1
|
Pelz JO, Kenda M, Alonso A, Etminan N, Wittstock M, Niesen WD, Lambeck J, Güresir E, Wach J, Lampmannn T, Dziewas R, Wiedmann M, Schneider H, Bayas A, Christ M, Mengel A, Poli S, Brämer D, Lindner D, Pfrepper C, Roth C, Salih F, Günther A, Michalski D. Outcomes After Decompressive Surgery for Severe Cerebral Venous Sinus Thrombosis Associated or Not Associated with Vaccine-Induced Immune Thrombosis with Thrombocytopenia: A Multicenter Cohort Study. Neurocrit Care 2024; 40:621-632. [PMID: 37498459 PMCID: PMC10959787 DOI: 10.1007/s12028-023-01782-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/09/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Clinical observations indicated that vaccine-induced immune thrombosis with thrombocytopenia (VITT)-associated cerebral venous sinus thrombosis (CVST) often has a space-occupying effect and thus necessitates decompressive surgery (DS). While comparing with non-VITT CVST, this study explored whether VITT-associated CVST exhibits a more fulminant clinical course, different perioperative and intensive care unit management, and worse long-term outcome. METHODS This multicenter, retrospective cohort study collected patient data from 12 tertiary centers to address priorly formulated hypotheses concerning the clinical course, the perioperative management with related complications, extracerebral complications, and the functional outcome (modified Rankin Scale) in patients with VITT-associated and non-VITT CVST, both with DS. RESULTS Both groups, each with 16 patients, were balanced regarding demographics, kind of clinical symptoms, and radiological findings at hospital admission. Severity of neurological symptoms, assessed with the National Institute of Health Stroke Scale, was similar between groups at admission and before surgery, whereas more patients with VITT-associated CVST showed a relevant midline shift (≥ 4 mm) before surgery (100% vs. 68.8%, p = 0.043). Patients with VITT-associated CVST tended to undergo DS early, i.e., ≤ 24 h after hospital admission (p = 0.077). Patients with VITT-associated CVST more frequently received platelet transfusion, tranexamic acid, and fibrinogen perioperatively. The postoperative management was comparable, and complications were evenly distributed. More patients with VITT-associated CVST achieved a favorable outcome (modified Rankin Scale ≤ 3) at 3 months (p = 0.043). CONCLUSIONS Although the prediction of individual courses remains challenging, DS should be considered early in VITT-associated CVST because an overall favorable outcome appears achievable in these patients.
Collapse
Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Martin Kenda
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Campus, Virchow-Klinikum, Berlin, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Wolf-Dirk Niesen
- Department of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Wach
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Tim Lampmannn
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrueck, Osnabrueck, Germany
| | - Markus Wiedmann
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
- Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antonios Bayas
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Monika Christ
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Dirk Brämer
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Christian Pfrepper
- Division of Haemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Farid Salih
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Campus, Virchow-Klinikum, Berlin, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| |
Collapse
|
2
|
Zhang R, sun D, Chen X, Xie Y, Dan B, Liu Y, Mei B, Li H. Successful hybrid endovascular treatment for refractory cerebral venous sinus thrombosis in pregnancy: A case report. Heliyon 2023; 9:e22262. [PMID: 38045129 PMCID: PMC10692894 DOI: 10.1016/j.heliyon.2023.e22262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/05/2023] Open
Abstract
Background Cerebral venous sinus thrombosis (CVST) in pregnancy was common and endovascular treatment (EVT) could be an effective and safe treatment for patients with severe and refractory CVST. However, the efficacy and safety of hybrid EVT (craniotomy + endovascular treatment) for CVST were unknown. We represented a rare case of hybrid EVT through the incision of the superior sagittal sinus in a pregnant woman with CVST who failed to EVT through the femoral vein pathway. Case presentation A 26-year-old woman, in her second month of pregnancy, complained of a headache for 5 days and aggravation with coma combined with convulsions for 2 days. She was diagnosed with CVST in the local hospital by digital subtraction angiography (DSA) and treated with anticoagulation. She had no history of illness and the biochemical tests were normal. Hybrid EVT (craniotomy + EVT) was attempted after failing to conduct EVT through the femoral vein pathway due to difficulty to reach the target cerebral venous sinus. Briefly, a small hole was made in the frontotemporal head to expose the superior sagittal sinus and a 6F sheath was inserted into 2cm of superior sagittal sinus incision and fixed on the scalp, after repeated aspiration by 5F intermediate catheter and balloon dilatation of stenosis in the right transverse sinus and right sigmoid sinus, the cerebral venous system got successful recanalization. No obvious complications were found and the patient recovered very well after the surgery. Conclusion Anticoagulation was the standard treatment for CVST. EVT could rapidly restore venous flow and improve the prognosis for refractory and severe CVST. EVT by hybrid surgery through the superior sagittal sinus incision may be safe and effective for desperate patients with severe CVST.
Collapse
Affiliation(s)
- Renwei Zhang
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong sun
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xinjun Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yu Xie
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Bitang Dan
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yumin Liu
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Bin Mei
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Huagang Li
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| |
Collapse
|
3
|
Misra S, Sudhir P, Nath M, Sharma VK, Vibha D. Decompressive surgery in cerebral venous thrombosis: A systematic review and meta-analysis. Eur J Clin Invest 2023; 53:e13944. [PMID: 36576370 DOI: 10.1111/eci.13944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Shubham Misra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.,Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Pachipala Sudhir
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manabesh Nath
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay K Sharma
- Division of Neurology, YLL School of Medicine, National University Hospital, National University of Singapore, Singapore City, Singapore
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
4
|
Moraes AADA, Conforto AB. Cerebral venous thrombosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:53-59. [PMID: 35976298 PMCID: PMC9491445 DOI: 10.1590/0004-282x-anp-2022-s108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 05/15/2023]
Abstract
Cerebral venous sinus thrombosis (CVT) consists of partial or complete occlusion of a sinus or a cerebral vein. CVT represents 0.5-1% of all strokes and is more frequent in young women. This review discusses particular aspects of CVT diagnosis and management: decompressive craniectomy (DC), anticoagulation with direct oral anticoagulants (DOACs), CVT after coronavirus-disease 19 (COVID-19) and Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT).
Collapse
Affiliation(s)
| | - Adriana Bastos Conforto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brazil
| |
Collapse
|
5
|
Characteristics of Cerebral Sinus Venous Thrombosis Patients Presenting with Intracerebral Hemorrhage. J Clin Med 2022; 11:jcm11041040. [PMID: 35207313 PMCID: PMC8876104 DOI: 10.3390/jcm11041040] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Patients with cerebral venous sinus thrombosis (CVST) occasionally present with intracerebral hemorrhage (ICH). In this study, we aimed to identify predictors for ICH in CVST patients. Prospective CVST databases from three academic centers were retrospectively analyzed. CVST patients with and without ICH upon presentation were compared. Among the 404 included patients (mean age 41.8 years, 33% male), 74 (18.3%) had an ICH. The patients with ICH were older (45 ± 20.6 vs. 41.1 ± 18 years, p = 0.045), and were more often pregnant or postpartum women (15% vs. 6%, p = 0.011), or chronically hypertensive (15% vs. 5%, p = 0.001). The ICH patients had higher rates of seizures (60% vs. 15%, p < 0.001), and focal neurological deficits (53% vs. 23%, p < 0.001). The ICH group had lower rates of excellent outcome measured by 90-day mRS 0 (56.7% vs. 80.3%, p < 0.001) and higher rates of 90-day mortality (8% vs. 3%, p = 0.041). Radiological variables associated with ICH included superior sagittal sinus (SSS) thrombosis (63% vs. 36%), isolated cortical vein thrombosis (38% vs. 8%), and presence of venous infarction (34% vs. 7%) (p < 0.001 for all). Upon multivariate analysis, chronic hypertension (OR 3.7, p = 0.027), being either pregnant or postpartum (OR 4.3, p = 0.006), isolated cortical thrombosis (OR 3.5, p = 0.007), and SSS involvement (OR 3.4, p < 0.001) were independently associated with ICH upon admission. In conclusion, among CVST patients, the following present higher for ICH: pregnant or postpartum women, and individuals with chronic hypertension, cortical vein, or SSS involvement.
Collapse
|
6
|
Elsherbini MM, Badr H, Khalil AF. Efficiency of decompressive craniectomy as a line of management of severe cerebral venous thrombosis. J Cerebrovasc Endovasc Neurosurg 2022; 24:129-136. [PMID: 35108760 PMCID: PMC9260463 DOI: 10.7461/jcen.2022.e2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/27/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Cerebral venous thrombosis (CVT) is a rare pathology with life threatening consequences, most of these fatal complications are due to raised intracranial pressure due to venous infarction and cerebral swelling, the purpose of this study is to evaluate the efficiency of decompressive craniectomy for favorable outcome. Methods A retrospective analysis of clinical, radiological and surgical data of patients who underwent decompressive craniectomy for CVT in a tertiary referral hospital between the years 2016 through 2020. Results The study included 7 patients, female predominance was noted (5/7), mean age was 18.14 years. Mean Glasgow coma score (GCS) at surgery was 8.26, good clinical outcome was achieved for the majority of cases 71.4%, and one case of mortality 14.28%. Conclusions Decompressive craniectomy is a life saving procedure for patients with severe brain swelling as a sequela of CVT, majority of patients (71.4%) showed favorable functional outcome by 6 months postoperatively.
Collapse
Affiliation(s)
- Mohamed M Elsherbini
- Department of Neurosurgery, Mansoura University Hospital, Mansoura University, Mansoura, Egypt
| | - Hatem Badr
- Department of Neurosurgery, Mansoura University Hospital, Mansoura University, Mansoura, Egypt
| | - Amr Farid Khalil
- Department of Neurosurgery, Mansoura University Hospital, Mansoura University, Mansoura, Egypt
| |
Collapse
|
7
|
Alselisly AM, Al-Shami H, Salah AM. Surgical management of cerebral venous sinus thrombosis: Case series and literature review. Surg Neurol Int 2021; 12:133. [PMID: 33880238 PMCID: PMC8053462 DOI: 10.25259/sni_804_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/19/2021] [Indexed: 11/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | - Ahmed Mohamed Salah
- Department of Neurosurgery, Faculty of Medicine, Kasr Al-Ainy Medical College, Cairo, Egypt
| |
Collapse
|
8
|
Mohamed MWF, Aung SS, Mereddy N, Ramanan SP, Hamid P. Role, Effectiveness, and Outcome of Decompressive Craniectomy for Cerebral Venous and Dural Sinus Thrombosis (CVST): Is Surgery Really an Option? Cureus 2020; 12:e12135. [PMID: 33489547 PMCID: PMC7811578 DOI: 10.7759/cureus.12135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Su Sandi Aung
- Medicine and Surgery, University of Medicine 1, Yangon, MMR
| | - Nakul Mereddy
- Medicine and Surgery, Bhaskar Medical College, Hyderabad, IND
| | | | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| |
Collapse
|
9
|
Features of intracranial hemorrhage in cerebral venous thrombosis. J Neurol 2020; 267:3292-3298. [PMID: 32572620 DOI: 10.1007/s00415-020-10008-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cerebral venous thrombosis (CVT) is associated with intracranial hemorrhage. AIM To identify clinical and imaging features of CVT-associated intracranial hemorrhage. We hypothesized that higher clot burden would be associated with a higher risk of intracranial hemorrhage. METHODS We performed a retrospective analysis of an international, multicenter cohort of patients with confirmed cerebral venous thrombosis who underwent computed tomography within 2 weeks of symptom onset. Clinical and imaging features were compared between patients with and without intracranial hemorrhage. Clot burden was assessed by counting the number of thrombosed venous sinuses and veins on confirmatory imaging. RESULTS We enrolled 260 patients from 10 institutions in Europe and Mexico. The mean age was 42 years and 74% were female. Intracranial hemorrhage was found in 102 (39%). Among them parenchymal hemorrhage occurred in 64 (63%), in addition, small juxta-cortical hemorrhage was found in 30 (29%), subarachnoid hemorrhage in 24 (24%) and subdural hemorrhage in 11 (11%). Multiple concomitant types of hemorrhage occurred in 23 (23%). Older age and superior sagittal thrombosis involvement were associated with presence of hemorrhage. The number of thrombosed venous sinuses was not associated with intracranial hemorrhage (median number IQRInterquartile ratio] of sinuses/veins involved with hemorrhage 2 (1-3) vs. 2 (1-3) without hemorrhage, p = 0.4). CONCLUSION The high rate of intracranial hemorrhage in cerebral venous thrombosis is not explained by widespread involvement of the venous sinuses. Superior sagittal sinus involvement is associated with higher bleeding risk.
Collapse
|
10
|
Kutty RK, Sreemathyamma SB, Sivanandapanicker J, Asher P, Prabhakar RB, Peethambaran A, Libu GK. The Conundrum of Ventricular Dilatations Following Decompressive Craniectomy: Is Ventriculoperitoneal Shunt, The Only Panacea? J Neurosci Rural Pract 2019; 9:232-239. [PMID: 29725175 PMCID: PMC5912030 DOI: 10.4103/jnrp.jnrp_395_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Introduction: Ventriculomegaly and hydrocephalus (HCP) are sometimes a bewildering sequela of decompressive craniectomy (DC). The distinguishing criteria between both are less well defined. Majority of the studies quoted in the literature have defined HCP radiologically, rather than considering the clinical status of the patient. Accordingly, these patients have been treated with permanent cerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomatic ventriculomegaly following DC should undergo aspiration with cranioplasty and be followed up regularly. Materials and Methods: All patients with post-DC who were scheduled for cranioplasty and satisfied the radiological criteria for HCP were included. These patients were categorized into two groups. Group 1 included ventriculomegaly with clinical signs attributable to HCP and Group 2 constituted ventriculomegaly but no clinical signs attributable to HCP. All patients in Group 1 underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patients in Group 2 underwent cranioplasty along with simultaneous ventriculostomy and temporary aspiration of the lateral ventricle. All patients were regularly followed as the outpatient basis. Results: There were 21 patients who developed ventriculomegaly following DC. There were 10 patients in Group 1 and 11 patients in Group 2. The average duration of follow-up was from 6 months to 2 years. Two patients in the shunt group - (group 1) had over drainage and required revision. One patient in aspiration group - (group 2) required permanent CSF diversion. Conclusions: Cranioplasty with aspiration is a viable option in selected group of patients in whom there is ventriculomegaly but no signs or symptoms attributable to HCP.
Collapse
Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | | | - Prasanth Asher
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | |
Collapse
|
11
|
|
12
|
Al-Sulaiman A. Clinical Aspects, Diagnosis and Management of Cerebral Vein and Dural Sinus Thrombosis: A Literature Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 7:137-145. [PMID: 31543733 PMCID: PMC6734737 DOI: 10.4103/sjmms.sjmms_22_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/10/2019] [Accepted: 07/16/2019] [Indexed: 12/29/2022]
Abstract
Cerebral vein and dural sinus thrombosis (CVST) is an uncommon cause of stroke, but its delayed diagnosis carries significant morbidity and mortality. Several studies have reported higher incidence of CVST than that previously reported. The clinical presentation of CVST varies and can be atypical. Advancement in neuroimaging modalities has made it possible to make an early diagnosis and initiate management with a wide range of therapeutic options, including direct oral anticoagulants and endovascular treatment. This narrative review summarizes the epidemiology, clinical aspects, diagnosis and management of CVST.
Collapse
Affiliation(s)
- Abdulla Al-Sulaiman
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| |
Collapse
|
13
|
Avanali R, Gopalakrishnan MS, Devi BI, Bhat DI, Shukla DP, Shanbhag NC. Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis. Front Neurol 2019; 10:511. [PMID: 31156540 PMCID: PMC6529953 DOI: 10.3389/fneur.2019.00511] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 04/29/2019] [Indexed: 12/31/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Raghunath Avanali
- Department of Neurosurgery, Government T. D. College, Allapuzha, India
| | - M S Gopalakrishnan
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - B Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| |
Collapse
|
14
|
Clavijo A, Khan AA, Mendoza J, Montenegro JH, Johnson ED, Adeleye AO, Rubiano AM. The Role of Decompressive Craniectomy in Limited Resource Environments. Front Neurol 2019; 10:112. [PMID: 30863354 PMCID: PMC6399379 DOI: 10.3389/fneur.2019.00112] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
Decompressive craniectomy (DC) is a neurosurgical procedure useful to prevent and manage the impact of high intracranial pressure (ICP) that leads to brain herniation and brain's tissue ischemia. In well-resourced environment this procedure has been proposed as a last tier therapy when ICP is not controlled by medical therapies in the management of different neurosurgical emergencies like traumatic brain injury (TBI), stroke, infectious diseases, hydrocephalus, tumors, etc. The purpose of this narrative review is to discuss the role of DC in areas of low neurosurgical and neurocritical care resources. We performed a literature review with a specific search strategy in web repositories and some local and regional journals from Low and Middle-Income Countries (LMICs). The most common publications include case reports, case series and observational studies describing the benefits of the procedure on different pathologies but with several types of biases due to the absence of robust studies or clinical registries analysis in these kinds of environments.
Collapse
Affiliation(s)
- Angélica Clavijo
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Ahsan A Khan
- MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Juliana Mendoza
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Jorge H Montenegro
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Erica D Johnson
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Amos O Adeleye
- Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom.,College of Medicine, University of Ibadan, and University College Hospital (UCH), Ibadan, Nigeria
| | - Andrés M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
15
|
Westwick HJ, Obaid S, Bordeleau-Roy F, Truffer E, Weil AG. Surgical Superior Sagittal Sinus Thrombectomy in Refractory Thrombosis: A Technical Note. Pediatr Neurosurg 2019; 54:212-217. [PMID: 30893680 DOI: 10.1159/000495808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/23/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Surgical treatment options are limited for medically and endovascular refractory cerebral venous sinus thrombosis (CVT). We describe the technical feasibility of open, direct sinus thrombectomy in a pediatric patient with medically and endovascular refractory CVT. METHODS A 15-year-old patient with superior sagittal sinus (SSS) thrombosis refractory to medical and endovascular treatment experienced clinical deterioration with the progression of bifrontal hematomas and cerebral edema. The patient was treated surgically with a decompressive hemicraniectomy and burr hole SSS thrombectomy with a Fogarty balloon and direct sinus injection of tissue plasminogen activator. RESULTS Surgical treatment with decompressive craniotomy and direct sinus thrombectomy was technically feasible with excellent intracranial pressure control, and radiological recanalization of the superior sagittal sinus with a good clinical outcome. CONCLUSION Direct surgical sinus thrombectomy is a potential concomitant treatment strategy with decompressive craniectomy for medically refractory CVT in a pediatric setting.
Collapse
Affiliation(s)
- Harrison J Westwick
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Québec, Canada
| | - Sami Obaid
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Québec, Canada
| | | | - Eric Truffer
- Department of Neurosurgery, Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Québec, Canada,
| |
Collapse
|
16
|
Wall J, Enblad P. Neurointensive care of patients with cerebral venous sinus thrombosis and intracerebral haemorrhage. J Clin Neurosci 2018; 58:83-88. [PMID: 30340972 DOI: 10.1016/j.jocn.2018.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/25/2018] [Accepted: 10/03/2018] [Indexed: 11/19/2022]
Abstract
The aim was to review the neurointensive care (NIC) of cerebral venous sinus thrombosis patients with haemorrhage during a 15-year period. This is a severe condition with substantial mortality caused by increased intracranial pressure (ICP) and studies are lacking describing the complex picture of the NIC, which offers a large treatment arsenal for intracranial hypertension. Patients treated 2000-2015 were investigated. Data regarding patient characteristics, symptoms, imaging, ICP-treatment, NIC-treatment intensity, and outcome were collected and analysed. Twenty-four patients (13 women) were studied, mean age 46 (range 16-75). Twenty patients were in Glasgow coma scale motor score 6 (obeys), 2 in score 5 (localizes) and 2 in score 2 (extension) on admission. Mean haemorrhage volume was 17 ml (range 1-70). Twenty patients (83%) received unfractionated heparin and 3 (13%) low molecular weight heparin. Haemorrhagic progression occurred in 10 patients (42%). In 9 patients (38%), 4-6 of the treatment options mechanical ventilation, hyperventilation, ICP-monitoring, cerebrospinal fluid-drainage, osmotherapy, barbiturates or surgery were used. In 3 patients mechanical ventilation only was used (hyperventilation in 1). Twelve patients were not managed with any of those treatment options. At follow up, 15/24 patients (62%) had favourable outcome (4 missing). The study shows that many patients needed multiple actions to treat intracranial preassure but more than 60% achieved favourable clinical outcome. Preferably, patients with cerebral venous sinus thrombosis and haemorrhage who are awake should have fast access to NIC because it appears difficult to predict who will deteriorate and promptly need NIC treatment.
Collapse
Affiliation(s)
- Jacob Wall
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden.
| |
Collapse
|
17
|
Goedemans T, Verbaan D, Coert BA, Kerklaan BJ, van den Berg R, Coutinho JM, van Middelaar T, Nederkoorn PJ, Vandertop WP, van den Munckhof P. Neurologic Outcome After Decompressive Craniectomy: Predictors of Outcome in Different Pathologic Conditions. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
18
|
Abstract
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.
Collapse
Affiliation(s)
- Suzanne M Silvis
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, University of Lisbon, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal
| | - José M Ferro
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, University of Lisbon, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
| |
Collapse
|
19
|
Ge P, Zhang Q, Ye X, Liu X, Deng X, Wang R, Zhang Y, Zhang D, Zhao J. Clinical Features, Surgical Treatment, and Long-Term Outcome in Elderly Patients with Moyamoya Disease. World Neurosurg 2017; 100:459-466. [PMID: 28132922 DOI: 10.1016/j.wneu.2017.01.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/12/2017] [Accepted: 01/16/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To elucidate the clinical features, surgical treatment, and long-term outcome in elderly patients with moyamoya disease (MMD). METHODS We retrospectively reviewed 87 elderly patients with MMD at Beijing Tiantan Hospital. Clinical features, radiologic findings, and outcomes were analyzed. RESULTS The mean age at diagnosis was 54.0 ± 3.7 years. Familial occurrence was 2.3%. Underlying vascular risk factors was 74.7%. Infarction was the most common symptom in elderly MMD (40.2%). Most patients presented with Suzuki stage 4 or 5 MMD (51.2%). Posterior cerebral artery involvement was observed in 22 (25.3%) patients. The incidence of postoperative infarction or hemorrhages was 6.9%. Diabetes was identified as a predictor of adverse postoperative events. During the average follow-up of 35.5 ± 22.2 months, rebleeding in patients with hemorrhagic MMD was higher than in those with ischemic MMD (P < 0.05). What's more, the rate of perfusion improvement in surgically treated patients was higher than in conservatively treated patients 3 months after discharge (P < 0.05). CONCLUSIONS Infarction was the most common symptom in elderly MMD. More vascular risk factors, a higher grade of Suzuki stage, fewer familial cases, and posterior cerebral artery involvement were observed in elderly patients with MMD. Diabetes was a risk factor of postoperative events for elderly patients. Hemorrhagic MMD had a higher rate of rebleeding than the ischemic type. Although surgical revascularization procedures can improve cerebral perfusion, further study is needed to determine whether surgical revascularization is effective in elderly patients or with certain techniques.
Collapse
Affiliation(s)
- Peicong Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingju Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaofeng Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurosurgery, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Department of Neurosurgery, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| |
Collapse
|
20
|
Zhang Q, Wang R, Liu Y, Zhang Y, Wang S, Cao Y, Zhao Y, Liu X, Wang J, Deng X, Gao F, Yang Z, Zhao M, Ge P, Ma Y, Zhao J, Zhang D. Clinical Features and Long-Term Outcomes of Unilateral Moyamoya Disease. World Neurosurg 2016; 96:474-482. [DOI: 10.1016/j.wneu.2016.09.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
|