By Dr Zdravka Poljakovic
Chairs: Prof Silke Walter (Saarland University, Germany) and Prof Jean Marc Olivot (University of Toulouse, France)
New Advances in Cerebral Venous Thrombosis
Th exciting session about rare but challenging condition started with a comprehensive review about new insights in epidemiology presented by Prof. Fadar Otite. In recent years incidence has increased, leading to changes in demographic characteristics, professor Otite stated. A striking example was a clear change in gender predominance, where in 2006. women represented 75% of patients with cerebral venous thrombosis (CVT), but only 10 years later we have experienced an increase of men proportion up to more than 43% of all patients. Furthermore, to the common (acute and chronic) risk factors for CVT there are some more added, like autoimmune diseases and COVID19 related CVT (including SarsCOV2 infection associated CVT, as well as postvaccination CVT, with or without thrombocytopenia syndrome). Postvaccination CVT with thrombocytopenia syndrome is potentially a most serious type with higher mortality and morbidity rate, and is considered as serious complication associated with adenovirus-vectored SARS-CoV-2. However, incidence of CVT following these vaccines is likely less than that following hospitalization due to COVID itself, Prof Otite concluded.
Next presentation, given by Prof Thanh N. Nguyen, was an exciting overview about therapeutic approach with direct oral anticoagulant drugs for CVT. Although the guidelines for CVT treatment are clearly in favor of anticoagulant therapy (heparin and later on varfarin) the data for DOACs are still not strong enough to change the guidelines. However, there are growing evidence that DOACs might be non-inferior, or of same effectiveness as VKA but with less hemorrhagic complications for oral phase of CVT treatment. Presented clinical studies RESPECT CVT (2019), EINSTEIN JR (2020) and ACTION CVT (2022) actually confirmed this result, and we are still awaiting the results of SECRET and DOAC CVT studies which might strongly influence the current guidelines. In conclusion, Prof Nguyen stated that anticoagulation remains first-line treatment for CVT, even in patients who present with hemorrhage and that we already have some observational data which demonstrated safety and efficacy of DOACs vs VKA in CVT, but for the change of current guidelines we still lack sufficient data.
Prof Diana Aguiar de Sousa gave a challenging talk about the importance of recanalization after CVT for final outcome, pointing out that not only functional outcome matters. She began her presentation with the data of functional outcome of CVT, showing that nearly 20% of patients have unfavorable outcome (19% of patient die or are dependent). She continued with presenting the pathophysiology of CVT which might explain the influence of the disease to brain tissue and chain of pathologic changes which are probably responsible for long-term consequences of cerebral venous thrombosis, which include not only functional disability, but also, even in patients with favorable mRS, cognitive decline, emotional problems and/or severe and frequent headaches. Considering possible therapeutic approach which might change the outcome, namely endovascular treatment, they did not show any benefit considering either functional outcome or recanalization rate. Continuing her presentation, Prof de Sousa showed detailed view on the studies dealing with the time point of achieving significant recanalization rate after CVT treatment. Studied basically showed that earliest evaluation of recanalization was performed at 22+/- 6 days after treatment initiation, which leaves the question about the moment of recanalization open. However, one study showed that at least partial recanalization can occur even in the time frame of 8 days. Still, the question if this early recanalization influences the outcome, remains. Finally, it has been proven that even early morphological changes of brain tissue on neuroimaging (like diffusion restriction) can be reversible in cases of timely treatment. In conclusion of her highly interesting talk professor de Sousa highlighted the need for new markers which could allow prediction of persistent venous occlusion and unfavorable evolution of brain damage but which are not necessarily in correlation with the recanalization rate.
Next talk, given by Prof Jose Ferro, gave an insight in the actual knowledge about decompressive craniotomy in patients with CVT. His talk enlightened clinical problem, surgical solution, evidence supporting surgery, guidelines as well as new study evidence and outcomes for decompressive craniotomy in this indication. In his talk he emphasized the importance of recognition and treatment of early and late epileptic seizures showing that cumulative 1 year incidence of epilepsy after surgery is 24%, with the incidence of status epilepticus of 5%. Also, there is no strict evidence of exact timing of surgery, considering the available data. The important question when to restart the anticoagulation therapy after surgery is still unanswered, but it seems that 24 hours after the surgery is safe enough. Special group of patients are (mostly) male patients after vaccination for SARS-CoV-2 who are at higher risk to develop serious CVT, as in one study in-hospital mortality was as high as 65%. In this serious group of patients, in all surgical cases the cause of death was brain herniation. To conclude, prof Ferro said, decompressive surgery can prevent death due to brain herniation and is judged as worthwhile by 4/5 of patients/caregivers. In addition, recent evidence supports ESO-EAN CVT guidelines recommendation, but still more research is needed on optimal time for surgery, how to prevent enlargement of venous infarcts and on specific subgroups of patients.
Final talk in this session, given by Prof Marcel Arnold highlighted some important points concerning complications and outcomes of CVT in general. Main complications after CVT are parenchymal damage, acute (and risk of late) seizures, dural arteriovenous fistula, intracranial hypertension, brain edema and herniation. The rate of the complications which can influence the outcome is hard to predict, but although the mortality rate is declining, some patients are still in high risk of bad or even fatal outcome. Several scales/scores are proposed to predict poor outcome after CVT, and in his talk, prof Arnold described CVT-GS, IN-RevASC and ISCVT scale. In addition, he recommended the use of SI2NCAL2C score which is evaluated in a study, showed good clinical value and is a freely available application at cerebralvenousthrombosis.com.