CEREBRAL VENOUS SINUS THROMBOSIS
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)
Local thrombolysis / mechanical recanalisation
- 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)
Local (intra-sinus) thrombolysis (LIST)
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Mechanical thrombectomy
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Surgery
External ventricular drainage (EVD)
- 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
- 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
Optic nerve decompression
- 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]