Abstract Number ‐ 72: A Successful Emergent Endovascular Mechanical Thrombectomy in An Extensive Deep Cerebral Venous Sinus Thrombosis
Authors: Mahat Bishow C , Dwairi Vanessa , Kuybu Okkes , Nogueira Raul G 
Published: April 2023

Introduction
Cerebral venous sinus thrombosis (CVST) is an uncommon variant of strokes, accounting for 0.5‐1% of all cases. Current guidelines recommend systemic anticoagulation as the first line therapy with endovascular approach reserved for those who fail to recanalize. We describe a 24‐year old female who presented with 3 days of headache and right sided weakness and was found to have extensive deep CVST with intracerebral hemorrhage and obstructive hydrocephalus. She underwent successful emergent intravenous thrombectomy with complete recanalization after clinical and radiological deterioration despite optimal systemic anticoagulation and bilateral external ventricular drains (EVDs).

Methods
The patient underwent thrombectomy under general anesthesia. Angiogram through the right radial artery was performed showing extensive thrombosis involving straight sinus, inferior sagittal sinus, vein of Galen and the internal cerebral vein. A right common femoral vein access was obtained and 80 cm Cook shuttle was placed and advanced to left internal jugular vein. Two passes mechanical thrombectomy using Y stent technique with the solitaire 6×40mm and Embotrap 6.5×45 mm stent retrievers and Zoom 008 with 071 aspiration catheters was performed with minimal recanalization of straight and inferior sinus. Attempted active aspiration and Power Pulse lytic thrombectomy through AngioJet Ultra Solent Omni Set 120cm but it was not long enough which was switched with 135cm length with successful access. This was followed by repeated attempts of aspirations with zoom 088 and 071 aspiration catheters resulting in near complete recanalization of straight, inferior sagittal sinuses, internal cerebral vein and vein of Galen.

Results
Two pass Simultaneous Mechanical Y‐Stent Retriever Thrombectomy andContact Aspiration Thrombectomy was performed with minimalrecanalization and reperfusion of straight sinus and inferiorsagittal sinus. This was followed by three pass Contact Aspiration Thrombectomy with large aspiration catheters and AngioJet Sets with near complete recanalization and drainage of straight sinus, inferior sagittal sinus, internal cerebral vein and vein of Galen. After 7 days of close ICU monitoring for malignant intracranial hypertension, patient was ultimately weaned off sedation and bilateral EVDs, extubated and transitioned to oral anticoagulation with significant clinical improvement and minimal residual neurological deficits.

Conclusions
Limited data is available on mechanical thrombectomies in deep CVST with hemorrhagic transformation. Our study describes a favorable outcome with combined stent retriever and aspiration thrombectomy approach. AngioJet 135cm Aspiration Catheter with Power Pulse lytic are also possible option to treat tough venous intracranial clots. Additional randomized controlled trials are needed to establish superiority between various approaches of mechanical venous thrombectomy in patients who have deep venous sinus thrombosis that fail medical management.