MR staging of acute dural sinus thrombosis: correlation with venous pressure measurements and implications for treatment and prognosis.

PURPOSE: To correlate parenchymal brain changes, venous sinus pressure measurements, and outcome in 29 patients with acute dural sinus thrombosis. METHODS: A retrospective review of 29 patients with angiographically proved acute dural sinus thrombosis was made from January 1989 to December 1993. MR examinations were performed on either a 0.5- or 1.5-T superconductive scanner in multiple planes. Direct dural sinus venography, cerebral angiography, and MR venography were performed. Venous sinus pressure measurements were obtained in 11 of 29 patients. RESULTS: We identified five distinct stages of brain parenchymal changes; each stage correlated with increasing intradural sinus pressure. The pressures measured in this study ranged from 20 to 50 mm Hg. Brain parenchymal changes were reversible up to stage III if thrombolytic treatment was performed. Beyond stage III, there were some residual changes, even after thrombolysis. All stage V patients died. CONCLUSION: Acute dural sinus thrombosis leads to distinct stages of parenchymal changes, the severity of which depends on the degree of venous congestion, which, in turn, is closely related to intradural sinus pressure. As intradural sinus pressure increases, progression from mild parenchymal change to severe cerebral edema and/or hematoma may occur if thrombolysis is delayed.

Percutaneous transluminal angioplasty adjunct to thrombolysis for acute middle cerebral artery rethrombosis.

PURPOSE: To report three patients, each of whom had acute rethrombosis of a reopened middle cerebral artery after urokinase treatment for proximal stenosis (percutaneous transluminal angioplasty of the stenosis was performed adjunctive to the thrombolytic treatment to preserve the success of the thrombolysis), and a fourth patient who had percutaneous transluminal angioplasty right after the completion of thrombolysis and had no rethrombosis despite a partial dilatation of the severe stenosis. METHODS: Thrombolytic treatment was carried out by a coaxial technique with a Tracker 18 catheter through a 5-F angiographic catheter; 80,000 U in 5 mL of urokinase were intermittently injected every 15 minutes after an initial dose of 250,000 U. All patients were given 3000 U of heparin with a booster dose of 1000 U every hour. Angioplasty was performed with a Stealth catheter balloon, 2 to 3 mm x 1.5 cm. RESULTS: Three patients recovered without hemorrhage after percutaneous transluminal angioplasty and thrombolytic treatment. Percutaneous transluminal angioplasty was unsuccessful in one patient because of the inability to pass a 2-mm Stealth balloon catheter, and the result was a second rethrombosis. This patient had a poor recovery. CONCLUSION: Acute thrombosis of the middle cerebral artery may be associated with severe proximal stenosis. Rethrombosis may occur even after complete thrombolysis. Percutaneous transluminal angioplasty may be safely performed to prevent rethrombosis.

Acute thrombosis of the intracranial dural sinus: direct thrombolytic treatment.

Acute intracranial dural sinus thrombosis may have severe morbidity or fatal complications without appropriate treatment. Direct dural sinus venography can be performed safely with a soft Tracker catheter to document the fresh thrombus as an adjunct to CT or MR. We are reporting our experience with successful direct urokinase thrombolytic therapy in three cases of superior sagittal sinus and two cases of transverse and sigmoid sinus thrombosis. All five patients have recovered completely without any residual clinical deficit.

Percutaneous transluminal angioplasty of the carotid artery.

Percutaneous transluminal angioplasty (PTA) is being extensively applied to treat arteriosclerotic lesions. However, this application has not been widely accepted for the treatment of carotid artery stenosis. Successful attempts to relieve cerebral ischemia from extracranial carotid arterial stenosis by PTA are reported. Twenty-seven patients with arteriosclerotic stenosis, fibromuscular disease, and Takayasu carotid arterial stenosis were treated by PTA. All anatomic carotid stenotic lesions were corrected without any neurologic complication. Follow-ups ranged from 3 months to 4 years without recurrent symptoms in any patient. These results may suggest that some patients with cerebral ischemia secondary to extracranial carotid artery stenosis may be treated safely and effectively by PTA.

Practical aspects of percutaneous transluminal angioplasty of the carotid artery.

The authors are reporting a total of 41 patients undergoing percutaneous transluminal angioplasty (PTA) at different levels of the carotid artery. The procedure for proximal carotid artery was performed on 17 patients, for mid or distal common carotid artery on 4 patients, for carotid bifurcations on 5 patients, for internal carotid artery on 6 patients, for external carotid artery on 4 patients, and for fibromuscular dysplasia of the internal carotid artery on 5 patients. We also collected research on an additional 53 patients from the literature for a total of 94 patients. To date, we have not encountered any mortalities nor neurologic complications in performing this procedure. Thus, we believe that PTA may be performed with reasonable safety and as an alternate procedure in the treatment of carotid artery stenosis.