Physicians in the USA have published details of—to their knowledge—the “first reported use” of the Indigo aspiration system (Penumbra) to treat cerebral venous sinus thrombosis (CVST) via endovascular thrombectomy. The treated patient underwent successful partial recanalisation of the superior sagittal sinus (SSS) and bilateral transverse sinuses (TS), and experienced improved outcomes, they state.
Writing in the journal Interventional Neuroradiology, Tareq Kass-Hout (University of Chicago, Chicago, USA) and colleagues note that CVST is an uncommon cause of stroke that can be difficult to treat and potentially “devastating”. Systemic anticoagulation is generally considered the first-line therapy for CVST, they add, but it may prove “insufficient” in cases of extensive thrombosis.
In these instances, EVT is often utilised to prevent the progression of ischaemic and/or haemorrhagic brain injury. However, according to the authors, while EVT techniques have evolved over time, “high-quality evidence for the efficacy and safety of these techniques for CVST is still lacking”.
“We present a 35-year-old male with ulcerative colitis initially admitted for a flare-up who then presented with altered mental status and was found to have extensive cerebral venous sinus thrombosis on computed tomography [CT] imaging,” Kass-Hout and colleagues write.
Initially, the patient underwent continuous low-dose heparin infusion for three days. However, this yielded “no improvement” and he was later intubated for airway protection. Owing to evidence of complete occlusion of the bilateral TS—and due to “persistently poor exams on systemic anticoagulation with concern for elevated intracranial pressure”—the decision was made to use EVT.
Relaying details of this procedure, the operators state that they gained access through the patient’s right femoral artery. Upon visualising the right internal carotid artery (ICA) view, there was evidence of “extremely slow perfusion”, with no significant drainage through the dural sinuses, as well as complete occlusion of the distal portion of the SSS and bilateral TS.
“Here, the decision was made to proceed with mechanical thrombectomy of the venous sinuses,” Kass-Hout and colleagues report.
A follow-up angiographic run revealed “significant thrombosis” of the right internal jugular (IJ) vein with “many completely occlusive thrombi”. Complete occlusion of the bilateral TS was also confirmed at this stage, and the intervention was then initiated, the authors add.
They deployed a 200cm Aristotle guidewire (Scientia Vascular) into a 160cm Zoom 35 catheter (Imperative Care), which was then advanced within the CAT12 large-bore aspiration catheter (Penumbra) and navigated across the occlusion to the SSS. Following multiple aspiration attempts, CAT8 and CAT7 catheters were advanced into the thrombus more anteriorly in the SSS and aspiration attempts were performed in the SSS with a separator device (all Penumbra).
At this stage, “evidence of partial recanalisation of the SSS and full recanalisation with normalised flow in [the] bilateral TS was seen”, Kass-Hout and colleagues note. And, while several additional thrombectomy attempts were made using the EmboTrap stent (Cerenovus) plus aspiration, no further significant recanalisation was observed, and the operators decided to stop the intervention given “significant thrombus removal” had already been achieved.
No thrombolytics were used during the procedure—nor additional heparin—and no procedure-related complications occurred.
The authors report that the patient had a prolonged recovery and a course in the neuro-critical care unit totalling six weeks. Repeat CT venography of the head, performed four weeks after intervention, revealed a decreased SSS burden of thrombus with otherwise patent dural venous sinuses and deep cerebral venous system. The patient was deemed neurologically stable and discharged to a rehabilitation centre. Approximately five months post-discharge, he was reportedly able to track people with his eyes, respond with smiles when shown pictures, and consistently follow commands with his left side, but remains hemiparetic on his right side with no apparent improvement in strength levels.
“This intervention prevented permanent brain injury, providing a better neurological outcome for this patient’s situation,” Kass-Hout and colleagues conclude.
Discussing the wider implications of this procedure, the authors note that several past case reports have demonstrated various methods for treating CVST via EVT—including use of the Penumbra system in combination with urokinase or alteplase infusions; balloon angioplasty; and the Solitaire flow restoration (FR) device (Medtronic).
“However, a single method has not been established as the most effective for CVST,” they continue. “The optimal EVT method for CVST treatment is not yet known, and the PIAS [Penumbra Indigo aspiration system] should be considered as a potential candidate, as demonstrated in our case.”
After highlighting the CAT12 catheter’s design, which helped to provide much-needed trackability and torqueability in a patient with tortuous venous vessels, and the Lightning intelligent aspiration technology’s (Penumbra) “extremely useful” ability to prevent significant blood loss, Kass-Hout and colleagues state that the Indigo aspiration system’s applicability in treating CVST “should be further explored”.