Endovascular Therapy for Cerebral Vein Thrombosis: A Propensity-Matched Analysis of Anticoagulation in the Treatment of Cerebral Venous Thrombosis

Abstract

BACKGROUND:Endovascular treatment (EVT) for cerebral vein thrombosis (CVT) has not been proven to be more effective than anticoagulation based on recent results of the Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis (TO-ACT) randomized clinical trial.OBJECTIVE:To compare outcomes of EVT vs medical management in CVT.METHODS:We compared EVT vs medical management in a retrospective multinational cohort of consecutive patients with CVT across 4 countries (USA, Italy, Switzerland, and New Zealand) and 27 sites (2015-2020), using propensity score matching (PSM) and inverse probability treatment weighting (IPTW), and meta-analyzed these results with the TO-ACT trial. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] 0-1) at 90 days.RESULTS:Of the 987 patients, the mean age was 45.7 ± 16.9 years and 79 (8%) underwent EVT. With PSM (n = 124), there were no major differences in clinical or imaging features between groups other than a higher proportion of female patients receiving EVT (81% vs 65%, P = .04). There was no difference in the primary outcome with PSM (odds ratio [OR] 1.48, 95% CI, 0.55-3.96) or IPTW (OR 1.02, 95% CI, 0.34-3.06). EVT was associated with a higher 90-day shift in modified Rankin Scale (OR 2.00, 95% CI, 1.01-3.98) and mortality with IPTW (OR 4.60, 95% CI, 1.10-19.23) but no other differences in secondary outcomes with PSM or IPTW. A meta-analysis of primary and secondary outcomes from TO-ACT and PSM patients from anticoagulation in the treatment of cerebral venous thrombosis also showed no significant association with EVT in primary or secondary outcomes.CONCLUSION:In this large observational cohort, there was no evidence of benefit with EVT for CVT. These findings corroborate the results from the TO-ACT trial.

Venous Pathologies and Interventions of the Head

“…Observational studies of EVTs for CVT have had mixed results, but generally show improved clinical outcomes with mechanical thrombectomy among those with severe deterioration despite systemic therapies, 41 although a recent large propensity-matched analysis from ACTION CVT showed no evidence of EVT benefit for CVT. 42 A randomized trial compared EVT to systemic anticoagulation in patients with acute CVT and clinical deterioration and did not show improved functional outcome for those receiving CVT. 43 However, this trial was limited by small sample size and large organizations still recommend consideration of EVTs for CVT in appropriate patient populations.…”

“…Observational studies of EVTs for CVT have had mixed results, but generally show improved clinical outcomes with mechanical thrombectomy among those with severe deterioration despite systemic therapies, 41 although a recent large propensity-matched analysis from ACTION CVT showed no evidence of EVT benefit for CVT. 42…”

Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association

“…54 Larger studies and meta-analyses showed that EVT is associated with higher mortality and no evidence of benefit with EVT. 55–58…”

Intracranial Dural Arteriovenous Fistulas

“…31 If there is suspicion of DAVF, the patency of the dural sinuses, as well as the cerebral venous drainage patterns, need to be carefully evaluated. [32][33][34] In carotid-cavernous fistulas (CCFs), CT and MRI may demonstrate dilatation of the cavernous sinuses and the superior ophthalmic veins (►Figs. 3 and 4).…”