Shunting in Acute Cerebral Venous Thrombosis: A Systematic Review

Abstract

Background and Purpose: The efficacy of cerebrospinal fluid shunting to reduce intracranial hypertension and prevent fatal brain herniation in acute cerebral venous thrombosis (CVT) is unknown. Method: From the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) and a systematic literature review, we retrieved acute CVT patients treated only with shunting (external ventricular drain, ventriculoperitoneal or ventriculojugular shunt). Outcome was classified at 6 months and final follow-up by the modified Rankin Scale (mRS). Results: 15 patients were collected (9 from the ISCVT and 6 from the review) who were treated with a shunt (external ventricular drain in 6 patients, a ventriculoperitoneal shunt in 8 patients or an unspecified type of shunt in another one). Eight patients (53.3%) regained independence (mRS 0-2), while 2 patients (13.3%) were left with a severe handicap (mRS 4-6) and 4 (26.7%) died despite treatment. Five patients with parenchymal lesions were shunted within 48 h from admission deterioration, 4 with an external ventricular drain: 2 (40%) recovered to independence, 2 (40%) had a severe handicap and 1 (20%) died. In contrast, all 3 patients with intracranial hypertension and no parenchymal lesions receiving a ventriculoperitoneal shunt later than 48 h regained independence. Conclusion and Implications: A quarter of acute CVT patients treated with a shunt died, and only half regained independence. With the limitation of the small number of subjects, this review suggests that shunting does not appear to be effective in preventing death from brain herniation in acute CVT. We cannot exclude that shunting may benefit patients with sustained intracranial hypertension and no parenchymal lesions.

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

“…Studies were case reports, case series and a systematic review of cases. 122 The systematic review found only 15 CVT patients treated with shunting. These patients had a death rate of 22.2%, a death or dependency rate of 55.6% and a severe dependency rate 16.7%.…”

“…Three patients with intracranial hypertension and no parenchymal lesions were treated with ventriculo-peritoneal shunt and regained independence. 122 In a recent case series of 14 CVT patients with acute hydrocephalus only one patient had a shunt. 121 Despite shunting the patient died.…”

External Ventricular Drainage in Acute Cerebral Venous Thrombosis with Bilateral Thalamic Infarcts

“…The authors conclude that some subgroups of patients (i.e., with increased ICP and without parenchymal lesions) could benefit from shunting. 3 Bithalamic infarction is usually caused by thrombotic events affecting the top of the basilar artery 4 but is also a known consequence of deep CVT. 4,6,20 The thalamic venous drainage is via the posterior thalamic veins that drain into the straight sinus.…”

“…[1][2][3] Clinical presentation is variable, and ranges from headaches with fever to seizures, focal neurological deficit, or coma. [1][2][3][4][5][6][7][8] The unspecificity of initial presentation often leads to a delayed diagnosis. When the deep cerebral venous system is occluded, venous hypertension can result in bithalamic infarction and edema.…”

“…[17][18][19] However, very few studies have addressed the efficacy of external ventricular drainage. 3 We present the case of a 20-month-old girl with deep CVT resulting in bilateral thalamic edema and left thalamic infarction. Imaging studies showed a dilatation of the lateral ventricles, due to an obstruction at the level of the third ventricle consecutive to bilateral thalamic swelling.…”