U.K, 2 November 2021, Cleaver et al, Journal of Neurointerventional Surgery
Patient records from 1 January 2021 to 20 July 2021 identified three patients who underwent endovascular treatment for CVST in the context of VITT. All were female and the median age was 52 years. The location of the CVST was highly variable. Two-thirds of the patients had multifocal dural sinus thromboses (sigmoid, transverse, straight and superior sagittal) as well as internal jugular vein thromboses. Intracerebral hemorrhage occurred in all patients; subarachnoid blood was noted in two of them, and intraparenchymal hemorrhage occurred in all. There was one periprocedural parenchymal extravasation which abated on temporary cessation of anticoagulation.
Case 1. Non-contrast axial computed tomography (CT) imaging demonstrating bilateral paracentral parenchymal hemorrhage and edema (A). Sagittal CT venography demonstrating occlusion of the anterior two-thirds of the superior sagittal sinus (SSS) (B, arrowheads). Lateral projection venous phase angiography following right internal carotid artery (ICA) injection showing occlusion of the anterior two-thirds of the SSS (C, arrowheads). Lateral fluoroscopic image showing positioning of the JET7 aspiration catheter (Penumbra) in the SSS (D, arrowhead). Lateral projection venous phase angiography following right ICA injection demonstrating partial recanalization of the middle third of the SSS (E, arrowheads). Completion subtraction Dyna CT venography demonstrating partial recanalization of the SSS (F, arrowheads). Follow-up CT venographic imaging on day 9 of admission showed a patent SSS (G, arrowheads).
Case 2. Initial axial non-contrast computed tomography (CT) head (A) and axial CT venogram (B) demonstrating parenchymal hemorrhage and edema in the left temporal lobe and left transverse and sigmoid sinus occlusion (arrowheads), respectively. Repeat axial CT imaging 24 hours later (C) demonstrating left temporal hematoma expansion. Repeat sagittal CT venography demonstrating progression with occlusion of the straight sinus (D, arrowheads). Left internal carotid artery (ICA) angiography in the venous phase demonstrating occlusion of the left transverse and sigmoid sinus and straight sinus (E, arrowheads). Frontal venography demonstrating a large left jugular bulb thrombus protruding into the left internal jugular vein (F, arrowheads). Axial on-table Dyna CT demonstrating a small contrast extravasation at the superior aspect of the hematoma (G). Left ICA angiography in the venous phase post-thrombectomy demonstrating recanalization (H, arrowheads). Sagittal CT venography preformed after endovascular traeatment on day 4 of admission demonstrating patency of the straight sinus (I, arrowheads).
Case 3. Initial non-contrast axial computed tomography of the head (CT-head) demonstrating bilateral frontal lobe edema with subarachnoid hemorrhage over both convexities (A). Axial CT imaging following generalized seizure demonstrating new right frontal parenchymal hemorrhage (B). On table sagittal Dyna CT venogram confirmed superior sagittal sinus (SSS) occlusion prior to endovascular treatment (C, arrowheads). Frontal venographic image following right internal jugular vein (IJV) injection showing large right jugular bulb thrombus projecting into the right IJV (D, arrowheads). Lateral projection venous phase angiography following right internal carotid artery (ICA) injection showing occlusion of the SSS (E, arrowheads). Frontal (F) and lateral (G) fluoroscopic imaging showing positioning of the stent-retriever in the SSS (black arrowheads), to track an aspiration catheter to target (white arrowhead), supported by distal guide-sheath positioning in the transverse sinus (outlined white arrowhead). Completion sagittal Dyna CT venography demonstrating partial SSS recanalization (H, arrowheads). Axial CT imaging on day 9 showed stable, maturing right frontal hemorrhage (I).