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J Neurosurg 103:368–371, 2005

Coronary AngioJet catheterization for the management of
dural venous sinus thrombosis
Technical note
CELSO AGNER, M.D., M.SC., ERIC M. DESHAIES, M.D., GARY L. BERNARDINI, M.D., PH.D.,
A. JOHN POPP, M.D., AND ALAN S. BOULOS, M.D.
Departments of Neurology and Neurosurgery, Albany Medical Center, Albany, New York
U In most cases of deep venous sinus thrombosis, systemic anticoagulation represents the initial treatment of choice for
preventing propagation of a clot in the dural sinuses. In patients with deep or extensive venous sinus thrombosis, a combination of treatment modalities may be required including systemic anticoagulation, selective venous thrombolysis, and
mechanical thrombectomy. In the current study the authors report on a patient who presented with the acute onset of
headache, vomiting, a depressed level of consciousness, and a left hemiparesis and in whom a right middle cerebral artery
(MCA) territory ischemic stroke with hemorrhagic conversion was initially diagnosed. Results of diagnostic cerebral angiography demonstrated a patent right MCA and a deep venous sinus thrombosis involving most of the dural sinuses. Despite adequate systemic heparinization, the patient’s neurological condition deteriorated and direct administration of alteplase into the transverse sinus in conjunction with mechanical clot disruption using a coronary AngioJet was required.
Venous flow was successfully reestablished in the deep and superficial venous sinuses by using a 0.014-in exchange wire
routed from the right common femoral vein through the sinuses and out the left common femoral vein. Excellent angiographic results were obtained, and the patient had recovered completely by the 7-month follow up.

KEY WORDS • alteplase • AngioJet • dural venous sinus thrombosis •
endovascular stroke • thrombolysis

URAL venous sinus thrombosis is an uncommon but
potentially life-threatening condition that can be
challenging to diagnose.20 Putative origins for
DVST include infection, systemic steroid agents, oral contraceptive agents, anemia, and severe dehydration.16,19–21,
23,27,28
This disease affects the dural sinuses and, in severe
cases, can extend into the superficial and deep cerebral
veins resulting in venous infarction with hemorrhagic conversion. It is initially managed with systemic heparinization
even in the presence of hemorrhagic conversion. In refractory cases, catheter-based selective thrombolysis and
mechanical clot disruption with AngioJet (Possis Medical,
Minneapolis, MN) may be effective.1,22 We report on a patient with DVST in whom systemic heparinization failed
and who required selective thrombolysis with alteplase and
mechanical clot disruption with a coronary AngioJet, a clotdisrupting device integrated with a water-suctioning mechanism capable of retrieving clots located in the distal portions of the catheter. We obtained excellent angiographic
and long-term clinical outcomes.
Alteplase is a recombinant fibrinolytic agent that has

D

Abbreviations used in this paper: DVST = dural venous sinus
thrombosis; ICH = intracranial hemorrhage; MCA = middle cerebral
artery.

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been used in the management of acute strokes and situations
in which acute clot disruption is indicated. It has been frequently used in endovascular surgery for the management
of acute vascular occlusions with successful results. The
main advantage of using recombinant fibrinolytic agents
lies in the low reaction ratio and the high effectiveness in
promoting thrombolysis in patients.
Illustrative Case
History and Examination. This 35-year-old healthy righthanded woman who was taking oral contraceptives had
been evaluated at an outside hospital for progressive left
hemiplegia and mental status changes for 5 days. An initial
diagnosis of the acute onset of a right MCA territory stroke
together with hemorrhagic conversion was made. She was
then referred to our hospital for further neurological evaluation.
Initial physical examination revealed a lethargic normotensive female with a right gaze preference, equal and
reactive pupils, left facial weakness, dense left hemiparesis,
and a left extensor plantar reflex. The next day, she suffered
several episodes of generalized tonic–clonic seizures requiring ventilatory support for airway protection and treatment with lorazepam and phenytoin for seizure control. A
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Coronary AngioJet catheterization
where she regained strength in her upper and lower extremities. At the 7-month follow up, the hemiparesis had resolved, Coumadin was stopped, and aspirin (81 mg daily)
was maintained.

FIG. 1. Magnetic resonance images revealing an area of venous
hemorrhagic infarction on the right tempoparietal lobe.

repeated head computerized tomography scan demonstrated hemorrhagic venous infarction in the territory of the cortical draining veins from the right frontal opercular region.
A magnetic resonance image of the brain confirmed our
suspicion of cortical venous hemorrhage in the right hemisphere (Fig. 1). The patient became comatose and intravenous heparinization was started. Her condition did not
respond to these initial measures, and rapid progression of
symptoms led to selective catheterization of the dural sinuses for endovascular thrombolysis of the superior sagittal and
transverse sinus thromboses.
Mechanical Thrombolysis. A diagnostic cerebral angiogram demonstrated delayed emptying of the contrast agent
from the superior sagittal and transverse sinuses, consistent
with extensive DVSTs. Given these findings, we accessed
the dural venous sinuses by inserting No. 5 French femoral
vein sheaths bilaterally because we planned on traversing
the sinuses with a coronary AngioJet. To do so, we first used
a 0.035-in Bentson wire (Boston Scientific, Natick, MA)
and a No. 5 French Envoy catheter (Cordis Corp., Miami
Lakes, FL) to engage the left jugular vein via the brachiocephalic vein. A Prowler-14 (Cordis Corp.) was advanced
over a Transcend EX wire (Boston Scientific) and then advanced into the left transverse and sigmoid sinuses. The
Transcend wire was exchanged for a Mailman wire. A No.
4 French XMI Coronary AngioJet was then used for mechanical thrombolysis across the sigmoid and transverse sinuses. The wire was advanced out through the contralateral
femoral vein sheath. Excellent recanalization of the sinuses
was obtained. Control angiograms demonstrated improved
flow in the superior sagittal sinus. A microcatheter was advanced into the straight sinus, and 5 mg alteplase was administered in this sinus and the internal cerebral veins because the AngioJet could not be used in these locations.
Follow-Up Evaluation. Follow-up angiography studies
demonstrated excellent recanalization of the superior sagittal, straight, transverse, and sigmoid sinuses as well as all
vessels of the internal carotid artery and vertebral artery territories (Fig. 2). Systemic heparinization was followed by
the administration of Coumadin and aspirin (81 mg/day) for
a target therapeutic international normalized ratio of 1.5 to
2 for 6 months. The patient’s left hemiparesis improved and
she was discharged to the subacute rehabilitation hospital
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Discussion
Hypercoagulable states and systemic disease predispose
patients to strokes and other vascular pathologies such as
deep venous sinus thrombosis.10,13,29 Overall, DVST mortality rates have been reported to range from 10 to 50%.3,23,24
Patients with DVST tend to fare worse clinically because of
extensive venous sinus involvement, sepsis, large intracerebral venous hemorrhages, and systemic hypercoagulable
states.4,5,9,23,30
Einhaupl, et al.,8 published results of a prospective double-blind study in which they had evaluated the use of systemic heparinization compared with no treatment in two
groups of patients with DVST: those with evidence of
DVST and ICH, and those without ICH. Complete neurological recovery occurred in the majority of heparinized
patients with DVST and no evidence of ICH, compared
with a 90% chance of no clinical recovery in the nonheparinized group. When there was concomitant ICH, there
was also significant neurological recovery and lower mortality rates in patients treated with anticoagulation compared with controls (69% mortality rate). Thus, the study
data supported the use of anticoagulation in patients with
dural sinus thrombosis independent of whether ICH was
present in conjunction with venous infarction. The patients
who had received systemic heparinization fared significantly better than those in the nonheparinized group, and the
study was stopped prematurely. Other authors have been
able to show that heparin anticoagulation is able to improve
outcomes in a high proportion of cases with DVST.
Endovascular management has been proposed in refractory
cases.2,3
Hemorrhage may delay diagnosis and increase the incidence of refractory cases. Endovascular techniques should
be considered in such instances.4,8,11,12,17,18,25,26
Selective catheter-based thrombolytic therapy with
urokinase and alteplase has been used to manage intracranial dural sinus thrombosis since the 1980s.6 Although
angiographic evidence of venous sinus recanalization has
been provided in the majority of cases following intravenous thrombolytic therapy, there was an increased risk of
ICH or systemic hemorrhage. In 1989 Higashida, et al.,14
reported on the first successful case of selective catheterbased thrombolysis with urokinase into a thrombosed superior sagittal sinus. Other authors demonstrated the effectiveness and safety of alteplase for the treatment of refractory
dural sinus thrombosis.15 In situations in which systemic
and selective catheter-based methods of thrombolysis fail to
improve flow in the dural venous sinuses, AngioJet can be
used to achieve immediate and complete recanalization of
the involved sinuses. Opatowsky, et al.,22 were the first to
report on mechanical thrombolysis for the management of
complicated DVST in a young patient whose diffuse disease was refractory to systemic anticoagulation. There was
no associated hemorrhage and the patient improved clinically, with resolution of the initial neurological deficit at the
6-month follow up. In the same year, other authors reported
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C. Agner, et al.

FIG. 2. Follow-up angiograms. Upper Left: Diffuse occlusion
of the deep dural sinuses. Upper Right: Reperfusion of the sinuses after thrombolysis and the use of the rheolytic catheter. Lower: Reperfusion of the M2 branch of the MCA after intraarterial
thrombolysis.

the successful use of rheolytic catheters for the management
of refractory dural sinus thrombosis.7
We reported on the case of diffuse sinus thrombosis,
which had initially been diagnosed as a stroke with hemorrhagic conversion, that was treated with mechanical
thrombectomy. Delayed medical treatment was associated
with a deterioration in the patient’s clinical status. Alteplase
would unlikely disrupt a 1-week-old clot and mechanical
thrombectomy with the coronary AngioJet was indicated. A
single use of the device would unlikely allow complete
sinus reperfusion, and a method was devised to permit complete opening of the superficial and deep venous sinuses
involved. Successful immediate and 6-month follow-up
outcomes indicated that our technique may be appropriate
for diffuse subacute sinus thrombosis that had not responded to systemic anticoagulation. Furthermore, dual application of the coronary AngioJet is a possible alternative whenever direct thrombolysis does not suffice in completely
reopening the dural sinuses. Decreases in morbidity and
death are the goals of any treatment and, in particular, for
the situation addressed in our paper.
Conclusions
The diagnosis of DVST can be challenging to make,
which might lead to a delay in treatment, thus increasing
risks of morbidity and death. Signs indicating sinus thrombosis can be subtle or nonexistent, complicating early identification. Prompt recognition of the disease and initiation
of treatment are crucial for decreasing complications. We
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reported on the excellent outcome in a patient with progressive neurological decline caused by DVST despite the systemic administration of anticoagulation agents. Although
not extensively practiced, this technique should be considered in cases of extensive DVST refractory to systemic anticoagulation. A delay in the initiation of systemic anticoagulation and the severity of the disease do not preclude the
use of the coronary AngioJet, although the right facility and
equipment should be available to optimize application of
the therapy in refractory cases.
Disclaimer
None of the authors has a financial interest in the AngioJet or
Possis Medical.
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Accepted in final form November 3, 2004.
Address reprint requests to: Alan S. Boulos, M.D., Department of
Surgery, Albany Medical Center, Albany, New York 12208. email:
boulosa@mail.amc.edu.

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