Stenting of symptomatic lateral sinus thrombosis refractory to mechanical thrombectomy

Endovascular treatment of cerebral venous sinus thrombosis: A systematic review and meta-analysis of efficacy based on technique

BackgroundCerebral venous sinus thrombosis (CVST) is rare but potentially life-threatening. Although systemic anticoagulation is the primary treatment, endovascular thrombectomy (EVT) or thrombolysis may be considered for refractory cases. Considering advanced techniques and device technology, we undertook an updated systematic review and meta-analysis to evaluate clinical and radiographic outcomes for treating CVST.MethodsWe searched PubMed and EMBASE for studies describing CVST patients treated with EVT. Presenting symptoms, procedural details, and clinical and radiographic outcomes were analyzed. Random-effects models were generated to calculate pooled proportions of clinical and radiographic outcome variables.ResultsWe analyzed 26 studies comprising 273 patients (mean age 37 years, 57.7% female). Preprocedural intracranial hemorrhage was present in 167/243 (67.1%) patients. Endovascular thrombectomy techniques included aspiration thrombectomy alone (29.3%), aspiration plus stent retriever (19%), stent retriever alone (12.5%), balloon/catheter maceration (6.6%), and AngioJet rheolytic system (32.6%). Random-effects model indicated that 37% of patients had complete recanalization and 57% had partial recanalization. The model indicated that 79% of patients had a good clinical outcome (modified Rankin Scale score 0-2) at last follow-up. There were no statistically significant differences between modern systems (stent retriever and/or aspiration) and older systems (rheolytic thrombectomy and catheter maceration). Aspiration alone yielded a significantly higher frequency of good clinical outcomes compared with the combined technique (83.8% vs. 61.5%, p = 0.004).ConclusionEndovascular thrombectomy for CVST refractory to systemic anticoagulation achieved high recanalization rates, favorable outcomes, and low procedural complication rates. Modern and older techniques exhibited similar safety and efficacy. These findings support EVT as an effective treatment option.

Early Versus Late Initiation of Endovascular Therapy in Patients with Severe Cerebral Venous Sinus Thrombosis

BACKGROUND

Endovascular therapy (EVT) for severe cerebral venous sinus thrombosis (CVST) is controversial in terms of indication and clinical benefit. The impact of delay of EVT on functional recovery is unclear. This study aimed to investigate the effect of early versus late initiation of EVT in severe CVST.

METHODS

From prospective EVT and CVST registries, patients with CVST diagnosed between January 2010 and December 2022 were retrospectively identified for this multicenter collaboration. EVT was considered in severe CVST with features prone to a poor prognosis. We compared early (< 24 h) with late (> 24 h) initiation of EVT after the presentation in the emergency department and subsequent CVST diagnosis. Outcome parameters included functional independence (modified Rankin Scale [mRS] score 0-2) at 90 days, mRS score at discharge, in-hospital mortality, and mortality at 3 months.

RESULTS

Of 363 patients with CVST, 45 (12.4%; 31 [early EVT] vs. 14 [late EVT]) were included in this study. We found a higher proportion of patients with functional independence at 3 months among early versus late EVT (66.7% vs. 27.3%; odds ratio [OR] 5.3; 95% confidence interval 1.02-25; p = 0.036). In multivariate logistic regression, late EVT was inversely correlated with functional independence (OR 0.17 [0.04-0.83]; p = 0.011). The mortality rate was 16.7% versus 36.4% (mRS 6 at 3 months, OR 0.34, 95% confidence interval 0.07-1.75; p = 0.217) at 90 days for early versus late EVT.

CONCLUSIONS

We observed a higher rate of functional independence in patients with early EVT. These preliminary findings must be confirmed in subsequent randomized controlled trials evaluating a "time-is-brain" paradigm for EVT in CVST.

Evolution and advances in endovascular mechanical thrombectomy of cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke and standard treatment involves anticoagulation. However, for some special CVST patients who are ineligible for anticoagulation or refractory to conservative treatment, endovascular treatment (EVT) may be an effective option. Mechanical thrombectomy (MT) is a commonly used treatment. Compared with anticoagulation treatment alone, MT may result in additional procedure-related complications, however, many studies have shown that it has a high rate of vessel recanalization and lower incidence of related complications in arterial large vessel occlusion stroke. In addition, the applicability of MT in children, patients with deep cerebral thrombosis, and patients with bleeding before treatment has been reported. MT combined with intravascular thrombolysis (IVT) and other multimodal therapeutic strategies, also has a good curative effect, and further research is needed to compare and optimize different treatment strategies. Owing to the low incidence of CVST, randomized controlled clinical trials with a large sample size to explore the safety and effectiveness of MT are scarce. In addition, devices specifically designed for cerebral venous sinus and effective endovascular therapies are currently not well-established. This article summarizes different endovascular instruments and multimodal therapies for cerebral venous thrombosis. We also discuss the limitations, prospects, prognostic factors, and applications in special cases of interventional thrombectomy.

Future Directions and Innovations in Venous Sinus Stenting

This review explores the future role of venous sinus stenting (VSS) in the management of idiopathic intracranial hypertension and pulsatile tinnitus. Despite its favorable safety profile and clinical outcomes compared with traditional treatments, VSS is not yet the standard of care for these conditions, lacking high-level evidence data and guidelines for patient selection and indications. Current and recently completed clinical trials are expected to provide data to support the adoption of VSS as a primary treatment option. Additionally, VSS shows potential in treating other conditions, such as dural arteriovenous fistula and cerebral venous sinus thrombosis, and it is likely that the procedure will continue to see an expansion of its approved indications. The current lack of dedicated venous stenting technology is being addressed with promising advancements, which may improve procedural ease and patient outcomes. VSS also offers potential for expansion into modulation of brain electrophysiology via endovascular routes, offering exciting possibilities for neurodiagnostics and treatment of neurodegenerative disorders.

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.