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

Posterior vascular anatomy of the encephalon: a comprehensive review

PURPOSE

This article presents a comprehensive exploration of neurovascular anatomy of the encephalon, focusing specifically on the intricate network within the posterior circulation and the posterior fossa anatomy; enhancing understanding of its dynamics, essential for practitioners in neurosurgery and neurology areas.

METHOD

A profound literature review was conducted by searching the PubMed and Google Scholar databases using main keywords related to neurovascular anatomy. The selected literature was meticulously scrutinized. Throughout the screening of pertinent papers, further articles or book chapters were obtained through additional assessment of the reference lists. Furthermore, four formalin-fixed, color latex-injected cadaveric specimens preserved in 70% ethanol solution were dissected under surgical microscope (Leica Microsystems Inc, 1700 Leider Ln, Buffalo Grove, IL 60089, USA), using microneurosurgical as well as standard instruments, and a high-speed surgical drill (Stryker Instruments 1941 Stryker Way Portage, MI 49002, USA). Ulterior anatomical dissection was performed.

RESULTS

Detailed examination of the basilar artery (BA), a common trunk formed by the union of the left and right vertebral arteries, denoted a tortuous course across the basilar sulcus. Emphasis is then placed on the Posterior Inferior Cerebellar Artery (PICA), Anterior Inferior Cerebellar Artery (AICA) and Superior Cerebellar Artery (SCA). Each artery's complex course through the posterior fossa, its divisions, and potential stroke-related syndromes are explored in detail. The Posterior Cerebral Artery (PCA) is subsequently unveiled. The posterior fossa venous system is explained, categorizing its channels. A retrograde exploration traces the venous drainage back to the internal jugular vein, unraveling its pathways.

CONCLUSION

This work serves as a succinct yet comprehensive guide, offering fundamental insights into neurovascular anatomy within the encephalon's posterior circulation. Intended for both novice physicians and seasoned neuroanatomists, the article aims to facilitate a more efficient clinical decision-making in neurosurgical and neurological practices.

New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline

Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.

Multicenter registry study of cerebral venous thrombosis in china (RETAIN-CH): Rationale and design

BACKGROUND AND RATIONALE

Cerebral venous thrombosis (CVT) is a rare cerebrovascular disorder that mainly affects young and middle-aged adults. Epidemiological data on the incidence, risk factors, diagnosis, treatment, and prognosis of CVT are lacking in China. In addition, there is a lack of evidence from large, multicenter, real-world studies on the efficacy and safety of endovascular.

AIM

To understand the incidence, diagnosis and treatment status of CVT in China and to estimate the effectiveness and safety of endovascular treatment in the real-world.

METHODS

A multicenter, retrospective observational cohort study will be conducted on CVT patient records from 104 hospitals, between January 1, 2018 and June 30, 2022, identified using a 2-stage cluster sampling design based on per capita gross domestic product. Each enrolled participant is required to complete a further follow-up, which includes the current situation and the assessment at 3 and 12 months after discharge.

STUDY OUTCOMES

The outcomes of this study will include the current status of the incidence, pathogenesis, etiology, clinical symptoms, diagnosis, and treatment of CVT in China, as well as the effectiveness and safety of endovascular treatment in the real-world.

DISCUSSION

Results from this study will provide evidence on the incidence, specific risk factors, symptomatic and imaging features, and clinical outcomes of CVT in China as well as indicate whether endovascular treatment is superior to medical management alone for patients with acute CVT in the real-world.

TRIAL REGISTRATION

http://www.

CLINICALTRIALS

gov.

IDENTIFIER

NCT05448248.

Acute management of cerebral venous thrombosis: Indications, technique, and outcome of endovascular treatment in two high-volume centers

INTRODUCTION

After several uncontrolled studies and one randomized clinical trial, there is still uncertainty regarding the role of endovascular treatment (EVT) in cerebral venous thrombosis (CVT). This study aims to describe and assess different acute management strategies in the treatment of CVT.

METHODS

We performed a retrospective analysis of an international two-center registry of CVT patients admitted since 2019. Good outcome was defined as a return to baseline modified Rankin scale at three months. We described and compared EVT versus no-EVT patients.

RESULTS

We included 61 patients. Only one did not receive systemic anticoagulation. EVT was performed in 13/61 (20%) of the cases, with a median time from diagnosis to puncture of 4.5 h (1.25-28.5). EVT patients had a higher median baseline NIHSS [6 (IQR 2-17) vs 0 (0-2.7), p = 0.002)] and a higher incidence of intracerebral hemorrhage (53.8% vs 20.3%, p = 0.03). Recanalization was achieved in 10/13 (77%) patients. Thrombectomy was performed in every case with angioplasty in 7 out of 12 patients and stenting in 3 cases. No postprocedural complication was reported. An improvement of the median NIHSS from baseline to discharge [6 (2-17) vs 1(0-3.75); p < 0.001] was observed in EVT group. A total of 31/60 patients (50.8%) had good outcomes. Adjusting to NIHSS and ICH, EVT had a non-significant increase in the odds of a good outcome [aOR 1.42 (95%CI 0.73-2.8, p = 0.307)].

CONCLUSIONS

EVT in combination with anticoagulation was safe in acute treatment of CVT as suggested by NIHSS improvement. Selected patients may benefit from this treatment.

Endovascular Treatment for Cerebral Venous Sinus Thrombosis: Comparison among Different Endovascular Procedures

Background

Cerebral venous sinus thrombosis (CVST) is a rare, treatable cause of stroke. Even though CVST has an established medical treatment, 15% of patients remain refractory to treatment. These patients may be candidates for endovascular treatment (EVT), yet the selection of patients remains a challenge. The study aims to understand the profile and outcome of patients treated with EVT and the type of procedure associated with good outcomes.

Methods

This is a single-center, retrospective analysis of CVST patients who underwent EVT from 2009 till 2022. Patients who received only medical management were excluded. Modified Rankin Scale (mRS) ≤2 at 3 months was taken as the primary outcome. Secondary outcomes assessed were hospital stay, death, recurrence, mRS ≤ 2 at discharge, and angiographic recanalization.

Results

Fifty-two patients were included. Twenty-eight (53.8%) were males; the mean age was 33.3 ± 12.3 years. Headache (n = 44, 84.6%) predominated among the symptoms. The common risk factors were anemia (n = 13, 25.5%) and hyperhomocysteinemia (n = 13, 25.5%). Worsening of sensorium (n = 21, 40.3%) and non-improvement of symptoms (n = 15, 28.8%) were the common indications for the procedure. Twenty-five (48.1%) people underwent in situ thrombolysis (IST). Death occurred in eight (15.3%) patients. Thirty-six (73.5%; 36/49) patients had a good outcome at 3 months. IST had a significantly better outcome (mRS ≤ 2, n = 20, 80%) compared to other procedures (P = 0.04). Hospital stay was lesser in the IST subgroup, but without statistical significance. Midline shift >5 mm (odds ratio [OR] 6.8 [1.5-30.9], P = 0.01) and Glasgow Coma Scale <9 before the procedure (OR 27.2 [3.1-236.4], P = 0.002) predicted bad outcomes at 3 months. Female gender (OR 4.5 [1.07-8.8], P = 0.03), presence of altered sensorium (OR 10.2 [1.2-87.5], P = 0.01), encephalopathic syndrome (P = 0.02), presence of parenchymal bleed (OR 3.7 [0.9-4.5], P = 0.04), and midline shift (OR 4.8 [1.1-20.2], P = 0.03) were associated with poor outcome at discharge.

Conclusion

EVT yielded good outcomes in carefully selected, medically refractory patients of CVST. IST performed well compared to other procedures.

Cerebral venous disorders: Diagnosis and endovascular management

The role of the venous circulation in neurological diseases has been underestimated. In this review, we present an overview of the intracranial venous anatomy, venous disorders of the central nervous system, and options for endovascular management. We discuss the role the venous circulation plays in various neurological diseases including cerebrospinal fluid (CSF) disorders (intracranial hypertension and intracranial hypotension), arteriovenous diseases, and pulsatile tinnitus. We also shed light on emergent cerebral venous interventions including transvenous brain-computer interface implantation, transvenous treatment of communicating hydrocephalus, and the endovascular treatment of CSF-venous disorders.

Endovascular treatment for severe cerebral venous sinus thrombosis in a patient with polycythemia vera and nephrotic syndrome: a case report

Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disease that can occur at any age and generally has a good prognosis. Polycythemia vera and nephrotic syndrome are uncommon risk factors for cerebral venous sinus thrombosis. A dilemma exists in the treatment of cerebral venous sinus thrombosis with polycythemia vera and nephrotic syndrome, as some cases are refractory to first-line therapy. Here, we report a patient with CVST who presented with a generalized seizure and was found to have bilateral frontal lobe hemorrhage and subarachnoid hemorrhage. Brain magnetic resonance venography showed extensive cerebral venous sinus thrombosis extending from the superior sagittal sinus to the left internal jugular vein. Further testing revealed that the patient had polycythemia vera and nephrotic syndrome. Anticoagulation therapy had limited effects. He underwent endovascular intervention, including stent thrombectomy, intermediate catheter aspiration, balloon dilatation, and local intravenous thrombolysis, to achieve revascularization. After 9 months of follow-up, the patient had recovered well without any sequelae. This case shows that in patients with critical cerebral venous sinus thrombosis who fail to respond to anticoagulant therapy, stent thrombectomy combined with intermediate catheter aspiration, balloon dilation, and local thrombolysis may be a viable option. This strategy can quickly resolve venous sinus obstruction and improve the prognosis of patients with critical cerebral venous sinus thrombosis.

A Preliminary Discussion on the Safety of Mild Therapeutic Hypothermia in Target Vessels after Endovascular Intervention in Acute Large Vessel Occlusion Cerebral Infarction

INTRODUCTION

The aim of this study was to discuss the safety of rapid administration of 4°C hypothermic normal saline into the occluded vessels using an intra-arterial catheter to induce mild hypothermia following endovascular thrombectomy in patients with acute large vessel occlusion cerebral infarction.

METHODS

We selected 78 patients with acute large vessel occlusion cerebral infarction who underwent endovascular thrombectomy in the Department of Neurology of our hospital from January 2020 to July 2022 and achieved TICI 2b recanalization.

RESULT

Twenty-five patients were administered 500 mL of 4°C hypothermic normal saline in the occluded vessels at a rate of 25 mL/min to induce mild hypothermia. Twenty pairs of subjects conformed to strict matching and were finally included in the statistical analysis. The two groups of patients differed significantly in white blood cell count and percentage of neutrophils (p < 0.05); however, there were no significant differences in D-dimer, procalcitonin, and BNP levels. The two groups of patients did not differ significantly with respect to the incidence of the following indicators: upper gastrointestinal bleeding; pulmonary infection; venous thrombosis; vasospasms; seizures; and chills (p > 0.05).

CONCLUSION

Mild therapeutic hypothermia in target vessels plus endovascular thrombectomy was shown to be safe in patients with acute large vessel occlusion cerebral infarction.

Endovascular Treatment of Cerebral Vein Thrombosis: Safety and Effectiveness in the Thrombectomy Era

Cerebral venous thrombosis (CVT) is a rare cause of stroke that tends to affect young people. Endovascular treatment (EVT) has not yet shown to be beneficial in CVT and is therefore actually only indicated as rescue therapy in severe and refractory cases for medical treatment. Clinical, neuroimaging, procedural and follow-up data were evaluated in order to define the safety and efficacy of EVT in the management of CVT between January 2016 and December 2022. Safety was assessed on the basis of recording adverse events. Functional outcomes (NIHSS, mRS) and neuroimaging were recorded at onset, at discharge and at a 6-month follow-up. Efficacy was assessed evaluating the recanalization rate at the end of the procedure. Twenty-one patients (17 female, 4 male, range 16-84 years) with CVT underwent EVT. Overall morbidity and mortality were both at 4.7%. Median NIHSS at the onset and at the discharge were, respectively, 10 and 2. Successful recanalization was achieved in 21/23 procedures (91.3%). Imaging follow-up (FUP) showed stable recanalization in all but one patient with successful recanalization. In 18/21 patients, a good clinical independence (mRS 0-2) was recorded at 6 months. Our study adds evidence on the safety and efficacy of endovascular techniques in the treatment of CVT.

The pioneering past and cutting-edge future of interventional neuroradiology

This review provides a thorough understanding of the developments in the field of interventional neuroradiology (INR). A concise overview of the pioneering past and current state of this field is presented first, followed by a greater emphasis on its future. Five main aspects predicted to undergo significant developments are identified and discussed. These include changes in 'education and training', 'clinical practice and logistics', 'devices and equipment', 'techniques and procedures', and 'relevant diagnostic imaging'. INR is at the crossroads of neuroradiology, neurosurgery, neurology, and the neurosciences. To progress we must value the uniqueness and vitality of this multidisciplinary aspect. While minimal access techniques offer very good anatomical accessibility to treat multiple pathologies of the central nervous system, it is also important to recognise its limitations. Medical, surgical, and radiosurgery modalities retain an important role in the management of some complex neuropathology. This review is certainly not exhaustive of all ongoing and predicted developments, but it is an important update for INR specialists and other interested professionals.

Cerebral venous sinus thrombosis in pregnancy and puerperium: A comprehensive review

Cerebral venous sinus thrombosis (CVST) is a distinct neurological emergency caused by occlusion, either partial or complete, of the dural venous sinus and/or the cerebral veins. It occurs more frequently in women during pregnancy and puerperium as compared to the general population. The clinical diagnosis is difficult in some cases due to its variable clinical presentation with numerous causes and risk factors. The diagnosis can be made at an early stage if clinical suspicion is high with the help of advanced neuroimaging techniques that were developed recently. Early therapeutic intervention using anticoagulants allows for preventing complications and improving outcomes. In this article, we review the topic of CVST in pregnancy and the postpartum period with an emphasis on its epidemiology, pathophysiology, clinical presentation, and treatment. We also elaborate on several practical points that are important to the treating team. This review will help obstetricians, neurologists, and emergency physicians diagnose affected pregnant women as early as possible to provide prompt treatment and avoid adverse outcomes.