Endovascular and surgical treatment of cerebral venous thrombosis

Created 09/04/2021, last revision 19/11/2022

patients with extensive thrombosis may benefit from recanalization treatment:
- if the clinical condition does not improve on anticoagulation treatment
- in patients with rapidly developing deterioration of consciousness due to an 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 in comparison with patients with no recanalization
however, the randomized TO-ACT trial did not demonstrate an effect of interventional therapy compared with standard medical therapy

Intravenous thrombolysis

IVT is rarely used; treatment results are inconclusive, and IVT seems to increase the risk of bleeding
dosage is not standardized (and not discussed in recent guidelines)
- according to small studies, a continuous infusion of 1-2 mg/h is used
- the duration of thrombolysis is unclear ⇒ 24-48 h?
there is insufficient data to recommend this treatment, especially in patients where a good prognosis can be expected (ESO guidelines 2017)

intra-sinus therapy should be performed in centers experienced in endovascular treatment
consider it in extensive venous thromboses where no significant effect of anticoagulation can be expected and in cases with progressive clinical deterioration
always consider decompressive craniectomy
ESO guidelines 2017 do not address endovascular treatment (nor its indication or technical implementation)

Content available only for logged-in subscribers (registration will be available soon)

Content available only for logged-in subscribers (registration will be available soon)

indicated in the patients with developing obstructive hydrocephalus; there are insufficient data to make a recommendation (ESO guidelines 2017)
consider carefully – surgery requires temporary interruption of anticoagulant/thrombolytic therapy

decompressive craniectomy with/without hematoma evacuation is typically reserved for patients with large parenchymal lesions causing herniation
a life-saving procedure, increasing the chance of a good outcome even in the most severe CVT cases (ESO guidelines 2017)
- better results can be expected in non-comatose young patients with unilateral lesions
there are no data to guide when to choose hemicraniectomy over endovascular management or when and how to combine them

indicated in case of large papilledema and impending blindness when medical treatment has failed
optic nerve sheath fenestration (ONSF) reduces intraneural pressure and facilitates venous outflow (the procedure requires interruption of anticoagulation/thrombolytic therapy)
it can lead to improvement in the vision and resolution of papilledema [Murdock, 2014]