Abstract
Cerebral venous sinus thrombosis (CVST) is a rare complication of surgical treatment of vestibular schwanomma. We present a rare case of extensive venous sinus thrombosis after trans-labyrinthine approach that was refractory to systemic anti-coagulation. Mechanical aspiration thrombectomy was utilized to re-canalize the venous sinuses and resulted in successful resolution of neurological symptoms. Indications of utilizing endovascular approaches are discussed that will enable skull base surgeons to address this uncommon yet potentially fatal complication.
1
Introduction
CVST (cerebral venous sinus thrombosis) is an infrequent yet serious complication of CPA (cerebellopontine angle) surgery . Venous hypertension and eventual development of increased ICP (intra-cranial pressure) depend on the degree of thrombosis, laterality of dominant sinus as well as collateral venous drainage. Venous outflow obstruction and increase in ICP lead to development of severe headache, visual symptoms and papilledema . In severe cases, more devastating complications such as intracranial hemorrhage and venous infarction can develop as well . The incidence of sigmoid and/or transverse sinus thrombosis complicating translabyrinthine or retrosigmoid approach for CPA tumors is reported as 4.6–11.6% . Diagnosis is confirmed with use of MR (magnetic resonance) venography, CT (computed tomography) venography and DSA (digital subtraction angiography). Once diagnosed, treatment options depend on neurological symptoms and extent of thrombosis. Systemic therapeutic anticoagulation should be started immediately . Adjunctive maneuvers including CSF (cerebral spinal fluid) diversion should be employed when there is evidence of increased intracranial pressure. In cases of acute neurological compromise, additional endovascular approaches including chemical or mechanical thrombectomy can be employed as well . Previous reports of CVST complicating CPA surgery have focused on use of systemic anticoagulation in asymptomatic cases whereas symptomatic cases were managed with drainage of CSF, including ventriculo-peritoneal drain placement .
We describe a case of unusually extensive venous sinus thrombosis complicating translabyrinthine removal of vestibular schwanomma with involvement of sigmoid, transverse and superior sagittal sinuses that was successfully managed with endovascular approach utilizing mechanical thrombectomy with the Penumbra aspiration thrombectomy system (Penumbra, Alameda, CA). This is the first reported case of successful use of state of the art mechanical thrombectomy approach leading to resolution of extensive CVST complicating a lateral skull base procedure.
2
Case description
A 21-year-old female underwent right trans-labyrinthine craniotomy for resection of vestibular schwanomma ( Fig. 1 A ). Immediate post-operative course was unremarkable and post-operative MRI showed no evidence of any ischemic or other neurological complication. Patient was discharged in stable condition on post-operative day 3. She presented to the emergency department with diplopia, blurry vision, right sided tinnitus, frontal and occipital headache as well as unremitting nausea and vomiting which peaked on the ninth post-operative day. She displayed binocular horizontal diplopia and severe (grade 4) papilledema. Imaging including MRI/MRV showed extensive thrombus involving the right jugular vein, sigmoid, and transverse sinuses with extension into the superior sagittal sinus ( Fig. 1 B). Lumbar puncture was performed with high opening pressure of 52 cm H 2 O and 35 ml of CSF was drained. She was admitted in neuro-intensive care unit and started on anticoagulation with intravenous heparin infusion. She failed to improve clinically and the decision was made to attempt endovascular venous mechanical thrombectomy. At this time, there was no clinical or radiographic evidence of venous infarction or hemorrhage from the extensive venous thrombus.
2
Case description
A 21-year-old female underwent right trans-labyrinthine craniotomy for resection of vestibular schwanomma ( Fig. 1 A ). Immediate post-operative course was unremarkable and post-operative MRI showed no evidence of any ischemic or other neurological complication. Patient was discharged in stable condition on post-operative day 3. She presented to the emergency department with diplopia, blurry vision, right sided tinnitus, frontal and occipital headache as well as unremitting nausea and vomiting which peaked on the ninth post-operative day. She displayed binocular horizontal diplopia and severe (grade 4) papilledema. Imaging including MRI/MRV showed extensive thrombus involving the right jugular vein, sigmoid, and transverse sinuses with extension into the superior sagittal sinus ( Fig. 1 B). Lumbar puncture was performed with high opening pressure of 52 cm H 2 O and 35 ml of CSF was drained. She was admitted in neuro-intensive care unit and started on anticoagulation with intravenous heparin infusion. She failed to improve clinically and the decision was made to attempt endovascular venous mechanical thrombectomy. At this time, there was no clinical or radiographic evidence of venous infarction or hemorrhage from the extensive venous thrombus.
