Endovascular and surgical treatment of cerebral venous thrombosis

Created 09/04/2021, last revision 15/06/2022

  • 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 to alleviate malignant venous congestion
  • recanalization (complete or partial) is associated with an improved outcome of CVT 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 neurological 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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External ventricular drainage (EVD)

  • indicated in the patients with developing obstructive hydrocephalus, but there are insufficient data to make a recommendation (ESO guidelines 2017)
  • consider carefully – surgery requires temporary interruption of anticoagulation/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 cases of CVT (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
Decompressive craniectomy in CVT

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 vision and resolution of papilledema [Murdock, 2014]
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