Dual-Stent retriever thrombectomy for extensive dural sinus thrombosis.

INTRODUCTION: First line treatment for cerebral venous thrombosis (CVT) is systemic anticoagulation. In cases with symptoms of elevated ICP, endovascular thrombectomy (EVT) is pursued. We describe two cases in which dual stent-retrievers were used for EVT. OBJECTIVES: The use of dual stent-retrievers has been described in arterial stroke when clot is present in the M1 artery and both M2 branches as a rescue therapy after 1 stent-retriever failed to remove the clot. We applied this same thinking to our EVT patients. METHODS: A 17-year-old female with imaging demonstrating occlusion of the superior sagittal sinus (SSS), dominant right transverse sinus (TS), right sigmoid sinus (SS), and upper right internal jugular vein (IJV). A 20-year-old female with a magnetic resonance venography (MRV) noting CVT in the dominant lateral left TS, SS, and upper left IJV. RESULTS: Both were taken for EVT due to severity of symptoms. Two 6 × 40 mm stent-retrievers were deployed into the CVT and then remove with continuous aspiration with significant recanalization. CONCLUSIONS: The average diameter of the dural sinuses is 8 mm compared to the average size of the middle cerebral artery 3-4 mm. The largest available SR in the United States is 6 mm, and the largest outer diameter of available aspiration catheters is 2-3 mm. Due to the larger size of the dural sinuses, using two SRs can result in more efficient recanalization and less radiation.

Lidocaine Versus Bupivacaine in the Treatment of Headache with Intranasal Sphenopalatine Nerve Block.

BACKGROUND: Intranasal sphenopalatine ganglion (SPG) block has been shown to be an effective treatment for headaches. Multiple therapeutic agents have been studied, although the wide availability and low cost of lidocaine and bupivacaine have made them attractive treatment options. To the authors knowledge, no study has yet demonstrated superiority of one anesthetic over the other. OBJECTIVE: To determine the efficacy of lidocaine versus bupivacaine when performing intranasal sphenopalatine ganglion (SPG) block for the treatment of headaches. STUDY DESIGN: Retrospective cohort study. SETTING: A single tertiary care academic institutionMETHODS: This retrospective study identified patients who underwent SPG block at a single institution from January 1, 2014 to December 20, 2017. Patients were included if they were treated with either lidocaine or bupivacaine and had both pre- and post-procedure pain scores recorded on a 0-10 scale. Patients were excluded if they were less than 18 years of age. RESULTS: 386 total procedures were performed. 303 (78.5%) were lidocaine delivered via the SphenoCath device, and 83 (21.5%) were bupivacaine delivered via the Tx360 device. 90.2% of treatments (n = 348) decreased the patient's pain level. Of the treatments performed with lidocaine, 89.1% (n = 270) resulted in improvement of the patient's pain level with a mean decrease in pain level of 3.1 (SD ± 2.3). Of the treatments performed with bupivacaine, 94.0% (n = 78) resulted in improvement of the patient's pain level, with a mean decrease in pain level of 3.0 (SD ± 1.9). No statistically significant difference was found between the 2 anesthetics. LIMITATIONS: The retrospective study design may introduce selection bias. Both lidocaine and bupivacaine were administered by different devices (Sphenocath and Tx360 respectively) which may account for differences in initial treatment success. There were differences in the size of the two groups, which may also introduce error. CONCLUSIONS: This study demonstrates similar efficacy of SPG block performed with lidocaine or bupivacaine. While no difference was found, the particular advantages and disadvantages of the intranasal delivery device may influence physician choice. KEY WORDS: Sphenopalatine ganglion nerve block, lidocaine, bupivacaine, sphenocath, Tx360, pain intervetnio, headache, miimally invasive therapy.