Randomized, placebo-controlled trial of anticoagulant treatment with low-molecular-weight heparin for cerebral sinus thrombosis.
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BACKGROUND AND PURPOSE: Treatment of cerebral sinus thrombosis with heparin is controversial. We conducted a double-blind, placebo-controlled multicenter trial to examine whether anticoagulant treatment improves outcome in patients with sinus thrombosis. METHODS: Patients were randomized between body weight-adjusted subcutaneous nadroparin (180 anti-factor Xa units/kg per 24 hours) and matching placebo for 3 weeks (double-blind part of trial), followed by 3 months of oral anticoagulants for patients allocated nadroparin (open part). Patients with cerebral hemorrhage caused by sinus thrombosis were also included. RESULTS: Sixty patients were enrolled, and none were lost to follow-up. In 1 patient the diagnosis proved wrong after randomization. After 3 weeks, 6 of 30 patients (20%) in the nadroparin group and 7 of 29 patients (24%) in the placebo group had a poor outcome, defined as death or Barthel Index score of <15 (risk difference, -4%; 95% CI, -25 to 17%; NS). After 12 weeks, 4 of 30 patients (13%) in the nadroparin group and 6 of 29 (21%) in the placebo group had a poor outcome, defined as death or Oxford Handicap Score of >/=3 (risk difference, -7%; 95% CI, -26% to 12%; NS). There were no new symptomatic cerebral hemorrhages. One patient in the nadroparin group had a major gastrointestinal hemorrhage, and 1 patient in the placebo group died from clinically suspected pulmonary embolism. CONCLUSIONS: Patients with cerebral sinus thrombosis treated with anticoagulants (low-molecular-weight heparin followed by oral anticoagulation) had a favorable outcome more often than controls, but the difference was not statistically significant. Anticoagulation proved to be safe, even in patients with cerebral hemorrhage. (+info)
Helical CT angiography: dynamic cerebrovascular imaging in children.
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BACKGROUND AND PURPOSE: The purpose of this study was to assess the feasibility of helical CT cerebrovascular imaging (CTCVI) in children and to make initial comparisons with MR angiography and digital subtraction angiography (DSA). METHODS: Twenty-six patients, ages 3 days to 17 years, were examined with CTCVI. Patients were scanned with 1-mm collimation and 2:1 pitch 30 seconds after the initiation of a hand injection of 2 mL/kg nonionic contrast material (320 mg/dL iodine) with a maximum dose that did not exceed 80 mL (minimum volume, 5 mL in a 2.5-kg infant). Reconstructions were done using maximum intensity projection and integral rendering algorithms. Four patients had CTCVI, MR angiography, and DSA (42 vessels studied) and nine patients had CTCVI and DSA (136 vessels studied). Scores of 1 (not present) to 3 (present in continuity to the first bifurcation) were assigned independently by two radiologists to 32 vessels in each correlated case for each available technique. RESULTS: There were no technical failures. CTCVI depicted 18 thrombosed dural sinuses, three vascular malformations, one intracranial aneurysm, and four tumors. Ninety-five percent of the vessels seen with DSA were also seen with CTCVI. CTCVI identified all vessels seen on MR angiography. CONCLUSION: Helical CTCVI is an effective technique for assessing the intracranial circulation in children. In this initial comparison, CTCVI showed more vascular detail than MR angiography, and had fewer technical limitations. (+info)
Rapid thrombectomy of superior sagittal sinus and transverse sinus thrombosis with a rheolytic catheter device.
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Thrombosis of the dural venous sinuses is a potentially lethal condition that remains a diagnostic dilemma. Clinical outcome is typically dependent on the timeliness of diagnosis and definitive treatment. We report a case of successful rapid thrombectomy of extensive thrombus within the superior sagittal and transverse sinuses using a rheolytic catheter device. This appears to be a promising treatment option, particularly in those patients who do not respond to other, more established, forms of therapy. (+info)
Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis: a new technique.
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We present a novel application of a transvascular rheolytic thrombectomy system in the treatment of symptomatic dural sinus thrombosis in a 54-year-old woman with somnolence and left-sided weakness. The diagnosis of bilateral transverse and superior sagittal sinus thrombosis was made and the patient was treated with anticoagulant therapy. After an initial period of improvement, she became comatose and hemiplegic 8 days after presentation. After excluding intracerebral hemorrhage by MR imaging, we performed angiography and transfemoral venous thrombolysis with a hydrodynamic thrombectomy catheter, followed by intrasinus urokinase thrombolytic therapy over the course of 2 days. This technique resulted in dramatic sinus thrombolysis and near total neurologic recovery. Six months after treatment, the patient showed mild cognitive impairment and no focal neurologic deficit. Our preliminary experience suggests that this technique may play a significant role in the endovascular treatment of this potentially devastating disease. (+info)
Variant arteriovenous fistula of the superior sagittal sinus--case report.
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A 57-year-old male presented with a rare variant of dural arteriovenous fistula, located in the wall of an unobstructed superior sagittal sinus. Drainage occurred through a cortical vein no longer connected to its parent sinus, which filled up a cluster of transmedullary running veins, one of which was the presumed site of hemorrhage. Arterial blood was supplied via the external carotid artery branches. This type of fistula seriously increases the risk of hemorrhage in the patient and therefore requires complete obliteration. Attempts to embolize the fistula failed. The draining vein was isolated and coagulated resulting in permanent occlusion of the fistula. The fistula probably developed through a process of thrombophlebitis and revascularization via arterioles of the vein rather than previous occlusion of the sinus. (+info)
Removal of a thrombus from the sigmoid and transverse sinuses with a rheolytic thrombectomy catheter.
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A rheolytic thrombectomy catheter was used to remove thrombus without thrombolytics from the sigmoid and transverse sinuses of a 34-year-old woman. Using small, high-flow fluid jets and Venturi-effect suction, this catheter allowed mechanical removal of thrombus. This technique may obviate the need for thrombolytic agents and the risks associated with their use. (+info)
Extrinsic cerebral venous sinus obstruction resulting in intracranial hypertension.
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We report the case of a 70-year-old man reporting with headache and visual disturbances who was being treated for prostate cancer. Investigations showed him to have intracranial hypertension caused by venous sinus obstruction. Patients with metastatic disease and raised intracranial pressure in the absence of focal signs should be considered as possible cases of venous outflow obstruction. (+info)
Cerebral venous sinus thrombosis.
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Cerebral venous sinus thrombosis is a challenging condition because of its variability of clinical symptoms and signs. It is very often unrecognised at initial presentation. All age groups can be affected. Large sinuses such as the superior sagittal sinus are most frequently involved. Extensive collateral circulation within the cerebral venous system allows for a significant degree of compensation in the early stages of thrombus formation. Systemic inflammatory diseases and inherited as well as acquired coagulation disorders are frequent causes, although in up to 30% of cases no underlying cause can be identified. The oral contraceptive pill appears to be an important additional risk factor. The spectrum of clinical presentations ranges from headache with papilloedema to focal deficit, seizures and coma. Magnetic resonance imaging with venography is the investigation of choice; computed tomography alone will miss a significant number of cases. It has now been conclusively shown that intravenous heparin is the first-line treatment for cerebral venous sinus thrombosis because of its efficacy, safety and feasability. Local thrombolysis may be indicated in cases of deterioration, despite adequate heparinisation. This should be followed by oral anticoagulation for 3-6 months. The prognosis of cerebral venous sinus thrombosis is generally favourable. A high index of clinical suspicion is needed to diagnose this uncommon condition so that appropriate treatment can be initiated. (+info)