Cerebral venous thrombosis (CVT) although previously accounted for lower incidence percentage of all strokes with a potentially fatal outcomes; however, in present covid era with increased thrombosis and prothrombotic risks; the Standard treatment for CVT is hydration and systemic anticoagulation with heparin (Unfractionated or low-molecular-weight heparin) at therapeutic dosage, even in patients with an intracranial hemorrhage (ICH) at baseline. Furthermore, monitoring of seizures and elevated intracranial pressure is reasonable. Amongst of these few do not respond to standard of care with medical management, and do progress to CVT with ischemic- hemorrhagic stroke, Deterioration in GCS, diffuse and local cerebral edema due to venous congestion or stasis or venous outflow obstruction, leading to mass effect, coma and death. The International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) identified a subgroup of patients (13%) with increased risk of poor outcomes highlighting male sex, age group of 40years, other thrombotic disorders, thrombosis of the deep cerebral venous system, coma, mental status Disorders and ICH on baseline computed tomography were noted as main predictors of death and dependence i.e., higher modified Rankin score (M.R.S). These high-risk patients might benefit from additional treatment options including endovascular therapy ¹.

Endovascular options, including intra-venous application of thrombolytic agents and/or mechanical thrombectomy (MT), for patients with neurologic deterioration refractory to anticoagulation therapy or with development of new or worsening ICH on anticoagulation have been described over last 2 decades with Heterogeneous results. Among these, thrombectomy techniques vary, including aspiration only, stent retriever thrombectomy, catheter directed thrombolysis (C.D.T), balloon-assisted thrombectomy, pharmaco-mechanical thrombectomy with C.D.T, rheolytic catheter thrombectomy.

Study Design: Retrospective study

Study Place: Bharati Vidyapeeth Deemed University Medical College and Hospital

Study Population: Patients with CVST who came to Bharati Vidyapeeth Deemed University Medical College and Hospital

Study Subjects: CVST patients above 18 years of age.

Inclusion Criteria:

1. All patients admitted in ICU/Wards & are in hospital till discharge or death.
2. Those patients who showed CVST with acute deterioration in GCS.

Exclusion Criteria: Pediatric Patients.

Sampling Technique: Convenient Sampling

Study Tools: Proforma and Laboratory Investigations along with CT/MRI with peripheral hardware.

Risk Involved: NIL

Below is the list of selected representative cases taken up after obtaining consents individually for detailed study and evaluation:

Table1: List of patients taken up for detailed evaluation

These patients presented to casualty or emergency medicine department with no preceding head or neck trauma with comorbidiities and risk factors and were put on anticonvulsants and drugs to control hypertension along with Side by side all the routine investigations were sent. Simultaneously interventional radiologist was contacted for further management of patient. All preop and post op CT brain plain and or  MRI brain with GRE and Venogram were performed and patient evaluated by Interventional radiologist and the team primary care physicians , EMD staff, medicine residents and sos neurologist and neurosurgeons were consulted on case wise need basis  & detailed councilleing regarding disease prognosis and complications and  procedure merits need and limitations and risk benefits were documented and emergency procedure with monitored anesthesia care with sos step-up  was done in this  selected cases with extensive cortical venous thrombosis and clinical symptomatology as detailed in table.

After high risk consent and re-explained about the procedure and thrombolysis its pros and cons ;Under all aseptic precautions under ultrasound,fluoroscopy and dsa guidance under FD10 Philips CathLab ; in some cases control dsa via right femoral artery accesses ,  through right internal jugular accesses  serial dilation  5f vascular sheath placed with modified seldinger technique followed by 7F long sheath through which coaxially guiding aspiration catheter agile cordis 6 and 7 F and diagnostic 5f cobra catheter cordis and using support stiff guide wire and glide wire single and exchange length alternatively  and thrombus maceration aspiration, balloon Venoplasty followed by bolus thrombolysis &with bolus lacing technique and then via multisideport spray infusion catheter thrombolysis performed with segmental pull back technique for the thrombosed  cortical venous sinuses of brain.  Post procedure patient was monitored in ICU, SOS drugs to control vitals and thrombolytic infusion.

On post op day 1 if patient on ventilator care were administered, they were weaned off from ventilator support and control of risk factors, hypertension, as well as with proper medical care and hydration and low molecular weight heparin was administered and anti-seizure prophylaxis.

On post op day 2 patient were reevaluated for power and GCS and evaluated for access site and repeat imaging was done which was suggestive of good recanalisation of the sinuses and to rule out any complications and Postop outcomes and comparison with preop imaging was done.  Postop Day 3 onwards patient were shifted in wards and started on regular physiotherapy and bridge to oral anticoagulants. After good clinical recovery on discharge patient were reevaluated for INR on day 10 and kept on regular follow-up with on follow up clinical and imaging revealed good clinical recovery, asymptomatic and good recanalization.

Figure1: MRI findings in patient of CVST

MRI Findings:

Extensive cortical venous sinus thrombosis involving the posterior 2/3^rd superior Sagittal sinus, transverse, sigmoid sinus involving the confluence of sinus with ADC/diffusion restriction noted in the bilateral basal ganglia and periventricular region along with hyper intense signal with loss of flow void in the internal cerebral vein, straight sinus and vein of Galen. Diffuse severe cerebral edema with ventricular asymmetry noted.

Figure2: CT BRAIN and DSA VENOGRAM in patient of CVST

Computed Tomography Findings: pre op CT revealed similar findings as noted on MRI with no acute Haemorrage, with hyper dense cortical venous sinus with severe edema and ventricular asymmetry.

Post op CT brain at 6 hr interval and day3 post op revealed gradually decreasing cerebral edema with decreased hyper density in the cortical venous sinus with no venous infarct residua/Haemorrage.

DSA Venogram:

Direct DSA Venogram revealed filling defects involving the cortical venous sinus with sluggish outflow.

Figure3: Mechanical thrombolysis and aspiration thrombectomy with venoplasty

Emergency cortical venous sinus pharmaco mechanical thrombolysis & aspiration thrombectomy with Venoplasty.

Clinical and medical management anti edema measures, hydration, anti-seizure prophylaxis, anticoagulation and supportive ICU care and ventilation support.

DSA At end of procedure: venous outflow established with Recanalised flow in the cortical venous sinus.

Figure 4:Intra operative internal juglar access with tiny post operative scab

Clinical image after patient consent showing Intraop direct right internal jugular accesses and Postop tiny healed scab day 3.

Cerebral Dural venous sinus thrombosis often affects young adults and children unlike arterial stroke which has distinct age group of presentation .² The mechanisms³ of neurological symptoms in CVT include :( a) Development of intracranial hypertension as result of occlusion of the major venous sinuses and (b) localized edema of the brain, venous infarction, and hemorrhages. the mainstay of management of thrombosis of the Dural sinus and cerebral veins (CVT) is hydration and systemic heparinization. Evaluation of underlying condition ⁴& promptly treating or prevention of complications should be contemplated along with heparinization and hydration. The systemic heparinization prevents thrombus propagation and increases the chances of recanalisation. Anticoagulation is safe and can be used in patients with acute CVT who have intracranial hemorrhagic lesions Chemical thrombolysis, is a procedure in which a thrombolytic drug usually urokinase or recombinant tissue plasminogen activator tenecteplase or alteplase or streptokinase is infused via a micro catheter into the thrombus locally. Endovascular thrombolysis (with or without mechanical thrombus disruption) is an advanced interventional radiology option available at expertise centers to be offered for severe cases or  in those cases who fail to improve to anticoagulation. Thrombolysis is accelerated through direct intra-thrombus infusion of the thrombolytic agent. ^5,6,7 and also Among these, thrombectomy techniques vary, including aspiration only, stent retriever thrombectomy, catheter directed thrombolysis (C.D.T), balloon-assisted thrombectomy, pharmaco-mechanical thrombectomy with C.D.T, rheolytic catheter thrombectomy.⁸ The incidence of hemorrhage, though low, can occur with locally catheter-administered thrombolytic agents. Thrombolysis can be advocated as first line therapy based on clinical and Venogram and Dsa angiography criteria in severe clinical grade or patients with mild clinical grade deteriorating on systemic heparin therapy⁹.

Indication for thrombolysis or pharmaco mechanical CDT or endovascular intervention are termed as rescue therapies based on clinical presentation, signs and symptoms and imaging and understanding the extent of  CVST having significant anatomical  segments involvement of the venous sinuses  and deterioration of GCS despite best medical therapy^10,11, cerebral congestion, raised Intra cranial hypertension, ventricular asymmetry , identifying visual impairment secondary to CVST, recurrent seizures, comatose,GCS less than 10, and after ruling out large intra cerebral  Haemorrage or intra cranial hematoma with midline shift and mass effect requiring  urgent need of neurosurgical decompressive craniotomy^12,13,14. Small to moderate Hemorrhagic venous infarct is not a contraindication for thrombolysis.

Technical Note: we have utilized the cost-effective alternative readily available peripheral hardware in contrast to traditional costly or cost prohibitive neuro-dedicated hardware but we had good clinical outcomes and recanalisation. We did all this cases from state government health scheme with a package of one Lakh INR /approx 1250$ which is all inclusive of CathLab& all hardware with consumables/procedure and surgeons fees and anesthesia cost/medications/in hospital stayi.e. ward and icu and critical care and investigations, labs, radiology and imaging which includes his pre and post operative and covers patient travel to home from date of admission.  Also in our limited experience, direct jugular approach helps in better ergonomics and patient comfort and less needed arterial approach contributing to lesser accesses site complications post thrombolysis; however, depending upon the need and case-based strategies we can make the decision. Also noteworthy to mention is recent advances wherein the application of direct jugular vein accesses approach for placement of Stentrode^TM15is the futuristic application that interventional radiologist can cater in foreseen future and overcome the learning curve. 

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10.   Aaron, S., et al. "Spectrum of Visual Impairment in Cerebral Venous Thrombosis: Importance of Tailoring Therapies Based on Pathophysiology." Annals of Indian Academy of Neurology, vol. 20, 2017, pp. 294-301.

11.   Tsai, F.Y., et al. "Cerebral Venous Congestion as Indication for Thrombolytic Treatment." Cardiovascular and Interventional Radiology, vol. 30, 2007, pp. 675–687.

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13.   Stack, C.A., and J.W. Cole. "Cerebral Venous Thrombosis: A Clinical Overview." Ischemic Stroke of Brain, edited by P. Sanchetee, IntechOpen, 2018, https://www.intechopen.com/chapters/62463, doi:10.5772/intechopen.79049.

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15.   "NCT03834857 - ClinicalTrials.gov." ClinicalTrials.gov, clinicaltrials.gov/ct2/show/NCT03834857.