Thrombolysis or anticoagulation for cerebral venous thrombosis: rationale and design of the TO-ACT trial

Outcomes and Recurrence Rates Among Patients With Provoked and Cryptogenic Cerebral Venous Thrombosis: Analysis of the ACTION CVT

Background and Objectives

Cerebral venous thrombosis (CVT) is a rare cause of stroke. While the standard treatment is anticoagulation, the type and duration of anticoagulation depends on the underlying etiology. This study aims to identify prevalence, risk factors, and recurrent venous thromboembolism (VTE) rates among patients with idiopathic (cryptogenic) CVT and CVT provoked by transient (peripartum, hormonal treatment, infection, trauma) and persistent (cancer, thrombophilia) factors.

Methods

We used the ACTION-CVT retrospective database which included consecutive patients who were treated for CVT in 27 stroke centers in the United States, Europe, and New Zealand from January 2015 to December 2020. We compared baseline characteristics and outcomes of patients with cryptogenic, transient provoked (TP) and those with persistent provoked (PP) CVT. Baseline characteristics was compared between the groups using χ2 test, t test, or Mann-Whitney U test as appropriate, followed by multivariable regression. We used Kaplan-Meier survival analysis to assess outcome occurrence. We used interaction analysis and Cox regression to assess the risks of recurrent VTE in patients with CVT.

Results

Among 1,025 included participants with CVT, 510 (49.8%) had no identified risk factor (cryptogenic), 363 (35.4%) had at least one transient provoking factor, and 152 (14.8%) had a persistent provoking factor. Patients with TP CVT were younger (p = 0.003) and more likely to be female patients (p < 0.001). When compared with patients with TP CVT, the risk of recurrent VTE was greater in patients with PP CVT (HR 2.59, 95% CI 1.29-5.22, p = 0.008) and nonsignificantly elevated in patients with cryptogenic CVT (HR 1.85. 95% CI 0.98-3.59, p = 0.059). In the interaction analysis, there was a trend toward higher rate of recurrent VTE in female patients with cryptogenic CVT and male patients with PP CVT.

Discussion

In this multicenter study, we found that outcomes of CVT differed depending on the underlying etiology. The risk of recurrent VTE in the PP and cryptogenic CVTs may be influenced by sex.

Global trends and hot spots in cerebral venous sinus thrombosis research over the past 50 years: a bibliometric analysis

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is an uncommon form of cerebrovascular disease. Although our understanding of CVST has improved significantly over the past decades, there has been no bibliometric analysis of CVST until now. We aimed to examine and visualize the hotspots and trends of the research related to CVST using a bibliometric analysis based on Citespace and provide new insights for scholars in their future researches in this area.

METHODS

The literature on CVST was collected from the Web of Science Core Collection database. Bibliometric analysis was performed using CiteSpace (6.2.R3) Advanced software.

RESULTS

A total of 2396 articles were included in the analysis. Publications regarding CVST have increased over time. U.S.A. contributed the most articles. Ferro JM had the highest number of published papers. Stroke was the journal with the most publications and the most commonly cited journal. Nine out of the top 10 cited journals belong to Q1. The risk factors for CVST, emerging and current treatment of CVST, and CVST related to COVID-19 and COVID-19 vaccines are the major potential research hot spots and trends.

CONCLUSIONS

CVST is a rapidly expanding research area and has received increasing attention by the researchers. Our study can provide researchers valuable information on the current status and trends in this area and guide for future studies.

Safety and clinical outcomes in endovascular treatment for symptomatic cerebral venous thrombosis: a single-center experience with meta-analysis

The role of mechanical thrombectomy (MT) in cerebral venous sinus thrombosis (CVT) is ambiguous. This study aims to share our experience with MT in CVT, supplemented by a meta-analysis on this treatment. All patients who had MT for CVT at our institution, between 2016 and 2021, were retrospectively reviewed for treatment indications, the technique used, success and complication rates, and clinical outcomes. A meta-analysis was performed for clinical and safety outcomes from published literature with > 10 patients. A total of 15 patients were included in this study. All had a venous hemorrhage or deteriorating despite anticoagulation. MT was performed using aspiration (with wide bore catheters) in 7 patients: aspiration with stent retriever in 5 and transjugular Fogarty-balloon thrombectomy in 3 patients. Adjunctive intra-sinus thrombolysis (IST) was used in 4 cases and venoplasty in 3. Technical success (restoring antegrade venous flow on arterial injection) was 100% with no procedure-related major complication. The direct transjugular approach was cheaper and faster. At 3-month follow-up, 86% of patients had good outcomes (MRS < 2). Meta-analysis of clinical and safety outcomes from 22 and 20 studies, respectively, demonstrated a positive association between MT and good outcomes as well as no significant association with hazardous periprocedural events. EVT via mechanical means for CVT is feasible in our series and meta-analysis. From our experience, trans-jugular Fogarty balloon embolectomy seems to be a potential cost-saving option, at least in a certain part of the world.

Cerebral venous sinus thrombosis following Russell's viper (Daboia russelii) envenomation: A case report and review of the literature

Snakebite is a life-threatening and often-neglected public health hazard with high chronic disability and mortality, mainly faced by rural communities in the tropics/subtropics. Stroke and neuromuscular paralysis are the most severe neurological complications. However, cerebral venous sinus thrombosis has rarely been reported among cerebrovascular complications. We report a previously healthy middle-aged Indian female who developed cerebral venous sinus thrombosis preceded by features of disseminated bleeding diathesis following Russell's viper bite. The cerebral venous sinus thrombosis was diagnosed by magnetic resonance imaging. The patient responded well to treatment with antivenom and subcutaneous enoxaparin and had no demonstrable neurological deficits at three months of follow-up.

Endovascular Treatment of Intracranial Vein and Venous Sinus Thrombosis—A Systematic Review

Background: Cerebral venous sinus or vein thromboses (SVT) are treated with heparin followed by oral anticoagulation. Even after receiving the best medical treatment, numerous patients experience neurological deterioration, intracerebral hemorrhage or brain edema. Debate regarding whether endovascular treatment (EVT) is beneficial in such severe cases remains ongoing. This systematic review summarizes the current evidence supporting the use of EVT for SVT on the basis of case presentations, with a focus on patient selection, treatment strategies and the effects of the COVID-19 pandemic. Methods: This systemic literature review included randomized controlled trials (RCTs) and retrospective observational data analyzing five or more patients. Follow-up information (modified Rankin scale (mRS)) was required to be provided (individual patient data). Results: 21 records (n = 405 patients; 1 RCT, 20 observational studies) were identified. EVT was found to be feasible and safe in a highly selected patient cohort but was not associated with an increase in good functional outcomes (mRS 0–2) in RCT data. In observational data, good functional outcomes were frequently observed despite an anticipated poor prognosis. Conclusion: The current evidence does not support the routine incorporation of EVT in SVT treatment. However, in a patient cohort prone to poor prognosis, EVT might be a reasonable therapeutic option. Further studies determining the patients at risk, choice of methods and devices, and timing of treatment initiation are warranted.

Treatment of Atypical Clots

The term unusual site thrombosis refers to the occurrence of venous thromboembolism outside of the lower limbs and the pulmonary arteries. Unusual site thrombosis can virtually affect any venous segment, with the most common and/or clinically relevant sites including the upper limbs veins, the retinal veins, the splanchnic veins and the cerebral veins. Clinical features are obviously heterogeneous, while many predisposing factors are common, though with different prevalence among the various disorders. Antithrombotic therapy is prescribed to most patients, but the type, intensity, and duration of treatment vary both within and among patient groups. Increasing evidence is supporting the use of the direct oral anticoagulants in patients with upper limb deep vein thrombosis, cerebral vein thrombosis, and with splanchnic vein thrombosis. This article will review available evidence on the treatment of venous thrombosis occurring in unusual sites.

Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is a rare form of stroke that often affects younger age groups, especially reproductive age group females. CVT is a potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. Headache is the most common presenting symptom. However, a wide range of symptoms can be present and the symptom onset can be acute, subacute, or chronic. Neuroimaging is mandatory in cases where CVT is suspected. Both magnetic resonance venography and computed tomography venography can confirm a diagnosis of CVT. Anticoagulation with low-molecular-weight heparin is the mainstay of treatment. Intracranial hemorrhage is not considered a contraindication to the use of anticoagulants in CVT. Endovascular intervention is still controversial but can be a treatment option for patients with neurological deterioration or thrombus progression, despite the use of anticoagulation or with development of new or worsening intracerebral hemorrhage. Patients with CVT have an increased risk of recurrence of CVT and other types of venous thromboembolism. This review provides an overview of the epidemiology, diagnosis, and treatment of CVT in adults. Commentary about increased presentation of CVT in patients with coronavirus disease 2019 (COVID-19), or after immunization against COVID-19, is also provided.

Clots in unusual places: lots of stress, limited data, critical decisions

Although much less common than deep vein thrombosis of the lower extremities or lungs, clots in unusual locations, including the splanchnic, cerebral, retinal, upper-extremity, and renal locations, present with significant morbidity and mortality. In the last 2 decades, treatment of clots in these unusual locations is primarily managed medically, with interventional and surgical approaches reserved for more severe or refractory cases. The hematologist is well positioned to provide consultation to organ-specific specialties (ie, neurosurgery, hepatology, ophthalmology), especially because acquired and congenital hypercoagulability plays a major role, and anticoagulation is often the primary treatment. Historically, treatment has been based on expert opinion, but systematic reviews and meta-analyses have recently been published. Various societies have produced guidelines for the treatment of clots in unusual locations; however, randomized clinical trial data remain scarce. In the last few years, increasing data have emerged concerning the efficacy of the direct oral anticoagulants in treating clots in unusual locations. Cases have recently been described highlighting atypical thrombosis associated with COVID-19 infection as well as with the ChAdOx1 nCoV-19 (AstraZeneca) vaccine and Johnson and Johnson's Janssen Ad26.COV2.S vaccine. This article reviews clots in unusual locations with an emphasis on the splanchnic (mesenteric, portal, splenic, hepatic) and cerebral circulation. Through a case-based approach, key questions are posed, and data are presented to help guide diagnosis and treatment.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Stroke is the third leading cause of early death worldwide. Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Patient outcomes might be improved if they are offered anticoagulants that reduce their risk of developing new blood clots and do not increase the risk of bleeding. This is an update of a Cochrane Review first published in 1995, with updates in 2004, 2008, and 2015.

OBJECTIVES

To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) for people with acute presumed or confirmed ischaemic stroke. Our hypotheses were that, compared with a policy of avoiding their use, early anticoagulation would be associated with: • reduced risk of death or dependence in activities of daily living a few months after stroke onset; • reduced risk of early recurrent ischaemic stroke; • increased risk of symptomatic intracranial and extracranial haemorrhage; and • reduced risk of deep vein thrombosis and pulmonary embolism.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (August 2021); the Cochrane Database of Systematic Reviews (CDSR); the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), in the Cochrane Library (searched 5 August 2021); MEDLINE (2014 to 5 August 2021); and Embase (2014 to 5 August 2021). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies.

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data. We assessed the overall certainty of the evidence for each outcome using RoB1 and GRADE methods.

MAIN RESULTS

We included 28 trials involving 24,025 participants. Quality of the trials varied considerably. We considered some studies to be at unclear or high risk of selection, performance, detection, attrition, or reporting bias. Anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence is related to effects of anticoagulant therapy initiated within the first 48 hours of onset. No evidence suggests that early anticoagulation reduced the odds of death or dependence at the end of follow-up (odds ratio (OR) 0.98, 95% confidence interval (CI) 0.92 to 1.03; 12 RCTs, 22,428 participants; high-certainty evidence). Similarly, we found no evidence suggesting that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (OR 0.99, 95% CI 0.90 to 1.09; 22 RCTs, 22,602 participants; low-certainty evidence) during the treatment period. Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.75, 95% CI 0.65 to 0.88; 12 RCTs, 21,665 participants; moderate-certainty evidence), it was also associated with an increase in symptomatic intracranial haemorrhage (OR 2.47; 95% CI 1.90 to 3.21; 20 RCTs, 23,221 participants; moderate-certainty evidence). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60, 95% CI 0.44 to 0.81; 14 RCTs, 22,544 participants; high-certainty evidence), but this benefit was offset by an increase in extracranial haemorrhage (OR 2.99, 95% CI 2.24 to 3.99; 18 RCTs, 22,255 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, four new relevant studies have been published, and conclusions remain consistent. People who have early anticoagulant therapy after acute ischaemic stroke do not demonstrate any net short- or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis, and pulmonary embolism but increased bleeding risk. Data do not support the routine use of any of the currently available anticoagulants for acute ischaemic stroke.

Developments in distinguishing secondary vascular headache from primary headache disorders in clinical practice

INTRODUCTION

Vascular headaches are secondary headache disorders with potentially devastating consequences if missed. Clinicians often struggle to distinguish these from primary headache disorders whereby there is no underlying structural pathology. Here, the authors describe the advancement in our understanding of vascular headache disorders, their clinical presentation and the developments in neuroimaging that facilitate diagnosis.

AREAS COVERED

Here the authors discuss the definition of primary and secondary headache disorders. They review the literature on the presentation, choice of neuroimaging and diagnostic tools that can be used to diagnose specific vascular headaches including Carotid or Vertebral artery dissection, Stroke, Temporal Arteritis, subarachnoid hemorrhage, cerebral venous thrombosis, Reversible Cerebral Vasoconstriction syndrome, Primary angiitis, AV malformation and Genetic vasculopathy. The authors discuss the influence of Covid-19 on the management of patients with headache.

EXPERT OPINION

Whilst developments in neuroimaging have been of paramount importance in the diagnosis of vascular headache disorders, there is no substitute for meticulous history taking and examination. Research has aided our understanding of clinical presentation, however further studies are needed as well as increased education of neurologists and acute physicians.

Mechanical thrombectomy and intravascular imaging for cerebral venous sinus thrombosis: a preclinical model

OBJECTIVE

Although the majority of patients with cerebral venous sinus thrombosis (CVST) will improve with anticoagulation therapy, a portion of patients will either present in a comatose state or continue to deteriorate clinically despite early anticoagulation. In these cases, along with treating the underlying thrombophilia, timely thrombolysis may be beneficial. Repurposed arterial thrombectomy devices may not perform as expected in the cerebral venous sinus, and there are currently no preclinical endovascular thrombectomy (EVT) models for CVST. Contrary to arterial stroke research, preclinical models utilized to test various endovascular techniques and devices are lacking. The purpose of this research was to develop a reliable preclinical animal model for the testing of endovascular strategies to treat CVST.

METHODS

Five consecutive male Yorkshire swine weighing 45 kg were utilized. Thrombosis of the superior sagittal sinus was induced with a bovine thrombin injection via a microcatheter under distal balloon occlusion for 15 minutes. Combined arterial injections and superselective sinus injections confirmed the extent of thrombosis. EVT was subsequently performed using a second-generation stent retriever, followed by intravascular optical coherence tomography (OCT) imaging to assess the luminal environment after thrombectomy.

RESULTS

Thrombosis of the superior sagittal sinus, EVT, and subsequent OCT imaging were technically successful in 4 of the 5 swine. Recanalization of the sinus with a second-generation stent retriever was successful after one attempt in 3 of 4 swine (75%), and 1 swine required two attempts. OCT imaging after thrombectomy revealed regions of residual sinus luminal thrombus despite complete angiographic recanalization. Thrombosed bridging cortical veins were also observed before draining into the sinus, along with patent cortical veins.

CONCLUSIONS

The authors describe a preclinical model to assess endovascular techniques and devices for the treatment of CVST. Repurposed devices from arterial stroke may not perform as expected, given the unique features of venous sinus thrombosis. Residual bridging cortical vein thrombus and residual sinus thrombus, visualized on intravascular OCT, may be present despite complete sinus recanalization on angiography, and this may be the etiology of the poor clinical outcome despite technical success. In the setting of bridging cortical vein thrombus after successful sinus thrombectomy, direct chemical thrombolysis may be warranted to dissolve the remaining clot. This model may be helpful in developing and testing a new generation of devices designed specifically for CVST treatment.

Cerebral venous thrombosis: a practical guide

All neurologists need to be able to recognise and treat cerebral venous thrombosis (CVT). It is difficult to diagnose, partly due to its relative rarity, its multiple and various clinical manifestations (different from 'conventional' stroke, and often mimicking other acute neurological conditions), and because it is often challenging to obtain and interpret optimal and timely brain imaging. Although CVT can result in death or permanent disability, it generally has a favourable prognosis if diagnosed and treated early. Neurologists involved in stroke care therefore also need to be aware of the treatments for CVT (with varying degrees of supporting evidence): the mainstay is prompt anticoagulation but patients who deteriorate despite treatment can be considered for endovascular procedures (endovascular thrombolysis or thrombectomy) or neurosurgery (decompressive craniotomy). This review summarises current knowledge on the risk factors, diagnosis, treatment and prognosis of CVT in adults, and highlights some areas for future research.

New Horizons for Diagnostic Pitfalls of Cerebral Venous Thrombosis: Clinical Utility of a Newly Developed Cerebral Venous Thrombosis Diagnostic Score: A Case Report and Literature Review

Patient: Male, 35-year-old

Final Diagnosis: Cerebral venous

Symptoms: Bloody diarrhea • throbbing persistent headache • weight loss

Medication: —

Clinical Procedure: —

Specialty: Neurology

Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial

Importance

To date, only uncontrolled studies have evaluated the efficacy and safety of endovascular treatment (EVT) in patients with cerebral venous thrombosis (CVT), leading to the lack of recommendations on EVT for CVT.

Objective

To evaluate the efficacy and safety of EVT in patients with a severe form of CVT.

Design, Setting, and Participants

TO-ACT (Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis) was a multicenter, open-label, blinded end point, randomized clinical trial conducted in 8 hospitals in 3 countries (the Netherlands, China, and Portugal). Patients were recruited from September 2011 to October 2016, and follow-up began in March 2012 and was completed in December 2017. Adult patients with radiologically confirmed CVT who had at least 1 risk factor for a poor outcome (mental status disorder, coma state, intracerebral hemorrhage, or thrombosis of the deep venous system) were included. Data were analyzed according to the intention-to-treat principle from March 2018 to February 2019. The trial was halted after the first interim analysis for reasons of futility.

Interventions

Patients were randomized to receive either EVT with standard medical care (intervention group) or guideline-based standard medical care only (control group). The EVT consisted of mechanical thrombectomy, local intrasinus application of alteplase or urokinase, or a combination of both strategies. Patients in the intervention group underwent EVT as soon as possible but no later than 24 hours after randomization.

Main Outcomes and Measures

Primary end point was the proportion of patients with a good outcome at 12 months (recovered without a disability; modified Rankin Scale [mRS] score of 0-1). Secondary end points were the proportion of patients with an mRS score of 0 to 1 at 6 months and an mRS score of 0 to 2 at 6 and 12 months, outcome on the mRS across the ordinal continuum at 12 months, recanalization rate, and surgical interventions in relation to CVT. Safety end points included symptomatic intracranial hemorrhage.

Results

Of the 67 patients enrolled and randomized, 33 (49%) were randomized to the intervention group and 34 (51%) were randomized to the control group. Patients in the intervention group vs those in the control group were slightly older (median [interquartile range (IQR)] age, 43 [33-50] years vs 38 [23-48] years) and comprised fewer women (23 women [70%] vs 27 women [79%]). The median (IQR) baseline National Institutes of Health Stroke Scale score was 12 (7-20) in the EVT group and 12 (5-20) in the standard care group. At the 12-month follow-up, 22 intervention patients (67%) had an mRS score of 0 to 1 compared with 23 control patients (68%) (relative risk ratio, 0.99; 95% CI, 0.71-1.38). Mortality was not statistically significantly higher in the EVT group (12% [n = 4] vs 3% [n = 1]; P = .20). The frequency of symptomatic intracerebral hemorrhage was not statistically significantly lower in the intervention group (3% [n = 1] vs 9% [n = 3]; P = .61).

Conclusions and Relevance

The TO-ACT trial showed that EVT with standard medical care did not appear to improve functional outcome of patients with CVT. Given the small sample size, the possibility exists that future studies will demonstrate better recovery rates after EVT for this patient population.

Trial Registration

ClinicalTrials.gov Identifier: NCT01204333.

Cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is a rare form of deep venous thrombosis (DVT), yet a leading cause of stroke in young adults, with an incidence that seems to be increasing in recent years. Risk factors for CVT overlap with those of DVT in other locations, with the addition of local risk factors, such as infections, head trauma and neurosurgery. The clinical presentation is highly variable, hence the diagnosis of CVT may be delayed or overlooked. Early recognition and timely initiation of anticoagulant treatment are of essence, while decompressive surgery can be lifesaving for patients with impending transtentorial herniation. Concomitant intracranial hemorrhage is not a contraindication to anticoagulant treatment. Endovascular treatment may be suggested for selected patients who deteriorate despite anticoagulant treatment. In this review we will provide an extensive and contemporary discussion of the incidence, pathophysiology, risk factors, clinical presentation, neuroimaging and management of CVT, in accordance with recent guidelines. Additionally, we will summarize the latest data with regards to direct oral anticoagulants (DOACs) treatment in CVT.

Hemorrhagic stroke

Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.

Successful Endovascular Treatment of Cerebral Venous Thrombosis with a Novel, Larger Aspiration Catheter (REACT): A Case Report

Cerebral venous thrombosis (CVT) is a rare clinical entity, with clinical presentations extending from headache and seizures to coma and death. For adults developing progressive neurological worsening despite adequate medical management, endovascular thrombolysis and/or mechanical thrombectomy may be considered as treatment options. We present one such patient with CVT who developed seizures and slipped into a coma, despite best medical management. A large-bore aspiration catheter was used as a standalone system for the endovascular procedure. The venous sinuses were successfully re-canalized. The patient was discharged a week later with a modified Rankin scale of 2. Studies show that endovascular thrombolysis used alone or in conjunction with thrombectomy for CVT has a higher risk of hemorrhagic complications. If we were to use mechanical thrombectomy devices (that are specifically designed for intracranial clot retrieval) as a stand-alone system, we would probably have better clinical outcomes with a lower risk of hemorrhagic complications.

The clinical analysis and treatment strategy of endovascular treatment for cerebral venous sinus thrombosis combined with intracerebral hemorrhage

Cerebral venous sinus thrombosis (CVST) combined with intracerebral hemorrhage(ICH) is a special subgroup, and whether intrasinus thrombolysis (IST) or mechanical thrombectomy (MT) therapy should be carried out is controversial because of previous hemorrhage and possible delayed hemorrhage.The aim of this study was to analyze the safety and effectiveness of endovascular treatment of CVST with ICH and further discuss the treatment strategy. This is a retrospective study of 56 cases admitted from January 2010 to June 2019 diagnosed with CVST combined with ICH, and all were treated with endovascular treatment including IST with or without MT. We reviewed the clinical, radiological, and outcome data of all patients. The percentage of cases that showed complete and partial recanalization were 67.8% and 26.9% after endovascular treatment. ICH exacerbation occurred in 5 cases during thrombolysis. The percentage of cases with good outcome was 87.5% at discharge. 51 cases were followed up at sixth month. 49 cases had a mRS score of 0–2,and 2 cases had a mRS score of 3–4 at sixth month.Our data suggest that endovascular treatment may improve clinical and radiological outcome in most patients of CVST with ICH, but confirmation in prospective, controlled studies is warranted.

Role, Effectiveness, and Outcome of Decompressive Craniectomy for Cerebral Venous and Dural Sinus Thrombosis (CVST): Is Surgery Really an Option?

Cerebral venous and dural sinus thrombosis (CVST) is predominantly a disease of young people. It accounts for 0.5% of all strokes, and patients usually have good outcomes. However, a minority of patients may present with elevated intracranial pressure characteristics in a serious illness type and may die from brain herniation if not treated promptly. Decompressive craniectomy (DC) is the only treatment modality that can prevent death in such cases of imminent brain herniation. Unfortunately, due to the condition's rarity and ethical concerns, randomized controlled trials are not available. This review assessed the available literature on cerebral venous and dural sinus thrombosis in different age groups and decompressive craniectomy in cerebral venous and dural sinus thrombosis. It revealed that decompressive surgery is extremely effective when done early and for the correct indications with patients achieving excellent functional outcomes post-surgery. Decompressive surgery is recommended in rapidly deteriorating patients with computed tomography (CT) scan evidence of basal cisterns effacement, a mass effect from haemorrhage and/or infarction, and significant midline shift.

Factors influencing therapy choice and clinical outcome in cerebral venous sinus thrombosis

We aimed was to assess the factors influencing therapy choice and clinical outcome after 3-4 months in patients with cerebral venous sinus thrombosis (CVST). In a retrospective, bi-centric study, the set consisted of 82 consecutive CVST patients (61 females; mean age 33.5 ± 15.7 years). Following data were collected: baseline characteristics, presence of gender-specific risk factors (GSRF), location and extent of venous sinus impairment, clinical presentation, type of treatment, recanalization, presence of parenchymal lesions, and clinical outcome after 3-4 months (assessed using the modified Rankin Scale [mRS], with excellent outcome defined as mRS 0-1). Multivariate logistic regression analysis was used for statistical evaluation. After 3-4 months, complete recovery was achieved in 41 (50%) and excellent clinical outcome in 67 (81.7%) patients. Female sex (OR 0.11; p = 0.0189) and presence of focal neurologic deficit (OR 0.16; p = 0.0165) were identified as significant independent negative predictors and, the presence of GSRF (OR 15.63; p = 0.0011) as significant independent positive predictor of excellent clinical outcome. In conclusion, in our CVST patients, the presence of GSRF was associated with excellent clinical outcome, while the female sex itself was associated with poorer clinical outcome.

Cerebral Venous Sinus Thrombosis in the COVID-19 Pandemic

BACKGROUND

Recent studies have noted concern for increased thromboembolic events in the setting of Coronavirus Disease 2019 (COVID-19). Cerebral venous sinus thrombosis (CVST) is a form of thromboembolism that has been observed as a neuro-ophthalmologic complication of COVID-19.

METHODS

Review of the scientific literature.

RESULTS

In this article, we report an overview of CVST epidemiology, clinical presentation, diagnostics, disease pathophysiology, and management in the setting of COVID-19.

CONCLUSION

CVST is an uncommon thromboembolic event with variable phenotypes and multiple etiologies. Neurologic complications can be severe, including significant visual deficits and death. Current observations suggest that the risk of CVST may be profoundly impacted by this novel COVID-19 pandemic, thus prompting increased attention to disease presentation, pathogenesis, and management.

Complicated Cerebral Venous Thrombosis During the First Trimester of Pregnancy

Pregnancy and puerperium are known conditions associated with venous thrombotic events, which may present atypically in cases such as cerebral venous thrombosis. Since these are uncommon events, there is a paucity of reports and protocols for the management of these patients, resulting in no clear consensus in the literature. We report a case of a woman, nine weeks pregnant, who developed thrombosis of the right transverse and superior sagittal sinuses. Our diagnosis was made with computed tomography angiography, and due to a significant midline shift, an emergency decompressive hemicraniectomy was required. Although medical and surgical therapies for intracranial hypertension and anticoagulation were optimized in accordance with current medical literature, the patient suffered a spontaneous abortion and remained with significant neurological sequelae.

Cerebral Venous Thrombosis: A Comprehensive Review

BACKGROUND

Cerebral sinus venous thrombosis (CSVT) is a relatively rare, potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. A literature search on PubMed using the keyword "Cerebral sinus venous thrombosis" was performed. We searched for the epidemiology, risk factors, pathophysiology, clinical features, diagnosis, and treatment of CSVT. All full-text articles in the last 10 years, in adults (>18 years), and the English language were included. We aim to give a comprehensive review of CSVT, with a primary focus on the management of the disease.

SUMMARY

The literature search revealed 404 articles that met our criteria. CSVT is a relatively rare condition that accounts for approximately 1% of all forms of stroke. They can be subdivided into acute, subacute, and chronic forms based on the time of onset of clinical symptoms. It is a multifactorial disease, and the major forms of clinical presentation include isolated intracranial hypertension syndrome, focal neurological deficits, and cavernous sinus syndrome. MRI with magnetic resonance venogram (MRV) is considered the gold standard for diagnosis. Anticoagulation with heparin or low-molecular-weight heparin is the mainstay of treatment. Endovascular management is indicated for those cases with severe symptoms or worsening of symptoms despite anticoagulation therapy. Favorable outcomes have been reported in patients who receive early diagnosis and treatment.

CONCLUSION

CSVT is a potentially fatal neurological condition that is often under-diagnosed due to its nonspecific presentation. Timely diagnosis and treatment can reduce morbidity and mortality, remarkably improving the outcome in affected individuals.

Endovascular treatment for cerebral venous sinus thrombosis - a single center study

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disorder. The majority of these patients respond favorably to systemic anticoagulation. However, a subset of patients will deteriorate clinically, despite optimal medical therapy.

METHODS

Retrospective single center study of 28 consecutive CVST patients treated with systemic anticoagulation and additional endovascular therapy.

RESULTS

Median age was 37.5 years (range 15-76 years), there were 21 (75%) women, and 20 (71%) had thrombosis involving ≥2 venous sinuses. Intracranial hemorrhage (ICH) was present at admission in 18 patients (64%). Endovascular therapy consisted of local thrombolysis in 26 (93%) patients; 9 patients (32%) had additional mechanical thrombectomy, and in 2 (7%) patients thrombectomy alone was performed. Complete recanalization at end of the final intervention was achieved in 15 patients (54%), partial recanalization in 11 patients (39%), whereas there was no recanalization in 2 patients (7%). On follow-up imaging, conducted between 3 and 6 months, recanalization further improved to 76%, 19% and 5%, respectively. A favorable outcome (mRS ≤ 2) was achieved in 63% of patients at 3 months, which improved to 79% at 6 months. Post-procedural ICH or volume expansion of preexisting ICH was seen in 9 patients (32%). In total 5 patients died (18%).

CONCLUSIONS

Systemic anticoagulation with the addition of endovascular therapy with local thrombolysis and/or mechanical thrombectomy is a potential strategy to obtain recanalization in patients with CVST who deteriorate clinically despite medical therapy or are comatose. Endovascular therapy may increase the risk of ICH.

Treatment of unusual thrombotic manifestations

Venous thrombosis rarely occurs at unusual sites such as cerebral, splanchnic, upper-extremity, renal, ovarian, or retinal veins. Clinical features, symptoms, and risk factors of rare thrombotic manifestations are heterogeneous and in large part differ from those typical of the commonest manifestations of venous thrombosis at the lower extremities. The therapeutic approach also varies widely according to the affected site, whether cerebral, abdominal, or extraabdominal. To date, anticoagulant therapy for thrombosis at unusual sites is generally accepted, but the optimal therapeutic approach remains challenging. This review is focused on the treatment of unusual thrombotic manifestations as reported in the most recent guidelines and according to the updated scientific literature.

Endovascular Mechanical Thrombectomy and On-Site Chemical Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare cause of cerebral infarction. Once patients survive the acute phase, long-term prognosis is generally satisfactory. CVST patients who harbored risk factors known for poor prognosis (e.g., deterioration of consciousness/neurological functions and seizures) were oftentimes unresponsive to systemic heparin treatment. The advantage of combined endovascular mechanical thrombectomy (EMT) and on-site chemical thrombolysis (OCT) plus systemic heparin for CVST over the heparin treatment alone has not been proved. A retrospective study was conducted to analyze consecutive patients with CVST from 2005 to 2015. Patients having clinical improvement or stable disease after heparin treatment were in I/S group; patients having continuous deterioration of consciousness/neurological functions and refractory seizures (despite the use of multiple anti-epileptic drugs) after heparin treatment were in D group. EMT and OCT were indicated for patients in D group. Imaging studies and medical records were reviewed for statistical analysis. Safety issues included new-onset/progression of symptomatic intracerebral hemorrhages (ICH) or procedure-related complications. Total thirty patients were included (I/S group = 16; D group = 14). In D group, the mean time frame from the start of heparin treatment to the endovascular treatment was 3.2 days. Compared with I/S group, all patients in D group had complete stenosis of the sinuses, with higher initial mRS, lower initial GCS, and more seizures (p = 0.006, 0.007, and 0.031, respectively), but no significant differences in the mRS at discharge (p = 0.504). Shorter length of thrombosis and lower initial mRS were associated with better outcomes (p = 0.009 and 0.003, respectively). Thrombosis involving the superior sagittal sinus (SSS) was associated with bad outcomes (p = 0.026). There were two patients (6.7%) with worsening symptomatic ICH, one in each group, managed surgically. The overall mortality of the study was 6.7% (2/30). Combined EMT and OCT after heparin treatment for severe CVST were reasonably safe, which might be considered as a salvage treatment in severe CVST patients who are unresponsive to heparin with heavy clot burden involving SSS in the acute phase. However, further studies are needed to confirm its efficacy and validity.

Successful endovascular therapy for cerebral venous sinus thrombosis accompanied by heparin-induced thrombocytopenia

INTRODUCTION

Heparin-induced thrombocytopenia (HIT) is an immune-mediated complication of heparin exposure. A limited number of studies have reported cerebral venous sinus thrombosis accompanied by heparin-induced thrombocytopenia. Here, we present a case of successful endovascular therapy (EVT) without periprocedural heparinization in this situation.

CASE PRESENTATION

A 47-year-old woman taking an oral contraceptive was admitted to our hospital with severe headache to be diagnosed as cerebral venous sinus thrombosis. Initially, she got improved by medical treatment with intravenous unfractionated heparin. However, she rapidly developed disturbance of consciousness and right hemiplegia due to cerebral venous sinus thrombosis accompanied by heparin-induced thrombocytopenia on the 14th hospital day. She underwent emergent EVT by immediate conversion of anticoagulation from heparin to argatroban. Despite a large clot burden, sufficient recanalization and anterograde venous drainage were re-established by combined EVT including aspiration, balloon sinoplasty, and local thrombolysis with urokinase infusion. She got improved immediately after the intervention and discharged home without any neurological sequelae after two months.

CONCLUSION

This unique case of cerebral venous sinus thrombosis worsened by occurrence of heparin-induced thrombocytopenia during the treatment finally resulted in excellent outcome highlights effectiveness of emergent endovascular intervention for critical cerebral venous sinus thrombosis resistant to initial medical treatment and of immediate establishment of effective anticoagulant strategy for both of heparin-induced thrombocytopenia and cerebral venous sinus thrombosis. Neuroendovascular therapy for cerebral venous sinus thrombosis using alternative argatroban to heparin for periprocedural anticoagulation might be safe and feasible.

Multimodal Regional Brain Monitoring of Tissue Ischemia in Severe Cerebral Venous Sinus Thrombosis

BACKGROUND

Comatose critically ill patients with severe diffuse cerebral venous thrombosis (CVT) are at high risk of secondary hypoxic/ischemic insults, which may considerably worsen neurological recovery. Multimodal brain monitoring (MBM) may therefore improve patient care in this setting, yet no data are available in the literature.

METHODS

We report two patients with coma following severe diffuse CVT who underwent emergent invasive MBM with intracranial pressure (ICP), brain tissue oximetry (PbtO2), and cerebral microdialysis (CMD). Therapy of CVT consisted of intravenous unfractionated heparin (UFH), followed by endovascular mechanical thrombectomy (EMT). EMT efficacy was assessed continuously at the bedside using MBM.

RESULTS

Despite effective therapeutic UFH (aPTT two times baseline levels in the two subjects), average CMD levels of lactate and glucose in the 6 h prior to EMT displayed evidence of regional brain ischemia. The EMT procedure was associated with a rapid (within 6 h) improvement in both CMD lactate (6.42 ± 0.61 4.89 ± 0.55 mmol/L, p = 0.02) and glucose (0.49 ± 0.17 vs. 0.96 ± 0.32 mmol/L, p = 0.0005). EMT was also associated with a significant increase in PbtO2 (22.9 ± 7.5 vs. 30.1 ± 3.6 mmHg, p = 0.0003) and a decrease in CMD glutamate (12.69 ± 1.06 vs. 5.73 ± 1.76 μmol/L, p = 0.017) and intracranial pressure (ICP) (13 ± 4 vs. 11 ± 4 mmHg (p = 004). Patients did not require surgical decompression, regained consciousness, and were discharged from the hospital with a good neurological outcome (modified Rankin score 3 and 4).

CONCLUSIONS

This study illustrates the potential utility of continuous bedside MBM in patients with coma after severe brain injury, irrespective of the primary acute cerebral condition. Despite adequate ICP and PbtO2 control, the presence of CMD signs of regional brain cell ischemia triggered emergent EMT to treat CVT, which was associated with a significant and clinically relevant improvement of intracerebral physiology.

Clinical Aspects, Diagnosis and Management of Cerebral Vein and Dural Sinus Thrombosis: A Literature Review

Cerebral vein and dural sinus thrombosis (CVST) is an uncommon cause of stroke, but its delayed diagnosis carries significant morbidity and mortality. Several studies have reported higher incidence of CVST than that previously reported. The clinical presentation of CVST varies and can be atypical. Advancement in neuroimaging modalities has made it possible to make an early diagnosis and initiate management with a wide range of therapeutic options, including direct oral anticoagulants and endovascular treatment. This narrative review summarizes the epidemiology, clinical aspects, diagnosis and management of CVST.

Stenting of symptomatic lateral sinus thrombosis refractory to mechanical thrombectomy

OBJECTIVE

Endovascular mechanical thrombectomy for the treatment of cerebral venous sinus thrombosis is not always successful. We present our experience of using self-expanding stents to facilitate effective recanalization of persistent lateral sinus thrombosis refractory to endovascular mechanical thrombectomy.

METHODS

Data from patients who underwent endovascular mechanical thrombectomy for the treatment of acute symptomatic cerebral venous sinus thrombosis between August 2015 and July 2018 were evaluated. Patient demographics, procedural techniques, devices used and follow-up outcomes were assessed.

RESULTS

A total of 14 patients underwent endovascular mechanical thrombectomy during the study period. Of these, stenting of the occluded sinus was performed in five patients with extensive sinus thrombosis after conventional endovascular mechanical thrombectomy. Three of the five patients had a variable degree of venous infarction and/or hemorrhage before treatment. The target lesion was located in the right lateral sinus in all five patients. Due to the length of the involved sinus, two stents were required in one patient and three stents in two patients. The only procedure-related complication was an asymptomatic tearing of the sinus wall in one patient. Stent patency could not be maintained in two patients due to stent buckling within the jugular foramen segment and an inability to maintain antiplatelet medication. Modified Rankin Scale scores at 2-16 months were zero in two patients, one in two patients, and five in one patient.

CONCLUSIONS

Stenting for the thrombotic occlusion of the lateral sinus is a feasible rescue method to overcome unsuccessful endovascular mechanical thrombectomy. However, currently available stenting systems may be unsuitable for use in the intracranial dural sinus system.

Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.

A Migraneur with a Usual Headache: A Near-miss of Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT), while rare, is a challenging diagnosis. It can be easily missed as the presenting symptom can be just a mild headache. However, if missed and left untreated, it can lead to multiple complications, even death. There are certain risk factors that should make one suspect CVT, such as pregnancy, puerperium, use of oral contraceptive pills (OCPs) or known underlying hypercoagulable disorder, to name a few. Imaging is required for diagnosis. Anticoagulation, typically long term, is the standard treatment. We present a case of a 25-year-old male who was initially discharged after an emergency department visit with symptomatic treatment for migraine headaches, and was later found to have extensive cerebral venous sinus thrombosis. It is worth emphasizing the importance of having a broad differential diagnosis and a low threshold to obtain imaging studies when patients present with persistent headaches, even in the absence of any obvious risk factors.

Spectrum of Cerebral Venous Thrombosis in Oman

Objectives

Cerebral venous thrombosis (CVT) can have varied and life-threatening manifestations. This study aimed to examine the spectrum of its clinical presentations and outcomes in a tertiary hospital in Oman.

Methods

This retrospective study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2009 and December 2017. The medical records of all patients with CVT were reviewed to determine demographic characteristics, clinical features and patient outcomes.

Results

A total of 30 patients had CVT. The mean age was 36.8 ± 11 years and the male-to-female ratio was 2:3. Common manifestations included headache (83%), altered sensorium (50%), seizures (43%) and hemiparesis (33%). Underlying risk factors were present in 16 patients (53%). Computed tomography or magnetic resonance imaging of the brain was abnormal in all patients, with indications of infarcts (40%) and major sinus thrombosis (100%). There were five cases (20%) of deep CVT. The patients were treated with low-molecular-weight heparin, mannitol and anticonvulsants. The majority (77%) had no residual neurological deficits at follow-up.

Conclusion

These findings indicate that CVT is a relatively uncommon yet treatable disorder in Oman. A high index of suspicion, early diagnosis, prompt anticoagulation treatment and critical care may enhance favourable patient outcomes.

Management of Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare subtype of cerebrovascular disease representing 0.5% of strokes. The signs and symptoms of CVST are often nonspecific, and variable in duration, with the common results being delayed diagnosis and treatment. Increased awareness in the medical community and advancements in imaging modalities have produced faster diagnosis with improved patient outcomes. The preferred initial treatment is with a low molecular weight heparin. After the acute stage of CVST, treatment with a vitamin K antagonist (oral anticoagulant therapy) is recommended. Current evidence suggests that in the future, factor Xa inhibitor drugs may be used for long-term therapy.

A Practical Score for Prediction of Outcome After Cerebral Venous Thrombosis

Background: Most patients with cerebral venous thrombosis (CVT) have independent survival in the short term. However, identification of high-risk individuals with an unfavorable outcome is a challenging task. We aimed to develop a CVT grading scale (CVT-GS) to aid in the short-term clinical decision-making.

Methods: We included 467 consecutive patients with CVT who were hospitalized from 1981 to 2015 in two third-level referral hospitals. Factors associated with 30-day mortality were selected with bivariate analyses to integrate a Cox proportional-hazards model to determine components of the final scoring. After the scale was configured, the prognostic performance was tested for prediction of short-term death or moderately impaired to death [modified Rankin scale (mRS) > 2]. CVT-GS was categorized as mild, moderate or severe for the prediction of 30-day fatality rate and a probability of mRS > 2.

Results: The 30-day case fatality rate was 9.0%. The CVT-GS (0–13 points; more points predicting poorer outcomes) was composed of parenchymal lesion size > 6 cm (3 points), bilateral Babinski signs (3 points), male sex (2 points), parenchymal hemorrhage (2 points), and level of consciousness (coma: 3 points, stupor: 2, somnolence: 1, and alert: 0). CVT was categorized as mild (0–2 points, 0.4% fatality rate), moderate (3–7 points, 9.9% fatality rate), or severe (8–13 points, 61.4% fatality rate). The CVT-GS had an accuracy of 91.6% for the prediction of 30-day mortality and 85.3% for mRS > 2.

Conclusions: CVT-GS is a practical clinical tool for prediction of outcome after CVT. This score may aid in clinical decision-making and could serve to stratify patients enrolled in clinical trials.

Cerebral venous sinus thrombosis

The cerebral venous system is an unusual site of thrombosis, with a particularly high incidence in young adults. This incidence has increased in past decades because of the improvement of neuroradiological techniques. Risk factors for cerebral venous sinus thrombosis overlap with those of other venous thromboembolism sites; however, some are specific for this particular anatomical district. Prognosis is favorable in most cases if diagnosis is made rapidly and treatment is promptly initiated, even if acute complications or chronic invalidity still occur in a quarter of patients. The mainstay of treatment is anticoagulation, which is necessary in order to block clot propagation and obtain recanalization. Intracranial bleeding does not contraindicate anticoagulation. Endovascular procedures are reserved for patients with a particularly severe presentation or rapidly declining neurological symptoms despite appropriate anticoagulation, although data from clinical trials are lacking. Specifically, this review addresses the epidemiology, clinical presentation and course, risk factors, and treatment of cerebral venous sinus thrombosis, with a special focus on the pediatric population.

[Clinical presentations, diagnosis and treatment of cerebral vein and sinus thrombosis]

The problem of thrombosis of cerebral veins and venous sinuses is insufficiently studied. The real incidence of cerebral venous thrombosis remains incompletely defined. The article presents results of clinical research on cerebral vein and sinus thrombosis, which served as a ground for an analysis of causes and development of the disease. In 20-35% of patients with cerebral venous thrombosis, this disease remains idiopathic after extensive investigation. Particular attention is given to risk factors, clinical presentations, early diagnosis, treatment, prognosis of cerebral vein and sinus thrombosis.

Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association

Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.

Severe Cerebral Venous and Sinus Thrombosis: Clinical Course, Imaging Correlates, and Prognosis

BACKGROUND

Severe cerebral venous-sinus thrombosis (CVT) is a rare disease, and its clinical course, imaging correlates, as well as long-term prognosis have not yet been investigated systematically.

METHODS

Multicenter retrospective study. Inclusion criteria were CVT, Glasgow coma scale ≤9, and treatment in the intensive care unit. Primary outcome was death or dependency, assessed by a modified Rankin Score (mRS) >2 at last follow-up.

RESULTS

114 patients were included. At last follow-up (median 2.5 years), 38 patients (33.3 %) showed no or minor residual symptoms (mRS = 0 or 1), 12 (10.5 %) had a mild (mRS = 2), 13 (11.4 %) a moderate (mRS = 3), 12 (10.5 %) a severe disability (mRS = 4 or 5), and 39 (34.2 %) had died. In bivariate analysis, predictors of poor outcome were any signs of mass effect on imaging, clinical deterioration after admission, and age. In contrast, clinical symptoms on admission and parenchymal lesions per se, such as edema, infarction, or hemorrhage were not predictive. Multivariate predictors of poor outcome were an increase in National Institutes of Health Stroke Scale ≥3 after admission [odds ratio (OR) 6.7], bilateral motor signs in the further course (OR 9.2), and midline shift (OR 5.1).

CONCLUSION

The outcome of severe CVT is almost equally divided between severe impairment or death and survival with no or only mild handicap. Specifically, space-occupying mass effect and associated neurologic deterioration seem to determine a poor outcome. Therefore, early detection and treatment of mass effect should be the focus of critical care.