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.
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.
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%.
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.
Cerebral venous thrombosis (CVT) is one of the most devastating cerebrovascular disorders with 15% mortality rate [
CVT can be predisposed by general pathologies e.g. infection, dehydration, pregnancy, anti-phospholipid syndromes, puerperium and oral contraceptives, several local pathologies can also predispose to CVT e.g. brain tumors, CNS infection, skull base fractures arteriovenous malformations [
Unlike ischemic stroke, CVT is liable to hemorrhagic transformation and subsequently raised intracranial pressure (ICP) [
Records of patients who underwent decompressive surgery for CVT between 2016 and 2020 in a tertiary referral hospital were reviewed; epidemiological, clinical and radiological data were analyzed, as well as outcome. Institutional agreement is approved, consent is waived due to the retrospective nature of the study.
Non-contrast Computed Tomography (NCCT) brain is the primary surveillance radiology of choice for patients presented with seizures, intractable headache, disturbed conscious level and/or focal neurological deficit. Magnetic resonance imaging (MRI) and MRI venogram (MRV) are indicated when CVT is suspected to evaluate brain parenchyma and venous sinuses respectively (
Surgical decision was based on both clinical and radiological manifestations of raised ICP, patients who were presented with disturbed conscious level and midline shift more than 5 mm were indicated for surgery immediately, while patients who were presented fully conscious were managed conservatively, surgery was indicated upon deterioration of conscious level. All cases underwent unilateral hemicraniectomy, no cases were indicated for bi-frontal decompression were encountered in this study.
For patients who presented fully conscious, medical treatment is initiated in the form of low molecular weight heparin (therapeutic dose) after initial lumbar puncture and cerebrospinal fluid (CSF) drainage, carbonic anhydrase inhibitor and fluid therapy are given all over the course of treatment.
For patients who underwent decompressive craniectomy, low molecular weight heparin (therapeutic dose) is initiated twelve hours postoperatively after surgery provided that postoperative computed tomography (CT) scans showed no new hemorrhagic events or hematoma expansion, patients are shifted to oral anticoagulant one week after surgery.
Aggressive dehydration is avoided for fear of dehydration induced aggravation of the thrombotic process.
Under general anesthesia, in supine position, a large fronto-tempro-parietal incision is performed followed by generous hemicraniectomy flap (
The study included 7 patients, 2 of them were males (
Five of the seven patients underwent immediate surgery upon presentation with disturbed level of conscious, while 2 patients were initially managed conservatively till surgery was indicated.
The most common involved was the transverse sinus in 6/7 patients, sinus involvement is summarized in table 1. Hemorrhagic transformation of the infarcted brain was found in 5/7 patients, midline shift was found in all patients prior surgery which ranged from 7 and 13 mm, with a mean of 9.29 mm. Only 2 patients showed superficial venous system involvement, both were vein of Labbe.
Outcome in this series was evaluated using Glasgow outcome scale (GOS) as per medical archive due its retrospective nature, GOS is reported upon discharge and 6 months postoperatively.
Good clinical outcome during follow up was achieved for 71.4% (5/7), while one patient suffered permanent disability. We reported one case of mortality (1/7), patient was presented acutely by disturbed conscious level and admitted with GCS 4, unequal pupils which was dilated fixed, age 44 years old.
Mean GOS upon discharge and after 6 months was 3.7 (7 patients) and 4.5 respectively (6 patients), mean follow up period was 11.5 months which ranged from 6 to 18 months.
Six patients who survived underwent cranioplasty within 55 +/- 3 days, one patient suffered flap necrosis and required plastic interference in the form of rotational flap.
CVT is a critical pathology, mortality and morbidity in such pathology may take place via different mechanisms; venous obstruction, CSF flow disruption and most importantly mass effect due to brain swelling and subsequent transtentorial herniation especially when complicated by hemorrhagic transformation [
For such a pathology with 8% mortality and 5% disabling morbidity according to the largest CVT series, the question whether or not these patients may benefit from decompression is to be investigated. In one of the largest CVT studies [
Endovascular thrombolysis and mechanical thrombectomy were studied on a lower scale of case series with discrepant results [
According to the European Federation of Neurologic Societies (EFNS) [
The term malignant CVT was first introduced by Bresson et al. [
This study population included four adults and three children with female predominance as noted in all previous studies, mean age of patients in our series was 18.14 years which is lower than previous studies which were 39.7 and 35.66 years for Zhang [
In line with our results, the mean duration of symptoms before surgery was 6.47 days for Aaron et al. [
In contrary to previous studies [
In absence of solid guidelines for decompressive craniectomy in CVT, literature in this topic included small case series. In this series for which mortality rates ranged from 0% to 28.6% [
Although it appears logic to resect the infarcted brain as a line of mass reduction and hence ICP i.e. internal decompression, it’s known that venous infarction, unlike ischemic infarction, is composed of more edema than necrosis which gives the possibility of reversal of the process [
According to previous studies, cases with bi-frontal infarcts due to anterior third superior sagittal sinus thrombosis are less likely to deteriorate and require surgical intervention, on contrary patients with isolated vein of Labbe thrombosis are liable to rapid neurological deterioration due to uncal swelling the consequent transtentorial herniation in absence of aggressive radiological findings which requires thorough clinical consideration [
GOS was adopted to evaluate outcome in this study, good functional outcome (GOS 5 and 4) was reported in five (71.4%) by the 6th months of follow up, this is in line with Aaron et al. [
Limitation of this study includes the low number of cases and absence of comparison to the full CVT population as patients were referred to neurosurgical care only when indicated for surgery. Further larger scale studies are encouraged to solidify and/or add to the current surgical indications.
Decompressive craniectomy is a lifesaving procedure for cases of malignant venous edema to decrease intracranial pressure, survivors are expected to have a good functional outcome without disability in majority of cases, randomized prospective studies should be performed to establish guidelines for early surgical intervention.
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Twenty-three years old female patient, presented to emergency room with disturbed conscious level and seizures, GCS on presentation was 10. CT brain showed hemorrhagic infarction with mass effect and midline shift of 8 mm (A), MRI with contrast showed filling defect in right transverse sinus (red arrow) (B). Decompressive craniectomy was performed, immediate follow up radiology showed sufficient decompression and improvement of midline shift (C and D). GCS, Glasgow coma score; CT, computed tomography; MRI, magnetic resonance imaging
Three years old male child’s MRI showing welling of the right temporal lobe and herniation (A), MRV showed thrombosis of right transverse sinus and vein of Labbe (B), decompressive craniectomy was performed which was tailored more towards temporal bone, two weeks follow up CT scan showing improvement of midline shift with residual increased CSF tension in subcutaneous collection (C), and the corresponding clinical follow up where patient was fully conscious with no deficit (GOS 5) (D). Six weeks follow up CT scan showing improvement of mass effect and midline shift with resolution of all increased tension signs (E). MRI, magnetic resonance imaging; MRV, MRI venogram; CT, computed tomography; CSF, cerebrospinal fluid; GOS, Glasgow outcome scale
Patients’ data: Clinical and radiological presentation and outcome
Age (years) | Sex | Time of surgery | Predisposing factor | GCS at time of surgery | Unequal pupils | Affected sinus | Hemorrhagic transformation | Midline shift (mm) | GOS at discharge | GOS (6 months post- operatively) | |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | 4 | M | Immediate | Infection | 10 | No | SSS | Yes | 8 | 5 | 5 |
2 | 1 | F | 12 hours | Dehydration | 8 | Yes | TS/Labbe | No | 10 | 3 | 3 |
3 | 24 | F | Immediate | Oral contraceptive | 7 | No | SSS/TS | Yes | 12 | 4 | 5 |
4 | 44 | M | Immediate | N/A | 4 | Yes | TS/SS | Yes | 13 | 1 | |
5 | 28 | F | 16 hours | Oral contraceptive | 10 | No | TS/SS | Yes | 7 | 5 | 5 |
6 | 23 | F | Immediate | Anti-phospholipid | 10 | No | TS | Yes | 8 | 4 | 4 |
7 | 3 | F | Immediate | Infection | 9 | No | TS/Labbe | No | 7 | 4 | 5 |
GCS, Glasgow coma score; GOS, Glasgow outcome scale; SSS, superior sagittal sinus; TS, transverse sinus; SS, sigmoid sinus