effect, and any material nearby will be entrained in the moving saline stream and evacuated out through the catheter. Arrows show the direction of the jets of saline. Pictures courtesy of Possis Medical. FIG. 2. Diagnostic conventional angiogram in the venous phase demonstrating straight sinus occlusion. Case Reports Case 1 History and Examination. This 48-year-old man was transferred to our institution after experiencing a 3-month progressive deterioration in neurological function. The patient presented with somnolence, bilateral tremor, and diffuse hyperreflexia. Admission MR images of the brain demonstrated a hyperintense signal in the bilateral thalami and basal ganglia and angiography revealed occlusion of the proximal straight sinus (Fig. 2). All laboratory values were within normal limits and no known associated comorbidities were identified. Initial Treatment. Despite heparin infusion, the patient s neurological status continued to decline. The rapidity of the decline precluded intravenous thrombolytic therapy. The patient was considered for mechanical thrombectomy but the deep nature of the thrombosis (that is, in the straight sinus) precluded an approach through the transfemoral or jugular route. This is because the stiff catheter cannot be easily navigated around the bend from the torcula herophili to the straight sinus. Operation. The patient was brought to the operating room, placed in a three-quarters prone position, and a threepoint headholder was affixed. An approximately 2-cm craniotomy was positioned directly over the torcula herophili, which was directly pierced using a micropuncture kit (Fig. 3). The AngioJet Xpeedior 100 catheter was advanced over a wire past the thrombosis. Mechanical thrombectomy was performed twice and venography demonstrated anterograde flow into the straight sinus (Fig. 4). The puncture in the sinus was secured with thrombin-soaked Gelfoam and the bone flap was replaced. Postoperative Course. The patient was maintained on heparin infusion and eventually started on a regimen of coumadin and baby aspirin. His neurological status improved daily until he was discharged to a rehabilitation facility. At the 348

3 Transcranial approach for direct thrombectomy of sinus thrombosis FIG. 4. Postoperative angiogram demonstrating that after mechanical thrombolysis, flow was restored through the straight sinus. last scheduled follow-up visit, the patient had normal cognitive function and a residual mild right-sided seventh cranial nerve palsy and upper-extremity paresis (Grade 4/5). Results of the hypercoagulation workup demonstrated a factor V Leiden deficiency. Case 2 History and Examination. This 60-year-old man who had a family history of protein S deficiency was transferred to our institution with a right-sided temporoparietal hemorrhage. The patient reported a headache, but otherwise was at his neurological baseline, which included left hemiparesis and third cranial nerve palsy from multiple infarcts. A diagnostic angiogram demonstrated a dural arteriovenous fistula, which was successfully embolized. Subsequently, the patient s level of consciousness declined and he experienced a generalized tonic clonic seizure along with new right-extremity paresis. A CT scan revealed a left-sided frontotemporal hemorrhage. Catheter angiography demonstrated complete SSS thrombosis (Fig. 5). Initial Treatment and Subsequent Operation. Mechanical thrombectomy was attempted through a transfemoral and transjugular route, but it was unsuccessful because of anatomical constraints and difficulty navigating the catheter. Therefore, the patient was brought to the operating room for direct transcranial mechanical thrombectomy. A craniotomy was planned and performed over the junction of the frontal and middle third of the SSS. The SSS was directly pierced using a micropuncture kit and a No. 6 French sheath was placed. A guidewire was passed retrograde through the SSS, the left transverse sinus, and ultimately the jugular vein. Flow was restored with one pass through the SSS, although multiple passes of the Angiojet catheter were required to restore patency to the left transverse sinus (Fig. 6). The dura was covered with thrombin-soaked Gelfoam and a piece of pericranium, and the bone flap was replaced with miniplates. Postoperative Course. The patient was begun on a regimen of heparin infusion that was eventually converted to coumadin. He slowly improved neurologically following the thrombectomy, and at the latest follow-up review he was living independently and had a normal mental status, baseline left hemiparesis, and new mild right upper-extremity weakness (Grade 4/5). Subsequent hematological evaluation disclosed protein S deficiency. FIG. 5. Lateral catheter angiogram (venous phase) demonstrating complete occlusion of the SSS. Discussion Cerebrovascular sinus thrombosis is a rare condition with an occurrence of 1.5 to 3 per million in adults 11 and approximately 7 per million in children (Canadian Pediatric Ischemic Stroke Registry). It usually affects young people who are otherwise healthy 24 and often presents with nonspecific signs and symptoms. The clinical diagnosis requires a high index of suspicion because there are no pathognomonic findings. Patients may present with headaches, nausea and/or vomiting, a depressed level of consciousness, seizures, and/or focal neurological deficits. 1,4,6,7,16,21,26,36,43,44,46 Unenhanced CT scans may demonstrate edema or infarct in a nonarterial distribution, although these findings may easily be overlooked. Magnetic resonance venography and angiography will depict the occluded sinus. Difficulty with diagnosis is highlighted by the fact that in more than 40% of patients there is a diagnostic delay of more than 10 days. 12 It is crucial to initiate therapy as soon as possible to avoid venous infarction or hemorrhage and a devastating neurological outcome. The reported mortality rate has been as high as 50% in some series. 6,29,30,40 Treatment options include medical observation accompanied by hydration, anticoagulation, chemical thrombolysis, or mechanical thrombectomy. The literature remains controversial regarding which option is optimal. Soleau, et al., 43 treated a subgroup of patients with cerebral venous thrombosis by using medical management alone. This group fared worse compared with the series as FIG. 6. Intraoperative venogram demonstrating that after several passes of the Angiojet catheter, flow was restored in the SSS and the left transverse sinus. 349

4 A. Chahlavi, et al. a whole; four of five patients suffered hemorrhagic complications and only two of five exhibited clinical improvement. Systemic anticoagulation therapy with heparin is commonly used and in many instances it is effective in preventing thrombus propagation and results in improved neurological status. Einhaupl, et al., 15 demonstrated improved outcome in patients who received heparin compared with those who did not. It has been and still is common practice among many neurosurgeons and neurologists to avoid anticoagulation therapy in the setting of venous thrombosis and ICH for fear of exacerbating the bleeding. Despite this belief, it has been shown that systemic anticoagulation with heparin is both safe and effective for the treatment of venous sinus thrombosis, even in the face of a preexisting ICH. 15,43 Systemic thrombolysis with urokinase has had some occasionally good yet inconsistent results. 3,13,48 Many positive reports on the use of direct endovascular delivery of thrombolytic agents exist in the literature. 2,3,17 22,24,27,35,38,40, 42,45,47 It appears that thrombolytic drugs are effective at improving flow through the occluded sinus and improving patient outcome. 43 Despite reported success with systemic and especially direct thrombolytic therapy, a potentially long time is required to achieve effective recanalization. This leads to a substantial risk of hemorrhagic complications (30% of patients who receive either tissue plasminogen activator or urokinase, according to a report by Soleau, et al. 43 ). Despite this risk of hemorrhage, 90% of sinus patency was restored and 60% of patients demonstrated clinical improvement. A significant amount of time is required to restore patency with chemical thrombolysis; studies have demonstrated infusion times of 88 to 244 hours, with a mean of 171 hours for lysis of massive clots. 37,47 Mechanical thrombectomy obviates the time required and averts potential hemorrhagic complications seen with chemical thrombolysis. Options include the use of endovascular Fogarty catheters and the Angiojet rheolytic thrombectomy catheter. With the latter, saline exits the catheter tip at high velocity through small jets oriented in a retrograde direction. These jets create a negative pressure gradient at the tip of the catheter; this is known as the Venturi effect. This negative pressure gradient serves to entrain and gently break up the thrombus. 34 The catheter has been successfully used to treat thrombosis of the coronary, pulmonary, and other peripheral vessels. 31,33,41 Furthermore, successful thrombolysis of dural venous sinuses has recently been reported. 14,34,39 Although mechanical thrombectomy may be optimal for the management of cerebral venous thrombosis, it cannot be applied in every patient. The catheter is relatively stiff, making navigation through tortuous or thrombosed vessels difficult and at times impossible. Furthermore, navigation into the deep venous structures (for example, straight sinus and beyond) may not be possible. These limitations may be especially true for a transfemoral approach. For these reasons, some practitioners have used a jugular approach for the application of the Angiojet system. If one is unable to navigate the thrombosis from this access point, the procedure may need to be abandoned. A transcranial approach has been used by Houdart, et al., 25 for embolization of dural arteriovenous fistula; these authors described their successful approach in 10 patients. In all patients in their series, a craniectomy was used to permit direct sinus puncture and introduction of microcatheters. Interestingly, the craniectomy was performed in the operating room and then the patient was transferred back to the angiography suite for the embolization. In seven cases the patient required a return to the operating room to enlarge the craniectomy. In the two cases presented herein, a transfemoral or transjugular approach was not possible. Because of the patients rapidly declining neurological status and the presence of ICH, chemical thrombolysis was not thought to be appropriate. A transcranial approach was chosen because it permits direct access to the venous system and avoids the difficulties encountered when navigating the stiff Angiojet catheter. This approach also permits access to the straight sinus, which may not be possible from a peripheral access point. In both cases the dural sinuses were easily entered through an appropriate craniotomy. The Angiojet catheter was easily navigated and permitted restoration of sinus patency in both patients. Multiple passes of the catheter were required in both patients, but this was believed to be independent of the transcranial approach. Sinus bleeding was easily controlled with thrombin-soaked Gelfoam and replacement of the bone flap. A drawback of the approach is the need to perform the procedure with the aid of portable fluoroscopy in the operating room; therefore, visualization may be somewhat limited. The craniotomy may be performed in the operating room and the patient can then be transferred to the angiography suite for definitive thrombectomy. As can be seen from the report by Houdart, et al., 25 if difficulty is encountered with the craniotomy, the patient will have to be brought back to the operating room. In our experience, the procedure may be safely performed entirely in the operating room, with no need to abort or alter the procedure because of imaging limitations. Conclusions Cerebral venous sinus thrombosis is a rare but life-threatening condition; it requires rapid diagnosis and institution of therapy. In cases of rapidly declining neurological status, mechanical thrombectomy with a rheolytic catheter is optimal. In situations in which a transfemoral or jugular approach is not possible, a direct transcranial approach is both safe and effective. Disclaimer None of the authors has any affiliation with or financial interest in any device or commercial organization mentioned in this paper that would pose a potential conflict of interest. References 1. Ameri A, Bousser MG: Cerebral venous thrombosis. 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