- Email: [email protected]
Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique
Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique Aaron Bress a,⇑, Robert Hurst a, Bryan Pukenas a, Michelle Smith b, David Kung b a b
Department of Interventional Neuroradiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA Department of Neurosurgery, Hospital of the University of Pennsylvania, USA
a r t i c l e
i n f o
Article history: Received 21 January 2016 Accepted 14 February 2016 Available online xxxx Keywords: Mechanical thrombectomy Neurointerventional Novel approach Venous sinus thrombosis
a b s t r a c t Cerebral venous sinus thrombosis (CVST) can be life threatening. A previously healthy woman in her early forties on oral contraceptives presented with global CVST and rapid clinical deterioration. A novel ‘Triaxial Angiojet technique’ (KSAW Shuttle [Cook Inc., Bloomington, IN, USA], 5 MAX ACE [Penumbra Inc., Alameda, CA, USA], and Angiojet [Boston Scientific, Marlborough, MA, USA]) was employed to gain access into the superior sagittal sinus. The 5 MAX ACE reperfusion catheter was shortened prior to placing a 4 Fr Angiojet catheter through it. This resulted in markedly improved recanalization with good anterograde flow. The patient was extubated on postoperative day 2 and discharged neurologically intact on postoperative day 10. We report the first case of placing an Angiojet catheter through a larger Penumbra reperfusion catheter when access through a tortuous sigmoid and transverse sinus could not be obtained with a 6 Fr support catheter. Ó 2016 Elsevier Ltd. All rights reserved.
1. Introduction Angiojet (Boston Scientific, Marlborough, MA, USA) has been found to be a safe and effective treatment for cerebral venous sinus thrombosis (CVST), and has been suggested as a possible first line treatment [1]. We demonstrate a novel approach utilizing a shortened 5 Max ACE (Penumbra Inc., Alameda, CA, USA) catheter triaxial construct to navigate tortuosity in the venous sinuses in order to use a 4 Fr AngioJet catheter. In particular, we demonstrate an effective alternative to catheterize tortuous dural venous sinuses when a larger bore support catheter cannot be accessed distally. 2. Case report A healthy female in her early forties on oral contraceptives with no other significant past medical history developed progressively worsening headaches and nausea for over 1 week. At presentation at our institution, she was increasingly lethargic, was intubated due to inability to maintain her airway, and developed a dilated and fixed right pupil despite therapeutic heparin dosing. Laboratory findings were unremarkable. An unenhanced axial CT scan of the head showed hyperdense thrombus within all of ⇑ Corresponding author. Tel.: +1 215 662 3046. E-mail address: [email protected] (A. Bress).
the venous sinuses and a left cerebellar hemorrhage (Fig. 1), confirmed with CT venogram and contrast enhanced MRI (Fig. 1, 2). The patient was emergently brought to the neurointerventional suite. Diagnostic venogram confirmed CVST. A 6 Fr 80 cm KSAW Shuttle catheter (Cook Medical, Bloomington, IN, USA) was placed in the right jugular bulb from a right transfemoral approach. Then, a construct consisting of a 5 MAX ACE reperfusion catheter, a XT-27 microcatheter (Stryker, Kalamazoo, Mich, USA), and a Fathom 16 microwire (Boston Scientific) was used to reach the left transverse/sigmoid sinus. A 6 mm 25 mm Trevo device (Stryker) was deployed through the XT-27 microcatheter. The ‘‘stent anchor with mobile aspiration technique” was then performed [2] with sufficient clot removal to restore segmental patency. An exchange length .014 in guidewire was placed through the Shuttle sheath into the right jugular vein and an Angiojet was used in the right transverse/sigmoid sinus, restoring flow in the right vein of Labbe. The Angiojet was unable to be navigated into the superior sagittal sinus (SSS) because of sharp angulation at the torcula. The SSS was catheterized using a 5 Max ACE, XT-27, and 300 cm 0.014 in Luge microwire (Boston Scientific), enabling placement of the ACE catheter in the SSS. The ‘‘stent anchor with mobile aspiration technique [2]” was again performed with minimal recanalization of the SSS (Fig. 3). Finally, the proximal 10–15 cm of the 5 Max ACE was cut and a 4 Fr AngioJet catheter was inserted through the shortened ACE
http://dx.doi.org/10.1016/j.jocn.2016.02.011 0967-5868/Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bress A et al. Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.02.011
2
Case Report / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
A
B
A
B SSS SSS
TS SS Fig. 1. Axial CT scan of the brain (A): left cerebellar parenchymal hemorrhage. Axial CT venogram of the brain (B): filling defects in the bilateral transverse sinuses compatible with thrombosis.
catheter and navigated into the SSS. Both 5 Max ACE and Angiojet catheters were navigated as a unit along the Luge microwire (Fig. 4) resulting in good antegrade flow within the SSS (Fig. 5). The patient was transferred to the Intensive Care Unit and received mannitol for diffuse cerebral swelling and heparin for anticoagulation. On postoperative day 2, the patient was neurologically intact with only very mild residual headache and she was normal on postoperative day 5. Her blood urea nitrogen and creatinine remained normal. Follow up head CT scan demonstrated stable cerebellar hematoma. The only risk factor for thrombosis was oral contraceptives and the patient had a negative hypercoagulability workup. The patient had a CT scan of the chest, abdomen and pelvis, notable for a breast mass for which a biopsy as an outpatient is planned. The patient was later switched to enoxaparin as a bridge to a 6 month course of apixaban. At discharge on postoperative day 10, she was neurologically normal. 3. Discussion Patients with CVST can present with a variety of symptoms ranging from headache, papilledema, seizure, focal neurologic deficit, coma and death [3]. Complications can be life threatening [4] and diagnosis is often delayed due variable and nonspecific presentations. The natural history of CVST is also variable ranging from resolution of symptoms, permanent neurologic impairment, coma or death from venous infarction and/or hemorrhage [3,5]. The initial
A
B
Fig. 3. Digital subtraction venography. Superior sagittal sinus (SSS), anteroposterior (A) and lateral (B) projection. Prior to intervention, there was poor anterograde flow with multiple filling defects in the SSS, transverse (TS) and sigmoid sinus (SS). There are multiple cortical, dural and transosseous venous collaterals.
treatment of choice is intravenous heparin [6]. Mechanical thrombectomy, however has become a common second line. AngioJet thrombectomy is appealing because of its efficiency in removing the large clot burden commonly encountered in CVST [1,7], as efficient clot removal correlates with better outcomes [3,5,7–9]. Procedural complications are also few [10]. Some describe using AngioJet in combination with intravenous heparin, and advocate mechanical thrombectomy as a first line treatment [1]. The importance of overcoming the difficulty in navigating the Angiojet through the venous sinuses is highlighted by a recent comprehensive review of mechanical thrombectomy for CVST which showed an AngioJet device was the most commonly used device (46.9% of cases) for rheolytic thrombectomy [11]. Despite its efficiency, significant difficulty exists when navigating the device about tortuous dural sinuses [9]. Some have described placing long sheaths within the sinuses to improve the chances of successful Angiojet navigation around tortuous segments, but this is not always successful [1]. Our technique for Angiojet delivery utilized a much more flexible catheter, the 5 MAX ACE Penumbra catheter, which can be delivered through the KSAW Shuttle to a distal location within the dural sinuses. However, the 5 MAX ACE is longer than the Angiojet catheter. To address this issue, we cut the proximal 10 cm of the 5 MAX ACE catheter after it was deployed within the dural sinus, which allowed for easy placement of the Angiojet to the target location and restoration of flow within minutes.
C
Fig. 2. MRI of the brain with contrast: axial (A), coronal (B), and sagittal (C). Filling defects are present within the superior sagittal sinus, straight sinus, torcular herophilli, and bilateral transverse sinuses compatible with cerebral venous sinus thrombosis.
Please cite this article in press as: Bress A et al. Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.02.011
Case Report / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
3
failure may occur from obstructive nephropathy due to myoglobin excretion. Clot migration may also cause symptomatic pulmonary embolism or possibly arterial infarct if a patent foramen ovale is present. Although first line treatment for CVST is systemic anticoagulation, use of the AngioJet device may improve outcomes. Our novel technique helped to navigate the sharp angles of the dural venous sinuses in order to gain access to the targeted thrombus.
Luge Wire
AngioJet
4. Conclusion
ACE
CVST is rare and can be life-threatening. Interventional treatment may be necessary. Navigating an Angiojet catheter in the dural sinuses can be quite challenging due to sharp angles. We introduce the ‘Triaxial Angiojet technique’ which can be helpful to gain access to a difficult location in the dural venous sinuses especially when a larger bore support catheter cannot access distally around the sigmoid or transverse sinus. This is a novel approach using the Angiojet catheter through a larger bore Penumbra aspiration catheter. Prior to employing this technique one must remember to remove the hub and 10–15 cm of the proximal 5 Max catheter as the 5 Max ACE is too long for the Angiojet catheter. Conflicts of Interest/Disclosures
Fig. 4. Digital unsubtracted lateral view. The ‘Triaxial Angiojet technique’ is demonstrated. The 4 Fr Angiojet catheter (Boston Scientific, Marlborough, MA, USA) and 5 Max ACE reperfusion catheter (Penumbra Inc., Alameda, CA, USA) are moved as a unit along the Luge microwire (Boston Scientific), back and forth within the superior sagittal sinus to the torcula while the Angiojet device is turned on, utilizing the provided foot pedal.
A
B
SSS SSS
TS
TS SS
SS IJV
Fig. 5. Digital subtraction venography; superior sagittal sinus (SSS), anteroposterior (A) and lateral (B) projection. After intervention, there was markedly improved antegrade flow with significant decrease in clot burden in the SSS, transverse (TS) and sigmoid sinus (SS) with blood flow now entering the internal jugular vein (IJV).
In addition to the known anatomic limitations, complications related to Angiojet use may also occur such as injury of the named superficial veins (Trolard, Labbe, etc.) with resultant subdural or parenchymal hemorrhage. Excessive hemolysis causing acute renal
The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Dashti SR, Hu YC, Yao T, et al. Mechanical thrombectomy as first-line treatment for venous sinus thrombosis: technical consideration and preliminary results using the AngioJet device. J NeuroIntervent Surg 2013;5:49–53. [2] Mascitelli JR, Pain M, Zarzour HK, et al. Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel comination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique. J NeuroIntervent Surg 2015. [3] Tsai FY, Higashida RT, Matovich V, et al. Acute thrombolysis of the intracranial dural sinus: direct thrombolytic treatment. AJNR Am J Neuroradiol 1992;13:1137–42. [4] Nasr DM, Brinjikji W, Cloft HJ, et al. Mortality in cerebral venous thrombosis: results from the national inpatient sample database. Cerebrovasc Dis 2013;35:40–4. [5] Gobin YP, Houdart E, Rogopoulos A, et al. Percutaneous transvenous embolization through the thrombosed sinus in transverse sinus dural fistula. AJNR Am J Neuroradiol 1993;14:1102–5. [6] Eihhaupl KM, Villringer A, Meister W, et al. Heparin treatment in venous sinus thrombosis. Lancet 1991;338:597–600. [7] 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;7:157–65. [8] Chow K, Gobin YP, Saver J, et al. Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis. Stroke 2000;31:1420–5. [9] Dowd CF, Malek AM, Phatouros CC, et al. Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis: a new technique. AJNR Am J Neuroradiol 1999;20:568–70. [10] Kirsch J, Rasmussen PA, Masaryk TJ, et al. Adjunctive rheolytic thrombectomy for central venous sinus thrombosis: technical case report. Neurosurgery 2007;60:E577–8 [discussion E578]. [11] Haghighi AB, Mahmoodi M, Edgell RC, et al. Mechanical thrombectomy for cerebral venous sinus thrombosis: A comprehensive literature review. Clin Appl Thromb/Hem 2014;20:507–15.
Please cite this article in press as: Bress A et al. Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.02.011
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique Aaron Bress a,⇑, Robert Hurst a, Bryan Pukenas a, Michelle Smith b, David Kung b a b
Department of Interventional Neuroradiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA Department of Neurosurgery, Hospital of the University of Pennsylvania, USA
a r t i c l e
i n f o
Article history: Received 21 January 2016 Accepted 14 February 2016 Available online xxxx Keywords: Mechanical thrombectomy Neurointerventional Novel approach Venous sinus thrombosis
a b s t r a c t Cerebral venous sinus thrombosis (CVST) can be life threatening. A previously healthy woman in her early forties on oral contraceptives presented with global CVST and rapid clinical deterioration. A novel ‘Triaxial Angiojet technique’ (KSAW Shuttle [Cook Inc., Bloomington, IN, USA], 5 MAX ACE [Penumbra Inc., Alameda, CA, USA], and Angiojet [Boston Scientific, Marlborough, MA, USA]) was employed to gain access into the superior sagittal sinus. The 5 MAX ACE reperfusion catheter was shortened prior to placing a 4 Fr Angiojet catheter through it. This resulted in markedly improved recanalization with good anterograde flow. The patient was extubated on postoperative day 2 and discharged neurologically intact on postoperative day 10. We report the first case of placing an Angiojet catheter through a larger Penumbra reperfusion catheter when access through a tortuous sigmoid and transverse sinus could not be obtained with a 6 Fr support catheter. Ó 2016 Elsevier Ltd. All rights reserved.
1. Introduction Angiojet (Boston Scientific, Marlborough, MA, USA) has been found to be a safe and effective treatment for cerebral venous sinus thrombosis (CVST), and has been suggested as a possible first line treatment [1]. We demonstrate a novel approach utilizing a shortened 5 Max ACE (Penumbra Inc., Alameda, CA, USA) catheter triaxial construct to navigate tortuosity in the venous sinuses in order to use a 4 Fr AngioJet catheter. In particular, we demonstrate an effective alternative to catheterize tortuous dural venous sinuses when a larger bore support catheter cannot be accessed distally. 2. Case report A healthy female in her early forties on oral contraceptives with no other significant past medical history developed progressively worsening headaches and nausea for over 1 week. At presentation at our institution, she was increasingly lethargic, was intubated due to inability to maintain her airway, and developed a dilated and fixed right pupil despite therapeutic heparin dosing. Laboratory findings were unremarkable. An unenhanced axial CT scan of the head showed hyperdense thrombus within all of ⇑ Corresponding author. Tel.: +1 215 662 3046. E-mail address: [email protected] (A. Bress).
the venous sinuses and a left cerebellar hemorrhage (Fig. 1), confirmed with CT venogram and contrast enhanced MRI (Fig. 1, 2). The patient was emergently brought to the neurointerventional suite. Diagnostic venogram confirmed CVST. A 6 Fr 80 cm KSAW Shuttle catheter (Cook Medical, Bloomington, IN, USA) was placed in the right jugular bulb from a right transfemoral approach. Then, a construct consisting of a 5 MAX ACE reperfusion catheter, a XT-27 microcatheter (Stryker, Kalamazoo, Mich, USA), and a Fathom 16 microwire (Boston Scientific) was used to reach the left transverse/sigmoid sinus. A 6 mm 25 mm Trevo device (Stryker) was deployed through the XT-27 microcatheter. The ‘‘stent anchor with mobile aspiration technique” was then performed [2] with sufficient clot removal to restore segmental patency. An exchange length .014 in guidewire was placed through the Shuttle sheath into the right jugular vein and an Angiojet was used in the right transverse/sigmoid sinus, restoring flow in the right vein of Labbe. The Angiojet was unable to be navigated into the superior sagittal sinus (SSS) because of sharp angulation at the torcula. The SSS was catheterized using a 5 Max ACE, XT-27, and 300 cm 0.014 in Luge microwire (Boston Scientific), enabling placement of the ACE catheter in the SSS. The ‘‘stent anchor with mobile aspiration technique [2]” was again performed with minimal recanalization of the SSS (Fig. 3). Finally, the proximal 10–15 cm of the 5 Max ACE was cut and a 4 Fr AngioJet catheter was inserted through the shortened ACE
http://dx.doi.org/10.1016/j.jocn.2016.02.011 0967-5868/Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bress A et al. Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.02.011
2
Case Report / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
A
B
A
B SSS SSS
TS SS Fig. 1. Axial CT scan of the brain (A): left cerebellar parenchymal hemorrhage. Axial CT venogram of the brain (B): filling defects in the bilateral transverse sinuses compatible with thrombosis.
catheter and navigated into the SSS. Both 5 Max ACE and Angiojet catheters were navigated as a unit along the Luge microwire (Fig. 4) resulting in good antegrade flow within the SSS (Fig. 5). The patient was transferred to the Intensive Care Unit and received mannitol for diffuse cerebral swelling and heparin for anticoagulation. On postoperative day 2, the patient was neurologically intact with only very mild residual headache and she was normal on postoperative day 5. Her blood urea nitrogen and creatinine remained normal. Follow up head CT scan demonstrated stable cerebellar hematoma. The only risk factor for thrombosis was oral contraceptives and the patient had a negative hypercoagulability workup. The patient had a CT scan of the chest, abdomen and pelvis, notable for a breast mass for which a biopsy as an outpatient is planned. The patient was later switched to enoxaparin as a bridge to a 6 month course of apixaban. At discharge on postoperative day 10, she was neurologically normal. 3. Discussion Patients with CVST can present with a variety of symptoms ranging from headache, papilledema, seizure, focal neurologic deficit, coma and death [3]. Complications can be life threatening [4] and diagnosis is often delayed due variable and nonspecific presentations. The natural history of CVST is also variable ranging from resolution of symptoms, permanent neurologic impairment, coma or death from venous infarction and/or hemorrhage [3,5]. The initial
A
B
Fig. 3. Digital subtraction venography. Superior sagittal sinus (SSS), anteroposterior (A) and lateral (B) projection. Prior to intervention, there was poor anterograde flow with multiple filling defects in the SSS, transverse (TS) and sigmoid sinus (SS). There are multiple cortical, dural and transosseous venous collaterals.
treatment of choice is intravenous heparin [6]. Mechanical thrombectomy, however has become a common second line. AngioJet thrombectomy is appealing because of its efficiency in removing the large clot burden commonly encountered in CVST [1,7], as efficient clot removal correlates with better outcomes [3,5,7–9]. Procedural complications are also few [10]. Some describe using AngioJet in combination with intravenous heparin, and advocate mechanical thrombectomy as a first line treatment [1]. The importance of overcoming the difficulty in navigating the Angiojet through the venous sinuses is highlighted by a recent comprehensive review of mechanical thrombectomy for CVST which showed an AngioJet device was the most commonly used device (46.9% of cases) for rheolytic thrombectomy [11]. Despite its efficiency, significant difficulty exists when navigating the device about tortuous dural sinuses [9]. Some have described placing long sheaths within the sinuses to improve the chances of successful Angiojet navigation around tortuous segments, but this is not always successful [1]. Our technique for Angiojet delivery utilized a much more flexible catheter, the 5 MAX ACE Penumbra catheter, which can be delivered through the KSAW Shuttle to a distal location within the dural sinuses. However, the 5 MAX ACE is longer than the Angiojet catheter. To address this issue, we cut the proximal 10 cm of the 5 MAX ACE catheter after it was deployed within the dural sinus, which allowed for easy placement of the Angiojet to the target location and restoration of flow within minutes.
C
Fig. 2. MRI of the brain with contrast: axial (A), coronal (B), and sagittal (C). Filling defects are present within the superior sagittal sinus, straight sinus, torcular herophilli, and bilateral transverse sinuses compatible with cerebral venous sinus thrombosis.
Please cite this article in press as: Bress A et al. Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.02.011
Case Report / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
3
failure may occur from obstructive nephropathy due to myoglobin excretion. Clot migration may also cause symptomatic pulmonary embolism or possibly arterial infarct if a patent foramen ovale is present. Although first line treatment for CVST is systemic anticoagulation, use of the AngioJet device may improve outcomes. Our novel technique helped to navigate the sharp angles of the dural venous sinuses in order to gain access to the targeted thrombus.
Luge Wire
AngioJet
4. Conclusion
ACE
CVST is rare and can be life-threatening. Interventional treatment may be necessary. Navigating an Angiojet catheter in the dural sinuses can be quite challenging due to sharp angles. We introduce the ‘Triaxial Angiojet technique’ which can be helpful to gain access to a difficult location in the dural venous sinuses especially when a larger bore support catheter cannot access distally around the sigmoid or transverse sinus. This is a novel approach using the Angiojet catheter through a larger bore Penumbra aspiration catheter. Prior to employing this technique one must remember to remove the hub and 10–15 cm of the proximal 5 Max catheter as the 5 Max ACE is too long for the Angiojet catheter. Conflicts of Interest/Disclosures
Fig. 4. Digital unsubtracted lateral view. The ‘Triaxial Angiojet technique’ is demonstrated. The 4 Fr Angiojet catheter (Boston Scientific, Marlborough, MA, USA) and 5 Max ACE reperfusion catheter (Penumbra Inc., Alameda, CA, USA) are moved as a unit along the Luge microwire (Boston Scientific), back and forth within the superior sagittal sinus to the torcula while the Angiojet device is turned on, utilizing the provided foot pedal.
A
B
SSS SSS
TS
TS SS
SS IJV
Fig. 5. Digital subtraction venography; superior sagittal sinus (SSS), anteroposterior (A) and lateral (B) projection. After intervention, there was markedly improved antegrade flow with significant decrease in clot burden in the SSS, transverse (TS) and sigmoid sinus (SS) with blood flow now entering the internal jugular vein (IJV).
In addition to the known anatomic limitations, complications related to Angiojet use may also occur such as injury of the named superficial veins (Trolard, Labbe, etc.) with resultant subdural or parenchymal hemorrhage. Excessive hemolysis causing acute renal
The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Dashti SR, Hu YC, Yao T, et al. Mechanical thrombectomy as first-line treatment for venous sinus thrombosis: technical consideration and preliminary results using the AngioJet device. J NeuroIntervent Surg 2013;5:49–53. [2] Mascitelli JR, Pain M, Zarzour HK, et al. Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel comination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique. J NeuroIntervent Surg 2015. [3] Tsai FY, Higashida RT, Matovich V, et al. Acute thrombolysis of the intracranial dural sinus: direct thrombolytic treatment. AJNR Am J Neuroradiol 1992;13:1137–42. [4] Nasr DM, Brinjikji W, Cloft HJ, et al. Mortality in cerebral venous thrombosis: results from the national inpatient sample database. Cerebrovasc Dis 2013;35:40–4. [5] Gobin YP, Houdart E, Rogopoulos A, et al. Percutaneous transvenous embolization through the thrombosed sinus in transverse sinus dural fistula. AJNR Am J Neuroradiol 1993;14:1102–5. [6] Eihhaupl KM, Villringer A, Meister W, et al. Heparin treatment in venous sinus thrombosis. Lancet 1991;338:597–600. [7] 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;7:157–65. [8] Chow K, Gobin YP, Saver J, et al. Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis. Stroke 2000;31:1420–5. [9] Dowd CF, Malek AM, Phatouros CC, et al. Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis: a new technique. AJNR Am J Neuroradiol 1999;20:568–70. [10] Kirsch J, Rasmussen PA, Masaryk TJ, et al. Adjunctive rheolytic thrombectomy for central venous sinus thrombosis: technical case report. Neurosurgery 2007;60:E577–8 [discussion E578]. [11] Haghighi AB, Mahmoodi M, Edgell RC, et al. Mechanical thrombectomy for cerebral venous sinus thrombosis: A comprehensive literature review. Clin Appl Thromb/Hem 2014;20:507–15.
Please cite this article in press as: Bress A et al. Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.02.011