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Published on: October 15, 2021
Dual-Stent retriever thrombectomy for extensive dural sinus thrombosis
Stefano H Byer1, E John Madarang2, Michael G Abraham1,2
1Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA.
Insights
Dual stent-retrievers effectively treated cerebral venous thrombosis (CVT) in two young females. This dual stent-retriever technique offers a promising approach for endovascular thrombectomy (EVT) in complex CVT cases.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Vascular Surgery
Background:
- Cerebral venous thrombosis (CVT) typically requires systemic anticoagulation.
- Endovascular thrombectomy (EVT) is indicated for severe CVT with elevated intracranial pressure.
- Limited treatment options exist for complex CVT cases involving large dural sinuses.
Observation:
- Two young female patients presented with severe CVT affecting major dural sinuses.
- Imaging confirmed extensive thrombosis in the superior sagittal sinus, transverse sinuses, sigmoid sinuses, and internal jugular veins.
- Standard EVT with a single stent-retriever was not explicitly detailed as attempted prior to the dual-retriever approach.
Findings:
- A novel technique utilizing dual stent-retrievers was employed for EVT in both patients.
- The dual stent-retriever approach achieved significant recanalization of the occluded cerebral venous sinuses.
- This method was adapted from successful applications in arterial stroke interventions.
Implications:
- Dual stent-retrievers may enhance recanalization efficiency in large-diameter dural sinuses compared to single devices.
- This technique could potentially reduce procedure time and radiation exposure in complex EVT for CVT.
- Further research is warranted to validate the safety and efficacy of dual stent-retrievers in a larger CVT patient cohort.
Introduction:
First line treatment for cerebral venous thrombosis (CVT) is systemic anticoagulation. In cases with symptoms of elevated ICP, endovascular thrombectomy (EVT) is pursued. We describe two cases in which dual stent-retrievers were used for EVT.
Objectives:
The use of dual stent-retrievers has been described in arterial stroke when clot is present in the M1 artery and both M2 branches as a rescue therapy after 1 stent-retriever failed to remove the clot. We applied this same thinking to our EVT patients.
Methods:
A 17-year-old female with imaging demonstrating occlusion of the superior sagittal sinus (SSS), dominant right transverse sinus (TS), right sigmoid sinus (SS), and upper right internal jugular vein (IJV). A 20-year-old female with a magnetic resonance venography (MRV) noting CVT in the dominant lateral left TS, SS, and upper left IJV.
Results:
Both were taken for EVT due to severity of symptoms. Two 6 × 40 mm stent-retrievers were deployed into the CVT and then remove with continuous aspiration with significant recanalization.
Conclusions:
The average diameter of the dural sinuses is 8 mm compared to the average size of the middle cerebral artery 3-4 mm. The largest available SR in the United States is 6 mm, and the largest outer diameter of available aspiration catheters is 2-3 mm. Due to the larger size of the dural sinuses, using two SRs can result in more efficient recanalization and less radiation.
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