Abstract Number ‐ 73: Successful Endovascular Treatment of Medically Refractory CVST Using a Large Bore Distal Platform Thrombo‐aspiration Catheters.
Authors: Mulatu Yohannes S , Mulatu Yohannes S , Ramaswamy Srinath , Eldokmak Mohamed , Buciuc Razvan , Wang Qingliang T 
Published: April 2023

Introduction
Cerebral venous sinus thrombosis (CVST) is a rare (0.5‐2/100,000 incidence) but potentially fatal (5% mortality rate) neurological condition. The diagnosis may be delayed due to the non‐specific presenting symptoms such as headache, altered mental status, or seizures. Anticoagulation has long been the standard therapy for CVST. However, a subset of patients do not respond to medical therapy, and may develop complications such as ischemic stroke, hemorrhage, and cerebral edema. In the ISCVT study, 13% of patients experienced poor outcomes despite anticoagulation. Recently, it has been shown that patients with extensive clot burden, cerebral edema, elevated ICP, and altered mentation may achieve better outcomes with endovascular thrombectomy (EVT) compared to anticoagulation. We present a patient with CVST who failed therapeutic anticoagulation but improved with thrombectomy using the novel Zoom 088 Aspiration system, that further demonstrating the efficacy of combination therapy with anticoagulation and EVT.

Methods
A case report of successful CVST treatment using large bore aspiration catheters.

Results
A 37‐year‐old woman with a history of migraine and current oral contraceptive use presented with acute, persistent, and severe right hemicranial and retro‐orbital headache. Non‐contrast CT head suggested thrombosis of the right transverse sinus. MR venogram confirmed CVST involving the right transverse sinus, sigmoid sinus, and internal jugular vein. We started therapeutic anticoagulation, but the patient’s headache progressively worsened. Repeat MR venogram revealed extension of the CVST. Given clinical and radiological worsening, we proceeded with EVT procedure using a Zoom 088 aspiration system, resulting in successful recanalization of the involved sinuses. However, there was persistent severe headache following the procedure. She developed a new long segment obstructive thrombus in the left transverse sinus and partial re‐occlusion of the right sigmoid sinus on repeat MR venogram. A second EVT procedure was performed using the Zoom 088 Aspiration system, with complete recanalization. Postoperatively, her symptoms resolved and at 3‐month follow‐up she remained largely asymptomatic without neurological deficits. To the best of our knowledge, this is the first reported successful clinical use of the Zoom 088 aspiration device for CVST. The Zoom 088 Aspiration system is a newer generation large distal platform thrombo‐aspiration catheter. Studies have established efficacy of contact aspiration and stent retriever technique for arterial thrombi. Venous sinus clots are loosely bound to the vessel wall, perhaps making them more readily removable through aspiration. However, its standard application for CVST, including its efficacy and complication rates, remain to be analyzed in larger prospective studies.

Conclusions
This case highlights the pivotal role of EVT, especially large‐bore catheter based aspiration approach, in the management of medically refractory CVST. Thrombo‐aspiration technology is evolving at an accelerated rate with versatile and navigable devices such as the Zoom 088 aspirator. Larger studies are warranted to establish its technical efficacy and safety profile.