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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThrombosis of the dural venous sinus and\/or cerebral veins (CVT) is a very complex problem that remains somewhat poorly understood. Yet, although it is an important consideration in cases of stroke, the evidence base for its medical and interventional management is lacking. This article discusses current perspectives on the pathogenesis and risk factors for CVT development, as well as treatment options. Other topics include the epidemiology and risk factors for CVT, medical management of CVT, as well as appropriate use of acute endovascular intervention.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIschemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIschemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeurology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThrombosis of the dural venous sinus and\/or cerebral veins (CVT) is a very complex problem that remains somewhat poorly understood. Yet, although it is an important consideration in cases of stroke, the evidence base for its medical and interventional management is lacking. Fernando Barinagarrementeria, MD, St. Universidad del valle de Mexico de Quer\u00e9taro, Mexico, launched a series of sessions that covered current perspectives on the pathogenesis and risk factors for CVT development, as well as treatment options. Data were presented from some of the clinical trials in medical management and acute endovascular intervention in these patients in an effort to guide physicians in decision-making when evidence is lacking.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPATHOGENESIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe risk factors for CVT are linked to Virchow\u0027s triad of factors that comprises the three broad categories of components that contribute to thrombosis: hypercoagulability, blood stasis, and endothelial damage [Saposnik G et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EAlthough the exact mechanism of clot formation in the central venous system is not well understood, thrombosis here results in outflow obstruction, venous congestion, and increased hydrostatic pressure, which drive fluid into the interstitium and cause edema. Sustained increase in intracerebral pressure may subsequently lead to parenchymal abnormalities in the form of venous infarction or intracerebral hemorrhage (ICH) [Dlamini N et al. \u003Cem\u003ENeurosurg Clin N Am\u003C\/em\u003E 2010].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EEPIDEMIOLOGY AND RISK FACTORS FOR CEREBRAL VEIN THROMBOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-5\u0022\u003ECVT is considered an uncommon form of a stroke, comprising 0.5% to 1.0% of all cases. It is, however, becoming an increasingly recognized cause. Numerous risk factors are involved in its development, and include young age, being female, pregnancy\/puerperium, oral contraceptive use, and thrombophilia [Saposnik G et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011]. Risk factors for an unfavorable clinical outcome include being male, age \u0026gt;37 years, mental status disorder, coma, ICH on admission, thrombosis of the deep cerebral venous system, central nervous system infection, and malignancy (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Li G. \u003Cem\u003ENeurosurg\u003C\/em\u003E 2013; Ferro JM et al. \u003Cem\u003EStroke\u003C\/em\u003E 2004].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/14310\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/14310\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14310\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003ERisk Factors for an Unfavorable Outcome in Patients With CVST\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMEDICAL MANAGEMENT OF CEREBRAL VEIN THROMBOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EOptions for treatment of CVT are limited, and there is a paucity of evidence-based regimens for medical management of these patients. Although thrombolytic agents are used in ischemic stroke, they are not a consideration in patients with CVT due to the potential for hemorrhage. Steroid use is also contraindicated [Saposnik G et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EGene Y. Sung, MD, MPH, Keck School of Medicine, University of Southern California, Los Angeles, California, USA, discussed some of the data that are available in this patient population. He highlighted that while anticoagulant treatment of CVT has been controversial due to the associated risk of ICH, data from trials continue to demonstrate its effectiveness in this setting, and it remains the mainstay of medical management for patients.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EIn 1991, data were reported from a small randomized, placebo-controlled trial that evaluated anticoagulation with adjusted-dose intravenous heparin for treatment of aseptic CVT in 20 patients [Einh\u00e4upl KM et al. \u003Cem\u003ELancet\u003C\/em\u003E]. The primary endpoint was CVT severity score and treatment was randomized to nothing or 3000 units of a heparin bolus, and then a partial thromboplastin time goal of 2x baseline. A difference in clinical course was evident in favor of the heparin group after only 3 days of treatment (p\u0026lt;0.05) and this remained significant (p\u0026lt;0.01) after 8 days of treatment. After 3 months, in the heparin-treated group (n=10), 8 patients had a complete clinical recovery and 2 had minor neurological deficits; there was no mortality, and no new ICHs developed (3\/10 had prior ICH at baseline). In the placebo group (n=10), only 1 patient had a complete recovery, 6 patients had neurological deficits; 3 patients died (p\u0026lt;0.01), and 2 new ICHs developed in this group. Although this study involved only a small number of participants, the mortality rate of 30% versus 0% in placebo and treatment groups was a statistically significant finding (p\u0026lt;0.05) in favor of anticoagulant treatment, and led to early cessation of the trial.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ELater, a 2002 Cochrane Review reported a meta-analysis of available evidence regarding the effectiveness and safety of anticoagulant therapy in patients with CVT [Stam J et al. \u003Cem\u003ECochrane Database Syst Rev\u003C\/em\u003E 2002]. It evaluated data from 2 small, randomized controlled trials (RCTs) that compared anticoagulant therapy with placebo or open control in CVT. Data demonstrated that anticoagulant therapy was associated with a pooled relative risk of death of 0.33 (95% CI, 0.08 to 1.21), and of death or dependency of 0.46 (95% CI, 0.16 to 1.31). No new ICHs developed, although major gastrointestinal hemorrhage occurred after anticoagulant treatment in 1 patient and in 2 patients in the placebo arm experienced probable pulmonary embolism, one of which was fatal. Although the results were not statistically significant, they showed a trend toward benefit in the form of a potentially important reduction in the risk of death or dependency. Based on the limited evidence available, it was concluded that anticoagulant treatment for CVT seems to be safe.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EIn 2006, the American Heart Association\/American Stroke Association Scientific Statement provided recommendation for managing patients with CVT [Sacco RL et al. \u003Cem\u003EStroke\u003C\/em\u003E 2006]. They concluded that low-molecular-weight heparin (LMWH) is a reasonable treatment option, even in the presence of hemorrhagic infarction, and that continuation of oral anticoagulant therapy for 3 to 6 months, followed by antiplatelet therapy, was reasonable.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EACUTE ENDOVASCULAR INTERVENTION IN PATIENTS WITH CEREBRAL VEIN THROMBOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EDespite aggressive anticoagulant therapy, however, 9% to 13% of patients with CVT still have a very poor outcome, noted Charles I. Prestigiacomo, MD, Neurological Institute of New Jersey, Newark, New Jersey, USA. Although evidence for use of endovascular management of CVT is also lacking, he added that some observational studies demonstrate that if deterioration persists despite maximum anticoagulant management, endovascular therapy (ET) maybe warranted as a final salvage effort.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EWHEN IS ENDOVASCULAR THERAPY INDICATED?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EAlthough it is clear that increasing venous outflow improves patient outcomes, it remains difficult to know when to choose this technique. However, recent publication of a proposed treatment algorithm has provided some guidance for physicians where little evidence exists (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Gala NB et al. \u003Cem\u003EJ Neurointerven Surg\u003C\/em\u003E 2013]. The algorithm highlights the need to initially identify the underlying cause of the CVT. It also indicates intravenous heparin or LMWH as first-line treatment. Thrombolytic treatment should only be instituted if the patient fails to improve or has risk factors, such as coma, for a poor prognosis. And only if there are serious findings on imaging studies, or if the patient is severely disabled, should emergent ET be considered. Rheolytic thrombectomy followed by thrombolysis to dissolve residual thrombi seems to produce good patient outcomes with appropriate long-term physical rehabilitation.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/29\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Treatment Algorithm for Patients With CVT\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-478738127\u0022 data-figure-caption=\u0022Treatment Algorithm for Patients With CVT\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/29\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/29\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/29\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14308\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003ETreatment Algorithm for Patients With CVT\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EDVST=dural venous sinus thrombosis; CTV=computed tomography venography; MRV=magnetic resonance venography; LMWH=low molecular weight heparin; CT= computed tomography; rt-PA= recombinant tissue plasminogen activator.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Gala NB et al. Current endovascular treatment options of dural venous sinus thrombosis: a review of the literature. \u003Cem\u003EJ Neurointerven Surg\u003C\/em\u003E 2013;;5(1):28\u201334. With permission from the BMJ Publishing Group.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe Thrombolysis Or Anticoagulation for Cerebral Cenous Thrombosis trial [TO-ACT; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01204333\u0026amp;atom=%2Fspmdc%2F14%2F1%2F29.atom\u0022\u003ENCT01204333\u003C\/a\u003E; Coutinho JM et al. \u003Cem\u003EInt J Stroke\u003C\/em\u003E 2013] is a multicenter, prospective, open-label, randomized study that is currently recruiting participants. It will aim to determine if ET improves the functional outcome of patients with a severe form of CVT. The primary endpoint of this study is the mRS score at 12 months. Dr Prestigiacomo hopes that emerging data from this trial will provide more insight into outcomes in CVT. He concluded that additional RCTs will be essential to provide evidence for best practices in how to medically and interventionally manage patients with this condition.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/1\/29.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzpdy2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzpdy2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzpdy2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}