Endovascular thrombectomy and thrombolysis for severe cerebral sinus thrombosis - A prospective study

Background and Purpose-Most patients with cerebral sinus thrombosis (CST) recover after treatment with heparin, but a subgroup has a poor prognosis. Those patients may benefit from endovascular thrombolysis. Methods-Prospective case series. Patients with sinus thrombosis were selected for thrombolysis if they had an altered mental status, coma, straight sinus thrombosis, or large space-occupying lesions. Urokinase was infused into the sinuses (bolus 120 to 600 x 10(3) U; then 100 x 10(3) U/ h) via a jugular catheter, in 15 cases combined with mechanical thrombus disruption or removal. Results-We treated 20 patients (16 women), mean age 32 years. Twelve patients were comatose and 14 had hemorrhagic infarcts before thrombolysis. Twelve patients recovered (Rankin score 0 to 2), 2 survived with handicaps, and 6 died. Factors associated with a fatal outcome were leukemia (3/6 versus 0/14, P = 0.02) and large hemorrhagic infarcts (4/6 versus 2/14, P = 0.04). Seizures were less frequent in the fatal cases (P = 0.05). Patients who died had a larger mean lesion surface than survivors (30.5 versus 13.6 cm2; P = 0.03), larger midline shift (5.2 versus 1.7 mm; P = 0.02), and a more rapid course (2.7 versus 8.2 days; P = 0.01). Five patients who died had large hemispheric infarcts and edema before thrombolysis, causing herniation. Five patients had increased cerebral hemorrhage (3 minor, 2 major) after thrombolysis. Conclusions-Thrombolysis can be effective for severe sinus thrombosis, but patients may deteriorate because of increased cerebral hemorrhage. Patients with large infarcts and impending herniation did not benefit.