High-Risk Features of Delayed Clinical Progression in Cerebral Venous Thrombosis: A Proposed Prediction Score for Early Intervention

Abstract

Background: Anticoagulation is the mainstay treatment for cerebral venous thrombosis (CVT). A subset of patients might deteriorate despite anticoagulation, and in such cases, endovascular therapy is recommended. Methods: A retrospective review was performed on subjects with CVT from January 2005 to October 2016. The primary outcome was clinical deterioration. Bivariate analysis, multiple logistic regression modeling, and linear discriminant analysis were used to determine a predictive model for deterioration; the results from these models were used to construct a CVT score in order to measure the individual likelihood of deterioration. Results: We identified 147 subjects with CVT. The majority were treated with anticoagulation (n = 109, 74.15%); 38 (25.85%) were found to have deterioration, 12 (8.16%) of whom underwent endovascular intervention. The most important risk factors of deterioration, per bivariate analysis, included decreased level of consciousness (odds ratio [OR] = 5.76; 95% confidence interval [CI] 2.59–12.77) and papilledema (OR = 4.52; 95% CI 1.55–13.18). The final multivariable model also included CVT location score (number of sinuses involved), oral contraceptive pill use, sodium level, platelet count, and seizure activity on presentation. This model had a predictive ability to identify deterioration of 83.2%, with a sensitivity of 71.4% and a specificity of 76.2%. Patients with a CVT score of ≥5 have at least 50% chance of deterioration. Conclusions: Decreased mental status, seizure activity, papilledema, number of involved sinuses, as well as sodium level and platelet count are the most important factors in predicting deterioration after CVT. This group may represent a subset of patients in whom early endovascular therapy may be considered.

Clinical presentation, risk factors and factors affecting short term outcome in patients with cerebral venous thrombosis

“…CVT was earlier considered as a disease of females, as demonstrated by many previous studies done abroad and in India and especially occurred during pregnancy and puerperium but studies done nowadays showed male preponderance with alcoholism and hyperhomocysteinemia as predominant risk factors and is usually seen in young individuals. [11][12][13][14][15][16][17][18][19][20] Study also proved same findings with preponderance of disease in young males. In contrast to some other studies done in India which showed a predominant sub acute mode of onset, our study most of the patients had acute onset of disease.…”

Endovascular Mechanical Thrombectomy and On-Site Chemical Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

“…However, (2020) 10:4937 | https://doi.org/10.1038/s41598-020-61884-5 www.nature.com/scientificreports www.nature.com/scientificreports/ questions about the safety and validity of the endovascular treatment plus heparin for CVST over the heparin treatment alone in the acute phase have not been answered 9,12,[18][19][20] . In the literature, a subgroup of CVST patients who harbored risk factors known for poor prognosis and mortality (e.g., decreased level of consciousness, coma, and seizure activity) were oftentimes unresponsive to systemic heparin treatment in the acute phase 4,5,[7][8][9] . In this study, all of the patients in D group had initial complete stenosis of the sinuses (type B or type D), with higher mRS (p = 0.006), lower GCS (p = 0.007), and more seizures (p = 0.031) at initial presentation, which reflected the disease severity and high risks of poor outcome and mortality in the acute phase 4,5,[7][8][9] .…”

“…In the literature, a subgroup of CVST patients who harbored risk factors known for poor prognosis and mortality (e.g., decreased level of consciousness, coma, and seizure activity) were oftentimes unresponsive to systemic heparin treatment in the acute phase 4,5,[7][8][9] . In this study, all of the patients in D group had initial complete stenosis of the sinuses (type B or type D), with higher mRS (p = 0.006), lower GCS (p = 0.007), and more seizures (p = 0.031) at initial presentation, which reflected the disease severity and high risks of poor outcome and mortality in the acute phase 4,5,[7][8][9] . In I/S group, patients were responsive to heparin with milder initial presentation.…”

“…Patients having (1) continuous deterioration of consciousness, (2) progression of neurological deficits (e.g. muscle power), or (3) worsening seizures (generalized tonic-clonic seizures, epilepsia partialis continua, etc., despite the use of multiple anti-epileptic drugs) after heparin treatment, which were poor prognostic factors in CVST patients according to the literature [5][6][7][8][9] , were defined as clinical deteriorating patients (D group). The treatment algorithm for CVST in the authors' institute was summarized in Fig.…”

Mechanical Thrombectomy as an Initial Treatment for Sinus Thrombosis

“…2) The American Heart Association (AHA) guidelines recommend anticoagulant therapy and state that endovascular treatment should be considered for patients with symptom progression. 3) However, symptoms deteriorate in 24-25.8% of patients with cerebral sinus thrombosis, 4,5) and early endovascular treatment may improve the outcome in patients in whom symptoms are expected to deteriorate. 5) We report a patient with cerebral sinus thrombosis with venous congestion for whom mechanical thrombectomy was performed on the day of arrival, leading to a favorable outcome.…”