Massive Venous Sinus Thrombectomy and Direct tPA Infusion

An underutilized protocol– direct intra-sinus tPA infusion — it works great and is relatively simple to do

Day 0 — SSS, lateral sinuses, proximal straight sinus thrombus

Day 2 — no therapy — extension into straight sinus, Galen, AND right Internal Cerebral Vein (ICV)…

Note lack of right ICV visualization — correlates with CT. Why no parenchymal edema or infarct? What is the adaptive venous drainage pattern overall?

How is left ICV draining? The rest of left hemisphere

Stereos

Often Inferior Petrosal Sinus keeps upper jugular veins patent, thankfully.

Venous phase Cone Beam CT images in stereo

Left pair are on top

Movies

Right hemisphere

Left hemisphere

Thrombectomy — 8F Shuttle Sheath in the jugulars. Zoom 88, Zoom 71, Sofia 6 do the work. Advancing over Aristotle Colossus and Wedge/Avigo when there are major stepoffs. Suggest aspirating with a syringe to minimize blood loss, which is substantial anyway — about 500 ccs. A cell saver would help.

Nice view of diploic and emissary veins — same one that are keeping this person alive from arterial injections

Straight sinus — these are some amazing images of the intrinsic venous sinuses of the tentorium and falx. They are likely adaptively dilated to help drain the deep system. Note sinuses along the insizura (arrows — discussed by R.S. Tubbs in ABC-WIN 2024) and sinuses inside the falx (oval). You can see the characteristic tram-tracking of the sinus with the artery inbetween. Can just imagine the same artery supplying falcotentorial fistulas (see case here)

DYNA STEREOS

MIPS

Movies

Post thrombectomy — its improved but not by much. The important image is not a venous injection showing a better more open sinus. What is important is venous phase of arterial injection to show that the brain is using the sinuses more. Thrombectomy alone is not sufficient. Need anticoagulation

Two microcatheters are placed — in the SSS and Straight Sinus. tPA is infused — 1 mg/hr into each at first, then down to 0.5 mg/hr after 24 hours. The images below are taken immediately after thrombectomy. Note hyperdense Galen and right ICV

One day later — all sinus hyperdensities have melted away. Whats left is Galen and ICV — imprortant leftovers… Placing microcatheter into Galen would have been better — but a bit risky given good clinical status. If needed it should be done — see case here.