Multimodal Regional Brain Monitoring of Tissue Ischemia in Severe Cerebral Venous Sinus Thrombosis

Abstract

Background: Comatose critically ill patients with severe diffuse cerebral venous thrombosis (CVT) are at high risk of secondary hypoxic/ischemic insults, which may considerably worsen neurological recovery. Multimodal brain monitoring (MBM) may therefore improve patient care in this setting, yet no data are available in the literature. Methods: We report two patients with coma following severe diffuse CVT who underwent emergent invasive MBM with intracranial pressure (ICP), brain tissue oximetry (PbtO 2), and cerebral microdialysis (CMD). Therapy of CVT consisted of intravenous unfractionated heparin (UFH), followed by endovascular mechanical thrombectomy (EMT). EMT efficacy was assessed continuously at the bedside using MBM. Results: Despite effective therapeutic UFH (aPTT two times baseline levels in the two subjects), average CMD levels of lactate and glucose in the 6 h prior to EMT displayed evidence of regional brain ischemia. The EMT procedure was associated with a rapid (within 6 h) improvement in both CMD lactate (6.42 ± 0.61 4.89 ± 0.55 mmol/L, p = 0.02) and glucose (0.49 ± 0.17 vs. 0.96 ± 0.32 mmol/L, p = 0.0005). EMT was also associated with a significant increase in PbtO 2 (22.9 ± 7.5 vs. 30.1 ± 3.6 mmHg, p = 0.0003) and a decrease in CMD glutamate (12.69 ± 1.06 vs. 5.73 ± 1.76 μmol/L, p = 0.017) and intracranial pressure (ICP) (13 ± 4 vs. 11 ± 4 mmHg (p = 004). Patients did not require surgical decompression, regained consciousness, and were discharged from the hospital with a good neurological outcome (modified Rankin score 3 and 4). Conclusions: This study illustrates the potential utility of continuous bedside MBM in patients with coma after severe brain injury, irrespective of the primary acute cerebral condition. Despite adequate ICP and PbtO 2 control, the presence of CMD signs of regional brain cell ischemia triggered emergent EMT to treat CVT, which was associated with a significant and clinically relevant improvement of intracerebral physiology.

Coma in adult cerebral venous thrombosis: The BEAST study

“…As with our study, the International Study on Cerebral Vein and Dural Sinus Thrombosis [2] found that 17.1% patients had thrombosis of concomitant cortical veins along with major sinuses, a result supported by others [3,[9][10][11][12]. Although we do not evaluate the pathophysiological basis of CVT coma, it seems that age [13] and thrombosis of SSS [10,11,14] may lead to the higher occurrence of coma in men due to impaired venous drainage and cerebrospinal fluid reabsorption, causing cytotoxic oedema, herniation, and diminished cerebral perfusion.…”

“…This study is the first report that transverse sinus thrombosis is significantly less likely to cause coma, possibly because it primarily affects the posterior parts of the brain and has a more localized impact, leading to slow onset thrombosis and less widespread neurological damage in the presence of collateral venous drainage [10–12]. In contrast, the SSS drains a more extensive area of the cerebral hemispheres, including motor areas, causing rapid and profound neurological impairment leading to coma in SSS thrombosis [11, 14, 15].…”