重症颅内静脉窦血栓形成病人的治疗体会

目的 总结重症颅内静脉窦血栓形成（CVST）病人的治疗经验。方法 回顾性分析2015年11月至2020年11月收治的8例重症CVST病人的临床资料。结果 1例保守治疗好转；1例保守治疗无改善，行去骨瓣减压术，但术中急性脑膨出合并严重静脉性出血，术后脑干功能迅速衰竭而死亡；6例抗凝治疗未见明显缓解，行介入治疗，术后1例病情仍无改善、GCS评分3分、家属放弃治疗而要求出院，5例症状明显改善，闭塞静脉窦再通，出院时GCS评分15分。术后随访1年，存活6例无血栓再形成及新发神经系统症状。结论 重症CVST病人常存在严重静脉窦堵塞或多个静脉窦血栓及脑实质损害，若应用抗凝治疗效果不理想，应及时实施血管介入取栓、接触性溶栓治疗，以更好地改善病人预后。     

微导丝引导下机械碎栓联合接触溶栓治疗多发性脑静脉窦血栓形成11例★

目的：多发性脑静脉窦血栓形成临床少见，传统内科抗凝治疗效果很差。采用微导丝引导下机械碎栓联合脑静脉窦内接触溶栓治疗，旨在进一步探讨多发性脑静脉窦血栓形成的有效治疗方法。 方法：选择2005-06/2007-04郧阳医学院附属人民医院神经内科收治的多发性脑静脉窦血栓形成患者11例，其中男5例，女6例。进行诊断性数字减影血管造影检查确诊，在微导丝引导下行机械碎栓及接触溶栓治疗，并动态观察症状、体征、颅内压力、影像学改变及有无并发症发生。患者家属对治疗知情同意。 结果：11例患者中有10例脑静脉窦实现再通，恢复良好，其中8例完全康复，1例临床症状明显改善，1例仅遗留右下肢轻偏瘫；1例放弃治疗后死亡，有效率高达91%（10/11），无一例并发症发生，随访3个月～2年无复发。 结论：微导丝引导下机械碎栓联合接触溶栓治疗多发性脑静脉窦血栓形成可显著提高再通率，减少并发症，改善预后。     

产后颅内静脉窦血栓形成三例报告

颅内静脉窦血栓形成(CVST)是一种独特的脑缺血病,死亡率高.初步探索认为CVST介入治疗是一种安全、有效的治疗手段[1].我们于2009年1月至2010年1月对3例CVST患者实施静脉窦血栓接触溶栓、机械碎栓并结合动脉内溶栓治疗,术后患者临床症状消失,报告如下.     

重症颅内静脉窦血栓形成的血管内治疗

目的探讨重症颅内静脉窦血栓形成血管内治疗方法的选择、溶栓药物的使用及其疗效和安全性。方法8例重症颅内静脉窦血栓形成患者均采用经静脉接触性溶栓治疗,其中2例联合机械性破栓术治疗,2例联合静脉窦内支架置入术治疗,2例动静脉联合溶栓治疗。结果除1例患者出现脑内血肿,留有一侧肢体轻瘫外,其余7例患者术中、术后均未出现与血管内治疗相关的并发症。出院时,患者格拉斯哥昏迷评分(GCS)评分由术前平均11分恢复到15分,原有的临床症状均得到改善(100%),闭塞的静脉窦均再通。平均随访12个月,所有患者腰穿压力均恢复正常,未出现血栓再形成和新的神经系统症状。结论对重症颅内静脉窦血栓形成患者采用合理的血管内介入治疗手段是有效的,对溶栓药物的使用、提高治疗安全性等问题上有待进一步研究。     

上矢状窦插管溶栓治疗颅内静脉窦闭塞性颅内压增高（附12例临床分析）

目的 探讨静脉窦插管溶栓加导丝疏通治疗颅内静脉窦闭塞性颅内压增高的治疗效果。方法 经上矢状窦插人导管鞘，滴注尿激酶溶栓的同时，在DSA下用导丝机械疏通上矢状窦、左右横窦。结果 12例病人颅内压增高症状全部缓解。无1例死亡，无并发症发生。有7例视力逐渐恢复，1例术前失明术后未能复明。结论 在DSA下进行静脉窦插管溶栓加导丝疏通，是治疗颅内静脉窦闭塞性颅内压增高的一个安全有效、创伤较小的方法。     

颅内静脉窦血栓形成的诊断和血管内治疗

目的探讨颅内静脉窦血栓形成(CVST)的血管内治疗方法。方法回顾性分析10例CVST病人的临床资料,采用血管内介入方法以导丝碎栓、尿激酶溶栓治疗,术后给予抗凝治疗。结果术后DSA显示:栓塞段静脉窦均再通。临床症状和体征完全恢复8例,改善1例,无明显改善1例。随访10例,时间8~30个月,复发2例。结论 CVST通过机械碎栓及药物溶栓后可达到再通,效果良好。     

颅内静脉窦血栓形成的临床研究

研究背景颅内静脉窦血栓形成是一种特殊类型的脑血管疾病,其病因及诱发因素复杂多样、临床表现各异,易被误诊或漏诊。该病具有较高的病残率和病死率,如何提高诊断与治疗水平一直是临床研究的热点问题,本文旨在探讨颅内静脉窦血栓形成不同治疗方法的安全性及有效性。方法回顾分析52例颅内静脉窦血栓形成患者的临床资料,并根据临床症状与体征、腰椎穿刺脑脊液压力和影像学表现分为轻症和重症组,分别接受全身抗凝联合静脉溶栓、血管内溶栓或锥颅上矢状窦溶栓治疗,同时辅助华法林口服6～12个月。术后通过磁共振静脉血管造影术观察静脉窦形态。结果轻症组27例患者接受全身抗凝药物联合静脉溶栓治疗,14例痊愈、9例好转、4例无效;重症组25例患者中22例经全身抗凝药物联合血管内溶栓治疗后18例痊愈、3例好转、1例死亡,余3例行锥颅上矢状窦溶栓治疗,均痊愈。共随访6～60个月(平均36个月),无一例复发。结论根据患者病情轻重程度,针对临床分型选择不同方法治疗颅内静脉窦血栓安全有效。     

尿激酶联合替罗非斑在颅内静脉窦血栓形成介入性治疗中的应用

目的 探讨尿激酶联合替罗非斑血管内溶栓治疗颅内静脉窦血栓形成(CVST)的疗效和安全性. 方法 广州军区武汉总医院神经外科自2009年1月至2011年1月行尿激酶联合替罗非斑经微导管选择性静脉窦内溶栓、机械性碎栓治疗9例重症CVST患者,分析其临床资料和疗效. 结果 出院前8例患者脑脊液(CSF)压力正常,DSA检查显示7例患者静脉窦主干通畅,皮层静脉和深静脉恢复正常.1例部分再通,皮层静脉部分代偿.术中和术后未发生手术操作相关的并发症;出院时8例患者症状、体征得到改善,其中头痛消失7例,遗留轻度头痛1例.1例死亡. 结论 尿激酶联合替罗非斑经微导管选择性静脉窦内溶栓治疗是CVST安全、有效的治疗手段.     

单侧静脉窦支架置入治疗特发性颅内压增高症

目的了解静脉窦狭窄在特发性颅内压增高症中所起的作用以及腔内支架治疗的可行性。方法回顾性研究应用静脉窦内支架成形术治疗静脉窦狭窄的特发性颅内压增高症的患者,观察资料包括临床症状、眼底检查、颅内压测定、脑血管造影情况、治疗方法、疗效及安全性。结果研究期间共有7例特发性颅内压增高症患者行逆行脑静脉造影并行静脉窦测压后行静脉窦支架置入术,其中4例伴有头痛,1例伴有鼻漏,术后伴发症状均有改善;7例患者均有视力下降,术后6例视力有所好转,1例术后视力无好转。结论怀疑存在静脉窦狭窄的特发性颅内压增高患者应行逆行脑静脉造影并且静脉窦测压。对于因静脉窦狭窄引起症状的患者,静脉窦内支架置入是一种可供选择的治疗方案。     

孕产妇合并颅内静脉窦血栓形成的诊治体会

目的探讨孕产妇合并颅内静脉窦血栓形成的诊断和治疗。方法选择2005-05-2015-09在我院治疗的孕产妇合并颅内静脉窦血栓患者15例,回顾分析其临床资料。结果妊娠早期发病2例患者中1例经抗凝治疗后无效,转行静脉窦内接触性尿激酶溶栓治疗;妊娠晚期3例患者均行剖宫产终止妊娠,术后24h给予抗凝治疗,1例发生发生意识障碍转行血管内溶栓治疗。产褥期发病10例中经抗凝治疗无效2例,2例伴癫痫发作转行血管内溶栓治疗,1例出现颅内静脉窦广泛血栓合并脑内出血,经抢救无效死亡。结论孕产妇出现抽搐、急性和亚急性头痛等症状需警惕出现颅内静脉窦血栓,符合静脉窦引流区域的脑实质异常信号为颅内静脉窦血栓形成的诊断依据,给予抗凝和溶栓等治疗以改善孕产妇结局。     

颅内静脉窦血栓形成的临床及影像学诊断25例报道

目的 研究颅内静脉窦血栓形成的病因、临床特点、特别是影像学的表现。方法 回顾性分析25例已确诊的静脉窦血栓形成患者（男2例,女23例）的临床资料及影像学特点,包括发病原因、临床表现、实验室检查及影像学头部CT、磁共振成像（MRI）和磁共振血管成像（MRA）的异常表现。结果 25例本病患者除2例男性外,余23例均有明确病因,如妊娠期、产褥期、口服避孕药等,临床表现以亚急性颅压高症状为主;部分头部CT可见条索征及空三征,MRI特征性表现为T1、T2加权像窦内异常高信号,MRA示栓塞的静脉窦未显影。结论 颅内静脉窦血栓形成患者多可找到明确病因,临床表现多样,无特异性,MRI/MRA可帮助确诊。     

Dural sinus thrombosis: a mechanism-based classification and review of 42 cases

Cranial venous outflow obstruction due to dural sinus thrombosis may result in venous hypertension, cerebral infarction, cerebral haemorrhage or impaired cerebrospinal fluid (CSF) absorption with consequent pseudotumour syndrome. We propose a mechanism based classification of dural sinus thrombosis from these four outcomes. Forty two cases of dural sinus thrombosis presenting to Royal Prince Alfred Hospital between 1986-1997 were retrospectively reviewed. These cases were classified according to mechanism of presentation and relevance of this to site of thrombosis, treatment and prognosis. This study shows that the superior sagittal sinus and transverse sinus are the commonest sites of thrombosis, and multiple sites of thrombosis (69%) are more frequent than a single site. Magnetic resonance imaging (MRI) with venous flow studies is the investigation of first choice for diagnosis but angiography remains the gold standard. A pseudotumour syndrome is the commonest presentation (43%) followed by cerebral haemorrhage (31%). The overall prognosis for sinus thrombosis is good, with 71% of cases recovering to normal function.     

Dural venous sinus thrombosis after cerebellopontine angle surgery: Should it be treated?

IntroductionDural venous sinus thrombosis is an uncommon, but significant sequela that may occur after resection of a cerebellopontine angle lesion. The natural history and management of this pathology has not been sufficiently studied.MethodsAll operative cases for cerebellopontine angle lesions performed in our local institution dating from 1 January 2005 to 30 June 2018 were retrospectively reviewed to identify patients who developed new post-operative dural venous sinus thrombosis. Patients who developed a significantly narrowed sinus without intrinsic thrombus were also identified. Progression of sinus thrombosis through time was followed, with comparisons made between complications amongst patients with and without a compromised sinus.ResultsOf the 126 patients, 20 were found to have new sinus thrombosis, with another 16 developing a critically narrowed sinus without intrinsic thrombus. These cases are significantly associated with translabyrinthine resection of acoustic schwannoma. 4 patients amongst the thrombosed group were commenced on additional therapeutic anticoagulation or antiplatelets, whilst the rest were observed. Based on available follow up imaging, 10/17 patients had significantly improved sinus thrombosis on serial imaging, including 8/14 amongst those not given additional anticoagulation. Patients with a compromised sinus demonstrated a higher rate of cerebrospinal fluid leak requiring blindsac procedures. When involving a dominant sinus, there is also an association of an increased requirement for permanent CSF diversion.ConclusionTherapeutic anticoagulation should be considered for symptomatic post-operative dural venous sinus thrombosis or if it involves a dominant sinus. Further prospective studies are warranted to better elucidate the risk-benefit justification of treatment for postoperative sinus thrombosis.     

Evolution of angiographic signs of venous hypertension and clinical signs of intracranial hypertension in intracranial dural arteriovenous fistulas]

Dural arteriovenous fistulas (dAVFs) can cause cerebral venous hypertension (VHT). The most common mechanism is due to the fact that some dAVFs can drain retrogradelly in cortical (better defined as leptomeningeal) veins (directly or after drainage in a dural sinus) causing venous engorgement and consequently an impairment of the cerebral venous drainage. However, more rarely, dAVFs without a cortical venous drainage can also be responsible for VHT probably due to dAVF shunts causing insufficient antegrade cerebral venous drainage. In addition, dAVFs are often associated with stenosis and/or thrombosis of dural sinus(es) which can worsen the VHT. Raised pressure within the superior sagittal sinus causes impeded cerebrospinal reabsorption in the arachnoid villi allowing increased intracranial pressure. The venous engorgement in the cortical veins can cause a venous congestive encephalopathy analogous to the venous congestive myelopathy of the spinal dural AVFs. Clinically VHT can cause not only symptoms related to increased intracranial pressure but also seizures, neurological deficits, impairment of the cognitive functions and dementia. An important aspect is the risk of hemorrhage in dAVFs with a leptomeningeal venous drainage leading to VHT. Although the term VHT sensu strictu should be used if venous pressure measurements are performed, angiographic criteria for VHT such as delayed circulation time, venous engorgement and abnormal visualization of the cerebral veins are well established. The purpose of our study was to evaluate the angiographic signs of VHT in patients with dAVF and to study the course of the VHT and of the clinical signs of increased intracranial pressure before and after dAVF endovascular treatment. A retrospective chart analysis of 22 patients (13 males, 9 females) ranging in age from 20 to 87 years (mean: 53 ys.) with a dAVF associated with angiographic signs of VHT was performed. Ten dAVFs were located on the transverse/sigmoid sinus(es), 6 on the superior sagittal sinus, 3 on the petro-tentorial incisura, 1 on the inferior petrosal sinus, 1 on the anterior ethmoidal region and 1 on the Galen vein region. All dAVFs had a retrograde leptomeningeal venous drainage. Stenosis or thrombosis of the dural AVF sinus was observed in 17 cases and stenosis or thrombosis of another sinus(es) and/or of the jugular vein in 8 cases. In 11 patients, the angiographic signs of VHT were global affecting the entire cerebral venous drainage and, in the other 11 patients, the VHT was focal. The VHT caused clinical symptoms of increased intracranial pressure in 18 patients. Other clinical findings included: bruit (11 cases), seizures (3 cases), vertigo (3 cases), visual deficits (2 cases) and impairment of cognitive functions (4 cases). Three patients presented hemorrhage (one parenchymal hematoma, one hemorrhagic infarction and one subarachnoid hemorrhage). The 4 patients without clinical symptoms of increased intracranial pressure presented only bruit in 2 cases, bruit and vertigo in 1 case, bruit and hemorrhagic infarction in another one. The dAVFs were treated by endovascular therapy (arterial approach: 3 cases, venous approach: 6 cases and both arterial and venous approach: 13 cases). Endovascular sessions ranged from 1 to 7 (mean: 2.8) for each patient. After the endovascular treatment, in 12 patients with complete occlusion of the dAVF, the disappearance of angiographic signs of VHT and clinical cure were observed. In 8 patients with partial occlusion of the dAVF, the disappearance of angiographic signs of VHT and clinical cure were observed in 4 cases (almost complete dAVF occlusion in 2 cases); in the other 4 cases, only reduction the angiographic signs of VHT and clinical improvement were obtained. In all 16 patients who were clinically cured angiographic signs of VHT disappeared despite the persistence of dAVF shunts as observed in 4 cases. (ABSTRACT TRUNCATED)     

MRI和MRV在脑静脉和静脉窦血栓诊断中的价值

目的探讨MRI和MRV对脑静脉和静脉窦血栓(CVST)形成的诊断价值。方法回顾性分析16例CVST患者的临床和影像学资料。结果受累的脑静脉和静脉窦有上矢状窦9例,横窦5例,直窦3例,乙状窦2例,大脑大静脉合并大脑内静脉2例。常规MRI可见受累静脉窦流空信号消失,静脉窦内信号高低不一,11例脑实质内出现静脉性脑梗死表现,其中4例合并出血。增强扫描15例静脉窦内出现充盈缺损及静脉窦壁强化表现,9例脑实质内出现脑回样强化。MRV表现为受累静脉窦部分或广泛高血流信号缺失、狭窄。结论MRI和MRV是诊断和随访CVST形成的最佳检查方法。     

Clinical picture of patients with cerebral venous thrombosis and patterns of dural sinus involvement

BACKGROUND/OBJECTIVES: Cerebral venous thrombosis may cause focal brain lesions or an isolated intracranial hypertension without focal signs. We investigated whether these different clinical pictures correspond to different patterns of dural sinus thrombosis. METHODS: Forty-eight patients with cerebral venous thrombosis were classified in 2 groups based on the clinical and neuroradiological picture at admission: one group had clinical signs of intracranial hypertension, without focal neurological signs; the other group had focal neurological signs. The extension of thrombosis in dural sinuses was compared between the groups. RESULTS: The amount of thrombosed sinuses was significantly different in the two groups, the involvement of the dural sinuses being greater in patients with isolated intracranial hypertension. CONCLUSIONS: The clinical picture of cerebral venous thrombosis is related to the pattern of dural sinus involvement. The presence of isolated intracranial hypertension is more frequent in patients with a more extended thrombosis of the dural sinuses.     

Superior Sagittal Sinus Thrombosis in the Presence of Idiopathic Bilateral Internal Jugular Vein Stenosis

Cerebral venous outflow obstruction and anomalies in cerebral venous circulation predispose to dural sinus thrombosis. This case report illustrates the magnetic resonance and angiographic findings in a patient who had superior sagittal sinus thrombosis secondary to idiopathic bilateral internal jugular vein stenosis, a previously unrecognized entity. The findings suggest that bilateral stenosis of the internal jugular veins at their junction with the innominate veins causes obstruction to cerebral venous outflow leading to dural sinus thrombosis.     

Urokinase treatment of sagittal sinus thrombosis with venous hemorrhagic infarction

Background: Selective catheterization of the dural venous sinuses with local infusion of urokinase may be beneficial in patients with venous sinus thrombosis, and has been reported to be safe in patients with venous infarction. However, information regarding safety in the presence of hemorrhage is sparse. Methods: Three patients presented with severe, progressive focal neurological symptoms (National Institutes of Health Stroke Scales: 14, 22, and 12) resulting from superior sagittal sinus thrombosis, with evidence of hemorrhage on computed tomographic scans (two intraparenchymal, one subarachnoid). Selective venous catheterization was performed and low-dose urokinase was delivered directly into the thrombus by continuous infusion at 60,000 U/h. Intravenous heparin was administered concurrently. Results: Angiographic patency was restored in all patients. The total duration of urokinase infusion ranged from 36 to 84 hours. There was no major morbidity or mortality related to the procedure. All patients had dramatic clinical improvement during and after the course of therapy, and none had worsening of pre-existing hemorrhage. All patients were independent at 3 months, with minimal or no deficit (National Institutes of Health Stroke Scales: 2, 0, and 2). Conclusion: In selected patients with superior sagittal sinus thrombosis associated with venous hemorrhagic infarction, urokinase appears to be safe and may reverse progressive neurological deterioration. Future prospective study is warranted to further investigate this treatment option, and patients with severe deficits or pre-existing hemorrhages should not be excluded.     

Cerebral cortical and deep venous thrombosis without sinus thrombosis: clinical MRI correlates

BACKGROUND: Cortical and/or deep vein thrombosis (CDVT) without dural sinus involvement is uncommon and presents diagnostic difficulty for many reasons. Our aim is to determine the relationship between magnetic resonance imaging (MRI) findings and clinical findings in patients with CDVT. METHODS: Forty-six patients with venous stroke proved on MRI included in our Registry, corresponding to 0.1% of 4650 patients with stroke, were studied. Magnetic resonance angiography (MRA) was performed in all patients, and 18 of them had follow-up MRA. Outcome was evaluated by using the Glasgow Outcome Scale at the time of discharge and during follow-up. RESULTS: Thirty-two patients presented cortical venous stroke; 21 of them had involvement of the dorsomedial venous system, six had a defect in the posteroinferior venous group, and five had a defect in the anteroinferior venous group. Thirteen patients presented simultaneous involvement of the superficial and deep venous system; seven with a defect in the parietal and internal cerebral veins (three with involvement of vein of Gallen), four with a defect in the temporooccipital (vein of Labbé) and basal vein of Rosenthal, two with a deficit in the anterior frontotemporal and uncal-pterygoid venous system. One patient had deep venous thrombosis primarily localized to the thalami bilaterally and the basal ganglia on the right because of occlusion of the thalamostriate veins. The main presenting symptoms of CDVT were headache, focal neurologic signs, partial complex or secondary generalized seizures, and consciousness disturbances in those with deep venous thrombosis, presented alone or in combination at onset. CDVT was more than twofold more frequent in women than in men. Pregnancy, puerperium, oral contraceptive use, and infections were the most common predisposing factors. CONCLUSION: Computerized tomography, conventional MRI and diffusion-weighted imaging showing ischemic and/or hemorrhagic lesion that does not follow the boundary of classical arterial boundaries without signs of sinus thrombosis, and partial or generalized seizures followed by focal neurologic signs may predict CDVT. The outcome of patients with cortical venous stroke was good, but not in those with cortical plus deep venous infarction.     

TCD动态监测静脉窦血栓形成五例

目的评价静脉窦血栓形成患者经颅多普勒超声(TCD)检测静脉侧枝的开放和再通情况以及颅内压变化。方法用TCD 2MHz探头检测5例静脉窦血栓形成患者的颅内静脉的血流速度以及动脉频谱形态的变化。结果 5例静脉窦血栓形成患者的颅内静脉(大脑中深静脉、基底静脉)的血流速度均明显增高(139cm/s,118 cm/s,99 cm/s,103 cm/s,58cm/s),动脉频谱呈高阻力,经过治疗,随着病情的好转,颅内静脉血流速度下降,颅内动脉频谱由高阻力型恢复正常。结论 TCD能可靠无创、准确地检测颅内静脉,在病程中通过多次的TCD检查,可以评价静脉窦血栓形成静脉侧枝的开放和再通情况以及颅内压变化。