Post-operative segmental cerebral venous sinus thrombosis: risk factors, clinical implications, and therapeutic considerations

Abstract

Cerebral venous sinus thromboses (CVSTs) are rare complications of neurosurgical interventions and their management remains controversial as most of cases appear clinically silent. Here, we analyzed our institutional series of patients with CVSTs evaluating clinical and neuroradiological characteristics, risk factors, and outcome. From the analysis of our institutional PACS, we collected a total of 59 patients showing postoperative CVSTs after supratentorial or infratentorial craniotomies. For every patient, we collected demographics and relevant clinical and laboratory data. Details on thrombosis trend were retrieved and compared along the serial radiological assessment. A supratentorial craniotomy was performed in 57.6% of cases, an infratentorial in 37.3%, while the remaining were a single cases of trans-sphenoidal and neck surgery (1.7%, respectively). A sinus infiltration was present in almost a quarter of patients, and in 52.5% of cases the thrombosed sinus was exposed during the craniotomy. Radiological signs of CVST were evident in 32.2% of patients, but only 8.5% of them developed a hemorrhagic infarct. CVST-related symptoms were complained by 13 patients (22%), but these were minor symptoms in about 90%, and only 10% experienced hemiparesis or impaired consciousness. The majority of patients (78%) remained completely asymptomatic along the follow-up. Risk factors for symptoms occurrence were interruption of preoperative anticoagulants, infratentorial sinuses involvement and evidence of vasogenic edema and venous infarction. Overall, a good outcome defined mRS 0–2 was observed in about 88% of patients at follow-up. CVST is a complication of surgical approaches in proximity of dural venous sinuses. CVST usually does not show progression and courses uneventfully in the vast majority of cases. The systematic use of post-operative anticoagulants seems to not significantly influence its clinical and radiological outcome.

Presentation and Management of Cerebral Venous Sinus Thrombosis After Supratentorial Craniotomy

“…In this study, a lesion ≤1 cm to a venous sinus was an independent risk factor of postoperative CVST as previously reported. 7 This possibly leads to local anatomic constraints and damage induced by sinus exposure (including dural opening, suture, clipping, compression, coagulation, usage of hemostatic material, and desiccation). 3,7 Indeed, in previous studies, an intraoperative cerebral venous sinus injury was a risk factor of postoperative CVST.…”

“…7 This possibly leads to local anatomic constraints and damage induced by sinus exposure (including dural opening, suture, clipping, compression, coagulation, usage of hemostatic material, and desiccation). 3,7 Indeed, in previous studies, an intraoperative cerebral venous sinus injury was a risk factor of postoperative CVST. 6 Thus, good surgical practice should avoid unnecessary venous sinus exposure.…”

“…Patients with postoperative CVST have been reported to be asymptomatic ranging 51.4% to 100% and as complaining headaches ranging 10.2% to 22.8%, neurological deficit ranging 8.5% to 20%, and epileptic seizures in 1.7%. 3,6,7 The difficulty to identify signs related to CVST in the early postoperative period may explain the underdiagnosis in clinical practice. In addition, the good tolerance we observe is strikingly different when compared with spontaneous CVST 21 and we recall those observed after posterior fossa surgery.…”

“…Rare studies, mixing posterior fossa and supratentorial surgeries with varying surgical positions and mixing extra-axial of intra-axial neoplasms, reported CVST, with the prevalence ranging from 1.5% to 5.6%. 6,7…”