Mechanical Thrombectomy and Thrombolysis for Neonatal Cerebral Venous Sinus Thrombosis

Introduction Cerebral venous sinus thrombosis (CVST) is exceedingly rare amongst the pediatric population and accounts for a prevalence of 0.67 per 100,000 children per year. Neonates account for about 30‐50% of pediatric CVST cases. The clinical presentation of this condition can often be non‐specific which can make diagnosis difficult. CSVT is typically managed with systemic anticoagulation and anti‐seizure medications. However, mechanical thrombectomy and thrombolysis can be utilized in treatment of severe cases with neurological deterioration, or in patients who are refractory to maximal medical treatment. Methods Electronic charts of a patient with neonatal cerebral venous sinus thrombosis were reviewed. Results We present a 6 day old female who was born full term via spontaneous vaginal delivery with no complications. She presented to the hospital on the 6 th day of life with lethargy and focal seizures of the right upper extremity which was captured on continuous EEG. Magnetic resonance imaging was obtained which demonstrated thrombosis of the thalamostriate and ependymal veins extending through the internal cerebral veins, vein of Galen, straight sinus, torcular, bilateral transverse sinuses and superiorly into the superior sagittal sinus, and additional thrombosis of multiple cortical veins including the vein of Trolard. Imaging also demonstrated left thalamic hemorrhage with mild intraventricular extension and mild ventricular dilation. Conclusion Given the patient's severity of thrombosis and rapidly deteriorating clinical exam, the decision was made to proceed with endovascular mechanical thrombectomy of the venous sinuses. The patient underwent emergent digital subtraction angiography which revealed extensive cerebral sinus venous thrombosis involving the superior sagittal sinus, straight sinus and lateral sinuses. Successful partial recanalization of the superior sagittal sinus, straight sinus and lateral sinuses was achieved. An alteplase catheter was left in the vein of Galen and heparinized saline catheter was left in the straight sinus for 22 hours of treatment prior to removal. The patient was returned to the neonatal ICU for medical management and eventually transitioned to oral anticoagulation and clinical improvement. Six months post‐hospitalization, the patient achieved normal development and gained total seizure freedom. Genetic testing revealed that her father had Antithrombin III deficiency and her mother was found to be heterozygous for Factor V Leiden mutation. The patient was eventually found to have Antithrombin III deficiency via genetic testing and remains on lifelong anticoagulation.This case illustrates the utility of mechanical thrombectomy and thrombolysis in severe cases of neonatal cerebral venous sinus thrombosis with rapid clinical deterioration.