Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis

Abstract

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.

Keywords: anticoagulation; cerebral venous sinus thrombosis; decompressive craniectomy; outcome; risk factors.

Figure 1

Cerebral venous sinus thrombosis (CVST). (A) Computed tomography depicts a confluence of blotchy areas of bleed typically seen in hemorrhagic CVST with mass effect. (B) Day 1, and (C) 8 months, post decompressive craniectomy. (D) Flowchart outlining the management of CVST. CT, computed tomography; ICU, intensive care unit. GCS, Glasgow coma scale; ICP, intracranial pressure.