Cabral de Andrade G, Lesczynsky A, Clímaco V M, Pereira E R, Marcelino P O, Franco Aoc, De Almeida D F
1 CINN - Integrated Center of Neurology and Neurosurgery, Maringá, Brazil.
2 Parana Hospital, Maringá, Brazil.
Interv Neuroradiol. 2017 Feb;23(1):84-89. doi: 10.1177/1591019916674917. Epub 2016 Oct 27.
Purpose Cerebral venous sinus thrombosis (CVST) is an unusual and potentially life-threatening condition with variable and nonspecific clinical symptoms and high morbimortality rates. Standard therapy consists of systemic anticoagulation; although there is no clear evidence about the best choice for treatment, intravenous heparin is used as the first-line treatment modality. Intravenous sinus thrombolysis can be an effective and relatively safe treatment for acutely deteriorating patients who have not responded to conventional therapy. This case report presents the possibility of endovascular treatment in multiple steps with mechanical thrombolysis with balloon, local pharmacological thrombolysis and stenting, in a patient with a severe form of CVST. Case summary A 67-year-old woman presented severe headache, agitation and confusion with diagnosis of venous sinus dural thrombosis in both lateral sinus and torcula. After 24 h there was neurological worsening evolving with seizures and numbness even after starting heparin, without sinus recanalization; CT scan showed left temporal intracerebral hemorrhage. We decided to take an endovascular approach in multiple steps. The first step was mechanical static thrombolysis with balloon; the second step was dynamic mechanical thrombolysis with a balloon partially deflated and "pulled"; the third step was local thrombolysis with Actilyse™; finally, the fourth step was angioplasty and reconstruction of the sinuses using multiple carotid stents and complete angiographic recanalization of both sinuses and torcula. After 24 h of endovascular treatment there was full clinical recovery and no tomographic complications. Conclusion This result shows that mechanical clot disruption, intrasinus thrombolysis and reconstruction of wall sinuses with stenting can be an endovascular option in the severe form of CVST with intracerebral hemorrhage and rapid worsening of neurological symptoms. Although this type of treatment can re-channel the occluded sinuses, further comparative and randomized studies are needed to clarify its efficacy versus other therapeutic modalities.
目的 脑静脉窦血栓形成（CVST）是一种罕见且可能危及生命的疾病，临床症状多样且不具特异性，病死率高。标准治疗包括全身抗凝；尽管对于最佳治疗选择尚无明确证据，但静脉注射肝素被用作一线治疗方式。静脉窦溶栓对于常规治疗无反应的急性病情恶化患者可能是一种有效且相对安全的治疗方法。本病例报告介绍了一名重症CVST患者采用球囊机械溶栓、局部药物溶栓和支架置入等多步骤血管内治疗的可能性。
病例摘要 一名67岁女性出现严重头痛、躁动和意识模糊，诊断为双侧横窦和窦汇静脉窦硬脑膜血栓形成。24小时后，即使开始使用肝素，神经功能仍恶化，出现癫痫发作和麻木，窦道未再通；CT扫描显示左颞叶脑出血。我们决定采用多步骤血管内治疗方法。第一步是球囊机械静态溶栓；第二步是球囊部分放气并“拉动”进行动态机械溶栓；第三步是使用阿替普酶进行局部溶栓；最后，第四步是使用多个颈动脉支架进行血管成形术和窦道重建，双侧横窦和窦汇完全血管造影再通。血管内治疗24小时后，患者临床完全康复，未出现影像学并发症。
结论 该结果表明，对于伴有脑出血且神经症状迅速恶化的重症CVST，机械性血栓破碎、窦内溶栓和支架置入重建窦壁可作为一种血管内治疗选择。尽管这种治疗方式可使闭塞的静脉窦再通，但仍需要进一步的比较和随机研究来阐明其与其他治疗方式相比的疗效。
