Case report: Mechanical thrombectomy using stent retriever devices in deep cerebral venous thrombosis. When anticoagulation fails

Case report: Mechanical thrombectomy using stent retriever devices in deep cerebral venous thrombosis. When anticoagulation fails | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case report: Mechanical thrombectomy using stent retriever devices in deep cerebral venous thrombosis. When anticoagulation fails Martínez Martín Álvaro, Hernández Fernández Francisco, Molina Nuevo Juan David, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3812095/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Treatment of cerebral venous thrombosis has traditionally been based on anticoagulant therapy. However, in certain circumstances, such as deep cerebral venous thrombosis, anticoagulation may be insufficient, so endovascular treatment by mechanical thrombectomy has been used for some years. There is currently no clear indication of which device is the gold standard in the endovascular treatment of cerebral venous thrombosis, although stent retriever devices are the most commonly used. Case presentation: We describe two cases of deep cerebral venous thrombosis refractory to anticoagulant treatment treated by mechanical thrombectomy with stent retriever devices, one of which has not been described to date as being used in the treatment of cerebral venous thrombosis (Tiger XL®). Conclusions: Some situations in like deep cerebral venous thrombosis may require endovascular treatment with mechanical thrombectomy if anticoagulation fails, with increasing evidence that it improves vital and functional prognosis. cerebral venous thrombosis endovascular treatment mechanical thrombectomy stent retriever Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Cerebral venous thrombosis (CVT) is a rare cause of stroke, ocurring especially in young adults and females [1]. This higher incidence in females is related to risk factors involved in its pathophysiology, such as pregnancy, puerperium and contraceptive use [1]. Its clinical presentation is broad, ranging from mild manifestations such as headache to the more severe such as coma [2]. This diverse form of presentation makes it necessary to maintain a high level of diagnostic suspicion to avoid diagnostic delay, which can be deleterious for the patient, both in terms of morbidity and mortality [3]. Involvement of the deep cerebral venous system (DCVT) increases morbidity and mortality in these patients, with an increased risk of both venous infarction and haemorrhagic transformation [4]. Diagnosis is based on neuroimaging using brain CT and/or MRI, with or without the use of specific venography sequences [1-3]. Use of transcranial Doppler (TCD) has been proposed as an alternative to diagnosis and even during the follow-up of CVT, as it allows the assessment of haemodynamic factors (unlike angioCT or angioMRI) that could have an implication on the functional prognosis of patients. However, currently it is not clear whether TCD can play a useful role in monitoring and steering anticoagulation treatment in CVT [4]. The classical therapeutic approach to CVT is based on anticoagulation [1-3], but there are some clinical situations in which this may not be sufficient, especially in the case of DCVT. Recently, endovascular treatment has become relevant in these cases, in particular mechanical thrombectomy (MT) [1-3, 5-6]. Anticoagulation therapy prevents thrombus growth or embolization, whereas MT allows rapid sinus recanalization [6]. According to current clinical guidelines [7], in patients presenting with altered mental status, coma, DCVT or intracranial haemorrhage, the risk of a fatal outcome is higher and endovascular treatment should be considered. We present two cases of DCVT refractory to anticoagulation therapy which were subjected to MT as a rescue treatment. Case Presentation Case 1: A 29-year-old woman with overweight and treatment with oral contraceptives (estrogen and gestagen) as a risk factors, seen in the emergency department because of headache, intracranial hypertension and diplopia. Physical examination revealed papilledema. A cerebral CT scan performed without contrast was normal. Lumbar puncture was carried out, with an opening pressure of 44 cmH 2 O (47 cmH 2 O after the Valsalva maneuver); cytobiochemistry of the cerebrospinal fluid was normal. The study was completed with cerebral MRI, which showed thrombosis of the sigmoid sinus and extension to the right transverse sinus (see Figure 1, image A for timeline scheme). The evolution was torpid, with worsening of the headache, mild right hemiparesis and bradylalia. CT scan was repeated, showing signs of CVT (Figure 2, image A). She was transferred to our centre, where anticoagulation with low molecular weight heparin at a dose of 1 mg/kg/12 h was started. After 12 hours she presented with impaired consciousness, global aphasia and right hemiparesis. An urgent electroencephalogram was performed, which ruled out a critical or post-critical neurological deficit. The TCD study showed hyperpulsatility and high resistance of both middle cerebral arteries, suggestive of severe intracranial hypertension, for which treatment was started with postural measures and mannitol. A complete analytical study was performed, in which only positive ANAs with a 1/160 speckled pattern (without evidence of underlying rheumatological pathology), a folic acid deficiency (1.1 ng/mL) and mild hyperhomocysteinemia (15.3 µmol/L) were detected, with the rest of the thrombophilia study being normal. The study was completed with cerebral arteriography, which showed large CVT with involvement of the sagittal and transverse sinuses and torcula, as well as involvement of the deep venous system (Figure 2, image B). MT was performed with manual and pump aspiration with Neuron MAX 0.88® and JET7® devices, as well as with a stent retriever (Trevo® 6 mm). A 4F diagnostic catheter was placed in the vertebral artery for successive diagnostic series. Cerebral venous circulation was accessed by puncture of the left internal jugular vein, placing a guide catheter in the sigmoid sinus and the beginning of the transverse sinus. Successive aspirative MT were performed on the left transverse dural sinus, right transverse sinus, superior sagittal sinus and with stent retriever in the rectus sinus (total passes: 6), removing large amount of clot. Final controls showed recovery of the deep venous drainage (Figure 2, images C-F). At 24 hours, the patient demonstrated complete neurological recovery. A control TCD study was performed, which showed reduced pulsatility and venous flow indices corresponding to deep venous system turbulence (vein of Rosenthal), which may it be suggestive of partial recanalization. Cerebral MRI was completed and revealed a patchy venous infarction with haemorrhagic transformation (Figure 2, images G and H). She was discharged with discontinuation of oral contraception, treatment with folic acid 5 mg/24 h and anticoagulation with acenocumarol. Case 2: A 25-year-old woman with polycystic ovary syndrome on treatment with an intravaginal contraceptive as a risk factors was seen in the emergency department for progressive headache, bradypsychia and generalised weakness. Physical examination revealed peripapillary haemorrhages in the ocular fundus, with no associated neurological deficits (see Figure 1, image B for timeline scheme). A non-contrast cranial CT scan was performed, which showed evidence of CVT (Figure 3, images A and B). Anticoagulation with intravenous sodium heparin was started. The patient's level of consciousness suddenly deteriorated after 24 h and she was transferred to our centre. Urgent cerebral arteriography was performed, which showed evidence of large CVT, again with DCVT (Figure 3, images C and D). MT was performed with Neuron MAX 0.88® and JET7® devices, as well as with a stent retriever (Tiger XL®) (Figure 3, images E-H). A 4F diagnostic catheter was placed in the right internal carotid artery for successive diagnostic series. Cerebral venous circulation was accessed by puncture of the right internal jugular vein by placing a guide catheter into the sigmoid sinus and the beginning of the transverse sinus. Successive aspirative MT were performed on the left transverse dural sinus, right transverse sinus, superior sagittal sinus, and with stent retriever in the rectus sinus (total passes: 6), removing again a large amount of clot. Final controls showed complete recanalization of the dural sinuses (Figure 4, images A and B). Cranial CT scan performed 24 h after MT showed no ischaemic or haemorrhagic complications. Neurological recovery was complete in the following days, with papilledema predominantly in the right eye and headache that improved with simple analgesia. As part of the etiological study, a complete blood analysis was performed, which only showed hypohomocysteinemia (2.1 µmol/L), the remainder being normal (including the thrombophilia study). The study was completed with cerebral MRI with angioMRI at 7 days, with no evidence of venous infarction and nearly complete recanalization of the venous system (Figure 4, images C-E). At discharge, oral contraception was suspended and treatment was started with folic acid 5 mg/24 h and anticoagulation with acenocoumarol. Discussion and conclusions: Classically, the gold standard treatment of CVT has been anticoagulation (preferably with low molecular weight heparins versus unfractionated [3]) for 3-12 months [1], regardless of the existence of associated intracranial haemorrhages, and this is still the recommendation of the current guidelines [7]. However, there are certain predictors of mortality in these patients in whom anticoagulation may not be sufficient [8]: rapid neurological deterioration despite anticoagulation, coma, intracranial haemorrhage, DCVT and posterior fossa involvement. In these patients, early endovascular treatment could be an adjuvant to anticoagulation, either by thrombolysis or by MT. Thrombolytic therapy (first applied in 1988 [3]) seems to have shown more limited efficacy in cases with high thrombus burden or extensive involvement of multiple venous sinuses, with MT allowing potentially faster recanalization [8]. In recent years, there has been growing scientific evidence for the use of MT in the treatment of CVT, especially in the above-mentioned scenarios. Multiple techniques have been used [3]: direct aspiration, use of stent retrievers, balloon-based MT, balloon and stent angioplasty, as well as different devices (AngioJetTM, PenumbraTM, MERCI retriever®, etc. [8]). To date, the largest clinical trial to assess the efficacy of endovascular treatment (both thrombolysis and MT) compared to medical treatment has been the TO-ACT trial [6]. The small sample size, as well as the fact that some currently available devices were under development at the time of the trial, may explain why it was stopped early, in part due to futility. Despite this, recanalization rates reported by different studies reach 70-90% [1]. To date, the optimal endovascular treatment in patients with CVT is not defined, and there are results for multiple devices used, with variable efficacies: stent retriever [9], stent retriever with direct aspiration [10], stent retriever with local thrombolysis [11], aspiration devices [5], AngioJetTM [8], balloon anchor with mobile aspiration [12], etc. Several systematic reviews have been conducted on the use of MT in the treatment of CVT and its comparison with medical treatment [5, 8, 13]. The results seen in all of these studies, in general (and similar to the TO-ACT trial [6]), conclude that medical treatment achieves better results in terms of functional independence and mortality, although this is a biased result: those patients who are referred to MT are those with a more severe clinical presentation at onset and greater thrombotic burden, with failure of anticoagulant treatment and rescued by MT [5], which inherently confers a worse prognosis [13]. Therefore, in cases refractory to anticoagulation therapy, with contraindications to anticoagulation [13], thrombus length >10 cm, superior sagittal sinus involvement [9] or pre-treatment intracerebral haemorrhage [5], MT would be an appropriate treatment. Regarding the use of endovascular devices, the current trend is to use stent retriever devices [8-11] as they can be used alone or as an anchor for a distal aspiration device [3] or in conjunction with local thrombolytic therapy [11]. In our case, we report two cases of MT for the treatment of CVT using stent retriever devices, one of which is the novel Tiger XL®, unreported to date for use in the treatment of venous thrombosis. Its adjustable diameter reduces resistance to thrombus removal and the continuous braiding reduces the risk of thrombus detachment during removal. Its length is 53 mm and its size is from 1.5-9 mm; we expanded it slow and progressively to its full size (9 mm). The functional outcome in our patients was excellent, with complete neurological recovery (modified Rankin Scale 0 at discharge) and virtually complete recanalization rates, indicating the safety and efficacy of these stent retriever devices. The main strength of this study is that it offers a therapeutic alternative to a potentially serious disease that significantly improves the functional prognosis of patients. The main limitation is that this is a series of only two cases performed in a short interval of time, so further studies are needed to establish which devices are most appropriate in this type of patient, as well as the exact indication for endovascular treatment. In conclusion, we present two cases of DCVT refractory to anticoagulation therapy and successfully treated by rescue MT with stent retriever devices, including the novel Tiger XL®. Anticoagulation is the first-line treatment in CVT. However, some situations predictive of poor functional prognosis such as DCVT with progressive neurological deterioration despite anticoagulation or the development of intracranial haemorrhage may require endovascular treatment with MT, with increasing evidence that it improves vital and functional prognosis. Abbreviations CVT: cerebral venous thrombosis; DCVT: deep cerebral venous thrombosis; TCD: transcranial Doppler; MT: mechanical thrombectomy. Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Consent for publication Informed onsent for publication was obtained for every individual person’s data included in the study. Availability of data and materials Not applicable. Competing interests The authors declare that they have no competing interests. Funding This study was not supported by any funding. Authors' contributions AMM, FHF, JDMN, BSS and TSM declare that everyone contribute equally on writing this manuscript. Acknowledgements Not applicable. References Silvis SM, de Sousa DA, Ferro JM, Coutinho JM. Cerebral venous thrombosis. Nat Rev Neurol . 2017;13(9):555-565. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med . 2005;352(17):1791-1798. Lee SK, Mokin M, Hetts SW, et al. Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg . 2018;10(8):803-810. Stolz EP. Role of ultrasound in diagnosis and management of cerebral vein and sinus thrombosis. Front Neurol Neurosci . 2008;23:112-121. Yeo LL, Lye PP, Yee KW, et al. Deep Cerebral Venous Thrombosis Treatment : Endovascular Case using Aspiration and Review of the Various Treatment Modalities. Clin Neuroradiol . 2020;30(4):661-670. Coutinho JM, Zuurbier SM, Bousser MG, et al. Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial. JAMA Neurol . 2020;77(8):966-973. Ferro JM, Bousser MG, Canhão P, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology. Eur J Neurol . 2017;24(10):1203-1213. Siddiqui FM, Dandapat S, Banerjee C, et al. Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases. Stroke . 2015;46(5):1263-1268. Peng T, Dan B, Zhang Z, Zhu B, Liu J. Efficacy of Stent Thrombectomy Alone or Combined With Intermediate Catheter Aspiration for Severe Cerebral Venous Sinus Thrombosis: A Case-Series. Front Neurol . 2022;12:783380. Lau KF, Toh TH, Kadir KAA, Tai MS, Tan KS. Mechanical Thrombectomy for Life-Threatening Cerebral Venous Thrombosis: A Case Report. Case Rep Neurol . 2020;12(Suppl 1):63-69. Wang Y, Zhao C, Huang D, Sun B, Wang Z. Stent retriever thrombectomy combined with long-term local thrombolysis for severe hemorrhagic cerebral venous sinus thrombosis. Exp Ther Med . 2020;20(5):66. Matsuda Y, Owai Y, Kakishita K, Nakao N. A novel combined approach using a Penumbra catheter and balloon catheter for cerebral venous sinus thrombosis. BMJ Case Rep . 2018;2018:bcr2017013730. Ilyas A, Chen CJ, Raper DM, et al. Endovascular mechanical thrombectomy for cerebral venous sinus thrombosis: a systematic review. J Neurointerv Surg . 2017;9(11):1086-1092. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3812095","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":263734445,"identity":"07ea5c85-d261-4024-9f10-16ba36ceaad6","order_by":0,"name":"Martínez Martín Álvaro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYDACdlQusxyIPPAAnxZmVBazMVhLAilaEhtAFD4t/M08hp8rKhii+WefP/bwZ451+vywww+BttjJ6TZg1yJxmMdY8swZhtwZ55LZDSS3peduvJ1mANSSbGx2AIc1h9kSJBvbGHIbzjCzSRhuO5y7cXYCSMuBxG04tMgfZkv+CdIyH6QlcdvhdMPZ6R/wajE4zHwMbMsGkJaD2w4nyEvn4LfFEKjFsuGMRO7GM8xmko3b0g03SOcUHEgwwO0XueONzTcbKmxy551hfCb5c5u1vPzs9M0fPlTYyeH0PgRIIDkVrNIAr3I0IN9AiupRMApGwSgYCQAAj1NeWiC+lSEAAAAASUVORK5CYII=","orcid":"","institution":"Complejo Hospitalario Universitario de Albacete","correspondingAuthor":true,"prefix":"","firstName":"Martínez","middleName":"Martín","lastName":"Álvaro","suffix":""},{"id":263734447,"identity":"f82e9943-fada-4567-8e68-4de79f1d6bdb","order_by":1,"name":"Hernández Fernández Francisco","email":"","orcid":"","institution":"Complejo Hospitalario Universitario de Albacete","correspondingAuthor":false,"prefix":"","firstName":"Hernández","middleName":"Fernández","lastName":"Francisco","suffix":""},{"id":263734449,"identity":"7e1b4ea2-fcad-47e3-92e0-17d6426c63cc","order_by":2,"name":"Molina Nuevo Juan David","email":"","orcid":"","institution":"Complejo Hospitalario Universitario de Albacete","correspondingAuthor":false,"prefix":"","firstName":"Molina","middleName":"Nuevo Juan","lastName":"David","suffix":""},{"id":263734451,"identity":"6f82a246-fb6e-47ac-8d0d-1900736cd8f9","order_by":3,"name":"Serrano Serrano Blanca","email":"","orcid":"","institution":"Complejo Hospitalario Universitario de Albacete","correspondingAuthor":false,"prefix":"","firstName":"Serrano","middleName":"Serrano","lastName":"Blanca","suffix":""},{"id":263734452,"identity":"cef50d62-9a87-46e4-b04e-3a8daf201437","order_by":4,"name":"Segura Tomás","email":"","orcid":"","institution":"Complejo Hospitalario Universitario de Albacete","correspondingAuthor":false,"prefix":"","firstName":"Segura","middleName":"","lastName":"Tomás","suffix":""}],"badges":[],"createdAt":"2023-12-27 11:59:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3812095/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3812095/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49083273,"identity":"814a7bf1-b35f-42a1-b73e-39c17eafdae2","added_by":"auto","created_at":"2024-01-02 20:22:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101937,"visible":true,"origin":"","legend":"\u003cp\u003etimeline scheme for case 1 (image A) and 2 (image B).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3812095/v1/fddcf21505f15ac245009ce8.jpg"},{"id":49082846,"identity":"bd6382f2-8cec-407d-bb56-5a9ae58a293d","added_by":"auto","created_at":"2024-01-02 20:14:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":110548,"visible":true,"origin":"","legend":"\u003cp\u003eimages obtained during the course of case 1. A: cerebral CT scan without intravenous contrast. CVT with hyperdensity of superior sagittal sinuses, straight sinus, vein of Galen and internal cerebral veins. B: selective right internal carotid arteriography, lateral view. Absence of the straight sinus and deep system due to thrombosis (arrow) and partial segmental thrombosis of the superior sagittal sinus. C: cerebral venography obtained by left internal jugular access, anteroposterior view. Recanalization of left transverse-sigmoid sinuses is evident after manual and pump aspiration through Neuron MAX 0.88® and JET7®. D and E: Selective left internal carotid arteriography cerebral arteriography in venous phase, anteroposterior (D) and lateral (E) view. Repermeabilization of the previously occluded sinuses can be seen, with residual partial thrombosis persisting at the torcula. F: selective left vertebral arteriography lateral view. Recovery of deep venous drainage. G and H: brain MRI, diffusion weighted images. Multiple signal alterations with diffusion restriction affecting bilateral basal ganglia, right thalamus and supratentorial white matter, compatible with venous infarcts.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3812095/v1/aa36c0586299bc30ade310b9.jpg"},{"id":49082845,"identity":"fc98d559-133d-46ba-9fa9-dd69f1faf88d","added_by":"auto","created_at":"2024-01-02 20:14:51","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":90988,"visible":true,"origin":"","legend":"\u003cp\u003eimages obtained during the course of case 2. A and B: cerebral CT scan without intravenous contrast. There is evidence of hyperdensity at the right transverse venous sinus, rectus sinus and superior sagittal sinus due to acute thrombosis. C and D: selective right internal carotid arteriography in venous phase, anteroposterior (C) and lateral (D) view. Multiple repletion defects are evident in both transverse sinuses, torcula, superior sagittal sinus, rectus sinus and deep cerebral venous system, secondary to thrombosis. E-H: cerebral venography obtained by left internal jugular access, MT. E: lateral view. Occlusion of the right transverse sinus. F: anteroposterior view. Recanalization of the right transverse sinus after endovascular treatment. G: lateral view. Occlusion of the rectus sinus is seen. H: lateral image view. Microcatheter is advanced through the rectus sinus prior to recanalization by stent retriever.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3812095/v1/a84b013fe8197f45ed2406c6.jpg"},{"id":49082847,"identity":"1b01dc56-0c61-423a-a788-8fa05bab4d53","added_by":"auto","created_at":"2024-01-02 20:14:51","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":99365,"visible":true,"origin":"","legend":"\u003cp\u003eimages obtained during the course of case 2. A and B: selective right internal carotid arteriography in venous phase, lateral views. A: pre-MT image. B: post-MT image. Recanalization of the rectus sinus, torcula, superior sagittal sinus and both transverse sinuses is seen. C-E: brain MRI performed 7 days after MT. C: 2D-TOF MRI angiography, sagittal view. Shows the complete recovery of the venous system. D: DWI sequence. No acute ischaemic lesions are evident. E: FLAIR sequence. No images suggestive of residual ischaemic or haemorrhagic pathology are seen.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3812095/v1/e96267e4ba1e86c10a872bf1.jpg"},{"id":62616366,"identity":"4737f41c-ef0e-4377-b7b0-4fa7744c7de4","added_by":"auto","created_at":"2024-08-16 13:14:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":694754,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3812095/v1/f697ec5e-c083-463c-bddf-62b088c55df3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case report: Mechanical thrombectomy using stent retriever devices in deep cerebral venous thrombosis. When anticoagulation fails","fulltext":[{"header":"Background","content":"\u003cp\u003eCerebral venous thrombosis (CVT) is a rare cause of stroke,\u0026nbsp;ocurring\u0026nbsp;especially in young adults and females [1]. This higher incidence in females is related to risk factors involved in its pathophysiology, such as pregnancy, puerperium and contraceptive use [1]. Its clinical presentation is broad, ranging from mild manifestations such as headache to the more severe such as coma [2]. This diverse form of presentation makes it necessary to maintain a high level of diagnostic suspicion to avoid diagnostic delay, which can be deleterious for the patient, both in terms of morbidity and mortality [3]. Involvement of the deep cerebral venous system (DCVT) increases morbidity and mortality in these patients, with an increased risk of both venous infarction and haemorrhagic transformation [4]. Diagnosis is based on neuroimaging using brain CT and/or MRI, with or without the use of specific venography sequences [1-3]. Use of transcranial Doppler (TCD) has been proposed as an alternative to diagnosis and even during the follow-up of CVT, as it allows the assessment of haemodynamic factors (unlike angioCT or angioMRI) that could have an implication on the functional prognosis of patients. However, currently it is not clear whether TCD can play a useful role in monitoring and steering anticoagulation treatment in CVT [4].\u003c/p\u003e\n\u003cp\u003eThe classical therapeutic approach to CVT is based on anticoagulation [1-3], but there are some clinical situations in which this may not be sufficient, especially in the case of DCVT. Recently, endovascular treatment has become relevant in these cases, in particular mechanical thrombectomy (MT) [1-3, 5-6]. Anticoagulation therapy prevents thrombus growth or embolization, whereas MT allows rapid sinus recanalization [6]. According to current clinical guidelines [7], in patients presenting with altered mental status, coma, DCVT or intracranial haemorrhage, the risk of a fatal outcome is higher and endovascular treatment should be considered.\u003c/p\u003e\n\u003cp\u003eWe present two cases of DCVT refractory to anticoagulation therapy which were subjected to MT as a rescue treatment.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eCase 1:\u003c/p\u003e\n\u003cp\u003eA 29-year-old woman with overweight and treatment with oral contraceptives (estrogen and gestagen) as a risk factors, seen in the emergency department because of headache, intracranial hypertension and diplopia. Physical examination revealed papilledema. A cerebral CT scan performed without contrast was normal. Lumbar puncture was carried out, with an opening pressure of 44 cmH\u003csub\u003e2\u003c/sub\u003eO (47 cmH\u003csub\u003e2\u003c/sub\u003eO after the Valsalva maneuver); cytobiochemistry of the cerebrospinal fluid was normal. The study was completed with cerebral MRI, which showed thrombosis of the sigmoid sinus and extension to the right transverse sinus (see Figure 1, image A for timeline scheme).\u003c/p\u003e\n\u003cp\u003eThe evolution was torpid, with worsening of the headache, mild right hemiparesis and bradylalia. CT scan was repeated, showing signs of CVT (Figure 2, image A). She was transferred to our centre, where anticoagulation with low molecular weight heparin at a dose of 1 mg/kg/12 h was started. After 12 hours she presented with impaired consciousness, global aphasia and right hemiparesis. An urgent electroencephalogram was performed, which ruled out a critical or post-critical neurological deficit. The TCD study showed hyperpulsatility and high resistance of both middle cerebral arteries, suggestive of severe intracranial hypertension, for which treatment was started with postural measures and mannitol. A complete analytical study was performed, in which only positive ANAs with a 1/160 speckled pattern (without evidence of underlying rheumatological pathology), a folic acid deficiency (1.1 ng/mL) and mild hyperhomocysteinemia (15.3 \u0026micro;mol/L) were detected, with the rest of the thrombophilia study being normal.\u003c/p\u003e\n\u003cp\u003eThe study was completed with cerebral arteriography, which showed large CVT with involvement of the sagittal and transverse sinuses and torcula, as well as involvement of the deep venous system (Figure 2, image B). MT was performed with manual and pump aspiration with Neuron MAX 0.88\u0026reg; and JET7\u0026reg; devices, as well as with a stent retriever (Trevo\u0026reg; 6 mm). A 4F diagnostic catheter was placed in the vertebral artery for successive diagnostic series. Cerebral venous circulation was accessed by puncture of the left internal jugular vein, placing a guide catheter in the sigmoid sinus and the beginning of the transverse sinus. Successive aspirative MT were performed on the left transverse dural sinus, right transverse sinus, superior sagittal sinus and with stent retriever in the rectus sinus (total passes: 6), removing large amount of clot. Final controls showed recovery of the deep venous drainage (Figure 2, images C-F). At 24 hours, the patient demonstrated complete neurological recovery. A control TCD study was performed, which showed reduced pulsatility and venous flow indices corresponding to deep venous system turbulence (vein of Rosenthal), which may it be suggestive of partial recanalization. Cerebral MRI was completed and revealed a patchy venous infarction with haemorrhagic transformation (Figure 2, images G and H). She was discharged with discontinuation of oral contraception, treatment with folic acid 5 mg/24 h and anticoagulation with acenocumarol.\u003c/p\u003e\n\u003cp\u003eCase 2:\u003c/p\u003e\n\u003cp\u003eA 25-year-old woman with polycystic ovary syndrome on treatment with an intravaginal contraceptive as a risk factors was seen in the emergency department for progressive headache, bradypsychia and generalised weakness. Physical examination revealed peripapillary haemorrhages in the ocular fundus, with no associated neurological deficits (see Figure 1, image B for timeline scheme). A non-contrast cranial CT scan was performed, which showed evidence of CVT (Figure 3, images A and B). Anticoagulation with intravenous sodium heparin was started. The patient\u0026apos;s level of consciousness suddenly deteriorated after 24 h and she was transferred to our centre.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUrgent cerebral arteriography was performed, which showed evidence of large CVT, again with DCVT (Figure 3, images C and D). MT was performed with Neuron MAX 0.88\u0026reg; and JET7\u0026reg; devices, as well as with a stent retriever (Tiger XL\u0026reg;) (Figure 3, images E-H). A 4F diagnostic catheter was placed in the right internal carotid artery for successive diagnostic series. Cerebral venous circulation was accessed by puncture of the right internal jugular vein by placing a guide catheter into the sigmoid sinus and the beginning of the transverse sinus. Successive aspirative MT were performed on the left transverse dural sinus, right transverse sinus, superior sagittal sinus, and with stent retriever in the rectus sinus (total passes: 6), removing again a large amount of clot. Final controls showed complete recanalization of the dural sinuses (Figure 4, images A and B). Cranial CT scan performed 24 h after MT showed no ischaemic or haemorrhagic complications. Neurological recovery was complete in the following days, with papilledema predominantly in the right eye and headache that improved with simple analgesia. As part of the etiological study, a complete blood analysis was performed, which only showed hypohomocysteinemia (2.1 \u0026micro;mol/L), the remainder being normal (including the thrombophilia study). The study was completed with cerebral MRI with angioMRI at 7 days, with no evidence of venous infarction and nearly complete recanalization of the venous system (Figure 4, images C-E). At discharge, oral contraception was suspended and treatment was started with folic acid 5 mg/24 h and anticoagulation with acenocoumarol.\u003c/p\u003e"},{"header":"Discussion and conclusions:","content":"\u003cp\u003eClassically, the gold standard treatment of CVT has been anticoagulation (preferably with low molecular weight heparins versus unfractionated [3]) for 3-12 months [1], regardless of the existence of associated intracranial haemorrhages, and this is still the recommendation of the current guidelines [7]. However, there are certain predictors of mortality in these patients in whom anticoagulation may not be sufficient [8]: rapid neurological deterioration despite anticoagulation, coma, intracranial haemorrhage, DCVT and posterior fossa involvement. In these patients, early endovascular treatment could be an adjuvant to anticoagulation, either by thrombolysis or by MT. Thrombolytic therapy (first applied in 1988 [3]) seems to have shown more limited efficacy in cases with high thrombus burden or extensive involvement of multiple venous sinuses, with MT allowing potentially faster recanalization [8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn recent years, there has been growing scientific evidence for the use of MT in the treatment of CVT, especially in the above-mentioned scenarios. Multiple techniques have been used [3]: direct aspiration, use of stent retrievers, balloon-based MT, balloon and stent angioplasty, as well as different devices (AngioJetTM, PenumbraTM, MERCI retriever\u0026reg;, etc. [8]). To date, the largest clinical trial to assess the efficacy of endovascular treatment (both thrombolysis and MT) compared to medical treatment has been the TO-ACT trial [6]. The small sample size, as well as the fact that some currently available devices were under development at the time of the trial, may explain why it was stopped early, in part due to futility. Despite this, recanalization rates reported by different studies reach 70-90% [1].\u003c/p\u003e\n\u003cp\u003eTo date, the optimal endovascular treatment in patients with CVT is not defined, and there are results for multiple devices used, with variable efficacies: stent retriever [9], stent retriever with direct aspiration [10], stent retriever with local thrombolysis [11], aspiration devices [5], AngioJetTM [8], balloon anchor with mobile aspiration [12], etc. Several systematic reviews have been conducted on the use of MT in the treatment of CVT and its comparison with medical treatment [5, 8, 13]. The results seen in all of these studies, in general (and similar to the TO-ACT trial [6]), conclude that medical treatment achieves better results in terms of functional independence and mortality, although this is a biased result: those patients who are referred to MT are those with a more severe clinical presentation at onset and greater thrombotic burden, with failure of anticoagulant treatment and rescued by MT [5], which inherently confers a worse prognosis [13]. Therefore, in cases refractory to anticoagulation therapy, with contraindications to anticoagulation [13], thrombus length \u0026gt;10 cm, superior sagittal sinus involvement [9] or pre-treatment intracerebral haemorrhage [5], MT would be an appropriate treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the use of endovascular devices, the current trend is to use stent retriever devices [8-11] as they can be used alone or as an anchor for a distal aspiration device [3] or in conjunction with local thrombolytic therapy [11]. In our case, we report two cases of MT for the treatment of CVT using stent retriever devices, one of which is the novel Tiger XL\u0026reg;, unreported to date for use in the treatment of venous thrombosis. Its adjustable diameter reduces resistance to thrombus removal and the continuous braiding reduces the risk of thrombus detachment during removal. Its length is 53 mm and its size is from 1.5-9 mm; we expanded it slow and progressively to its full size (9 mm). The functional outcome in our patients was excellent, with complete neurological recovery (modified Rankin Scale 0 at discharge) and virtually complete recanalization rates, indicating the safety and efficacy of these stent retriever devices.\u003c/p\u003e\n\u003cp\u003eThe main strength of this study is that it offers a therapeutic alternative to a potentially serious disease that significantly improves the functional prognosis of patients. The main limitation is that this is a series of only two cases performed in a short interval of time, so further studies are needed to establish which devices are most appropriate in this type of patient, as well as the exact indication for endovascular treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, we present two cases of DCVT refractory to anticoagulation therapy and successfully treated by rescue MT with stent retriever devices, including the novel Tiger XL\u0026reg;. Anticoagulation is the first-line treatment in CVT. However, some situations predictive of poor functional prognosis such as DCVT with progressive neurological deterioration despite anticoagulation or the development of intracranial haemorrhage may require endovascular treatment with MT, with increasing evidence that it improves vital and functional prognosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCVT: cerebral venous thrombosis; DCVT: deep cerebral venous thrombosis; TCD: transcranial Doppler; MT: mechanical thrombectomy.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed onsent for publication was obtained for every individual person\u0026rsquo;s data included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAMM, FHF, JDMN, BSS and TSM declare that everyone contribute equally on writing this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSilvis SM, de Sousa DA, Ferro JM, Coutinho JM. Cerebral venous thrombosis. \u003cem\u003eNat Rev Neurol\u003c/em\u003e. 2017;13(9):555-565. \u003c/li\u003e\n\u003cli\u003eStam J. Thrombosis of the cerebral veins and sinuses. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2005;352(17):1791-1798. \u003c/li\u003e\n\u003cli\u003eLee SK, Mokin M, Hetts SW, et al. Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. \u003cem\u003eJ Neurointerv Surg\u003c/em\u003e. 2018;10(8):803-810. \u003c/li\u003e\n\u003cli\u003eStolz EP. Role of ultrasound in diagnosis and management of cerebral vein and sinus thrombosis. \u003cem\u003eFront Neurol Neurosci\u003c/em\u003e. 2008;23:112-121.\u003c/li\u003e\n\u003cli\u003eYeo LL, Lye PP, Yee KW, et al. Deep Cerebral Venous Thrombosis Treatment : Endovascular Case using Aspiration and Review of the Various Treatment Modalities. \u003cem\u003eClin Neuroradiol\u003c/em\u003e. 2020;30(4):661-670. \u003c/li\u003e\n\u003cli\u003eCoutinho JM, Zuurbier SM, Bousser MG, et al. Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial. \u003cem\u003eJAMA Neurol\u003c/em\u003e. 2020;77(8):966-973. \u003c/li\u003e\n\u003cli\u003eFerro JM, Bousser MG, Canh\u0026atilde;o P, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology. \u003cem\u003eEur J Neurol\u003c/em\u003e. 2017;24(10):1203-1213. \u003c/li\u003e\n\u003cli\u003eSiddiqui FM, Dandapat S, Banerjee C, et al. Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases. \u003cem\u003eStroke\u003c/em\u003e. 2015;46(5):1263-1268. \u003c/li\u003e\n\u003cli\u003ePeng T, Dan B, Zhang Z, Zhu B, Liu J. Efficacy of Stent Thrombectomy Alone or Combined With Intermediate Catheter Aspiration for Severe Cerebral Venous Sinus Thrombosis: A Case-Series. \u003cem\u003eFront Neurol\u003c/em\u003e. 2022;12:783380. \u003c/li\u003e\n\u003cli\u003eLau KF, Toh TH, Kadir KAA, Tai MS, Tan KS. Mechanical Thrombectomy for Life-Threatening Cerebral Venous Thrombosis: A Case Report. \u003cem\u003eCase Rep Neurol\u003c/em\u003e. 2020;12(Suppl 1):63-69. \u003c/li\u003e\n\u003cli\u003eWang Y, Zhao C, Huang D, Sun B, Wang Z. Stent retriever thrombectomy combined with long-term local thrombolysis for severe hemorrhagic cerebral venous sinus thrombosis. \u003cem\u003eExp Ther Med\u003c/em\u003e. 2020;20(5):66. \u003c/li\u003e\n\u003cli\u003eMatsuda Y, Owai Y, Kakishita K, Nakao N. A novel combined approach using a Penumbra catheter and balloon catheter for cerebral venous sinus thrombosis. \u003cem\u003eBMJ Case Rep\u003c/em\u003e. 2018;2018:bcr2017013730. \u003c/li\u003e\n\u003cli\u003eIlyas A, Chen CJ, Raper DM, et al. Endovascular mechanical thrombectomy for cerebral venous sinus thrombosis: a systematic review. \u003cem\u003eJ Neurointerv Surg\u003c/em\u003e. 2017;9(11):1086-1092. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cerebral venous thrombosis, endovascular treatment, mechanical thrombectomy, stent retriever","lastPublishedDoi":"10.21203/rs.3.rs-3812095/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3812095/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTreatment of cerebral venous thrombosis has traditionally been based on anticoagulant therapy. However, in certain circumstances, such as deep cerebral venous thrombosis, anticoagulation may be insufficient, so endovascular treatment by mechanical thrombectomy has been used for some years. There is currently no clear indication of which device is the gold standard in the endovascular treatment of cerebral venous thrombosis, although stent retriever devices are the most commonly used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe describe two cases of deep cerebral venous thrombosis refractory to anticoagulant treatment treated by mechanical thrombectomy with stent retriever devices, one of which has not been described to date as being used in the treatment of cerebral venous thrombosis (Tiger XL®).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome situations in like deep cerebral venous thrombosis may require endovascular treatment with mechanical thrombectomy if anticoagulation fails, with increasing evidence that it improves vital and functional prognosis.\u003c/p\u003e","manuscriptTitle":"Case report: Mechanical thrombectomy using stent retriever devices in deep cerebral venous thrombosis. When anticoagulation fails","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-02 20:14:47","doi":"10.21203/rs.3.rs-3812095/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"625418e3-d735-4172-a33f-bedc37e7ece4","owner":[],"postedDate":"January 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-16T13:06:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-02 20:14:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3812095","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3812095","identity":"rs-3812095","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}