Cerebral Venous Sinus Thrombosis After Vaxzevria (AstraZeneca) Exposure: Successful Endovascular Recanalization with Manual Rheolysis Using a 50 cc Luer Lock Syringe

Whether endovascular treatment is beneficial in patients with cerebral venous sinus thrombosis remains uncertain. We present the case of a 22-year-old woman with the first episode of left focally initiated generalized epileptic seizure after 1 week of gradually worsening headache. She had a history of COVID-19 vaccination with the AstraZeneca vaccine (Vaxzevria) 1 week before. Laboratory examinations revealed mild thrombocytopenia and PF4 antibodies, both most likely induced by the vaccination. CT showed a focal subarachnoid hemorrhage over the cerebral hemispheric convexity and hyperdensity of the superior sagittal sinus and left transverse sinus. MRI/MRA and DSA confirmed the suspected venous sinus thrombosis. Given the extent of the thrombosis and the cerebral venous congestion, an insufficient response to systemic anticoagulation alone was anticipated. The patient underwent successful endovascular recanalization of the superior sagittal sinus and left transverse sinus under therapeutic heparinization. Recanalization was achieved with a 6F aspiration catheter through which 15–20 cc contrast medium diluted with physiological saline solution were injected and aspirated in an alternating fashion, similar to rheolysis and aspiration thrombectomy. The endovascular procedure was well tolerated. Repeated cranial MRI examinations showed adequate absorption of the subarachnoid hemorrhage and permanent patency of the cerebral venous sinuses. The patient had a good clinical outcome with an mRS of 1 upon discharge. The CVS remained patent, and the patient was asymptomatic during the following months under continuous oral anticoagulation and anticonvulsive medication. This case supports previous anecdotal observations regarding the safety and effectiveness of mechanical rheolysis in patients with severe cerebral venous sinus thrombosis. The feasibility of the endovascular treatment in patients with cerebral venous sinus thrombosis is the main topic of this chapter.