Article Figures & Data
Figures
- Fig 1.
Four axial FLAIR MR images during hospitalization (A,B) and 12 weeks after (C,D) hospitalization for DVST. Multifocal FLAIR signal intensity abnormality in the frontal and parietal lobes (A,B) is attributed to nonhemorrhagic venous infarction because of SSS and cortical vein thrombosis. After treatment and maturation of cortical venous collaterals, only minimal signal intensity abnormality remains in this neurologically intact patient.
- Fig 2.
Oblique frontal angiogram (A) demonstrates segmental visualization of the SSS and no significant opacification of the right TS and proximal SS because of DVST (arrows). Balloon thrombectomy (B, C) of the SSS and right TS was performed, and after 5 days of intrasinus heparin infusion, a frontal angiogram (D) demonstrates near-complete flow restoration with only minimal residual filling defect (arrows; D) in the right TS.
- Fig 3.
Three sequential axial gradient-recalled echo images (A-C) demonstrate characteristic “blooming” of SSS and cortical vein thrombosis (tarantula sign). Axial FLAIR image (D) shows swelling of the left frontal and parietal gyri with increased signal intensity in the adjacent sulci attributed to venous congestion.
- Fig 4.
Frontal oblique and lateral angiographic views (A,B) demonstrate extensive SSS, torcular, and TS filling defects in keeping with DVST. After balloon thrombectomy and 7 days of intrasinus heparin infusion, despite only minimal recanalization of the SSS, robust cortical venous flow (arrows; C,D) is evident in this neurologically intact patient. Note recanalization of the TS and SS.
Tables
- Table 1:
Summary data for 16 patients undergoing intrasinus catheter–directed heparin infusion
Pt No. Pt Age/Sex Clinical Presentation Site of Thrombosis Site of Access Infusion Catheter/Wire Duration of Infusion (days) Ancillary Reperfusion Techniques Final Angiographic Result Complications Last Clinical Follow-up 1 76 yo M Rt sided paresthesias, TIA SSS CFV CM 7 SAC, systemic and local changed to argatroban day 3 PR SSS, development of cortical and diploic collaterals HIT mRS = 0 2 51 yo F HA, seizure SSS, Lt TS, SS, IJV IJV CM 2 BT PR SSS-IJV None mRS = 6* 3 48 yo M Lt arm numbness, seizure SSS CFV KW 4 SAC PR SSS None mRS = 0 4 40 yo M HA, fever, meningismus SSS, TS IJV CM 5 SAC, BT PR SSS-TS None mRS = 1 5 38 yo M HA SSS, Bilat TS, StS, vL IJV CM 2 BT PR TS and StS None mRS = 0 6 27 yo F HA Rt TS stenosis, non-occlusive CFV CM 3 SAC Smooth stenosis; no clot None mRS = 0 7 25 yo F HA, seizure SSS, Rt TS, SS, IJV, Bilat cortical veins IJV CM 6 SAC, BT, UK day 1 PR SSS-Rt IJV, development of cortical collaterals None mRS = 6* 8 24 yo M Trauma, logging tree vs head Rt SS, IJV IJV CM 3 None No change None mRS = 0 9 20 yo F Trauma, fall from horse Rt TS CFV CM 6 None No change None mRS = 0 10 18 yo M Trauma, skateboard accident Lt SS, IJV CFV CM 3 SAC, BT PR SS-IJV None mRS = 4 11 17 yo F HA, Lt hand paresthesias SSS, Bilat TS, SS, IJV CFV CM 2 SAC, BT PR SSS-Rt IJV None mRS = 1 12 16 yo F HA, seizure, 9 months postpartum SSS, TS CFV CM 1 BT PR SSS-TS None mRS = 6* 13 14 yo M Trauma, ATV collision Rt TS, SS, IJV CFV CM 3 BT PR TS-IJV None mRS = 0 14 8 yo M HA, Lt mastoiditis Lt TS CFV CM 2 SAC PR TS None mRS = 0 15 2 yo F Lethargy, FTT ICV, StS, SSS, Bilat TS, SS, IJV CFV CM 3 SAC, BT PR SSS-Lt IJV Small subdural/SS perforation mRS = 4 16 14 do M Seizure ICV, StS, SSS, Bilat TS, SS, IJV CFV CM 2 SAC PR SSS-Rt IJV None mRS = 0 Note:—yo indicates year old; do, day old; TIA, transient ischemic attack; HA, headache; SSS, superior sagittal sinus; TS, transverse sinus; SS, sigmoid sinus; IJV, internal jugular vein; StS, straight sinus; ICV, internal cerebral vein; vL, vein of Labbe; Lt, left; Rt, right; CFV, common femoral vein; CM, Cragg-McNamara; KW, Katzen wire; SAC, systemic anticoagulation; BT, balloon thrombectomy; UK, urokinase; PR, partial recanalization; HIT, heparin-induced thrombocytopenia; mRS, modified Rankin scale (0, no disability; 6, death); DD, developmental delay; FTT, failure to thrive; Bilat, bilateral; ATV, all terrain vehicle.
* Mortality occurring during initial hospitalization
Pt No. Imaging Modality Imaging Findings Candidate for SAC 1 MRI Left frontoparietal nonhemorrhagic VI* Yes 2 MRI Extensive Rt parietal hemorrhagic VI† No 3 MRI Biparietal and Lt frontal nonhemorrhagic VI* Yes 4 MRI Bifrontal non-hemorrhagic VI Yes 5 CT Lt parietal hemorrhagic VI Yes 6 MRI/MRA No associated findings Yes 7 MRI Rt temporal, parietal, and frontal lobe non-hemorrhagic VIs; Lt posterior frontal and occipital nonhemorrhagic VI† Yes 8 CT/CTA Rt temporal bone fracture No 9 CT/CTA Rt temporal and occipital bone fractures No 10 CT/CTA Lt temporal bone fracture Yes 11 MRI Rt frontal and bilateral frontoparietal nonhemorrhagic VI* Yes 12 MRI Bifrontal hemorrhagic VI† Yes 13 CT/CTA SAH, IPH, bifrontal contusions, Rt temporal bone fracture No 14 CT (temporal bone) Lt mastoiditis Yes 15 CT Bithalamic nonhemorrhagic VI Yes 16 CT Small bithalamic hemorrhagic VI* Yes Note:—MRA indicates MR angiography; MRI, MR imaging; CTA, CT angiography; VI, venous infarct; SAH, subarachnoid hemorrhage; IPH, intraparenchymal hemorrhage.
* Reversible FLAIR signal abnormality on last imaging follow-up.
† Patient subsequently died.
- Table 3:
Imaging and clinical follow up for 16 patients treated with endovascular catheter-directed intrasinus heparin infusion
Pt No. Follow-up Interval (mo) Imaging Modality Imaging Result Clinical Result 1 7 CTA Nonocclusive filling defect SSS NND 2 N/A N/A N/A Death 3 1 CTA No DVST NND 4 3 MRA No DVST Mild left lower extremity weakness, independent 5 13 None N/A NND 6 28 CT No DVST NND 7 N/A N/A N/A Death 8 33 CT No DVST NND 9 4 MRA Nonocclusive filling defect TS NND 10 3 CT No DVST Severe neurologic impairment secondary to TBI 11 6 MRA No DVST Mild spasticity right upper extremity, independent 12 N/A N/A N/A Death 13 7 CTA No DVST NND 14 11 CTA No DVST NND 15 4 MRA No DVST Severe developmental delay 16 4 MRI No DVST NND Note:—N/A indicates not applicable; NND, no neurologic deficit; TBI, traumatic brain injury; DVST, dural venous sinus thrombosis.
