Heparin or Local Thrombolysis in the Management of Cerebral Venous Sinus Thrombosis?

Abstract

<jats:p> Patients with acute cerebral venous sinus thrombosis treated with Heparin or in situ thrombolysis in our department were evaluated in an attempt to rationalize treatment with heparin or thrombolysis. 279 patients with angiographically proven acute cerebral venous sinus thrombosis were included in the study. Patients were classified into mild and severe clinical grade. The study was divided into three phases. Phase I included 27 patients treated with systemic heparin. Phase II included 72 patients, 30 in severe grade and 42 in mild. 26 were thrombolysed with 14 in severe and 12 in mild grade. Phase III included 180 patients treated according to a defined protocol. 133 were in mild grade and 47 in severe. 67 patients were thrombolysed. In the thrombolysed group 27 patients were in mild grade and 40 in severe. 113 patients were treated with systemic heparin. Following acute management all were anticoagulated for six months. </jats:p><jats:p> The baseline characteristics were found to be same in all three phases. On comparison of outcome in Phase III with Phase 1 the likelihood ratio was found to be statistically significant in favor of Phase III (p &lt; 0.0001). The likelihood ratio was found to be statistically significant in mild and severe clinical grade in favor of thrombolysis in Phase III (p 0.039 in mild and p 0.00001 in Severe clinical grade). This ratio was insignificant (p = 0.716) for intracranial bleed; however, local puncture site bleeding was found to be significant in the thrombolysed group (0.00005). </jats:p>

Endovascular Treatment of Acute Thrombosis of Cerebral Veins and Sinuses

“…Hence, there are no proven treatment guidelines. However, according to a retrospective review, the mortality rate for patients treated with either IV heparin or local thrombolytics was 13% compared with 48% in untreated patients 12 and local thrombolysis has better follow-up results in severe cases 15 .…”

Role of local thrombolysis in cerebral hemorrhagic venous infarct

“…All patients had proven CVT with cerebral hemorrhagic venous infarcts. The grading of CVT was done using the criteria proposed by INR, King Edward Memorial Hospital (KEM), Mumbai, India: [10] Six patients with clinical Grade 3, two with Grade 4, and two with Grade 5 [ Table 1]. …”

“…Among our patients, one patient died and was related to the disease and not to thrombolytic therapy. [10] Intravenous thrombolysis is associated with variable outcomes, as the concentration of the thrombolytic agent delivered at the site of occlusion is low. Thrombolysis is accelerated through direct intrasinus infusion of the thrombolytic agent.…”

Endovascular Interventional Management of Cerebral Venous Sinus Thrombosis

“…Complete and partial recanalization was seen in 87% and 6% respectively, whereas 8% of the patients showed no recanalization. At discharge, only 3 patients had a poor mRS (3)(4)(5), whereas 45 had an excellent clinical outcome of mRS (0-2). Six patients died despite receiving aggressive treatment.…”

“…This study showed the efficacy and safety of IST in patients with severe clinical symptoms and no added benefit in those with mild clinical symptoms. 5 In a small prospective study by Garge and colleagues, 6 10 patients underwent IST; 9 of them had a good clinical outcome (mRS ≤ 2), and only 1 patient did not respond to local thrombolysis and succumbed to intracranial hemorrhagic infarct within 48 hours.…”