Successful intra-arterial thrombolysis of isolated deep cerebral venous thrombosis

Cerebral venous thrombosis is a rare cerebrovascular disorder with variable outcome. The involvement of the deep cerebral venous system is often associated with a poor prognosis.

A 49-year-old man was treated with oral anticoagulation due to a hereditary antithrombin deficiency, which resulted in a thrombosis of the superior sagital sinus at the age of 30 and a lung embolism at the age of 43. Anticoagulation was discontinued four weeks before symptoms onset due to dental therapy. The day before admission the patient suffered from headache, with a progressively decreasing level of consciousness. On admission the patient was found to be stuporous, with a slurred speech, a left sided hemiparesis and multimodal hemineglect on the left side. Diffusion weighted MRI revealed extended bithalamic lesions, a right sided mesencephalic lesion and an occlusion of the inner venous system. Even with intravenous anticoagulation, the patient continued to deteriorate the next hours, therefore it was decided to attempt an intra-arterial thrombolysis. Intra-arterial infusion of 54mg rt-PA into both internal carotid arteries and the left vertebral artery over 3.5h resulted in a complete resolution of the thrombus.

We describe for the first time the successful use of intra-arterial thrombolysis to revasculate a thrombosis of the inner venous system. Follow-up MRI showed no intracranial hemorrhage but a consecutive regression of the former diffusion positive areas in the bilateral thalamic nuclei. The patient was discharged with excellent clinical outcome.