Fazeel M. Siddiqui
Cerebral venous thrombosis (CVT) is a rare cause of stroke. Usual treatment includes anticoagulation, but there is a subset of patients who do not do well despite adequate anticoagulation. In those cases, CVT can rapidly progress to cause ischemic and hemorrhagic strokes, cerebral edema and mass effect, and eventually death. In the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT), approximately 13% of patients experienced bad outcomes even after treatment with anticoagulation.1 There is a lack of data on the endovascular management of severe cerebral venous thrombosis. We initially reviewed and published a large series of patients with cerebral venous thrombosis who underwent mechanical thrombectomy versus patients who received intra-sinus thrombolysis alone. We found that physicians chose between 2 modalities of treatment based on symptom severity.2
We followed up with a systematic review of 185 cases of mechanical thrombectomy published in the literature. The idea behind this systematic review was to look into the possible complications and benefits of mechanical thrombectomy in patients who do not respond to anticoagulation.1
Our patient population represented a subset of those with severe CVT. Out of the available data, 60% of patients had pretreatment ICH, 47% were stuporous or comatose, 37% had seizures, and 59% had focal neurologic deficits. In 82% of patients, thrombosis of 2 or more venous sinuses was present. Seventy percent of patients were treated with a therapeutic dosage of anticoagulation prior to the endovascular procedure. Overall, 156 patients (84%) had a good outcome, 7 (4%) had a poor outcome, and 22 (12%) died. The major peri-procedural complication besides death was new or increased ICH, which occurred in 18 patients (10%). Numerous devices were utilized, with AngioJet being the most common and oldest device.