| BackgroundCerebral venous sinus thrombosis is one of intractable diseases in neurology, which standard therapy is the application of heparin or low molecular weight heparin anticoagulant therapy. Anticoagulant therapy of cerebral venous sinus thrombosis greatly reduced the fatality rate, but there are still 5 to 30% mortality. With the rapid development of neural interventional radiology technology, the sinus thrombolysis, mechanical thrombectomy, mechanical embolectomy and venous sinus stenting become an effective treatment of cerebral venous sinus thrombosis. It greatly reduce the morbidity and mortality of cerebral venous sinus thrombosis, bring hope for the treatment of this disease. Successful cases and small sample of researches have been reported on using intravascular interventional therapy for critically ill patients, deteriorating condition and anticoagulant therapy ineffective patients. Since there is little case researched, the optimal timing of endovascular treatment needs further discussion. The main pathophysiological changes of cerebral venous sinus thrombosis was cerebral blood circulation outflow tract obstruction. The blood flow obstruction phenomenon had elevated the venous pressure in the brain tissue. When venous pressure increases to a certain extent, cerebral arterial perfusion effectively reduced, thereby forming a intravenous ischemic cerebral infarction. Ischemia area may include a central necrotic area and surrounding ischemic penumbra. This study intended to clear and definite whether there is a venous infarction ischemic penumbra in the vein cerebral infarction, as well as the evolution of venous infarction ischemic penumbra. Anticoagulant therapy is the standard treatment of cerebral venous sinus thrombosis, and the efficacy and safety of antiplatelet aggregation therapy in the prevention of the recurrence of cerebral venous sinus thrombosis remains to be discussed. The present study was to investigate the efficacy and safety of antiplatelet aggregation therapy in the prevention of the recurrence of cerebral venous sinus thrombosis. In patients with cerebral venous sinus thrombosis, there will be vasogenic cerebral edema, cerebral infarction, cerebral infarction and hemorrhage, cerebral hemorrhage, subarachnoid hemorrhage, and a variety of pathological lesions. This study intended to study the relationship between the parenchymal lesions and prognosis of disease in patients with cerebral venous sinus thrombosis. Carried out local intervention on treatment of patients with severe cerebral venous sinus thrombosis, this study aimed to evaluate the efficacy and safety of topical endovascular interventional in the treatment of severe cerebral venous sinus thrombosis.PART I Clinical analysis of 72 cases with cerebral venous sinus thrombosisObjective:1. To investigate the relationship between the parenchymal lesions and prognosis of disease in patients with cerebral venous sinus thrombosis.2. To explore the efficacy and safety of antiplatelet aggregation therapy in the prevention of the recurrence of cerebral venous sinus thrombosis.3.To explore whether there is a venous infarction ischemic penumbra in the vein cerebral infarction, as well as the evolution of venous infarction ischemic penumbra.4. To evaluate the efficacy and safety of topical endovascular interventional in the treatment of severe cerebral venous sinus thrombosis.5. To study the optimal timing of endovascular treatment.Methods:From January 2008 to December 2014,72 patients with cerebral venous sinus thrombosis were made a definite diagnosis after MRV or DSA examination in the department of neurology of Liaocheng People's Hospital. A retrospective analysis was performed on the 72 patients. All patients were treated with low molecular weight heparin anticoagulant therapy. And the patient's condition changes were observed sufficiently during treatment. When the patient's condition is stable, no new neurological deficit signs and symptoms, or the existing neurological deficit symptoms and signs is declining, it indicating that the patients have a good response to anticoagulant therapy, then continue the anticoagulation therapy. But if adequate anticoagulant therapy were given, neurological deficits remained progressive increase, or new neurological deficit signs and symptoms appeared, NIHSS score increased 2 points or more. This indicated that patients with poor response to anticoagulant therapy, then started the intravascular local thrombolysis, those patients had been defined as severe patients. Additional coma patients had also been defined as severe patients. Without anticoagulation therapy observation in these patients, and endovascular interventional treatment was initiated directly. After the acute phase, oral anticoagulants or antiplatelet aggregation drugs six months to prevent the recurrence of cerebral venous sinus thrombosis. Follow-up every 6 months, to know whether there are signs of recurrence of the patient's cerebral venous sinus thrombosis or not. Lumbar puncture, fundus check or MRV and DSA were given if necessary. Proceeding with Brain CT, CTP, MRI, MRV or DSA examination at admission and discharge, to understand the condition of the patient's brain lesions, brain perfusion and venous sinus recanalization. Using mRS score to assess the rehabilitation condition after patients was discharged and treated six months.Results:In 72 patients with CVST,53 cases of good response to anticoagulant therapy, given low molecular weight heparin anticoagulant therapy. MRS score results showed that there were 41 cases mRS 0 point,10 cases mRS 1 point,1 case mRS 2 points, and 1 case mRS 3 points at discharge. Six months after discharged,51 cases of complete recovery mRS 0 points,2 cases of partial recovery mRS 2 points. Give low molecular heparin anticoagulant therapy in mild patients with good response to anticoagulant therapy, the complete recovery rate was 96.2%. Among 19 patients with severe CVST,5 patients' family members refused to surgical intervention and continued anticoagulation therapy, then three patients died, mRS 6 points; two patients with severe disability, mRS 5 points. Given 14 patients local interventional surgery,12 patients recovered fully at discharge, mRS 0 point,1 patient with hemiparesis, mRS 2 points and 1 patient died, mRS 6 points, the patient with hemiparesis recovered after six months, mRS 0 points. Carried out local intervention treatment of critically ill patients with CVST, the complete recovery rate was 92.9%, the mortality was 7.1%, and the pure anticoagulation mortality rates as high as 60%. In various brain parenchymal lesions,23 patients of vasogenic cerebral edema group (100%) and 6 patients of group (100%) of no abnormalities in the brain parenchyma had good response to anticoagulant therapy, no critically ill patient of poor response to anticoagulant therapy. Of 15 patients in cerebral infarction group, there are 12 patients of good response to anticoagulant therapy (80%), and 3 critically ill patients of poor response to anticoagulant therapy (20%). Of 28 cases of Intracranial hemorrhage group, the good response to anticoagulant therapy 12 cases (42.9%), and poor response to the anticoagulant therapy of critically ill patient 16 cases (57.1%). No critically ill patient in the vasogenic cerebral edema group and no abnormal brain parenchyma group. Cerebral infarction group had a 20% incidence of severe patients, and the incidence of critically ill patients in intracranial hemorrhage was more than 57.1%. After the acute stage, in order to prevent recurrence of cerebral venous sinus thrombosis,25 patients with oral coumadin,43 patients with aspirin and clopidogrel platelet aggregation treatment. The longest follow-up has been more than 6 years, no 1 case recurrence in patients with cerebral venous sinus thrombosis. Given Brain MRV or DSA examination at admission and at discharge, to know the situation of the sinus recanalization. In the anticoagulant group of 58 cases,18 cases refused the cerebral MRV or DSA examination at the time of discharge. Cerebral MRV examination were given at the time of 40 patients were discharged from hospital, including 4 cases of sinus recanalization completely (10%),6 cases of venous sinus partial recanalization (15%),30 cases of no recanalization of venous sinus (75%). In local interventional treatment group,14 patients were given craniocerebral MRV or DSA examination at the time of admission and discharge, including 9 cases of sinus completely recanalization (64.3%),4 cases of sinus partial recanalization (28.6%),1 case of no recanalization venous sinus (7.1%). Row CT perfusion imaging in 2 patients,1 patients with CT perfusion imaging examination before the anticoagulant therapy,4 days after anticoagulation,8 days after anticoagulation, respectively; 1 patients 1 days after anticoagulation and 4 days after anticoagulation respectively. It found that the presence of ischemic penumbra in patients with cerebral venous sinus thrombosis and penumbra exists time is longer, as the effective anticoagulation therapy, ischemic penumbra may evolve to normal brain tissue area; the necrotic area and the ischemic penumbra staggered promiscuous exists.Conclusion:1. Parenchymal brain lesions in patients with cerebral venous sinus thrombosis is closely associated with the prognosis of disease.2. It is safe and effective to treat with aspirin and (or) clopidogrel platelet aggregation to prevent the recurrence of intracranial venous sinus thrombosis in puerperium. Antiplatelet aggregation therapy may be an effective treatment for the prevention of the recurrence of postpartum intracranial venous sinus thrombosis.3. Local endovascular interventional treatment is a safe and effective treatment for patients with severe CVST.4. It is benefit to implement local thrombolysis interventional therapy for the sufficient anticoagulation patients who's neurological deficit was still progressively aggravated, NIHSS score increased?2 points and the coma patients.5. Venous collateral circulation compensatory play an important role in the recovery of disease. 6. It found that the presence of ischemic penumbra in patients with cerebral venous sinus thrombosis and penumbra exists time is longer, as the effective anticoagulation therapy, ischemic penumbra may evolve to normal brain tissue area.PART? Endovascular interventional treatment for severe cerebral venous sinus thrombosisObjective:To explore and evaluate the efficacy and safety of local thrombolytic therapy in superior sagittal sinus in patients with severe cerebral venous sinus thrombosis, as well as the optimal timing of endovascular interventional treatment.Methods:From January 2008 to December 2014, there were 19 critically ill patients with CVST in Liaocheng People's Hospital, in which family members of 5 patients refused interventional surgery, but continued anticoagulant therapy, so local interventional surgery were performed in the remainder 14 patients. The 14 patients received local thrombolytic therapy and mechanical thrombus maceration. Venous sinus recanalization is the indications of stopping thrombolysis treatment. All the patients were treated with body weight-adjusted subcutaneous low molecular weight heparin in the acute phase. After the acute phase, All 13 patients accepted anti-platelet aggregation treatment for 6 months. DSA or magnetic resonance venography (MRV) was performed to assess the recanalisation of venous sinuses. Data regarding demographic, clinical and radiological features were collected. Follow-up every 6 months, to know whether there are signs of recurrence of the patient's cerebral venous sinus thrombosis or not. Lumbar puncture, fundus check or MRV and DSA were given if necessary.Result:5 patients refused to surgical intervention and continued anticoagulation therapy, then three patients died, mRS 6 points; two patients with severe disability, mRS 5 points.14 patients accepted local interventional treatment,12 patients recovered fully at discharge, mRS 0 point,1 patient with hemiparesis, mRS 2 points and 1 patient died, mRS 6 points, the patient with hemiparesis recovered after six months, mRS 0 points. Before discharge, the intracranial pressure in 13 patients was under 200 mmH2O at discharge. DSA or MRV confirmed that superior sagittal sinus of 9 patients were smooth. The cortex venous and deep venous recovered to normal. Superior sagittal sinus of 4 patients recanalized partly, and cortex venous and deep venous had compensation. Eyeground edema obviously lightened or disappeared. No endovascular treatment-related complications were noted. The longest follow-up has been more than 6 years, no patients recurred.Conclusion:Local thrombolysis treatment in superior sagittal sinus is a safe and effective for patients with severe CVST in puerperium. It is benefit to implement local thrombolysis interventional therapy for the sufficient anticoagulation patients who's neurological deficit was still progressively aggravated, NIHSS score increased?2 points and the coma patients.The conclusion:1. Parenchymal brain lesions in patients with cerebral venous sinus thrombosis is closely associated with the prognosis of disease.2. It is safe and effective to treat with aspirin and (or) clopidogrel platelet aggregation to prevent the recurrence of intracranial venous sinus thrombosis in puerperium. Antiplatelet aggregation therapy may be an effective treatment for the prevention of the recurrence of postpartum intracranial venous sinus thrombosis.3. Local thrombolysis treatment in superior sagittal sinus is a safe and effective for patients with severe CVST in puerperium..4. It is benefit to implement local thrombolysis interventional therapy for the sufficient anticoagulation patients who's neurological deficit was still progressively aggravated, NIHSS score increased?2 points and the coma patients.5. Venous collateral circulation compensatory play an important role in the recovery of disease.6. It found that the presence of ischemic penumbra in patients with cerebral venous sinus thrombosis and penumbra exists time is longer, as the effective anticoagulation therapy, ischemic penumbra may evolve to normal brain tissue area. |
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