Endovascular and surgical treatment of cerebral venous thrombosis

David Goldemund M.D.
Updated on 30/04/2024, published on 20/11/2022

in the clinical trials, 10-15% of the patients treated with heparin had a poor outcome
patients with extensive thrombosis may benefit from recanalization treatment:
- if no improvement is observed with anticoagulation treatment
- in patients with rapidly deteriorating consciousness due to extensive thrombosis and/or involvement of the deep venous system
endovascular therapy aims to re-establish anterograde venous outflow in the targeted sinus and alleviate malignant venous congestion
recanalization (complete or partial) is associated with an improved outcome compared to those without recanalization
however, the randomized TO-ACT trial did not demonstrate a significant benefit of interventional therapy over standard medical therapy

Intravenous thrombolysis

intravenous thrombolysis (IVT) is rarely used; treatment results are inconclusive, and IVT seems to increase the risk of bleeding
dosage is not standardized (and is not even discussed in recent guidelines)
- according to small studies, a continuous infusion of ALTEPLASE 1-2 mg/h is used
- the duration of thrombolysis is unclear ⇒ 24-48 h may be considered
insufficient data exist to recommend this treatment, particularly in patients expected to have a favorable prognosis (ESO guidelines 2017)

local intra-sinus therapy should be performed in centers with expertise in endovascular treatment
advisable in extensive venous thromboses where no significant effect of anticoagulation is seen or can be expected
- in a systematic review including 10 studies comprising 339 patients who underwent EVT for CVT, the authors found a complete and partial postoperative recanalization in 90.0% of patients (Paybast, 2022)
the theoretical advantage of local thrombolysis is that the drug is delivered where needed and downstream from cerebral venous—often hemorrhagic—infarcts
mechanical methods result in more rapid recanalization and increase the surface of the thrombus exposed to thrombolytics
there is no current evidence to determine which EVT technique (e.g., stent retriever, microcatheters, aspiration catheters, aspiration pump systems) is superior to other
therapeutic strategies
guidelines do not address endovascular treatment in depth (no indication criteria or technical implementation are stated) (ESO guidelines 2017) (AHA guidelines, 2024)

Intrasinus therapy may be offered in these cases:

symptoms have not improved significantly or have worsened during anticoagulation treatment
extensive thrombosis on baseline imaging (especially affecting the deep venous system) with severe neurological deficit
assumed poor prognosis because of altered mental status (cognitive disturbances including abnormal alertness and orientation or coma)

randomized trials are lacking, but the efficacy of endovascular therapy is supported by case series
- analysis of several cohorts of 235 patients [Llyas, 2017]
- a review encompassed 185 patients undergoing mechanical recanalization, achieving partial or complete recanalization in 95% of cases (AngioJet was used in 40% of cases) [Siddiqui, 2015]
the presence of ischemic and/or hemorrhagic lesions is not a contraindication to LIST
retrograde access, mostly via the femoral vein, is used; a microcatheter is inserted into the affected sinus for continuous infusion
patients are usually heparinized throughout the procedure, but no standardized protocol exists (local or systemic? UFH or LMWH? what dose?)
different tPA dosing regimens exist (total dose 8-300 mg, median dose 78.4±64.7mg, median therapy duration 41±49h) [Canhao, 2003]

ALTEPLASE (Actilyse / Activase)

bolus 2-10 mg into the thrombus, then continuous infusion of 1-2 mg/h (Mathukumalli, 2016) [Lee, 2018]
bolus 10 mg into the thrombus, followed by 15 mg/h for 3 hours and then 5 mg/h (max 100mg/day) [Kim, 1997]
usually given for 24-48 h (max. 200 mg in total)

HEPARIN

200-1000 IU/h administered together with tPA serves to flush the catheter and prevent pulmonary embolism
alternatively, systemic heparin/LMWH administration may be continue (no data are available on safety/efficacy) (Stam, 2008)

repeat angiography every 12-24 hours to monitor response to local thrombolysis
thrombolysis may be combined with thrombectomy (see below)
continue standard anticoagulant therapy after completion of the procedure
- LMWH
- UFH (→ Heparinization protocol

thrombolysis can be combined with mechanical methods such as thrombus disruption, thrombectomy, or angioplasty
thrombectomy can also be performed as a standalone primary procedure, notably in cases with extensive bleeding [Lee, 2018]
several devices are used:
- AngioJet [Curtin, AJNR 2004]
- balloon thrombectomy (Fogarty)
- direct aspiration [Jankowitz, 2012]
- stent retrievers [Chen, 2017]
- Penumbra aspiration thrombectomy [Mammen,2017]
  - promising were results reported even without thrombolysis

consider in patients with developing obstructive hydrocephalus; however, data are insufficient to make a formal recommendation (ESO guidelines 2017)
consider carefully as surgery requires temporary interruption of anticoagulant/thrombolytic therapy

decompressive craniectomy, with/without hematoma evacuation, is typically reserved for patients with acute severe CVT and parenchymal lesions with impending herniation
it is considered a life-saving procedure that increases the chance of a favorable outcome even in the most severe CVT cases (ESO guidelines 2017)
- DECOMPRESS2 trial showed that 2/3 of patients with severe CVT survived, and more than one-third were independent 1 year after decompressive surgery
- better results can be expected in:
  - non-comatose young patients with unilateral lesions
  - surgery within 48 hours of admission
- factors associated with poor outcome:
  - age >50 years
  - midline shift >10 mm
  - total effacement of basal cisterns
there is insufficient data to determine the preferred method between hemicraniectomy and endovascular treatment, as well as how and when to combine them

indicated in case of substantial papilledema and imminent blindness
optic nerve sheath fenestration (ONSF) alleviates intraneural pressure and facilitates venous outflow
the procedure requires interruption of anticoagulation/thrombolytic therapy
intervention may result in visual improvement and resolution of papilledema [Murdock, 2014]