Endovascular thrombectomy followed by decompressive surgery in a patient with cerebral venous sinus thrombosis (CVST)

A 45-year-old woman was admitted to our hospital due to headache and hypaesthesia of the left arm (GCS = 15). She developed over the course moderate dysarthria and hemiparesis with sensory and visual neglect on the left side. The initial cranial computer tomography (CCT) was inconspicuous. CT-angiography showed a segmental occlusion of the superior sagittal sinus (SSS) (Fig. 1a). Treatment was started with i.v Heparin (pTT = 70 s). When no improvement was observed on this therapy and patient developed hemiplegia without showing any infarction or bleeding in CCT (Fig. 1b), endovascular thrombectomy (Penumbra 041 catheter ) (ET) of the SSS was done with some residual clot in the distal segment (Fig. 1c, d). The next day patient developed anisocoria (GCS = 3). CCT-scan showed a right frontal intracranial hemorrhage with a consecutive midline shift of about 1 cm (Fig. 1e). ICP was elevated with values above 20 mmHg (intraparenchymatous-pressure probe: Neurovent-P; Raumedic ). Decompressive hemicraniectomy (DH) was carried out (Fig. 1f). Systemic heparinization was continued during ET and DH (pTT = 70 s). Due to the elevated ICP a multimodal therapy with deep sedation, analgesics and osmotic drugs was added. Heparinization was continued until oral anticoagulation was started 2 weeks after the initial event. Three weeks later there was a significant improvement in the clinical status of the patient with residual spastic hemiplegia on the left side and she was transferred to a rehabilitation clinic. Six weeks later the cranial bone flap was reimplanted. The patient was able to use a wheelchair with a hemiparesis on the left side. Five months after the initial event patient was ambulatory with a severe residual paresis of the left arm (Fig. 1g). The modified ranking scale was 3. A protein-S deficiency was detected. Protein-C, antithrombin III, lupus anticoagulant and factor V Leiden mutation tests were unremarkable.