Q) When should we consider endovascular treatment (EVT) for patient with cerebral venous thrombosis (CVT)? 

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A) The Society of Neurointerventional Surgery (SNIS) guideline in 2018 recommends that EVT can be considered in patients with the following conditions: 

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• Clinical deterioration despite anticoagulation
• Contraindication to anticoagulation
• Coma (GCS <9)
• Deep cerebral venous thrombosis
• Posterior fossa involvement
• Intracerebral hemorrhage (ICH)

 

     According to SNIS guideline, exact indications for neurointerventional procedures
require further validation. Currently, we do not have strong evidence to support EVT for severe CVT patients. A large systemic review of 185 cases who received EVT in CVT demonstrated 95% of recanalization (partial & complete) with good clinical outcomes in 84% of cases. The mortality and new or increase ICH of 12% and 10% respectively. However, This study is based on a retrospective case report and case series, therefore it is prone to publication bias and under - reporting of poor-outcomes.

     The only randomized trial of EVT in severe CVT was TO-ACT trial (67 patients) which failed to show the benefit of EVT in severe CVT patients in 12 month follow up. The mortality was higher in EVT group (12% vs 3%, P=0.2) but major hemorrhagic complication was higher in control group (24% vs 18%, P= 0.59).
 

     From TO-ACT paper discussion, “Although the point estimate of the primary end point in the trial did not point toward a beneficial effect of EVT in CVT (RR ratio, 0.99), the large width of the 95% CI (0.71-1.38) indicates that a clinically meaningful treatment effect cannot be excluded. Similarly, we cannot exclude the possibility that EVT was effective in a subgroup of patients (for instance, to those in a coma) because the number of patients in such groups was small”.

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     We really need more studies in this topic! Using new devices in future trials might change the outcome of EVT.

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References

     1) Lee SK, Mokin M, Hetts SW, et al. Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg. 2018;10 (8) : 803-810.
     2) Coutinho JM, Zuurbier SM, Bousser MG, et al. Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial [published online ahead of print, 2020 May 18]. JAMA Neurol. 2020;e201022.
     3) Siddiqui FM, Dandapat S, Banerjee C, et al. Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases. Stroke. 2015;46(5):1263-1268.
     4) Siddiqui FM, Weber MW, Dandapat S, et al. Endovascular Thrombolysis or Thrombectomy for Cerebral Venous Thrombosis: Study of Nationwide Inpatient Sample 2004-2014. J Stroke Cerebrovasc Dis. 2019;28(6):1440 -1447.