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Editorial
Cerebral venous thrombosis: Endovascular therapy J. M. K. Murthy Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad, Andhra Pradesh, India Address for correspondence: Dr. J. M. K. Murthy, Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad ‑ 500 034, Andhra Pradesh, India. E‑mail: [email protected] Received : 05-11-2014 Review completed : 05-11-2014 Accepted : 05-11-2014
Thrombosis of the dural sinuses and/or cerebral veins (CVT) is a rare type of stroke and accounts for only about 0.5% of all strokes. The prevalence is only 5 per one million.[1] It tends to occur in young adults, in the International Study of Cerebral Vein and Dural Sinus Thrombosis (ISCVT) the median age was 37 years.[2] Outcomes in this disease are generally trend to be favorable, in the ISCVT 81% of women had complete recovery versus 71% of men. However, women without sex-specific risk factors tended to have a worse outcome than women with these risk factors.[3] The recent reports quote a less than 10% mortality rate.[4] Death is most often due to transtentorial herniation from cerebral edema or hemorrhagic stroke.[5] CVT is a hemodynamic disorder in which the outflow of blood from the brain is blocked. The mechanisms of neurologic dysfunction in these patients include: Thrombosis of cerebral veins causing localized edema of the brain and venous infarction and thrombosis of major sinuses leading to elevated intracranial pressure (eICP) as result of increased venous pressure and impaired absorption of cerebrospinal fluid.[6] Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144431
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
The key to successful treatment of CVT is rapid recanalization of the venous sinuses. Anticoagulation is the standard initial treatment and is associated with a lower relative risk of death[7,8] and of death or dependency.[9] The findings in the ISCVT suggest that low molecular weight heparin might be safer and perhaps more effective than unfractionated heparin.[10] However, despite intensive medical treatment and optimal anticoagulation, some patients develop progressive neurologic deterioration. In these patients probably there is a possible place for endovascular therapy. Endovascular strategies involve superselective delivery of thrombolytic agents via several routes including transfemoral, transjugular, transcarotid, or directly through the venous sinus and mechanical thrombectomy. There is insufficient data on the efficacy of endovascular thrombolysis in CVT. Higher recanalization rates have been reported with endovascular thrombolysis.[11-13] In this issue of Neurology India; Garg et al.,[14] published their experience of endovascular thrombolysis in 10 patients with CVT. Six patients with dural sinus occlusion with restricted venous outflow, all had modified Rankin Scale (mRS) sore of 1 at 30-day follow-up. Of the two patients with deep venous system occlusion, one had mRS 1 and the other had mRS 2 at 30-day follow-up. Of the two patients with dural sinus and deep vein occlusion with restrictive venous outflow, one had mRS 2 at 30-day follow-up and the other did not respond to local thrombolysis and succumb to intracranial hemorrhagic infarct within 48 h. 485
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for journal Murthy: Endovascular therapy
American Heart Association Guidelines suggest that endovascular treatment may be an option in patients with progressive neurologic deterioration despite intensive medical treatment (Class IIb),[15] whereas, the European Federation of Neurological Societies (EFNS) Guidelines[16] mentions it as a “good practice point”. Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis (TO-ACT) trial is under way to determine the place of endovascular thrombolysis in CVT.[17]
3.
Mechanical fragmentation of the clot with or without thrombolytic agent is a direct method of recanalization. The data is limited in this area. The two commonly used devices are AngioJet and balloon venoplasty without stenting. In the literature review of mechanical thrombectomy by Borhani et al., 62.5% patients had no or minor disability, 10.9% had major disability, and 16.1% was the mortality. [18] Shui et al.,[19] treated 26 patients with digital subtraction angiography-confirmed CVT with balloon dilatation and thrombus extraction. Recanalization of the cerebral venous sinus was achieved in all the patients and no endovascular treatment-related complications occurred. At discharge Glasgow Coma Scale (GCS) score improved from a mean of 12.3 points to 15 points and clinical symptoms were improved in 100% of the patients. The EFNS recommends that mechanical fragmentation should be a treatment choice for CVT patients with intracerebral hemorrhage or in whom other methods have been unsuccessful (level of evidence IV).[16]
7.
The present evidence as reviewed above suggests that endovascular therapy, both chemical thrombolysis and mechanical thrombectomy, may be a treatment option in patients who develop progressive deficit despite intensive medical treatment and optimal anticoagulation and have no intracerebral hemorrhage, eICP, or evidence of herniation. Mechanical thrombectomy may be preferred option in patients with intracerebral hemorrhage. However, well-designed randomized control studies involving a large cohort of patients are needed to determine the place of endovascular treatment in patients with CVT.
References 1. 2.
486
Bousser MG, Ferro JM. Cerebral venous thrombosis: An update. Lancet Neurol 2007;6:162-70. Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F. ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: Results of the International Study of Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004;35:664-70.
4.
5. 6.
8. 9. 10.
11. 12. 13. 14. 15.
16.
17.
18.
19.
Coutinho JM, Ferro IM, Cahao P, Barinagarrementeria F, Cantú C, Bousser MG, et al. Cerebral venous and sinus thrombosis in women. Stroke 2009;40:2356-61. Schwarz S, Daffertshofer M, Schwarz T, Georgiadis D, Baumgartner RW, Hennerici M, et al. Current controversies in the diagnosis and management of cerebral venous and dural sinus thrombosis. Nervenarzt 2003;74:639-53. Canhao P, Ferro JM, Lindgren AG, Bousser MG, Stam J, Barinagarrementeria F, et al. ISCVT Investigators. Causes and predictors of death in cerebral venous thrombosis. Stroke 2005;36:1720-5. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791-8. Einhaupl KM, Villringer A, Meister W, Mehraein S, Garner C, Pellkofer M, et al. Heparin treatment in sinus venous thrombosis. Lancet 1991;338:597-600. de Bruijn SF, Stam J. Randomized, placebo-controlled trial of anticoagulant treatment with low-molecular-weight heparin for cerebral sinus thrombosis. Stroke 1999;30:484-8. Coutinho J, de Bruijn SF, Deceber G, Stam J. Anticoagulation for cerebral venous thrombosis. Cochrane Database Syst Rev 2011:CD002005. Coutinho JM, Ferro JM, Canhao P, Barinagarrementeria F, Bousser MG, Stam J, et al. ISCVT Investigators. Unfractionated or low-molecular-weight heparin for the treatment of cerebral venous thrombosis. Stroke 2010;41:2575-80. Strupp M, Covi M, Seelos K, Dichgans M, Brandt T. Cerebral venous thrombosis: Correlation between recanalization and outcome-a longterm follow-up of 40 patients. J Neurol 2002;249:1123-4. Baumgartner RW, Studer A, Amold M, Georgiadis D. Recamalization of cerebral venous thrombosis. J Neurol Neurosurg Psychiatry 2003;74:459-61. Stolz E, Trittmacher S, Rahimi A, Gerriets T, Röttger C, Siekmann R, et al. Influence of recanalization on outcome in dural sinus thrombosis: A prospective study. Stroke 2004;35:544-7. Garg SS, Shah VD, Surya N, Khadhikar SK, Modi PD, Ghatge SB. Role of local thrombolysis in cerebral hemorrhagic venous infarct. Neurol India 2014;521-4. Saposnik G, Barinagarrementeria F, Robert D, Bushnell CD, Cucchiara B, Cushman M, et al. American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: A statement for healthcare professionals from the american heart association/American stroke association. Stroke 2011;42:1158-92. Einhupl K, Stam J, Bousser MG, De Bruijn SF, Ferro JM, Martinelli I, et al. European Federation of Neurological Societies. EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. Eur J Neurol 2010;17:1229-35. Coutinho JM, Ferro JM, Zuurbier SM, Mink MS, Canhão P, Crassard I, et al. Thrombolysis or anticoagulation for cerebral venous thrombosis: Rationale and design of the TO-ACT trial. Int J Stroke 2013;8:135-40. Haghighi AB, Mahmoodi M, Edgell RC, Cruz-Flores S, Ghanaati H, Jamshidi M, et al. Mechanical thrombectomy for cerebral venous sinus thrombosis: A comprehensive literature review. Clin Appl Thrombo Hemost 2013;20:507-15. Shui SF, Li TF, Han XW, Ma J, Guo D. Balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis. Neurol India 2014;62:371-5.
How to cite this article: Murthy J. Cerebral venous thrombosis: Endovascular therapy. Neurol India 2014;62:485-6. Source of Support: Nil, Conflict of Interest: None declared.
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial
Cerebral venous thrombosis: Endovascular therapy J. M. K. Murthy Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad, Andhra Pradesh, India Address for correspondence: Dr. J. M. K. Murthy, Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad ‑ 500 034, Andhra Pradesh, India. E‑mail: [email protected] Received : 05-11-2014 Review completed : 05-11-2014 Accepted : 05-11-2014
Thrombosis of the dural sinuses and/or cerebral veins (CVT) is a rare type of stroke and accounts for only about 0.5% of all strokes. The prevalence is only 5 per one million.[1] It tends to occur in young adults, in the International Study of Cerebral Vein and Dural Sinus Thrombosis (ISCVT) the median age was 37 years.[2] Outcomes in this disease are generally trend to be favorable, in the ISCVT 81% of women had complete recovery versus 71% of men. However, women without sex-specific risk factors tended to have a worse outcome than women with these risk factors.[3] The recent reports quote a less than 10% mortality rate.[4] Death is most often due to transtentorial herniation from cerebral edema or hemorrhagic stroke.[5] CVT is a hemodynamic disorder in which the outflow of blood from the brain is blocked. The mechanisms of neurologic dysfunction in these patients include: Thrombosis of cerebral veins causing localized edema of the brain and venous infarction and thrombosis of major sinuses leading to elevated intracranial pressure (eICP) as result of increased venous pressure and impaired absorption of cerebrospinal fluid.[6] Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144431
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
The key to successful treatment of CVT is rapid recanalization of the venous sinuses. Anticoagulation is the standard initial treatment and is associated with a lower relative risk of death[7,8] and of death or dependency.[9] The findings in the ISCVT suggest that low molecular weight heparin might be safer and perhaps more effective than unfractionated heparin.[10] However, despite intensive medical treatment and optimal anticoagulation, some patients develop progressive neurologic deterioration. In these patients probably there is a possible place for endovascular therapy. Endovascular strategies involve superselective delivery of thrombolytic agents via several routes including transfemoral, transjugular, transcarotid, or directly through the venous sinus and mechanical thrombectomy. There is insufficient data on the efficacy of endovascular thrombolysis in CVT. Higher recanalization rates have been reported with endovascular thrombolysis.[11-13] In this issue of Neurology India; Garg et al.,[14] published their experience of endovascular thrombolysis in 10 patients with CVT. Six patients with dural sinus occlusion with restricted venous outflow, all had modified Rankin Scale (mRS) sore of 1 at 30-day follow-up. Of the two patients with deep venous system occlusion, one had mRS 1 and the other had mRS 2 at 30-day follow-up. Of the two patients with dural sinus and deep vein occlusion with restrictive venous outflow, one had mRS 2 at 30-day follow-up and the other did not respond to local thrombolysis and succumb to intracranial hemorrhagic infarct within 48 h. 485
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for journal Murthy: Endovascular therapy
American Heart Association Guidelines suggest that endovascular treatment may be an option in patients with progressive neurologic deterioration despite intensive medical treatment (Class IIb),[15] whereas, the European Federation of Neurological Societies (EFNS) Guidelines[16] mentions it as a “good practice point”. Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis (TO-ACT) trial is under way to determine the place of endovascular thrombolysis in CVT.[17]
3.
Mechanical fragmentation of the clot with or without thrombolytic agent is a direct method of recanalization. The data is limited in this area. The two commonly used devices are AngioJet and balloon venoplasty without stenting. In the literature review of mechanical thrombectomy by Borhani et al., 62.5% patients had no or minor disability, 10.9% had major disability, and 16.1% was the mortality. [18] Shui et al.,[19] treated 26 patients with digital subtraction angiography-confirmed CVT with balloon dilatation and thrombus extraction. Recanalization of the cerebral venous sinus was achieved in all the patients and no endovascular treatment-related complications occurred. At discharge Glasgow Coma Scale (GCS) score improved from a mean of 12.3 points to 15 points and clinical symptoms were improved in 100% of the patients. The EFNS recommends that mechanical fragmentation should be a treatment choice for CVT patients with intracerebral hemorrhage or in whom other methods have been unsuccessful (level of evidence IV).[16]
7.
The present evidence as reviewed above suggests that endovascular therapy, both chemical thrombolysis and mechanical thrombectomy, may be a treatment option in patients who develop progressive deficit despite intensive medical treatment and optimal anticoagulation and have no intracerebral hemorrhage, eICP, or evidence of herniation. Mechanical thrombectomy may be preferred option in patients with intracerebral hemorrhage. However, well-designed randomized control studies involving a large cohort of patients are needed to determine the place of endovascular treatment in patients with CVT.
References 1. 2.
486
Bousser MG, Ferro JM. Cerebral venous thrombosis: An update. Lancet Neurol 2007;6:162-70. Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F. ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: Results of the International Study of Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004;35:664-70.
4.
5. 6.
8. 9. 10.
11. 12. 13. 14. 15.
16.
17.
18.
19.
Coutinho JM, Ferro IM, Cahao P, Barinagarrementeria F, Cantú C, Bousser MG, et al. Cerebral venous and sinus thrombosis in women. Stroke 2009;40:2356-61. Schwarz S, Daffertshofer M, Schwarz T, Georgiadis D, Baumgartner RW, Hennerici M, et al. Current controversies in the diagnosis and management of cerebral venous and dural sinus thrombosis. Nervenarzt 2003;74:639-53. Canhao P, Ferro JM, Lindgren AG, Bousser MG, Stam J, Barinagarrementeria F, et al. ISCVT Investigators. Causes and predictors of death in cerebral venous thrombosis. Stroke 2005;36:1720-5. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005;352:1791-8. Einhaupl KM, Villringer A, Meister W, Mehraein S, Garner C, Pellkofer M, et al. Heparin treatment in sinus venous thrombosis. Lancet 1991;338:597-600. de Bruijn SF, Stam J. Randomized, placebo-controlled trial of anticoagulant treatment with low-molecular-weight heparin for cerebral sinus thrombosis. Stroke 1999;30:484-8. Coutinho J, de Bruijn SF, Deceber G, Stam J. Anticoagulation for cerebral venous thrombosis. Cochrane Database Syst Rev 2011:CD002005. Coutinho JM, Ferro JM, Canhao P, Barinagarrementeria F, Bousser MG, Stam J, et al. ISCVT Investigators. Unfractionated or low-molecular-weight heparin for the treatment of cerebral venous thrombosis. Stroke 2010;41:2575-80. Strupp M, Covi M, Seelos K, Dichgans M, Brandt T. Cerebral venous thrombosis: Correlation between recanalization and outcome-a longterm follow-up of 40 patients. J Neurol 2002;249:1123-4. Baumgartner RW, Studer A, Amold M, Georgiadis D. Recamalization of cerebral venous thrombosis. J Neurol Neurosurg Psychiatry 2003;74:459-61. Stolz E, Trittmacher S, Rahimi A, Gerriets T, Röttger C, Siekmann R, et al. Influence of recanalization on outcome in dural sinus thrombosis: A prospective study. Stroke 2004;35:544-7. Garg SS, Shah VD, Surya N, Khadhikar SK, Modi PD, Ghatge SB. Role of local thrombolysis in cerebral hemorrhagic venous infarct. Neurol India 2014;521-4. Saposnik G, Barinagarrementeria F, Robert D, Bushnell CD, Cucchiara B, Cushman M, et al. American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: A statement for healthcare professionals from the american heart association/American stroke association. Stroke 2011;42:1158-92. Einhupl K, Stam J, Bousser MG, De Bruijn SF, Ferro JM, Martinelli I, et al. European Federation of Neurological Societies. EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. Eur J Neurol 2010;17:1229-35. Coutinho JM, Ferro JM, Zuurbier SM, Mink MS, Canhão P, Crassard I, et al. Thrombolysis or anticoagulation for cerebral venous thrombosis: Rationale and design of the TO-ACT trial. Int J Stroke 2013;8:135-40. Haghighi AB, Mahmoodi M, Edgell RC, Cruz-Flores S, Ghanaati H, Jamshidi M, et al. Mechanical thrombectomy for cerebral venous sinus thrombosis: A comprehensive literature review. Clin Appl Thrombo Hemost 2013;20:507-15. Shui SF, Li TF, Han XW, Ma J, Guo D. Balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis. Neurol India 2014;62:371-5.
How to cite this article: Murthy J. Cerebral venous thrombosis: Endovascular therapy. Neurol India 2014;62:485-6. Source of Support: Nil, Conflict of Interest: None declared.
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
