Original Paper Received: June 18, 2013 Accepted: October 22, 2013 Published online: December 18, 2013
Cerebrovasc Dis 2014;37:38–42 DOI: 10.1159/000356524
Shunting in Acute Cerebral Venous Thrombosis: A Systematic Review S. Lobo a J.M. Ferro a F. Barinagarrementeria b M.G. Bousser c P. Canhão a J. Stam d ISCVT Investigators
a
Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal; Department of Neurology, Instituto Nacional de Neurologia y Neurocirurgia, Mexico City, Mexico; c Department of Neurology, Hôpital Lariboisière, Paris, France; d Department of Neurology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
b
Abstract Background and Purpose: The efficacy of cerebrospinal fluid shunting to reduce intracranial hypertension and prevent fatal brain herniation in acute cerebral venous thrombosis (CVT) is unknown. Method: From the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) and a systematic literature review, we retrieved acute CVT patients treated only with shunting (external ventricular drain, ventriculoperitoneal or ventriculojugular shunt). Outcome was classified at 6 months and final follow-up by the modified Rankin Scale (mRS). Results: 15 patients were collected (9 from the ISCVT and 6 from the review) who were treated with a shunt (external ventricular drain in 6 patients, a ventriculoperitoneal shunt in 8 patients or an unspecified type of shunt in another one). Eight patients (53.3%) regained independence (mRS 0–2), while 2 patients (13.3%) were left with a severe handicap (mRS 4–6) and 4 (26.7%) died despite treatment. Five patients with parenchymal lesions were shunted within 48 h from admission deterioration, 4 with an external ventricular drain: 2 (40%) recovered to independence,
© 2013 S. Karger AG, Basel 1015–9770/13/0371–0038$38.00/0 E-Mail [email protected] www.karger.com/ced
2 (40%) had a severe handicap and 1 (20%) died. In contrast, all 3 patients with intracranial hypertension and no parenchymal lesions receiving a ventriculoperitoneal shunt later than 48 h regained independence. Conclusion and Implications: A quarter of acute CVT patients treated with a shunt died, and only half regained independence. With the limitation of the small number of subjects, this review suggests that shunting does not appear to be effective in preventing death from brain herniation in acute CVT. We cannot exclude that shunting may benefit patients with sustained intracranial hypertension and no parenchymal lesions. © 2013 S. Karger AG, Basel
Introduction
The main cause of death during the acute phase of a cerebral venous thrombosis (CVT) is brain herniation produced by either a large parenchymal lesion, usually hemorrhagic, or massive brain edema [1]. Several interventions can be used to reduce increased intracranial pressure in acute CVT. Evidence from a retrospective
Names and affiliations of the ISCVT investigators are listed in reference 3.
José M. Ferro, MD, PhD Department of Neurosciences Hospital de Santa Maria, University of Lisboa PT–1649-035 Lisboa (Portugal) E-Mail jmferro @ fm.ul.pt
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/16/2015 11:45:45 AM
Key Words Shunt · Cerebral veins and sinuses · Cerebral venous thrombosis · Intracranial pressure · Neurosurgery · Treatment
Methods We performed a systematic review of individual patient information of published acute CVT cases treated with a shunt since 1997. We used the Medline-Pubmed electronic database. Key words and search strategy are described in appendix 1. References of selected publications were hand searched for further titles. In addition, we retrieved from the International Study on cerebral Vein and Dural Sinus Thrombosis (ISCVT) cohort [3] (which was launched in 1997) all cases of acute CVT treated with shunting. Inclusion criteria for both sources were: (1) patients with acute CVT; (2) any age; (3) submitted to cerebral spinal fluid drainage with a shunt; (4) use of one of the following types of shunt: external ventricular, ventriculoperitoneal or ventriculojugular; (5) followup information on survival or disability available. We excluded from this study all patients with arterial or venous malformations, including dural fistulas, and also cases with congenital or acquired hydrocephalus previous to CVT. To avoid confounding by treatment we excluded cases who besides shunting also had decompressive surgery (decompressive craniectomy or hematoma evacuation). Outcome was graded using the modified Rankin Scale (mRS) at the last follow-up. Outcome was classified as complete recovery (mRS 0–1), independence (mRS 0–2), severe dependence (mRS 4–5) and death (mRS 6). When other scales or only descriptive information on outcome were available, two independent observers (J.M.F. and S.L.) converted them into mRS grades. We performed the following subgroup analysis regarding death and independence: (a) shunt type, (b) hydrocephalus, (c) time to treatment (interval from clinical admission or clinical deterioration if initially stable to shunting), (d) CNS hemorrhagic lesions and (e) comatose patients. All variables were categorized. The χ2 method and Fisher’s exact test (p < 0.05) were used to compare conditions of predictor variables on outcomes. The p level for significance was
Cerebrovasc Dis 2014;37:38–42 DOI: 10.1159/000356524
Shunting in Acute Cerebral Venous Thrombosis: A Systematic Review S. Lobo a J.M. Ferro a F. Barinagarrementeria b M.G. Bousser c P. Canhão a J. Stam d ISCVT Investigators
a
Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal; Department of Neurology, Instituto Nacional de Neurologia y Neurocirurgia, Mexico City, Mexico; c Department of Neurology, Hôpital Lariboisière, Paris, France; d Department of Neurology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
b
Abstract Background and Purpose: The efficacy of cerebrospinal fluid shunting to reduce intracranial hypertension and prevent fatal brain herniation in acute cerebral venous thrombosis (CVT) is unknown. Method: From the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) and a systematic literature review, we retrieved acute CVT patients treated only with shunting (external ventricular drain, ventriculoperitoneal or ventriculojugular shunt). Outcome was classified at 6 months and final follow-up by the modified Rankin Scale (mRS). Results: 15 patients were collected (9 from the ISCVT and 6 from the review) who were treated with a shunt (external ventricular drain in 6 patients, a ventriculoperitoneal shunt in 8 patients or an unspecified type of shunt in another one). Eight patients (53.3%) regained independence (mRS 0–2), while 2 patients (13.3%) were left with a severe handicap (mRS 4–6) and 4 (26.7%) died despite treatment. Five patients with parenchymal lesions were shunted within 48 h from admission deterioration, 4 with an external ventricular drain: 2 (40%) recovered to independence,
© 2013 S. Karger AG, Basel 1015–9770/13/0371–0038$38.00/0 E-Mail [email protected] www.karger.com/ced
2 (40%) had a severe handicap and 1 (20%) died. In contrast, all 3 patients with intracranial hypertension and no parenchymal lesions receiving a ventriculoperitoneal shunt later than 48 h regained independence. Conclusion and Implications: A quarter of acute CVT patients treated with a shunt died, and only half regained independence. With the limitation of the small number of subjects, this review suggests that shunting does not appear to be effective in preventing death from brain herniation in acute CVT. We cannot exclude that shunting may benefit patients with sustained intracranial hypertension and no parenchymal lesions. © 2013 S. Karger AG, Basel
Introduction
The main cause of death during the acute phase of a cerebral venous thrombosis (CVT) is brain herniation produced by either a large parenchymal lesion, usually hemorrhagic, or massive brain edema [1]. Several interventions can be used to reduce increased intracranial pressure in acute CVT. Evidence from a retrospective
Names and affiliations of the ISCVT investigators are listed in reference 3.
José M. Ferro, MD, PhD Department of Neurosciences Hospital de Santa Maria, University of Lisboa PT–1649-035 Lisboa (Portugal) E-Mail jmferro @ fm.ul.pt
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/16/2015 11:45:45 AM
Key Words Shunt · Cerebral veins and sinuses · Cerebral venous thrombosis · Intracranial pressure · Neurosurgery · Treatment
Methods We performed a systematic review of individual patient information of published acute CVT cases treated with a shunt since 1997. We used the Medline-Pubmed electronic database. Key words and search strategy are described in appendix 1. References of selected publications were hand searched for further titles. In addition, we retrieved from the International Study on cerebral Vein and Dural Sinus Thrombosis (ISCVT) cohort [3] (which was launched in 1997) all cases of acute CVT treated with shunting. Inclusion criteria for both sources were: (1) patients with acute CVT; (2) any age; (3) submitted to cerebral spinal fluid drainage with a shunt; (4) use of one of the following types of shunt: external ventricular, ventriculoperitoneal or ventriculojugular; (5) followup information on survival or disability available. We excluded from this study all patients with arterial or venous malformations, including dural fistulas, and also cases with congenital or acquired hydrocephalus previous to CVT. To avoid confounding by treatment we excluded cases who besides shunting also had decompressive surgery (decompressive craniectomy or hematoma evacuation). Outcome was graded using the modified Rankin Scale (mRS) at the last follow-up. Outcome was classified as complete recovery (mRS 0–1), independence (mRS 0–2), severe dependence (mRS 4–5) and death (mRS 6). When other scales or only descriptive information on outcome were available, two independent observers (J.M.F. and S.L.) converted them into mRS grades. We performed the following subgroup analysis regarding death and independence: (a) shunt type, (b) hydrocephalus, (c) time to treatment (interval from clinical admission or clinical deterioration if initially stable to shunting), (d) CNS hemorrhagic lesions and (e) comatose patients. All variables were categorized. The χ2 method and Fisher’s exact test (p < 0.05) were used to compare conditions of predictor variables on outcomes. The p level for significance was
