896 M a le k et al. Endovascular Recanalization with Balloon Angioplasty and Stenting of an Occluded Occipital Sinus for Treatment of Intracranial Venous Hypertension: Technical Case Report V e n o u s s in u s t h r o m b o s i s c a n result i n i n t r a c r a n i a l v e n o u s h y p e r te n s io n a n d c a n b e c o m p l i c a t e d b y in tr a c r a n ia l h e m o r r h a g e . T h i s c o n d i t i o n u s u a lly re­ s p o n d s t o s y s t e m ic a n t ic o a g u la t io n , which is r e c o m m e n d e d e v e n i n t h e p re s e n c e of i n t r a c r a n i a l h e m o r r h a g e (5 ). F o r patients w h o s e c o n d i t i o n s f a i l t o i m p r o v e despite a n t i c o a g u l a t i o n , a n u m b e r o f r e p o r t s have d e s c r i b e d g o o d c l i n i c a l s u c c e s s u s in g d i­ re c t e n d o lu m in a l Adel M. Malek, M.D., Ph.D., Randall T. Higashida, M.D., Peter A. Balousek, M.D., Constantine C. Phatouros, F.R.A.C.R., Wade S. Smith, M.D., Christopher F. Dowd, M.D., Van V. Halbach, M.D. Department of Radiology (AMM, RTH, PAB, CCP, CFD, W H ), Division of Interventional Neurovascular Radiology, and Departments of Neurosurgery (RTH, CFD, W H ) and Neurology (WSS), University of California at San Francisco, San Francisco, California in fu s io n o f urokinase f o r r e e s t a b l i s h i n g s i n u s p a t e n c y (9,16,18). W e h e r e i n d e s c r i b e t h e f i r s t ca se o f me­ c h a n ic a l r e c a n a liz a tio n , b a llo o n angio­ p l a s t y , a n d e n d o l u m i n a l s t e n t p la ce m e n t w ith in t h e o c c i p i t a l s i n u s f o r th e treat­ m e n t o f i n t r a c r a n i a l v e n o u s h y p e rte n s io n i n a p a t i e n t w i t h l o n g - s t a n d i n g d u r a l pan­ s i n u s t h r o m b o s i s a n d a c u t e c lin ic a l dete­ r io r a tio n d e s p ite s y s te m ic a n tic o a g u la ­ tio n . W e d is c u s s th e c lin ic a l m anagem ent and OBJECTIVE A N D IM P O R T A N C E : D u ra l sinus throm bosis can lead to in tra ­ cranial venous hypertension and can be c o m p lic a te d by in tra c ra n ia l h em o rrh ag e. W e present a case re p o rt o f a p atien t w h o u n d e rw e n t endovascular re c a n a liza tio n and stenting o f a th ro m bo sed o ccip ital sinus. C L IN IC A L PRESENTATIO N: A 13-year-old patient w ith a history of chronic sinus thrombosis refractory to anticoagulant therapy presented w ith acute onset of aphasia and hemiparesis. C om puted tom ography and magnetic resonance imaging revealed hydrocephalus and cerebral edem a. Angiogra­ phy delineated m ultiple dural arteriovenous fistulae and persistent occlusion of the posterior sagittal, occipital, and bilateral transverse dural sinuses w ith retrograde cortical venous drainage. IN T E R V E N T IO N : After em bolization of the dural arteriovenous fistulae, a trans­ venous approach was used to recanalize and perform balloon angioplasty of the right internal jugular vein and the occipital and left transverse sinuses, resulting in subsequent clinical im provem ent. The patient's condition d ete­ riorated 3 days later w ith reocclusion of both balloon-dilated sinuses. Repeat angioplasty and then deploym ent of an endovascular stent in the occipital sinus w ere perform ed, and reestablishment of venous outflow was achieved, resulting in a decrease of intracranial venous pressure from 41 to 14 m m Hg and neurological im provem ent. At the 3-m onth follow -up exam ination, the stented occipital sinus rem ained patent and served as the only conduit for extracranial venous outflow; the patient rem ained neurologically intact at the 12-m onth follow -up exam ination. C O N C L U S IO N : This is the first report of m echanical recanalization, balloon angioplasty, and stent deploym ent in the occipital sinus to provide sustained venous outflow for the treatm ent of venous hypertension w ith retrograde cortical venous drainage in a patient w ith dural pansinus thrombosis refrac­ tory to anticoagulant therapy. (Neurosurgery 4 4 : 8 9 6 - 9 0 1 , 1 9 9 9 ) Key words: Cerebral edema, Dural arteriovenous fistula, Hemiplegia, Interventional neuro­ radiology, Neurological deficit, Vascular malformation, Venous sinus thrombosis , N e u r o s u r g e r y V o l. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/4/896/2982670 by University of Tasmania Library user on 04 January 2018 44, No. 4, A p r i l 1 9 9 9 t e c h n i c a l a s p e c t s o f t h e case, p ro ­ v i d e a n g i o g r a p h i c f o l l o w - u p a t 3 m onths a n d c l i n i c a l f o l l o w - u p a t 1 y e a r , a n d dis­ c u s s d u r a l a r t e r i o v e n o u s f i s t u l a (D A V F ) p a th o g e n e s is . C L IN IC A L P R E S E N TA TIO N T h is 1 3 - y e a r - o ld h is to r y m a le p a tie n t had a o f a fa ll fr o m p re s e n te d w it h tin n itu s a t r e e a n d had h e a d a c h e a n d p u ls a tile 15 m o n th s b e f o r e th e c u rre n t a d m i s s i o n . A t t h a t t i m e , m a g n e t ic reso­ n a n c e ( M R ) i m a g i n g a n d d ia g n o s t ic an­ g i o g r a p h y r e v e a l e d t h a t t h e p a t ie n t was s u ffe r in g fr o m s p o n t a n e o u s d u r a l pa n ­ s i n u s t h r o m b o s i s o f t h e s u p e r i o r sag­ itta l s in u s , s tr a ig h t s in u s , b ila te ra l t r a n s v e r s e s i n u s e s , a n d o c c i p i t a l sin us, a n d h e u n d e r w e n t a la b o r a t o r y w o rk u p f o r a h y p e r c o a g u l a b l e s t a t e , th e results o f w h i c h w e r e n e g a t i v e . H i s f i r s t a n g io ­ g r a m r e v e a l e d n o a r t e r i o v e n o u s shunts. He was tre a te d fo r 7 m o n t h s w it h a r e g i m e n o f o r a l l y a d m i n i s t e r e d w a r ta r m a n d a s p i r i n b u t p r e s e n t e d a t th e tim e ot th e c u rre n t a d m is s io n w ith aphasia, r i g h t h e m i p a r e s i s , a n d e n g o r g e d scalp v e in s . M R im a g in g a n d c o m p u t e d to m o g r a p h y s h o w e d n o e v i d e n c e o f c o rti c a l i n f a r c t o r i n t r a p a r e n c h y m a l h e rn o r rh a g e (Fig. 1) b u t d e m o n s t r a t e d dilatec te m p o ra l h o rn s a n d basal c is te r n s , e f f a c e m e n t o t the c o n s is te n t w it h h y d ro O c c ip ita l Sinus Stent F IG U R E 1. A , sagittal T 1 -w e ig h te d M R im age o f the head, w ith o u t contrast e n h a n c e m e n t, d em o n stratin g ed em a in the posterior fossa and associated tonsillar ecto p ia, consistent w ith venous hypertension and ed em a. B, axial T 1 -w e ig h te d postgadolinium M R im age show ing d ilated te m p o ral horns and effaced basal cisterns w ith dilated cortical veins. F IG U R E 2. A , lateral p ro jectio n arterial phase digital subtraction angiogram (D SA ) o f the left internal caro tid a rte ry (IC A ), show ing early arterio ven ou s shunting fro m the m eningohypophyseal tru nk to a D A V F in the region o f the transverse sinus ( a r r o w h e a d ). B, arterial phase D SA o f a left external carotid in jectio n , revealing dural arteriovenous shunting fro m the ascending pharyngeal a rte ry (s h o r t a r r o w ) and fro m the posterior branch o f the a n te rio r division o f the m id d le m eningeal a rte ry ( lo n g a r r o w ) . Late venous phase angiogram s o f the left IC A in the lateral ( C ) and an tero p o sterio r (E ) projections, the right IC A the lateral p ro jectio n (D ), and the left verteb ral a rte ry in the lateral p ro jectio n (F ) c o n firm venous sinus throm bosis in the posterior region o f the superior sagittal sinus, both transverse sinuses, and th e to rc u la r h ero p h ili. Venous drainage is via cortical veins w ith diversion to the deep venous system and diversion a n te rio rly to the cavernous sinus via transcortical pathw ays. The a n te rio r falcine sinus is patent. n o u s c h a n n e ls t o b ila t e r a l c a v e r n o u s s i­ A a n d B), t h e l e f t t r a n s v e r s e s i n u s , t h e n u s e s a n d tra n s o s s e o u s c h a n n e ls to th e cephalus and cerebral edem a. venous structures w ere su lated so as to distort the ram s u p e r io r s a g itta l s in u s , a n d th e o c c ip it a l s c a l p (Fig. 1, C - F ) . O f c l i n i c a l i m p o r t a n c e s in u s . T h e ^ di_ and nQ w a s th e p re s e n c e o f r e tr o g r a d e c o r tic a l n o te d to b e o c c lu d e d , a s w a s th e s u p e r io r v e n o u s d r a in a g e result in cerebellar ectopia/ evidence of intraparenchym a hernorled s a g itta l s in u s a t its ju n c t io n w i t h th e t o r ­ te m p o r o p a r ie ta l v e in , w h ic h m a y , in p a r t, c u la r h e r o p h ili. V e n o u s d r a in a g e w a s r e t­ h a v e b e e n r e s p o n s ib le f o r th e p a t ie n t 's le f t r o g r a d e v ia h e m is p h e r ic is c h e m ia . A rhage. Diagnostic angiograp y multiple DAVTs involving sepa right transverse-sigmoid junction , the y ^ r ig h t tra n s v e rs e s in u s th e a n te r io r p o r tio n was o f th e s u p e r io r s a g itta l s in u s v ia c o lla te r a l v e ­ •i Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/4/896/2982670 by University of Tasmania Library user on 04 January 2018 in to a la r g e p o s t e r io r c o m b in a tio n o f 898 M a le k et al s in u s v e n o u s p r e s s u r e w a s m e a s u r e d a t vanced to v e n o u s a p p ro a c h e s w a s u s e d to e m b o liz e 21 m m v e in . A b a llo o n th e d u r a l a r te r io v e n o u s fis tu la e , w i t h s e rv e d d o w n s u p e r s e le c tiv e tr a n s a r te r ia l a n d tra n s ­ H g a n d a n te g ra d e flo w w a s o b ­ t h e l e v e l o f t h e in n o m in a te w a s t h e n p a s s e d over th e o c c ip it a l s in u s to th e t h e e x c h a n g e w i r e a n d u s e d t o p e rfo rm r e s u ltin g d e c re a s e in th e a m o u n t o f a rte ­ r ig h t IJ V a n d th e le f t tr a n s v e r s e d o w n to b a l l o o n a n g i o p l a s t y o f t h e e n t i r e venous r io v e n o u s s h u n tin g . th e le ft IJ V w i t h p a th w a y a d is a p p e a r a n c e o f th e fro m th e r i g h t I J V , o c c ip ita l r e tr o g r a d e c o r tic a l v e n o u s d r a in a g e p a t ­ s i n u s , l e f t t r a n s v e r s e s i n u s , a n d le f t IJV. d e r ta k e n , a n d a d ia g n o s tic a n g io g r a p h ic te rn . T h e v e n o u s p r e s s u r e m e a s u r e m e n t re­ c a th e te r w a s p o s itio n e d in th e h ig h c e r­ p r o v e d a n d h e m ip a r e s is c le a r e d w i t h i n v e a le d a v a lu e o f 21 m m v ic a l le ft (IJ V ) 12 h o u r s o f th e p r o c e d u r e , b u t h e d e v e l­ 4 0 -m m S c h n e i d e r W a l l S t e n t (S c h n e id e r w h e re m u ltip le a tte m p ts a t c a th e te r iz - o p e d s e v e r a l t r a n s ie n t e p is o d e s o f a p h a ­ I n c . , P l y m o u t h , M N ) w a s t h e n in se rte d in g th e le f t s ig m o id s in u s w e r e u n s u c ­ s ia 3 d a y s l a t e r , p r o m p t i n g r e e v a l u a t i o n . o v e r t h e g u i d e w i r e a n d d e p l o y e d in the c e s s fu l. T h e c a t h e t e r w a s t h e n p la c e d in R e p e a t a n g io g r a p h y r e v e a le d r e o c c lu ­ o c c i p i t a l s i n u s . T h e s t e n t w a s t h e n post­ th e r ig h t IJ V , a n d a tt e m p ts a t r e c a n a liz - s io n o f th e p r e v io u s ly r e c a n a liz e d a n d d i l a t e d u s i n g a n O p t r a 5 b a l l o o n a n g io ­ in g th e r ig h t s ig m o id d ila te d p la s ty A tra n s v e n o u s a p p ro a c h w a s th e n u n ­ in te r n a l ju g u la r v e in s in u s w e r e a g a in The p a t ie n t 's m e n ta l o c c ip it a l s in u s a n d s ta tu s im ­ r ig h t tra n s ­ c a th e te r ( C o r d is Hg. An 8 X E n d o v a s c u la r ) , ch a n n e l w a s, h o w e v e r, v e r s e s in u s e s w i t h r e t u r n o f r e t r o g r a d e a f t e r w h i c h v e n o u s p r e s s u r e w a s m ea­ f o u n d in th e p o s te r io r m e d ia l r ig h t ju g u ­ c o r tic a l v e n o u s d r a in a g e p a tte r n . A d e ­ s u re d a t 14 m m la r b u lb . R e c a n a liz a tio n a lo n g th is c h a n ­ c is io n m e n t o f t h e s t e n t , t h e r e w a s e v id e n c e of nel tra n s v e n o u s u n s u c c e s s fu l. A u s in g a m ic r o w ir e /m ic r o c a th e te r c o m b in a tio n le d to th e o c c ip it a l s in u s , th e n m ade to r e c a n a liz a tio n re p e a t th e p ro c e d u re . b lo o d f lo w t h r o u g h t h e p a t e n t o c c ip ita l 9 -F re n c h g u id e c a th e te r ( C o r d is E n ­ s i n u s o u t f l o w w i t h d i s a p p e a r a n c e o f ret­ to r c u la r h e r o p h ili, a n d th e n to th e le ft d o v a s c u la r , M ia m i L a k e s , F L ) w a s u s e d r o g r a d e c o r t i c a l v e n o u s d r a in a g e (Fig. 4C). tra n s v e rs e c o a x ia lly o v e r a 5 -F re n c h d ia g n o s tic a n ­ T h e p a t i e n t m a d e a n u n e v e n t f u l recovery g io g r a p h ic fro m s in u s . M e a s u r e m e n t o f th e v e n o u s p r e s s u r e y ie ld e d 41 m m H g in A was H g . A f t e r t h e d e p lo y ­ c a th e te r to c a th e te r iz e th e t h e p r o c e d u r e a n d r e m a in e d neuro- th e le f t tr a n s v e r s e s in u s . A n a n g io p la s t y h ig h s e g m e n t o f th e r i g h t IJ V . A b a llo o n c a th e te r w a s g u id e d o v e r a n e x ­ T r a n s it m ic r o c a th e te r ( C o r d is E n d o v a s ­ c h a n g e g u id e w ir e a n d u s e d to b a llo o n - c u la r ) w a s u s e d o v e r a m ic r o g u id e w ir e w a r fa r in , tic lo p id in e , a n d d ila te , in fa s h io n , th e to tr a v e r s e a n d n a v ig a te th e r e o c c lu d e d p a t i e n t r e t u r n e d 3 m o n t h s la t e r , a n d re­ s te n o tic a n d p a r t ia lly th r o m b o s e d o c c ip ­ o c c ip it a l s in u s , t o r c u la r h e r o p h ili, a n d p e a t a n g io g r a p h y it a l s in u s , le f t tr a n s v e r s e s in u s , a n d a le f t tr a n s v e r s e s in u s a n d in t o th e le f t IJ V t e n t p > a te n c y o f t h e o c c i p i t a l s in u s stent s tr ic tu r e a t th e tr a n s v e r s e - s ig m o id ju n c ­ (Fig. 4 ) . A n e x c h a n g e w i r e w a s t h e n i n ­ a s t h e m a j o r e x t r a c r a n i a l o u t f l o w p a th ­ s e rte d w a y , w ith tio n an o v e r la p p in g (Fig. 3 ) . A f t e r a n g i o p l a s t y , o c c i p i t a l R a p id o v e r th e m ic r o c a th e te r a n d ad­ l o g i c a l l y in t a c t . T h e p a t i e n t w a s d i s c h a r g e d h o m e on no r e v e a le d e v id e n c e a s p ir i n . The th e p e rsis ­ o f c o r t ic a l ve- F IG U R E 3. A , recanalization using a fem o ral transvenous approach of the o ccipital and left transverse sinuses. % A n te ro p o s te rio r projection flu o ro g rap h ic o f the cranium , revealing the m ic ro c a th e te r course from the right internal jugular to the occipital sinus, to rc u la r h e ro p h ili, and left transverse jA sinus. R, distal injection of the m ic ro c a th e te r in the left transverse sinus, revealing m in im a l flo w through the largely throm bosed left transverse sinus. An exchange guidewire was used to c a th e te rize the left l)V fro m a right internal jugular venous ap p ro ach and was used to perform balloon angioplasty ot the o ccipital sinus and the left transverse sinus. C, postangioplasty venous injection revealing the significant im p ro v e m e n t in venous o u tflo w . N e u ro s u rg e r y , V ol. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/4/896/2982670 by University of Tasmania Library user on 04 January 2018 44, N o . 4, A p r i l 1 4 4 4 O c c ip ita l Sinus Stent 899 1 ^ FIG U R E 4. Patient was taken back to the n euroangiography suite 3 days after undergoing angioplasty and experiencin g w orsening episodes o f aphasia despite con tin ued intravenous an tico ag u latio n . A ngiography revealed reocclusion o f the previously balloondilated segments (not show n). ^ A , fem oral transvenous app roach was again u nd ertaken to pass a g u id e w ire through the occipital sinus and to the left transverse and sigmoid sinuses and d o w n into the IJV. B, 8 x 4 0 -m m Schneider W a llS te n t was then deployed in the occipital sinus over the g u id ew ire. C, DSA of the left IC A , obtained during the late venous phase, dem on strating patency o f the occipital sinus and passage of angiographic contrast to the right IJV. ( *}; r. i . i 1 F IG U R E 5. F o llo w -u p diagnostic DSA, obtained at 3 m onths durin g the late venous phase, o f the right (A and C ) and left (B and D ) ICAs in the lateral and an tero p o sterio r projections, respectively. The angiogram s d em onstrate continued patency o f the stented o ccipital sinus, w h ic h constitutes the sole o u tflo w am o n g the m ajor venous sinuses. N o te that the previously b allo o n -d ilated but nonstented left transverse sinus is occluded. JL. i i g.(F i5) . N o n e w D A V F s r a in a g e D a v e ^0111^ - A ll p r e v io u s ly tre a te d s w e re c lo s e d , e x c e p t f o r o n e in v o l v i n a f u 6 me • , r ig h t r tra n s v e rs e s in u s , w h ic h u n d e rw e n t re p e a t tr a n s a r te r ia l fe e d e rs . A fte r s t e n t p la c < e m b o liz a t io n u s in g a b s o lu te e th a n o l v ia th e p a tie n t r e m a in e d w it h o u t n e i its a s c e n d in g p h a r y n g e a l a n d p o s t e r io r ic a l s y m p t o m s o r d e f ic it s a t 1 y d iv is io n c lin ic a l a n d n e u r o lo g ic a l f o llo w - i o f th e le ft m id d le m e n in g e a l N e u r o s u r g e r y , Vol. 4 4 , N o . 4, A p r i l 1 9 9 9 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/4/896/2982670 by University of Tasmania Library user on 04 January 2018 a rte ry M a le k et al 900 D IS C U S S IO N D u ra l s is h a s b e e n s in u s th r o m b o s is is u s u a lly tr e a te d u s in g s y s te m ic a n t ic o a g u la tio n , e v e n in th e p re s e n c e o f in tr a p a r e n c h y m a l h e m o rrh a g e (5 ). A n u m b e r o f re ­ p o r t s h a v e a ls o d e s c r ib e d t h e u s e o f s u ­ p e r s e le c tiv e in fu s io n of th r o m b o ly tic s t h r o u g h a n in d w e llin g c a th e te r v ia b o th a tr a n s ju g u la r and tra n s v e n o u s ap­ p r o a c h , w i t h g o o d s u c c e s s (2 , 9 , 1 6 , 1 8 ). A lth o u g h u s in g s u p e r s e le c tiv e u r o k in a s e th r o m b o ly s is ( A b o k in a s e ; A b b o tt L a b s , C h ic a g o , IL ) w a s c o n s id e r e d fo r th e c u r r e n t p a tie n t, th e re w a s s ig n ific a n t c o n c e r n r e g a r d in g its p o t e n t ia l e ffic a c y , d e s c r ib e d p la c e m e n t in t o in w h ic h th e le f t IJ V s te n t r e s u lte d in s ig n ific a n tly d e c re a s e d in tr a c r a n ia l p re s ­ s u re (4 ). A l t h o u g h we d id n o t d ir e c tly m e a s u re in tr a c r a n ia l p re s s u re a n d d id n o t r e s o rt to c e r e b r o s p in a l f lu id d iv e r s io n f o r th e c u r r e n t p a tie n t, p r e v io u s w o r k h a s e s­ ta b lis h e d t h a t in c r e a s e d v e n o u s in t r a c r a ­ n ia l p r e s s u r e r e s u lts i n in c r e a s e d i n t r a ­ c r a n ia l p re s s u re . A lt h o u g h s p o n ta n e o u s th r o m b o s is o f th e s te n te d s e g m e n t re ­ m a in s a r is k , its c o n t in u e d p a t e n c y m a y n o t o n ly b e th e r e s u lt o f s y s te m ic a n t i­ c o a g u la t io n b u t a ls o m a y b e b e c a u s e i t c a r r ie s a v e r y h ig h f l o w ra te . H ig h f l o w c o n s id e r in g th e p a t ie n t 's e x te n s iv e a n d and lo n g - s t a n d in g v e n o u s s in u s th r o m b o s is . c r e a s e d e n d o g e n o u s r e le a s e o f p r o s t a c y ­ A lth o u g h c lin tia lly th e p a t ie n t 's im p r o v e d w ith s y m p to m s in i­ e m b o liz a tio n of a s s o c ia te d (7 ) and in c r e a s e d re n c e o f d y s p h a s ia , m o s t lik e ly as a r e ­ p la s m in o g e n s u lt c o n tr ib u te m e n te d is c h e m ia p ro d u c e d by venous h y p e r te n s io n . docu­ T h is is n itr ic o x id e (6 ), b o th of p r o d u c tio n of tis s u e - ty p e a c t iv a t o r (3 ), w h ic h to in d is s o lu tio n m ay o f fo rm e d c lo t. T h is ca se illu s tr a te s th e h y p o th e s iz e d p r o v e m e n t a fte r m e c h a n ic a l r e c a n a liz a ­ l i n k b e tw e e n v e n o u s s in u s t h r o m b o s is tio n a n d a n g io p la s ty o f th e o c c ip ita l a n d a n d th e r e s u ltin g v e n o u s h y p e r te n s io n le ft and s in u s e s . The v a lu e of s u b s e q u e n t d e v e lo p m e n t o f D A V F s te n t d e p lo y m e n t in th is p a tie n t w a s e v ­ ( 1 3 , 1 4 , 1 8 ). T h i s p a t i e n t h a d p r e s e n t e d 1 5 id e n t a fte r r e c a n a liz a tio n w ith b a llo o n m o n th s b e fo re th e c u r r e n t a d m is s io n w it h a n g io p la s ty a n tic o a g u la ­ a d ia g n o s is o f d u r a l s in u s th r o m b o s is th a t tio n fa ile d to m a in t a in th e p a te n c y o f th e w a s n o t a s s o c ia t e d w i t h a n y d u r a l a r t e r i o ­ o c c ip it a l a n d le f t tr a n s v e r s e s in u s e s f o r v e n o u s s h u n tin g . C o n s is te n t w i t h p r e v i­ lo n g e r th a n 3 d a y s . o u s r e p o r t s (1 , 1 4 ), i t is p o s s i b l e t h a t t h e and s y s te m ic In tr a v a s c u la r s te n ts a re b e in g u s e d in ­ v e n o u s s i n u s t h r o m b o s i s m a y h a v e le d t o c r e a s in g ly f o r th e tr e a tm e n t o f e x tr a c r a ­ th e d o w n s tr e a m d e v e lo p m e n t o f D A V F s . n ia l a n d , in s e le c t c a s e s , i n t r a c r a n i a l a r ­ A lte r n a tiv e ly , D A V F s m a y fo r m as a c o n ­ te r ia l c a r o tid s e q u e n c e o f v e n o u s h y p e r t e n s io n a lo n e , d is s e c tio n p e r h a p s b y fo s te r in g th e g r o w t h o f a r te ­ (2 2 ), a n d as a s c a ffo ld fo r c o il e m b o liz a ­ r io v e n o u s s h u n ts f o u n d w it h in n o r m a l tio n p a c h y m e n in g e s . In d u c e d v e n o u s h y p e r ­ and a b n o r m a litie s , v e rte b ra l in c lu d in g s te n o s is o f fu s ifo r m and a n e u ry s m s (8 ). S te n t p la c e m e n t in th e v e n o u s s y s te m is le s s te n s io n w ith o u t th r o m b o s is has been o f lo n g ­ s h o w n to p r o d u c e D A V F s in ra ts , p e r ­ te r m th r o m b o s is , c o n s id e r in g th e t h r o m - h a p s m e d ia te d b y a n a n g io g e n ic fa c to r b o g e n ic ity o f a fo r e ig n b o d y in a n o n ­ (1 0 , 19, 2 0 ). In th e c a s e r e p o r t e d h e r e in , a n tic o a g u la te d t h r o m b o s is o f d u r a l s in u s w a s p r e s e n t p r e v a le n t b e c a u s e o f th e r is k p a tie n t. In tr a v a s c u la r s te n tin g in th e v e n o u s s y s te m h a s b e e n fo r lim it e d to ca se s o f d ia ly s is fis tu la s te n o ­ te m ic a n tic o a g u la tio n b e fo r e th e D A V F s s is ( 1 5 ) , a x i l l a r y - s u b c l a v i a n t h r o m b o s i s f o r m e d , s u g g e s tin g v e n o u s h y p e r te n s io n (1 7 ), a n d suc­ a s a c o n t r i b u t i n g f a c t o r . I t is p o s s i b l e t h a t c e s s f u lly (2 1 ). S te n t p la c e m e n t in th e i n ­ th e p la c e m e n t o f th e o c c ip ita l s te n t a n d tr a c r a n ia l v e n o u s s y s te m h a s b e e n p r e ­ th e v io u s ly of v e n o u s s in u s p r e s s u r e m a y h a v e a ls o c o n ­ s te n o s is o f th e tr a n s v e r s e s in u s b u t n o t tr ib u te d to s p o n ta n e o u s D A V F th r o m b o ­ fo r tr e a tm e n t o f a n o c c lu d e d s in u s a fte r s is a n d t h e d e c r e a s e i n D A V F p r o m i n e n c e r e c a n a liz a tio n (1 2 ). r e v e a le d fre s h venous re p o rte d in th e th ro m b u s tre a tm e n t M o r e r e c e n tly , a c a s e o f t r a u m a t ic b i ­ la te r a l in t e r n a l j u g u l a r v e n o u s t h r o m b o ­ som e tim e d o c u m e n te d by g io g r a p h y w ith c o n c o m ita n t consequent th e 3 - m o n th sys­ d e c re a s e d fo llo w - u p an­ (1 1 ) . It is c l e a r t h a t n o n e w D A V F s fo r m e d d u r in g th is in te r v a l. , N e u r o s u r g e r y , V o l. 44, N o . 4 A p r i l 1 9 9 9 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/4/896/2982670 by University of Tasmania Library user on 04 January 2018 c o n c lu s io n , th e case presented h e r e i n i l l u s t r a t e s t h e v a l u e o f s te n t place­ m e n t i n a r e c a n a l i z e d a n d b a llo o n -d ila te d t h r o m b o s e d d u r a l s i n u s a f t e r reocclusion a s a m e a n s o f p r o v i d i n g a lo w -re s is ta n c e o u t f l o w p a t h w a y f o r v e n o u s hype rte nsio n. Received, August 18, 1998. Accepted, December 7, 1998. Reprint requests: Adel M. 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Cathet Cardiovasc Diagn 44: 1-6,1998. 901 illu s tr a te s th a t, c o n t r a r y to p o p u la r th o u g h t, s te n ts c a n b e 1 -y e a r d e p lo y e d in a re a s o f lo w f lo w o n th e v e ­ f o llo w - u p e x a m in a tio n s . n o u s s id e , a l t h o u g h I s u s p e c t t h a t a s t h e c lin ic a l and n e u r o lo g ic a l In s u m m a r y , th is r e p o r t illu s tr a te s th e n u m b e r o f c a s e s in c r e a s e , t h e i n c i d e n c e o f v a lu e s te n t th r o m b o s is m ig h t b e h ig h e r . T h a t b o s e d d u r a l s in u s as a m e a n s o f p r o v i d ­ b e in g th e ca se , s u c h a n tip la te le t a g e n ts as in g a lo w R e o p r o m a y b e a d v a n ta g e o u s . A s te c h ­ fo r v e n o u s h y p e r te n s io n . In d ic a tio n s fo r n o lo g y im p r o v e s , a p p lic a tio n o f e n d o v a s ­ c u la r te c h n iq u e s to in tr a c r a n ia l and v e n o u s d is e a s e w i l l b e c o m e m o r e c o m ­ m o n p la c e , a n d th e s e a u th o r s in t r o d u c e it f o r d is e a s e o n t h e v e n o u s s id e . o f s te n t p la c e m e n t in a th ro m ­ r e s is ta n c e o u t f l o w s te n t p la c e m e n t w e r e p a tie n t fo r w h o m p a th w a y ju s tifie d in th is m o re tr a d itio n a l a n d c o n s e r v a tiv e th e r a p y h a d fa ile d . T h e a u ­ th o rs used a lo g ic a l and s y s te m a tic tr e a tm e n t a p p r o a c h th a t r e s u lte d in a n Robert H. Rosenwasser Philadelphia , Pennsylvania a lm o s t im m e d ia te r e d u c tio n o f v e n o u s h y p e r te n s io n . In a d d itio n , th e a u th o r s p r e s e n t a n in t e r e s t in g d is c u s s io n o f th e T h is a r tic le s h o w s a n in n o v a tiv e a p ­ p r o a c h t o d u r a l s in u s t h r o m b o s is . P la c e ­ m e n t o f a s te n t in th is s e ttin g w a s p r o b ­ u s e s o f a n g io p la s ty a n d s te n tin g o f th e d u r a l s in u s e s . In o u r e x p e r ie n c e w ith tw o p a tie n ts a b ly th e o n ly w a y p a te n c y o f th e s in u s w i t h d u r a l s in u s s te n o s e s w i t h a n d w i t h ­ c o u ld b e m a in ta in e d . T h is case h a s a ll th e o u t t h r o m b o s i s , t h e s t e n t e d s in u s e s e i t h e r e l e m e n t s o f d is e a s e a f f e c t i n g t h e d u r a l s i ­ r a p id ly re s te n o s e d o r o c c lu d e d . T h e a u ­ n u s e s , a n d t h e a u t h o r s p r e s e n t t h e i r e x c e l­ th o rs ' e n th u s ia s m fo r th is le n t m a n a g e m e n t a n d d o c u m e n ta tio n . s h o u ld b e te m p e re d by th e k n o w le d g e te c h n iq u e th a t s te n te d v e in s ( in b o d y in t e r v e n t io n a l Stanley L. Barnwell Portland, Oregon cases) have P e rh a p s in v e ry th e r a p id ly re s te n o s e d . fu tu re , s o m e te c h n iq u e s u c h as in tr a lu m in a l b r a c h y th e r a p y m a y T h e a u t h o r s p r e s e n t a te c h n ic a l ca se r e p o r t o f a 1 3 - y e a r - o ld p a tie n t w it h a h is t o r y o f c h r o n ic s in u s t h r o m b o s is r e ­ fra c to ry th e to a n tic o a g u la n t th e r a p y w it h a c u te o n s e t o f a p h a s ia and h e m i­ h e lp to r e d u c e th e s e p o s t v e n o u s - s t e n t in g re s te n o s e s . A s a te c h n ic a l n o te , w e h a v e f o u n d th e fle x ib ility 7 -F re n c h and s h e a th tr a c k a b ility (A rro w of th e In te r n a tio n a l, p a r e s is . T h e p a t ie n t h a d a tr a n s v e r s e s i­ In c ., R e a d in g , P A ) to b e s lig h t ly s u p e ­ n u s d u r a l a r te r io v e n o u s fis tu la , w h ic h r io r to th e 9 -F re n c h g u id e c a th e te r ( C o r ­ was and d is E n d o v a s c u la r ) u s e d b y th e a u th o r s tr a n s a r te r ia l a p p ro a c h e s . A s u b to ta l e m ­ in th is r e p o r t. T h is s h e a th m a y b e o b ­ b o liz a tio n ta in e d in u p to a 9 0 -c m le n g th a n d w i t h ­ e m b o liz e d was w ith tra n s v e n o u s a c h ie v e d , and c o r tic a l v e n o u s d r a in a g e a n d v e n o u s h y p e r te n ­ out s io n r e m a in e d . It w a s th e r e fo r e n e c e s ­ a b lin g th e in te r v e n tio n a lis t to p a s s o th e r s a r y to r e c a n a liz e t h r o u g h a n g io p la s t y d e v ic e s , s u c h as W a llS t e n t d e li v e r y s y s ­ o f th e in v o lv in g te m s , c o a x ia lly o r th e u s e o f d ia g n o s tic and le ft c a th e te rs a n d m ic r o c a th e te r s f o r a n e f­ tr a n s v e r s e s in u s . T h e p a t ie n t im p r o v e d fe c tiv e t r ia x ia l s y s te m . W e h a v e f o u n d year-old p a t ie n t w i t h a h i s t o r y o f c h r o n i c c lin ic a lly th is d e v ic e | lnus t h r o m b o s is r e f r a c t o r y t o a n t i c o a g u ar|t therapy w i t h a s s o c ia t e d f o c a l n e u r o - g r a p h ic a lly , th e c o r tic a l v e n o u s d r a in ­ a g e r e s o lv e d . H o w e v e r , w i t h i n 3 d a y s , °gical d e fic its r e l a t e d t o v e n o u s h y p e r - n e u r o lo g ic a l ens io n . re p e a t a n g io g r a p h y C O M M EN TS th e M a le k e t a l. d e s c r i b e a c a s e o f a 1 3 - The a u th o rs rTlanag e m e n t o f a n p re s e n t e x tr e m e ly th e ir d iffic u lt d u r a l s in u s o c c ip ita l d r a in a g e s in u s , w ith in to r c u la , 12 h o u rs , a n d s y m p to m s a n g io - re tu rn e d r e v e a le d and ^ase w ^ h a n e x c e lle n t o u t c o m e . I n a d d i - ita l J )n, th is f u r t h e r e m p h a s i z e s a n d w i t h r e t u r n o f c o r tic a l v e n o u s d r a in a g e . illu s - ates th e p r e s e n c e o f c h r o n i c v e n o u s h y ­ and r ig h t Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/4/896/2982670 by University of Tasmania Library user on 04 January 2018 tra n s v e rs e s in u s T h e a u th o r s , a t th a t tim e , r e d ila te d th e N e u r o s u r g e r y , V o l. h e m o s ta tic to b e e x tr e m e ly c a r o tid s te n tin g , as w e ll c a th e te r access to th e v a lv e , en­ u s e fu l fo r as fo r g u id e ju g u la r venous s y s te m . r e o c c lu ­ s io n o f th e p r e v io u s ly r e c a n a liz e d o c c ip s in u s a p r o x im a l 4 4 N o . 4, A p r i l 1 9 9 9 Donald W. Larsen George P. Teitelbaum Interventional Neuroradiologists Los Angeles , California