Decompressive craniectomy for malignant cerebral oedema of cortical venous thrombosis: an analysis of 13 patients

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy

INTRODUCTION

Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC.

MATERIALS AND METHODS

Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed.

RESULTS

Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization.

CONCLUSION

In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Decompressive surgery in cerebral venous thrombosis: A systematic review and meta-analysis

OBJECTIVE

The efficacy of decompressive surgery (DS) in cerebral venous thrombosis (CVT) patients has been reported in several case reports and case series. We aimed at determining the association of DS compared with medical management and timing of surgery with functional outcome and mortality. We also aimed at determining the prevalence of DS in CVT patients.

METHODS

The literature search was conducted till 7 November 2022 in PubMed, Google Scholar, EMBASE and Cochrane Library databases. Risk of bias was examined using Joanna Briggs Institute scale for case series and case reports. Association of DS compared with medical management and timing of surgery with functional outcome and mortality was determined using odds ratio (OR) and 95% confidence interval (CI). Pooled prevalence of DS in CVT patients with 95%CI was calculated. Heterogeneity was explored using outlier, meta-regression, sensitivity and subgroup analyses.

RESULTS

Fifty-one studies consisting of 483 CVT cases with DS were included. The OR of poor outcome with surgery was 0.03; (95%CI: 0.00-0.22) and of mortality with surgery was 0.25; (95%CI: 0.02-2.60) versus that with medical management. Surgery done ≤48 h of admission was significantly associated with less mortality (OR: 0.26; 95%CI: 0.10-0.69). Pooled prevalence of DS in CVT was 12% (95%CI: 8%-17%; I²  = 91%). Revised pooled prevalence after removing outliers was 10% (95%CI: 7%-13%; I²  = 73%).

CONCLUSIONS

Surgery ≤48 h of admission might decrease mortality in CVT patients and may result in improved functional outcome. Further prospective studies with appropriate control arms are required to confirm its efficacy over medical management.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy

INTRODUCTION

Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC.

MATERIALS AND METHODS

Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed.

RESULTS

Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization.

CONCLUSION

In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Surgical management of cerebral venous sinus thrombosis: Case series and literature review

Background:

Cerebral venous sinus thrombosis (CVST) is not a common type of stroke (5%) but still hazardous to be misdiagnosed or mistreated. Aggressive medical treatment is usually failed to hinder increase intracranial tension. Therefore, decompressive craniectomy (DC) is the final measure to mitigate the deleterious effect of supratentorial herniation. The purpose of the study is to illustrate our experience with the surgical treatment of CVST and reviewing the previous works of literature.

Methods:

Forty-two patients were admitted to Kasr Al-Ainy University Hospital from June 2019 to March 2020. The admission was either to the neurology department or intensive care unit or neurosurgery department. Every patient who was diagnosed with CVST received an emergency neurosurgery consultation. Seven patients were operated on with DC according to the criteria mentioned above. Therapeutic heparin was given in addition to intracranial pressure lowering measures.

Results:

The mean and standard deviation of the age was (25.14 ± 10.1) years. There were five females (71.45%) in our series. The mean and standard deviation of clinical manifestations are (8.5 ± 7.77) weeks with range (3– 14 weeks). Most of the cases were presented by a decreased level of consciousness (6/7) and anisocoria (6/7), followed by fits (3/7). Four cases out of seven had the previous history of oral contraceptive administration.

Conclusion:

DC provides an urgent last arm for intractable increased intracranial tension. Patients with CVST need urgent consultation for neurosurgical intervention.

Role, Effectiveness, and Outcome of Decompressive Craniectomy for Cerebral Venous and Dural Sinus Thrombosis (CVST): Is Surgery Really an Option?

Cerebral venous and dural sinus thrombosis (CVST) is predominantly a disease of young people. It accounts for 0.5% of all strokes, and patients usually have good outcomes. However, a minority of patients may present with elevated intracranial pressure characteristics in a serious illness type and may die from brain herniation if not treated promptly. Decompressive craniectomy (DC) is the only treatment modality that can prevent death in such cases of imminent brain herniation. Unfortunately, due to the condition's rarity and ethical concerns, randomized controlled trials are not available. This review assessed the available literature on cerebral venous and dural sinus thrombosis in different age groups and decompressive craniectomy in cerebral venous and dural sinus thrombosis. It revealed that decompressive surgery is extremely effective when done early and for the correct indications with patients achieving excellent functional outcomes post-surgery. Decompressive surgery is recommended in rapidly deteriorating patients with computed tomography (CT) scan evidence of basal cisterns effacement, a mass effect from haemorrhage and/or infarction, and significant midline shift.

Cerebral venous thrombosis in adults

Summary. Thromboses of cerebral veins and/or sinuses (CVT) encompass a clinically rather heterogenous, relatively rare entity, which is nonetheless an important cause of stroke in the young. While until the mid of the last century the prognosis of CVT was thought to be poor or even fatal in the majority of cases, the advance and wider use of modern imaging technology since the early 1980s, together with the results of registries and population-based studies, revealed that CVT is more frequent and less life-threatening than previously assumed. However, because headache is frequently the only symptom, many oligosymptomatic cases might be overlooked. Both, CT- and MR-venography are suitable methods to confirm or rule out CVT, while the sensitivity of laboratory tests (D-dimer) alone is too low to rely on. Despite low evidence anticoagulation remains the treatment of choice during the acute phase and for secondary prevention.

Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.

Malignant Cerebral Venous Infarction: Decompressive Craniectomy versus Medical Treatment

BACKGROUND

Cerebral venous thrombosis (CVT) is a common type of stroke in young adults and associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are the most common causes of death in these patients. In contrast with malignant arterial middle cerebral infarction, there are few studies reporting the efficacy of decompressive craniectomy (DC) for treatment of high ICP in patients with CVT. In this study, we assess the clinical outcome of patients with CVT with impending brain herniation treated with DC versus medical management.

METHODS

In this retrospective study, medical records of all patients with CVT admitted to our hospital were reviewed. Patients with the following inclusion criteria were entered into the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive midposition pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups.

RESULTS

Of 357 patients with CVT hospitalized in our center, 48 patients entered into the study. Twenty-three patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils' reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P < 0.001). Favorable outcome (modified Rankin scale score 0-2) was achieved in 52% of the DC group and 0% of the MG group (P < 0.001).

CONCLUSIONS

The results of our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcome in most patients.

Decompressive craniectomy in hemorrhagic cerebral venous thrombosis: clinicoradiological features and risk factors

OBJECTIVE

Decompressive craniectomy (DC) is a life-saving treatment for severe hemorrhagic cerebral venous thrombosis (CVT). However, the correlations between the clinicoradiological features and surgical outcomes of this disease are not well established. Therefore, the authors endeavored to analyze the potential risk factors for this more severe subtype of CVT and to provide more evidence regarding the benefits of DC in patients with hemorrhagic CVT.

METHODS

The clinical features, radiological findings, and surgical outcomes of patients with severe hemorrhagic CVT who had undergone DC treatment in the period from January 2005 to March 2015 were retrospectively analyzed, and the risk factors for this disease were evaluated.

RESULTS

Fifty-eight patients, 39 females (67.2%) and 19 males (32.8%), with a mean age of 39.7 ± 12.5 years, were included in this study. The mean duration from symptom onset to surgery was 3.3 ± 1.9 days, and 21 patients experienced acute courses. On neuroimaging, the mean mass lesion volume was 114.7 ± 17.7 ml. Nine patients had bilateral lesions, and 7 patients had deep CVT. According to their hemorrhagic proportion, cases were divided into hemorrhage-dominated (27 [46.6%]) and edema-dominated (31 [53.4%]) groups. After 6 months of follow-up, 56.9% of patients had achieved a favorable outcome, and 8 patients had died. The hemorrhage-dominated lesions (p = 0.026) and deep cerebral venous involvement (p = 0.026) were significantly associated with a poor outcome.

CONCLUSIONS

In patients suffering from severe hemorrhagic CVT, DC is an effective life-saving treatment that is associated with favorable outcomes. Hemorrhage-dominated lesions and deep cerebral venous involvement have a significant impact on the outcome of this disease.

Cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is an important cause of stroke in young adults. Data from large international registries published in the past two decades have greatly improved our knowledge about the epidemiology, clinical manifestations and prognosis of CVT. The presentation of symptoms is highly variable in this disease, and can range from a patient seen at the clinic with a 1-month history of headache, to a comatose patient admitted to the emergency room. Consequently, the diagnosis of CVT is often delayed or overlooked. A variety of therapies for CVT are available, and each should be used in the appropriate setting, preferably guided by data from randomized trials and well-designed cohort studies. Although deaths from CVT have decreased in the past few decades, mortality remains ∼5-10%. In this Review, we provide a comprehensive and contemporary overview of CVT in adults, with emphasis on advancements made in the past decade on the epidemiology and treatment of this multifaceted condition.

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology

The current proposal for cerebral venous thrombosis guideline followed the Grading of Recommendations, Assessment, Development, and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews of all available evidence and writing recommendations and deciding on their strength on an explicit and transparent manner, based on the quality of available scientific evidence. The guideline addresses both diagnostic and therapeutic topics. We suggest using magnetic resonance or computed tomography angiography for confirming the diagnosis of cerebral venous thrombosis and not screening patients with cerebral venous thrombosis routinely for thrombophilia or cancer. We recommend parenteral anticoagulation in acute cerebral venous thrombosis and decompressive surgery to prevent death due to brain herniation. We suggest to use preferentially low-molecular weight heparin in the acute phase and not using direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations due to very poor quality of evidence concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that in women who suffered a previous cerebral venous thrombosis, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular weight heparin should be considered throughout pregnancy and puerperium. Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of cerebral venous thrombosis.

Isolated cortical vein thrombosis: a rare cause of venous stroke with good prognosis after timely diagnosis and treatment

BACKGROUND

Isolated cortical vein thrombosis (ICoVT) is a rare condition representing approximately 6% of cerebral vein thromboses (CVT). In all its forms, CVT is more prevalent in women. ICoVT shares the same group of predisposing conditions typical of other CVT. It may thus be easily missed due to its non-specific clinical presentation and confounding radiological findings, which may lead to a delay in appropriate diagnosis and treatment.

METHODS

A comprehensive literature search was conducted to identify manuscripts discussing epidemiology, risk factors, clinical presentation, radiological techniques and presentation, management, and outcome in patients with ICoVT.

RESULTS

We identified 40 papers published between 1991 and 2012 that met our criteria for review.

DISCUSSION

MR techniques are essential in the diagnosis of this entity. Without appropriate therapy, these thromboses may extend bidirectionally and even compromise the dural sinuses. Correction of predisposing factors for venous thrombosis and anticoagulation is the therapy of choice for most patients. The overall prognosis with adequate and timely therapy is very good.