Cerebral venous thrombosis - Combined intrathrombus rtPA and intravenous heparin

Background and Purpose-We chose to evaluate the safety and efficacy of comb ined intrathrombus rtPA and intravenous heparin in cerebral Venous thrombos is (CVT). Methods-We treated 12 patients with symptoms of 1 to 40 days' duration (eg, headache, somnolence, focal deficits, seizures, and nausea and vomiting). Pretreatment MRI disclosed subtle hemorrhagic venous infarction in 4 patien ts, obvious hemorrhagic infarction in 2, small parenchymal hemorrhage from recent pallidotomy in I, and no focal lesion in 5. Magnetic resonance venog raphy and contrast venography identified thrombi in the superior sagittal s inus (SSS) in 3 patients; transverse/sigmoid sinus (TS/SS) in 2; SSS and bo th TS/SS in I; SSS and 1 TS/SS in 5; and SSS, 1 TS/SS, and straight sinus i n 1 patient. A loading dose of rtPA was instilled throughout the clot at 1 mg/cm, followed by continuous intrathrombus infusion at 1 to 2 mg/h. Intrav enous heparin was infused concomitantly. Results-Flow was restored completely in 6 patients and partially in 3, with a mean rtPA dose of 46 mg: (range, 23 to 128 mg) at a mean time of 29 hour s (range, 13 to 77 hours). Symptoms improved in these 9 patients concomitan tly with flow restoration. Flow could not be restored in 3 patients. In 1 o f them, treatment was stopped when little progress had been made, and fibri nogen level dropped to 118 mg/dL. In the other 2 patients, hemorrhagic wors ening occulted, and treatment was abbreviated after initial rtPA dosing. In 1 of these, the hematoma was evacuated. Conclusions-Our experience with intrathrombus rtPA in conjunction with intr avenous heparin in patients with CVT is encouraging. This therapy should pr obably be regarded as unsafe in patients with obvious hemorrhage. Time to r estore flow may be faster than with urokinase (an average of 71 hours has b een reported for 29 documented patients). Further evaluation of rtPA with h eparin in CVT is warranted.