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|Year : 2014 | Volume
| Issue : 5 | Page : 485-486
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
|Date of Submission||05-Nov-2014|
|Date of Decision||05-Nov-2014|
|Date of Acceptance||05-Nov-2014|
|Date of Web Publication||12-Nov-2014|
J. M. K. Murthy
Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad - 500 034, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Murthy J. Cerebral venous thrombosis: Endovascular therapy. Neurol India 2014;62:485-6
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.  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.  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.  The recent reports quote a less than 10% mortality rate.  Death is most often due to transtentorial herniation from cerebral edema or hemorrhagic stroke. 
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. 
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 , and of death or dependency.  The findings in the ISCVT suggest that low molecular weight heparin might be safer and perhaps more effective than unfractionated heparin.  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. ,, In this issue of Neurology India; Garg et al.,  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. American Heart Association Guidelines suggest that endovascular treatment may be an option in patients with progressive neurologic deterioration despite intensive medical treatment (Class IIb),  whereas, the European Federation of Neurological Societies (EFNS) Guidelines  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. 
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.  Shui et al.,  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). 
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.
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