Urokinase treatment of sagittal sinus thrombosis with venous hemorrhagic infarction

Selective catheterization of the dural venous sinuses with local infusion of urokinase may be beneficial in patients with venous sinus thrombosis, and has been reported to be safe in patients with venous infarction. However, information regarding safety in the presence of hemorrhage is sparse.

Three patients presented with severe, progressive focal neurological symptoms (National Institutes of Health Stroke Scales: 14, 22, and 12) resulting from superior sagittal sinus thrombosis, with evidence of hemorrhage on computed tomographic scans (two intraparenchymal, one subarachnoid). Selective venous catheterization was performed and low-dose urokinase was delivered directly into the thrombus by continuous infusion at 60,000 U/h. Intravenous heparin was administered concurrently.

Angiographic patency was restored in all patients. The total duration of urokinase infusion ranged from 36 to 84 hours. There was no major morbidity or mortality related to the procedure. All patients had dramatic clinical improvement during and after the course of therapy, and none had worsening of pre-existing hemorrhage. All patients were independent at 3 months, with minimal or no deficit (National Institutes of Health Stroke Scales: 2, 0, and 2).

In selected patients with superior sagittal sinus thrombosis associated with venous hemorrhagic infarction, urokinase appears to be safe and may reverse progressive neurological deterioration. Future prospective study is warranted to further investigate this treatment option, and patients with severe deficits or pre-existing hemorrhages should not be excluded.