J Korean Neurosurg Soc.  2024 Sep;67(5):578-585. 10.3340/jkns.2023.0026.

Surgical Thrombectomy for Extensive Cerebral Venous Sinus Thrombosis after COVID-19 Vaccination : A Novel Surgical Technique and Literature Review

• Chung Y
• Ryu J
• Choi SK

• KMID: 2558683
• DOI: http://doi.org/10.3340/jkns.2023.0026

Abstract

Surgical treatment of refractory and extensive cerebral venous sinus thrombosis (CVST) has limited applications. Here, we describe an open, direct sinus thrombectomy in the early phase of extensive CVST. A 49-year-old man with extensive CVST that occurred after the coronavirus disease 2019 (COVID-19) vaccination and affected the drainage of the Labbé vein presented with clinical deterioration and left temporal hemorrhagic infarction. Since the patient had extensive CVST, we determined that systemic anticoagulation and endovascular treatment were not suitable treatment options. Therefore, we decided on an emergency surgical treatment and performed direct surgical thrombectomy. We followed extended suboccipital approach and made multiple incisions on the sinuses, exposing the posterior superior sagittal sinus to the transverse sigmoid junction. Consequently, the clinical condition of the patient dramatically improved, resulting in a favorable outcome with a modified Rankin scale score of 0. Performing emergency open surgical thrombectomy was a technically feasible treatment option that recanalize obstructed sinuses. Importantly, the patient recovered with a good clinical outcome. Early maximal surgical thrombectomy can be an effective and lifesaving method to treat extensive CVST with hemorrhagic infarction.

Keyword

Cerebral venous sinus thrombosis; Surgical thrombectomy; Vein of Labbé; Neurosurgery; COVID-19 vaccination

Figure

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  Fig. 1. Preoperative imaging findings of sinus thrombosis, venous congestion, and hemorrhagic infarction. A : Initial non-contrast computed tomographic scan demonstrates left temporal cortical and subcortical hemorrhage (white arrow) and increased density of the left transverse and sigmoid sinus junctions due to a dense thrombus (black arrow). B : Computed tomographic venogram coronal view showing low density in the left internal jugular vein, representing sinus thrombosis (white arrow). C : Computed tomographic venogram axial view showing low density in the left internal jugular vein, representing sinus thrombosis (white arrow). D : Computed tomographic venogram coronal view showing low density in the superior sagittal sinus near the torcula and left transverse sinus representing sinus thrombosis (white arrows). E : Susceptibility-weighted magnetic resonance image showing hemorrhagic infarction in the left temporal lobe (black arrow) and venous congestion in the left temporal and occipital lobes (white arrows). F : Diffusion-weighted magnetic resonance image showing a high-intensity lesion in the left temporal lobe (white arrow).

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  Fig. 2. Digital subtraction angiography of left internal carotid artery venous phase in oblique view. A : Preoperative digital subtraction angiography demonstrates pronounced thrombosis of the superior sagittal sinus near the torcula (white arrows), left transverse sinus, and sigmoid sinus, preventing the drainage of the Labbé vein. B : Postoperative digital subtraction angiography demonstrates recanalization of the superior sagittal and transverse sinuses (white arrows) with patency restoration of the Labbé vein (black arrow). C : Nine days after operation, digital subtraction angiography demonstrates a more prominent restoration of patency in the superior sagittal sinus, transverse sinus, and Labbé vein (black arrow).

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  Fig. 3. Surgical procedure. A : Schematic drawing of the operative position (Park-bench position). B : Schematic drawing indicating the locations of skin and dural incisions. C : Schematic drawing of the dural incision and anchoring sutures at the transverse sinus near the drainage site of Labbé. D : Operative image of the patient with a reflected skin flap after a hockey stick incision. The expected location of the transverse sinus was marked using forceps. E : Operative image of a dural incision with anchoring sutures at the transverse sinus near the drainage site of Labbé. F : Intraoperative findings during thrombectomy using Frazier suction and forceps. Continuous saline irrigation was applied to the torcula.

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  Fig. 4. Postoperative imaging findings. A : Computed tomographic venogram coronal view showing recanalization of the superior sagittal and transverse sinuses (white arrows). B : Computed tomographic venogram sagittal view showing prominent restoration of patency in the Labbé vein (white arrow). C : Susceptibility-weighted magnetic resonance imaging showing no change in the amount of hemorrhagic infarction (black arrow) and decreased venous congestion in the left temporal and occipital lobes (white arrow).

Reference

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