J Korean Neurosurg Soc.  2023 Nov;66(6):735-742. 10.3340/jkns.2022.0254.

Mechanical Thrombectomy for Refractory Cerebral Venous Sinus Thrombosis in a Child with Nephrotic Syndrome : A Case Report

• Ye J
• Yang Y
• Wan W
• Ma X
• Liu L
• Liu Y
• He Z
• Yuan Z

• KMID: 2547467
• DOI: http://doi.org/10.3340/jkns.2022.0254

Abstract

Nephrotic syndrome (NS) is associated with cerebral venous sinus thrombosis (CVST), which is a rare cerebrovascular disorder in children. Systemic anticoagulation with heparin is the standard therapy for CVST, and mechanical thrombectomy (MT) has been described as a salvage treatment for adult anticoagulant refractory CVST, However, it has never been reported in children. We describe a case of MT for refractory CVST in a child with NS. A 13-year-old boy with newly diagnosed NS presented to an emergency department with acute headache. A head computed tomography showed acute thrombus in the superior sagittal sinus, straight sinus and transverse sinus. The child was started on heparin therapy, but clinically deteriorated and became unresponsive. In view of the rapid deterioration of the condition after anticoagulation treatment, the patient received intravascular treatment. Several endovascular technologies, such as stent retriever and large bore suction catheter have been adopted. After endovascular treatment, the patient’s neurological condition was improved within 24 hours, and magnetic resonance venography of the head demonstrated that the CVST was reduced. The child recovered with normal neurological function at discharge. This case highlights the importance of considering MT for refractory CVST, and we suggest that MT may be considered for refractory CVST with NS in children.

Keyword

Sinus thrombosis; Nephrotic syndrome; Thrombectomy; Child; Case report

Figure

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  Fig. 1. A-C : Computed tomography head revealing a hyperdense sign noted (white arrows) in the superior sagittal sinus and transverse sinus suggesting cerebral venous sinus thrombosis. D and E : Magnetic resonance venography revealed thrombus in superior sagittal sinus and transverse sinus (white arrows). F : The right cortical veins (green arrows) on the susceptibility weighted imaging sequence are significantly larger than the left, suggesting obstruction of venous return. G and H : The venous phase of right internal carotid angiography suggests thrombosis of the superior sagittal and right transverse sinuses (white arrows). I : Venous phase of left internal carotid angiography. No thrombus was found in the left transverse sinus.

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  Fig. 2. Procedure of transvenous endovascular mechanical thrombectomy. A and B : Right femoral vein approach, suction catheter guided target vessel reading. C : Intras sagittal sinus angiography suggests obstruction of venous return (white arrows). D-F : Large volume venous clots retrieved using the skysurfer aspiration catheter (white arrow), Syphonet stent retriever (green arrow), and balloon catheter disruption of the thrombus (black arrow). G-I : Right transverse sinus recanalization (white arrow), with a small amount of thrombus remaining (black arrow). Urokinase was administered into the superior sagittal and right transverse sinus. Anticoagulation with heparin was resumed after the procedure.

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  Fig. 3. A-C : Computed tomography head revealing that the hyperdense sign had disappeared in the superior sagittal sinus and transverse sinus whitin 1 weak after endovascular mechanical thrombectomy. D : Hematoxylin and Eosin staining (×400) demonstrated that the cerebral venous sinus thrombosis was mixed clot. E and F : Lymphatic fluid oozes from the right femoral vein puncture point, stopped oozing after compression.

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  Fig. 4. Magnetic resonance venography in coronal (A) and axial views (B) showed that the cerebral venous sinus was completely recanalization at the 2 weeks clinic follow-up. The left and right sides of the cortical veins are symmetrical on the susceptibility weighted imaging sequence (C).

Reference

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