SOLITAIRE 2 ™

REVASCULARIZATION DEVICE IS THE STANDARD IN

INTERVENTIONAL STROKE CARE

VOLUME 28 - No. 2 - april 2015

CLINICAL STUDIES

ISSN 1971-4009 Online ISSN 2385-1996

• Solitaire FR With the Intention For Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME). The New England Journal of ™

NRJ - THE NEURORADIOLOGY JOURNAL - VOLUME 28, No. 2 - pages 81- 228, 2015

Medicine, April 2015

• Solitaire™ FR With the Intention For Thrombectomy (SWIFT). The Lancet, 2012 • Solitaire™ FR Thrombectomy for Acute Revascularization (STAR). Stroke AHA Journals, 2013

• The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) Study. The New England Journal of Medicine, February 2015 • Extending the Time for Thrombolysis in Emergency Neurological Deficits – Intra-Arterial (Extend-IA) Study. The New England Journal of Medicine, February 2015 • MR CLEAN: A Multi-center Randomized Clinical trial of Endovascular treatment for Acute Ischemic Stroke in the Netherlands. The New England Journal of Medicine, December 2014

• REVASCAT: Update on a Recently Terminated Randomized Trial of Mechanical Embolectomy With The Solitaire™ Device versus Best Medical Therapy In Acute Stroke. The New England Journal of Medicine, April 2015

The Solitaire™ device has been observed to double the rate of good neurological outcomes (71% vs. 40%) and reduce the rate of mortality by half (9% vs. 20%) compared to standard of care treatment alone. 1, 2, 3, 4, 5, 6 Clinical References: 1. EXTEND-IA Study presented by Dr. Bruce Campbell at the International Stroke Congress 2015 2. ESCAPE Study presented by Dr. Michael Hill at the International Stroke Congress 2015

Official Journal of:

3. Trevo Versus Merci Retrievers for Thrombectomy Revascularisation of Large Vessel Occlusions in Acute Ischaemic Stroke (TREVO 2): a randomised trial. Nogueira et. al., doi:10.1016/S0140-6736(12)61299-9.

AINR - Associazione Italiana di Neuroradiologia

4. Broderick, Joeseph, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 1 0

and: The Neuroradiologists of Alpe-Adria ANRS - Albanian Neuroradiological Society PANRS - Pan Arab NeuroRadiology Society Radiological Society of Saudi Arabia, Division of Neuroradiology Egyptian Society of Neuroradiology ISNR - Indian Society of Neuroradiology Indonesian Society of Neuroradiology Neuroradiology Section of the Radiology Society of Iran Israeli Society of Neuroradiology College of Radiology Malaysia

5. Presented by Dr. Dippel, Erasmus University at World Stroke Congress 2014 6. ADAPT FAST Study: Turk AS, et al. J NeuroIntervent Surg 2014;0:1–5. doi:10.1136/neurintsurg-2014-011125

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Original article

Cerebral Venous Sinus Thrombosis: Successful Treatment of Two Patients Using the Penumbra System and Review of Endovascular Approaches

The Neuroradiology Journal 2015, Vol. 28(2) 177–183 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1971400915576633 neu.sagepub.com

Weihua Liao1, Yunhai Liu2, Wenping Gu2, Jie Yang2, Changqing Chen1, Fan Liu1, Feiyue Zeng1 and Xiaoyi Wang1

Summary Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially life-threatening condition. When showing resistance to treatment or a malignant progression despite anticoagulant therapy, endovascular interventional treatment is of help. The Penumbra System (PS), a novel thrombectomy device specifically designed to remove the thrombus in acute ischemic stroke, also proved to be an effective device for mechanical recanalization of CVST. We first reported two cases successfully treated using the PS in the management of intractable CVST in Asia, and analyzed the technical differences of use of the device through a systematic review of the literature. One patient underwent mechanical thrombectomy of the thrombosed superior sagittal sinus using the 0.054-inch PS catheter when direct pharmacological thrombolysis failed. The other patient underwent mechanical thrombectomy using the 0.041-inch PS catheter with adjuvant local pharmacological thrombolysis. Literature reports on the use of the PS in patients with CVST were reviewed. Successful venous recanalization was achieved using the PS. The patients improved symptomatically following the intervention. Literature reports showed that the PS can be successfully applied for treatment of CVST, though the methods used previously were diverse. The PS has proved to be effective in the rapid recanalization of CVST, but different treatment techniques exist. The solution to these problems depends on more clinical trials as well as further improvements to devices.

Keywords cerebral venous vinus thrombosis, treatment, vascular intervention, thrombectomy

Introduction Cerebral venous sinus thrombosis (CVST) has been associated with coagulation disorders, hormonal changes, and acute and chronic systemic diseases.1 The approach to treatment includes anticoagulation (intravenous heparin or subcutaneous low molecular weight heparin), thrombolysis (systemic or local), and symptomatic treatment (including antiepileptic therapy, lowering intracranial pressure, decompressive craniectomy and so on).2,3 When the thrombosis is refractory to anticoagulation or deteriorating progressively, endovascular interventional treatment, including pharmacological thrombolysis and mechanical thrombectomy, is frequently advocated. Mechanical thrombectomy can be performed alone or in combination with pharmacological thrombolysis.4,5 In spite of limitations, mechanical devices such as balloon angioplasty, rheolytic catheters or snares have sometimes been used to disrupt and remove clot material.6–8 Recently, some researchers attempted to make use of the Penumbra

System (PS; Alameda, CA, USA) in the treatment of CVST,9–13 which proved to be a novel device for the revascularization of large vessel thromboembolic occlusions in acute ischemic stroke.14 However, the techniques of treatments they adopted were varied. We report on the successful use of the PS in the management of two patients with CVST and analyze technical differences through a systematic review of the literature.

1

Department of Radiology Department of Neurology, Xiangya Hospital, Central South University; Changsha, Hunan, China

2

Corresponding author: Xiaoyi Wang MD, PhD, Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China. Email: [email protected]

178

Materials and Methods All patients or their immediate family members in our case provided informed consent using a protocol approved by our institutional ethics committees.

Case 1 The patient was a 29-year-old man with a history of hyperthyroidism. He presented to an outlying hospital with six-day history of headache and vomiting. His headache was not responding to treatment and worsening. At the time of admission to our hospital, neurological examination revealed left hemiparesis. Initial non-contrast brain computed tomography (CT), magnetic resonance imaging (MRI), and MR venography (MRV) studies demonstrated an acute hemorrhage in right parietal lobe and dural venous sinus thrombosis involving superior sagittal sinus (SSS) and the right transverse sinuses (Figure 1). Although he received anticoagulation with subcutaneous low-molecular weight heparin (90 IU/kg twice daily) and intracranial pressure lowering mannitol in drip, on day 2 he experienced obnubilation and frequent convulsions. He also

The Neuroradiology Journal 28(2) developed ophthalmocele, bulbar conjunctival hyperemia, and progressively increasing intracranial pressure. On the basis of clinical deterioration, he was taken urgently for endovascular treatment. Firstly, he received local infusion thrombolytic therapy. A 6- and a 5-Fr introducer sheath were placed in the right femoral vein and left femoral artery, respectively. A 5-Fr diagnostic catheter was used for accessing the left internal carotid artery. Contrast material injections demonstrated complete occlusion of the SSS (Figure 2). Through the femoral route, a 6-Fr guiding catheter (Boston Scientific, Natick, MA, USA) was navigated to reach the right jugular bulb. The microcatheter was then navigated coaxially through the 6-Fr guiding catheter to the thrombus of the SSS. A gentle contrast injection showed string-like venous outflow directed anteriorly. Through the microcatheter, continuous local infusion thrombolytic therapy with urokinase was initiated at a rate of 40,000 U/h. One day later, a repeat angiogram showed no improved recanalization of the SSS and accordingly, he was referred for mechanical thrombectomy under general anesthesia. After venous guiding catheter and

Figure 1. Preprocedure MRI and MRV. A lesion in the right parietal lobe is isointense on axial T1WI (a), hyperintense on axial T2WI (b), and hypointense on axial T2*WI (c), demonstrating an acute hemorrhage. Occlusion of SSS and the right transverse sinuse on MRV (d).

Liao et al.

Figure 2. Right ICA angiogram, lateral view, late venous phase, demonstrating the lack of parietal cortical veins, and complete occlusion of SSS, especially the posterior two-thirds of the SSS (white arrows).

microcatheter were removed, the 0.054-in PS reperfusion catheter was then navigated over a 0.035-in guidewire to reach the right jugular bulb. Then, the 0.035-in guidewire was handled to enter through the thrombus in the right transverse sinus, and reached the left jugular bulb. The 0.054-in reperfusion catheter was pushed ahead under shoring of 0.035-in guidewire, and reached the right transverse sinus. The 0.035-in guidewire was exchanged for the 0.014-in microwire, and the 0.054-in reperfusion catheter was then navigated over the 0.014in microwire through the thrombus into the posterior portion of the SSS. Lateral SSS venogram showed occlusion of the posterior two-thirds of the SSS (Figure 3). The separator was pushed into the anterior portion of the SSS. Advancing and withdrawing the separator through the reperfusion catheter continuously facilitated breaking up large pieces of clot. Mechanical thrombectomy was performed for over 30 minutes, resulting in amounts of liquefied and tremelloid clot aspirated (Figure 4). Venogram after treatment demonstrated reopening of the occlusion with some residual thrombosis (Figure 5). Four days later, repeat angiography was performed, which demonstrated total recanalization of the SSS (Figure 6). After the procedure, the same catheter was connected to the infusion pump providing a route for locally administered UK for three days. The patient’s neurological status normalized on postprocedure day 5 with the exception of 4/5 strength in the left leg.

Case 2 A 27-year-old woman presented to our hospital with ten-day history of progressively worsening headache and vomiting ten days after abortion. Neurological examination demonstrated paresis of the right limb.

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Figure 3. Lateral superior sagittal sinus venogram showing occlusion of the posterior two-thirds of the SSS (white arrow) and 0.054-in Penumbra reperfusion catheter in the posterior SSS (black arrow).

Figure 4. Tremelloid and liquefied clot retrieved from the Penumbra reperfusion catheter.

MRI and MRV demonstrated an infarction in the left frontal lobe and occlusion of the SSS (Figure 7). Continuous anticoagulation with subcutaneous lowmolecular weight heparin for three days did not result in symptom control. Local infusion thrombolytic therapy with urokinase also failed to relieve her intractable headache. Due to the signs of impending uncal herniation with a dilated right pupil and change of consciousness, she was referred for endovascular mechanical thrombectomy. Contrast material injections demonstrated complete occlusion of the SSS (Figure 8). The 0.041-in PS reperfusion catheter was then navigated over a 0.035-in guidewire to reach the right jugular bulb. The 0.035in guidewire was exchanged for the 0.014-in microwire. The 0.041-in. reperfusion catheter was then navigated

180

Figure 5. Lateral superior sagittal sinus venogram after treatment with the Penumbra system showing reopening of the occlusion with some residual thrombosis (white arrow).

Figure 6. Postprocedure left ICA-angiogram 4 days later, lateral view, late venous phase demonstrating patency of the SSS with satisfactory flow(white arrows).

The Neuroradiology Journal 28(2)

Figure 7. Preprocedure MRV, demonstrating occlusion of the SSS.

Figure 8. Left ICA angiogram after continuous anticoagulation with subcutaneous low-molecular weight heparin for 3 days, demonstrating complete occlusion of the SSS.

neurological symptoms and referred for outpatient follow-up. over the 0.014-in microwire through the thrombus into the posterior portion of the SSS. Mechanical thrombectomy was performed for over 30 minutes with to and fro movement of the separator through the reperfusion catheter, resulting in a small granular and solid clot aspirated. Repeat angiography demonstrated recanalization of a small part of the SSS. She remained on local infusion urokinase via reperfusion catheter after the procedure. The patient’s headache was relieved on post-procedure day 4, and MR venography (MRV) studies demonstrated subtotal recanalization of the SSS (Figure 9). The patient was doing well without any

Discussion Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially life-threatening condition.9 One large multicenter prospective observational study found an 8.3% overall mortality rate. Anticoagulation therapy has mostly been accepted to date for CVST, which may be efficient in 90% of cases.15 However, some researchers believe it may not be the best choice for each and every patient. When showing a malignant progression despite anticoagulant

Liao et al.

Figure 9. Postprocedure day 4, MRV, demonstrating subtotal recanalization of the SSS.

therapy, endovascular treatment might provide an ideal solution. There are several different approaches to endovascular treatment of CVST, including transjugular and transfemoral approach. Transjugular endovascular treatment of CVST includes pharmacological thrombolysis and mechanical thrombectomy. In pharmacological thrombolysis, a microcatheter is advanced via a retrograde approach to the cerebral dural sinuses, and thrombolytic agents such as rt-PA or urokinase are administered as a bolus or with infusion over a period of time. Mechanical thrombectomy is done with different types of catheters, balloons, stents, or snares to disrupt the thrombus,6 such as AngioJet Rheolytic catheter, balloon angioplasty or stenting, microsnare, Fogarty embolectomy catheter balloon, etc.16–21 Theoretically, mechanical thrombectomy has an immediate recanalization effect, lowering intracranial pressure more promptly and facilitating pharmacological thrombolysis.22,23 Rheolytic thrombectomy utilizes the Venturi effect which creates a negative pressure fragmenting and aspirating the cerebral venous thrombus.24 Endovascular thrombolysis, with or without mechanical clot removal, may be beneficial for a subgroup of patients with CVST who have a poor prognosis despite treatment with heparin. Published experience with endovascular thrombolysis is promising, though based on case series and not on controlled trials.25 Recently, technological advances have yielded mechanical devices with improved handling properties and effectiveness for the treatment of acute cerebral vascular obstruction. The PS, a novel thrombectomy device specifically designed to remove the thrombus in acute ischemic stroke,2,26 proved to be an effective device for mechanical recanalization of CVST combined with local pharmacologic thrombolysis.

181 The PS is composed of two main components: a reperfusion catheter (0.054, 0.041, 0.032 and 0.026 in.) and a separator. Reperfusion catheters come with a relatively larger internal diameter and a distal end of greater flexibility, ensuring access to the target vessel. The separator provides an aspiration-debulking approach for recanalization, and is atraumatic to the vessel walls. Repeated to and fro movement of the separator is used to fragment the thrombus. Recently, some researchers attempted to make use of the PS in mechanical thrombectomy of CVST. Kulcsar et al. performed serial mechanical thrombectomies using the PS in combination with local infusion of urokinase to successfully recanalize a thrombosed SSS in a female patient.9 Siddiqui et al. and Blackham reported simultaneous use of the PS in conjunction with intrasinus rt-PA infusion for multifocal venous sinus thrombosis.10,11 Choulakian et al. described patients with CVST who underwent mechanical thrombectomy using the PS plus adjuvant balloon angioplasty, achieving satisfactory flow without the use of direct pharmacologic thrombolysis.12 Raychev et al. used the PS in combination with the Solitaire FR clot retrieval device to completely revascularize the occluded sinus.27 Direct thrombectomy using the PS without adjuvant local pharmacologic thrombolysis or additional mechanical interventions was detailed by Velat et al.13 Although the conclusions that the PS is helpful for recanalization of thrombosed venous sinus were drawn from previous reports, the methods they took were different (Table 1) such as whether to use adjuvant local pharmacologic thrombolysis and additional mechanical interventions or not, select tPA or urokinase as thrombolysis agent, select the 0.041-inch or 0.054-inch PS catheter as the reperfusion catheter, navigate guiding catheter into the transverse sinus or jugular bulb, as well as whether to use the guiding catheter or not. We first report here two cases successfully treated using the PS for mechanical venous sinus thrombectomy with adjuvant local infusion of urokinase in Asia. The technique of the treatment we adopted was also not the same as those of above reports. In order to reduce the danger of damaging and perforating the venous sinus, we successfully introduced the PS reperfusion catheter into the posterior portion of the SSS, without using a guiding catheter in the transverse sinus, which has not been reported previously. We also found that when the guiding catheter was placed in the jugular bulb, it was difficult for the PS reperfusion catheter to reach the SSS because it is only about 40 cm longer than the guiding catheter. Therefore, we believe that if the reperfusion catheter is designed longer, it would be more suitable to recanalize thrombosed venous sinuses. In addition, we compared the recanalization effect of the 0.054-inch reperfusion catheter with that of the 0.041-inch. The 0.054-inch catheter with a larger separator allows for stronger fragmentation and aspiration of thrombus, and more rapid and complete sinus

182

The Neuroradiology Journal 28(2)

Table 1. Summary of case reports on the penumbra system for treatment of venous sinus thrombosis. Size of Penumbra catheter

Author

Year of report

No. of Cases

Adjuvant treatment

Kulcsar et al9.

2009

1

0.041-in

Siddiqui et al. [10] Blackham [11]

2012

2

2011

1

Local thrombolysis with urokinase Local thrombolysis with tPA Local thrombolysis with tPA

Choulakian et al. [12]

2010

4

Velat et al. [13]

2011

1

Three patients underwent balloon angioplasty No use

Raychev et al. [27]

2014

1

Our reports

2014

2

Combined with Solitaire FR retrieval device Local infusion of urokinase

recanalization, although it was more difficult to handle through the intracranial venous sinus.

Conclusions The Penumbra System proved to be effective in the rapid recanalization of cerebral venous sinus thrombosis, however, there exists a diversity in treatment techniques. The solution to these problems depends on more clinical trials as well as further improvement of devices. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Conflict of interest The authors declare no conflict of interest.

Acknowledgements This study was supported by the National Natural Science Foundation of China (No.81000596) and Postdoctoral Science Foundation of China (No. 2013M531815).

References 1. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005; 352: 1791–1798. doi: 10.1056/ NEJMra042354. 2. Filippidis A, Kapsalaki E, Patramani G, et al. Cerebral venous sinus thrombosis: review of the demographics, pathophysiology, current diagnosis, and treatment. Neurosurg Focus. 2009; 27: E3. doi: 10.3171/ 2009.8.FOCUS09167.

Location of guiding catheter

0.054-in

Right jugular bulb Unknown

0.041-in

Unknown

0.041-in

Right transverse sinus

0.054-in

Left transverse sinus

0.054-in

Unknown

0.054-in (case 1), 0.041-in (case 2)

No use

Outcome Complete patency of SSS Remarkable clinical recovery Complete resolution of the dural venous thrombus Neurologic improvement in all patients Returned to work without additional seizures Excellent recovery

Patency of SSS, Patient’s neurological status normalized

3. Schultz DW, Davis SM, Tress BM, et al. Recanalisation and outcome cerebral venous thrombosis. J Clin Neurosci. 1996; 3: 133–138. doi: 10.1016/S09675868(96)90006-5. 4. Wasay M, Bakshi R, Kojan S, et al. Nonrandomized comparison of local urokinase thrombolysis versus systemic heparin anticoagulation for superior sagittal sinus thrombosis. Stroke. 2001; 32: 2310–2317. doi: 10.1161/ hs1001.096192. 5. Borhani Haghighi A, Mahmoodi M, Edgell RC, et al. Mechanical thrombectomy for cerebral venous sinus thrombosis: A Comprehensive Literature Review. Clin Appl Thromb Hemost. 2013; 20(5): 507–515. [Epub ahead of print]. doi: 10.1177/1076029612470968. 6. Baker MD, Opatowsky MJ, Wilson JA, et al. Rheolytic catheter and thrombolysis of dural venous sinus thrombosis: a case series. Neurosurgery. 2001; 48: 487–493. doi: 10.1097/00006123-200103000-00005. 7. Caso V, Billeci AM and Leys D. Interventional neuroradiology in the treatment of cerebral venous thrombosis. Front Neurol Neurosci 2008; 23: 144–160. 8. Renowden S. Cerebral venous thrombosis: local thrombolysis. J R Soc Med 2000; 93: 241–243. 9. Kulcsa´r Z, Marosfoi M, Berentei Z, et al. Continuous thrombolysis and repeated thrombectomy with the Penumbra SystemTM in a child with hemorrhagic sinus thrombosis: technical note. Acta Neurochir (Wien). 2010; 152: 911–916. doi: 10.1007/s00701-009-0570-4. 10. Siddiqui FM, Pride GL and Lee JD. Use of the Penumbra system 054 plus low dose thrombolytic infusion for multifocal venous sinus thrombosis. A report of two cases. Interv Neuroradiol 2012; 18: 314–319. 11. Blackham KA. Extensive dural sinus thrombosis: successful recanalization with thrombolysis and a novel

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thrombectomy device. J Neurosurg. 2011; 114(1): 133–135. doi: 10.3171/2010.2.JNS091186. Choulakian A and Alexander MJ. Mechanical thrombectomy with the penumbra system for treatment of venous sinus thrombosis. J Neuro Intervent Surg 2010; 2: 153–156. Velat GJ, Skowlund CJ, Waters MF, et al. Direct thrombectomy using the Penumbra thromboaspiration catheter for the treatment of cerebral venous sinus thrombosis. World Neurosurg 2012; 77: 591.e15–8. Bose A, Henkes H, Alfke K, et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. Am J Neuroradiol. 2008; 29: 1409–1413. doi: 10.3174/ajnr.A1110. Ferro JM, Canha˜o P, Stam J, et al. ISCVT Investigators.Prognosis of cerebral vein and dural sinus thrombosis: results of the international study on cerebral vein and dural sinus thrombosis (ISCVT). Stroke. 2004; 35: 664–670. doi: 10.1161/01.STR.0000117571.76197.26. Soleau SW, Schmidt R, Stevens S, et al. Extensive experience with dural sinus thrombosis. Neurosurgery. 2003; 52: 534–544. doi: 10.1227/01.NEU.0000047815.21786.C1. Baker MD, Opatowsky MJ, Wilson JA, et al. Rheolytic catheter and thrombolysis of dural venous sinus thrombosis: a case series. Neurosurgery. 2001; 48: 487–494. doi: 10.1097/00006123-200103000-00005. Curtin KR, Shaibani A, Resnick SA, et al. Rheolytic catheter thrombectomy, balloon angioplasty, and direct recombinant tissue plasminogen activator thrombolysis of dural sinus thrombosis with preexisting hemorrhagic infarctions. Am J Neuroradiol 2004; 25: 1807–1811. Kirsch J, Rasmussen PA, Masaryk TJ, et al. Adjunctive rheolytic thrombectomy for central venous sinus thrombosis: technical case report. Neurosurgery. 2007; 60: E577–578. doi: 10.1227/01.NEU.0000255339.26027.68.

183 20. Zhang A, Collinson RL, Hurst RW, et al. Rheolytic thrombectomy for cerebral sinus thrombosis. Neurocrit Care. 2008; 9: 17–26. doi: 10.1007/s12028-008-9058-y. 21. Khan SH, Adeoye O, Abruzzo TA, et al. Intracranial dural sinus thrombosis: novel use of a mechanical thrombectomy catheter and review of management strategies. Clin Med Res. 2009; 7: 157–165. doi: 10.3121/ cmr.2009.847. 22. Bishop FS, Finn MA, Samuelson M, et al. Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis. Case report. J Neurosurgery. 2009; 111: 17–21. doi: 10.3171/2009.2.JNS08491. 23. Barnwell SL, Clark WM, Nguyen TT, et al. Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke. Am J Neuroradiol 1994; 15: 1817–1822. 24. Caso V, Billeci AM and Leys D. Interventional neuroradiology in the treatment of cerebral venous thrombosis. Front Neurol Neurosci 2008; 23: 144–160. 25. Coutinho JM1, Ferro JM, Zuurbier SM, et al. Thrombolysis or anticoagulation for cerebral venous thrombosis: rationale and design of the TO-ACT trial. Int J Stroke. 2013; 8: 135–140. doi: 10.1111/j.17474949.2011.00753.x. 26. Psychogios MN, Kreusch A, Wasser K, et al. Recanalization of large intracranial vessels using the Penumbra System: A single-center experience. Am J Neuroradiol. 2012; 33: 1488–1493. doi: 10.3174/ ajnr.A2990. 27. Raychev R, Tateshima S, Rastogi S, et al. Successful treatment of extensive cerebral venous sinus thrombosis using a combined approach with Penumbra aspiration system and Solitaire FR retrieval device. J Neurointerv Surg. 2014; 6(5): e32. doi: 10.1136/neurintsurg-2013010866.rep.

Cerebral Venous Sinus Thrombosis: Successful Treatment of Two Patients Using the Penumbra System and Review of Endovascular Approaches.

Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially life-threatening condition. When showing resistance to treatment or a malignant...
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