Post-operative segmental cerebral venous sinus thrombosis: risk factors, clinical implications, and therapeutic considerations

Venous Sinus Thrombosis-Associated with Posterior Cranial Fossa Surgery. A Systematic Review and Meta-Analysis of Natural History, Risk Factors, Treatment, and Outcome

BACKGROUND

Venous sinus thromboses (VSTs) are rare complications of neurosurgical procedures in the proximity of the dural sinuses. Surgery of the posterior cranial fossa (PCF) and particularly of the cerebellopontine angle (CPA) shows increased risk of VST. VST management is challenging because anticoagulant therapy must be balanced with the risk of postoperative bleeding. We performed a systematic review and meta-analysis to summarize the most important neuroradiologic and clinical aspects of VST after PCF/CPA surgery.

METHODS

We performed a comprehensive literature search to identify articles reporting data on VST after PCF/CPA surgery. We selected only comparative studies providing adequate neuroimaging assessing VST and a control group.

RESULTS

We included 13 articles reporting 1855 patients. VST occurred in 251/1855 cases (estimated incidence, 17.3%; 95% confidence interval [CI], 12.4%-22.2%). Only presigmoid approach (odds ratio [OR], 2.505; 95% CI, 1.161-5.404; P = 0.019) and intraoperative sinus injury (OR, 8.95; 95% CI, 3.43-23.34; P < 0.001) showed a significant association with VST. VST-related symptoms were reported in 12/251 patients with VST (pooled incidence, 3.1%; 95% CI, 1%-5.2%). In particular, we found a significantly increased OR of cerebrospinal fluid leak (OR, 3.197; 95% CI, 1.899-5.382; P < 0.001) and cerebrospinal fluid dynamic alterations in general (OR, 3.625; 95% CI, 2.370-5.543; P < 0.001). Indications for VST treatment were heterogeneous: 58/251 patients underwent antithrombotics, with 6 treatment-related bleedings. Recanalization overall occurred in 56.4% (95% CI, 40.6%-72.2%), with no significant difference between treated and untreated patients. However, untreated patients had a favorable outcome.

CONCLUSIONS

VST is a relatively frequent complication after PCF/CPA surgery and a presigmoid approach and intraoperative sinus injury represent the most significant risk factors. However, the clinical course is generally benign, with no advantage of antithrombotic therapy.

Prevalence and patterns of cerebral venous sinus thrombosis following vestibular schwannoma surgery: a systematic review and meta-analysis

PURPOSE

Cerebral venous sinus thrombosis (CVST) is a potentially serious complication following surgical treatment of vestibular schwannoma, a benign tumor originating from Schwann cells of the vestibulocochlear nerve. This study aimed to determine the prevalence of CVST following surgical treatment of vestibular schwannoma and the factors contributing to its occurrence.

METHOD

Two independent researchers searched the global databases of PubMed, Web of Science, Scopus, and the Cochrane Library up to September 01, 2023. We employed a random-effects model for data analysis. Heterogeneity was evaluated using the I2 test. To assess the quality of the studies meeting our inclusion criteria, we employed the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

We included 23 articles in this meta-analysis. The pooled prevalence of CVST after vestibular schwannoma surgery was 6.4% (95%CI 3.4-11.5%). The pooled prevalence of CVST following the retrosigmoid (RS), translabyrinthine (TL), and middle cranial fossa (MCF) approaches was 4.8% (95%CI 2.0-11.0%), 9.6% (95%CI 4.3-20.3%) and 9.9% (95%CI 1.6-42.2%), respectively, revealing a significant difference between the TL and the RS approaches (Odds ratio = 2.10, 95%CI 1.45-3.04, P < 0.001). The sigmoid sinus exhibited the highest post-operative thrombosis rate (7.9%), surpassing the transverse sinus (3.7%) and involvement of both sigmoid and transverse sinuses (1.6%), respectively. No significant associations were found with demographic or surgical factors.

CONCLUSION

In the current meta-analysis, we identified a 6.4% CVST prevalence following vestibular schwannoma surgery, with varying rates depending on the surgical approach. No significant associations with patient or surgical factors were found, emphasizing the need for heightened clinical vigilance and further research in this context.

TRAIL REGISTRATION

PROSPERO ID: CRD42023453513.

Presentation and Management of Cerebral Venous Sinus Thrombosis After Supratentorial Craniotomy

BACKGROUND AND OBJECTIVES

Cerebral venous sinus thrombosis (CVST) after supratentorial craniotomy is a poorly studied complication, for which there are no management guidelines. This study assessed the incidence, associated risk factors, and management of postoperative CVST after awake craniotomy.

METHODS

This is an observational, retrospective, monocentric analysis of patients who underwent a supratentorial awake craniotomy. Postoperative CVST was defined as a flow defect on the postoperative contrast-enhanced 3D T1-weighted sequence and/or as a T2* hypointensity within the sinus.

RESULTS

In 401 supratentorial awake craniotomies (87.3% of diffuse glioma), the incidence of postoperative CVST was 4.0% (95% CI 2.5-6.4): 14/16 thromboses located in the superior sagittal sinus and 12/16 located in the transverse sinus. A venous sinus was exposed during craniotomy in 45.4% of cases, and no intraoperative injury to a cerebral venous sinus was reported. All thromboses were asymptomatic, and only two cases were diagnosed at the time of the first postoperative imaging (0.5%). Postoperative complications, early postoperative Karnofsky Performance Status score, and duration of hospital stay did not significantly differ between patients with and without postoperative CVST. Adjusted independent risk factors of postoperative CVST were female sex (adjusted Odds Ratio 4.00, 95% CI 1.24-12.91, P = .021) and a lesion ≤1 cm to a venous sinus (adjusted Odds Ratio 10.58, 95% CI 2.93-38.20, P < .001). All patients received standard prophylactic-dose anticoagulant therapy, and none received treatment-dose anticoagulant therapy. No thrombosis-related adverse event was reported. All thromboses presented spontaneous sinus recanalization radiologically at a mean of 89 ± 41 days (range, 7-171).

CONCLUSION

CVST after supratentorial awake craniotomy is a rare event with satisfactory clinical outcomes and spontaneous sinus recanalization under conservative management without treatment-dose anticoagulant therapy. These findings are comforting to neurosurgeons confronted with postoperative MRI reports suggesting CVST.