Novel Use of Computer-Aided Vacuum Thrombectomy for the Treatment of Cerebral Venous Sinus Thrombosis: A Multistep Approach.

Abstract

Cerebral venous sinus thrombosis (CVST) is a rare subtype of stroke with a high mortality rate. First-line treatment is medical management with anticoagulation such as low molecular weight heparin or unfractionated heparin. However, in cases with extensive thrombosis of the superficial dural venous sinuses or deep galenic venous system, there can be significant venous congestion with subsequent venous infarction or hemorrhage. In these patients, more aggressive treatment with endovascular methods may be indicated. In this technical report, we describe the utilization of a computer aided suction aspiration system combined with intra-arterial alteplase (Boehringer Ingelheim, Ingelheim am Rheim, Germany) administration in treating cerebral venous sinus thrombosis refractory to conventional endovascular therapies. We describe a multistep approach using the Penumbra (Alameda, CA) Lightning aspiration system for computer aided vacuum thrombectomy in a patient with refractory cerebral venous sinus thrombosis. We also perform a systematic review of studies involving the endovascular management of CVST. We demonstrate a multi-stepwise escalation and utilization of multiple endovascular strategies to improve venous sinus revascularization including suction aspiration, stent-retriever, and intravenous administration of tissue plasminogen activator. Because of the overwhelming clot burden within the venous sinus system of this patient, vacuum thrombectomy was used as an off-label use of a peripheral vascular device and was a last measure to improve revascularization. Cerebral venous sinus thrombosis can be challenging to treat. The utilization of endovascular techniques should be a multistep process with escalating strategies in patients with large thrombus burden. Computer aided vacuum thrombectomy can be safely utilized in the cerebral venous sinuses in cases refractory to conventional thrombectomy techniques.