VARIATION IN MANAGEMENT OF ACUTE CEREBRAL VEIN AND DURAL SINUS THROMBOSIS

JM Ferro, MG Bousser, F Barinagarrementeria, J Stam, P Canhão and the ISCVT collaborators

Background. The management of cerebral vein and dural sinus thrombosis (CVDST) is not based on evidence from randomised clinical trials, except for the use of IV heparin or SC low molecular heparin (LMWH). Purpose. To evaluate regional variations onin the acute management of CVDST in the International Study on Cerebral Vein Thrombosis (ISCVT) cohort. Results. 624 patients from 89 centres and 21 countries were included in the ISCVT. Treatments: IV heparin 48% (81% in Germany, 30% in Mexico), therapeutical LMWH 19% (57% in the Netherlands, none in Spain), both 16%, prophylactic LMWH 11%, oral anticoagulants 73%, antiplatelets 12%, (local thrombolytics 2% (in 8 centres), anticonvulsants 44% (100% in Chile, 9% in Sweden), steroids 24% (72% in Brasil, 3% in the Netherlands), acetazolamide 10% (88% in Chile, none in Germany), diuretics 5%, mannitol 13% (37% in Italy, none in the UK), therapeutical lumbar puncture 4%. 18% (5% in France, 64% in Mexico) of the patients did not receive any therapeutic anticoagulant treatment. Some clinical variables such as CGS score, seizures, diagnostic delay, predisposing conditions and worsening after admission also influenced the choice of therapeutical interventions.

Conclusion. Either IV or SC LMWH heparin were used in 82% of ISCVT patients reflecting a consensus between participants. Considerable variations were found regarding use of local thrombolytics, steroids, other interventions to reduce intracranial pressure and antiepileptics. Centre and country had a considerable influence on the choice of interventions, indicating a variable degree of uncertainty regarding the best management of acute CVDST and the need for clinical trials, which could be feasible within the ISCVT group.

THE PROGNOSIS OF ACUTE CEREBRAL VEIN AND DURAL SINUS THROMBOSIS. ISCVT RESULTS

JM Ferro, J Stam, MG Bousser, F Barinagarrementeria, P Canhão and the ISCVT investigators

Background. The information on the prognosis of cerebral vein and dural sinus thrombosis (CVDST) was not previously addressed by adequately powered prospective studies.

Purpose. ISCVT is a multinational (21 countries), multicentre (89 centres) prospective, observational study aiming to describe the acute and long term prognosis of CVDST and to identify its predictors.

Results. From 5/98 to 5/2001, 624 adult cases of CVDST (confirmed by appropriate imaging) were registered. Mean age was 39 years, mean admission GCS was 14, median delay from onset to admission was 4 days. At discharge (median stay 16 days) the modified Rankin grade was: 0-27% of the patients, 1-39%, 2-15%, 3-7%, 4-5%, 5-2%, and 6 (death)-4%. 21 (3,4%) patients died within 30 days. Multivariate predictors of death within 30 days were GCS score (GCS between 3 and 8, OR=13; GCS between 9 and 13, OR=8.6), mental status disorder (OR=2.9), haemorrhage on admission CT (OR=4.0) and thrombosis of the deep venous system (OR=6.1). Multivariate predictors of death or dependency (Rankin>2) at discharge were GCS score (GCS between 3 and 8, OR=6.9; GCS between 9 and 13, OR=3.5), age (between 27 and 49 years old, OR=2.8; more than 50 years old, OR=3.4), mental status disorder (OR=1.8), hemiparesis (OR=2.8), haemorrhage on admission CT (OR=2.7), thrombosis of the deep venous system (OR=2.4) and CNS disorder (OR=2.8) or cancer (OR=2.2) as a predisposing condition.

Conclusion. In this large multicentre cohort the prognosis of CVDST was better than previously reported. We identified a number of factors in the acute phase that were associated with poor prognosis. This subgroup of high-risk patients could be the target for trials of more aggressive interventions.

International Study on Cerebral Vein Thrombosis  (ISCVT): baseline data

 P Canhão, JM Ferro, MG Bousser, J Stam, F Barinagarrementeria and the ISCVT collaborators

 Background. The experience of individual centres with cerebral vein and dural sinus thrombosis (CVDST) is usually limited to a few cases each year. Information on several descriptive features of CVDST is largely based on single centre case series.

Purpose. ISCVT is a multinational, multicentre prospective observational study on the prognosis of CVDST whose objectives are to describe the long-term prognosis of CVDST, to identify predictors of outcome, variability on CVDST management and associated risk factors/ conditions.

Results. From 5/98 to 5/2001, 624 valid (confirmed by appropriate imaging) adult cases, from 89 centres in 21 countries were registered. The female/male ratio was 2.9. Mean age was 39 years. 33 patients were older than 70. The most frequently occluded sinus were the superior saggital (62%), the left transverse (43%) and the right transverse (40%). The deep venous system was involved in 11%. Multiple sinus were occluded in 50%. Headache (89%), paresis (37%), generalised (30%) or focal (20%) seizures, papilloedema (28%), mental status disorders (22%) were the most frequent presenting symptoms/signs. 143 (23%) patients had isolated intracranial hypertension. 19% had a admission GCS <14. 392 (63%) had either focal oedema/infarct (47%) or haemorrhage (39%) on the admission CT/MR. The aetiology was unknown in 14%. One (48%) or multiple (38%) predisposing conditions were identified in the majority (86%) of the patients.

Conclusion. ISCVT produced robust descriptive information on CVDST in a worldwide cohort of cases. ISCVT collaboration can be a useful network for future interventional studies