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Proceedings SNO “Percorsi clinici in Neuroscienze”

moid sinus and left jugular vein thrombosis were Heparin (unfractioned for 8 days, then LMWH) was
found; occlusion of P3 segment of the left posterior carried on.
cerebral artery was present, with hypoperfusion of An extensive panel of laboratory tests was performed
basal nuclei of both sides, in the left temporo.occipi- to exclude genetic ematological factors: only MTHFR
tal region and in the cranial part of cerebellar verme. mutation C677T was detected.
Anticoagulant therapy (LMWH) was introduced and Because of early stage of pregnancy, imaging evalua-
after collegial discussion, she underwent to tradition- tions were no more performed until pre-partum RM
al angiography: occlusion of Galen vein, straight si- with MR angiography:
nus, left transversus-sigmoid sinus, left jugular vein Elective caesarean section was decided and a fine girl
were confirmed, with venous stasis in bilateral tem- was born. LWMH was replaced with oral anticoagu-
poro-occipital and nucleo-talamo-capsular regions. lant therapy until 1 year from onset symptoms.
Venous thrombectomy was performed, using both One MR was obtained after 3 months, showing nor-
thromboaspiration and stent retriver use. Left internal mal features.
jugular vein, left sigmoid and transversus sinus, The therapy was stopped and at follow-up (18 months
straight sinus were recanalizated, while only partial from CVT onset) the patient was fine.
recanalization of Galen vein was obtained. The glob-
al venous drainage in brain was better at control im-
aging after EVT. Neurological examination on ad- DISCUSSION
mission to Stroke Unit was improved with NIHSS 9.
An extensive panel of laboratory and imaging tests Cerebral venous thrombosis is a condition with a po-
was performed to exclude malignancy and infections. tentially fatal outcome. Standard treatment for CVT
Heparin therapy was continued and progressive im- is systemic anticoagulation with heparin (unfraction-
aging and neurological improvement were achieved ated or low-molecular-weight heparin) at therapeutic
(NIHSS 6), with discharge to rehabilitation facility. dosage, even in patients with an ICH at baseline.

■ ■ Case 2. A 34 years old woman was admitted to However, a subset of patients does not respond to
emergency room because of worsening headache (on- standard medical therapy, leading to progression of
set 10 days before) with nausea and vomiting, CVT with ischemic and hemorrhagic stroke, cerebral
psycho-motor slow functions and left hemiparesis edema, mass effect, and death.
(which begun a few hours earlier). The patient was Endovascular options, including intra-arterial appli-
12nd-13rd weeks pregnant. No previous illness was cation of thrombolytic agents and/or mechanical
reported. She had 3 sons, without problem during thrombectomy, for patients with neurological deterio-
previous pregnancies. Because of her factor risks, a ration refractory to anticoagulation therapy or with
CVT was suspected and with patient’s and her hu- development of new or worsening ICH on anticoagu-
sband’s consensus, CT scan was performed: superior lation have been described over last 2 decades with
longitudinal sinus, straight sinus and right transversus heterogeneous results. Among these, thrombectomy
sinus appeared hyperdense, suggesting thrombosis in techniques vary, including aspiration, stent retriever
these venous sinus. Imaging of cerebral arteries and thrombectomy, direct catheter thrombolysis, balloon-
veins was obtained, confirming the thrombosis. assisted thrombectomy, and rheolytic catheter
Considering rapid worsening of neurological status, thrombectomy.
traditional angiography was performed to allow ve- In the only randomized study about EVT in CVT, the
nous thrombectomy. Thromboaspiration was per- TO-ACT trial, EVT along with medical care did not
formed in the right jugular vein and sigmoid sinus, in appear to be superior to medical care only in patients
the right transversus sinus, in torcular, in straight si- with a severe form of CVT. Because of the small
nus and in superior sagittal sinus; stent retriver was sample size, the authors cannot exclude the possibili-
needed to remove thrombus in the right transversus ty that future studies, using other methods of patient
sinus. Thrombospiration in Galen vein was perfor- selection and endovascular techniques, may identify
med. The final angiographic imaging showed good better recovery rates after EVT for patients with se-
recanalization in the treated veins. vere CVT.
The patient was observed in NeuroIntensive Care Coma or mental status disorder, thrombosis of the
Unit for a few hours and then she was admitted to deep venous system, number of thrombotic venous
Stroke Unit, with normal neurological examination. sinus and ICH on baseline computed tomography was

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