Mechanical Thrombectomy in Cerebral Venous Thrombosis: A Systematic Review of 185 Cases
Non-infectious thrombosis of the cerebral venous thrombosis (CVT) is an uncommon condition with potentially disastrous neurological consequences for the patient because of hemorrhage, edema, and mass effect. Anticoagulant therapy is favored by most treating physicians but may not be associated with improvement in all patients. Rarely, endovascular therapy (ET) has been proposed as a last resort approach to improve venous circulation in patients not responding to (or ineligible for) anticoagulation therapy. Siddiqui et al present the results from a systematic review of the literature to assess efficacy and safety of ET in patients with CVT. They identified 42 studies informing on the therapy in 185 patients. As one might suspect, patients were young (mean, 35 years), mostly women (64%), and had severe neurological symptoms, such as pretreatment intracerebral hemorrhage (60%), had a severely depressed sensorium (47%), focal neurological deficits (59%), and seizures (37%). The majority of described patients had involvement of ≥2 venous sinuses (82%). Seventy percent of patients received anticoagulants before ET but in 27% this information was not reported so that this rate was possibly higher. Good outcome, defined as functionally independent (modified Rankin Scale 0–2), was achieved in 84% of patients (12% died). Ten percent of patients developed increasing intracerebral hemorrhage after ET (39% of which were de novo). Overall, baseline intracerebral hemorrhage and depressed sensorium were predictive of a poor outcome. Complete recanalization was predictive of a good outcome. The authors repeatedly caution that given the nature of the included reports (mostly individual cases or small case series) the results may be significantly skewed toward better outcomes because of reporting bias. Nevertheless, in aggregate the results highlight that even in the presence of a poor baseline a favorable outcome can be achieved with use of aggressive recanalization strategies. It is hoped that with the advent of novel endovascular devices periprocedural complications will decrease and that the ongoing Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis (TOACT; NCT01204333) trial will improve our understanding of the efficacy and safety of ET for the treatment of severe CVT. See p 1263.
Reperfusion of Very Low Cerebral Blood Volume Lesion Predicts Parenchymal Hematoma After Endovascular Therapy
The very low cerebral blood volume (VLCBV) represents a promising imaging marker for the risk of reperfusion therapy associate parenchymal hematoma (PH). Mishra et al sought to investigate whether VLCBV can be identified with automated image processing software, and whether its presence predicts the development of PH after endovascular reperfusion. To this end, they studied patients included in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) study. VLCBV was defined on perfusion magnetic resonance imaging scans and calculated from the relative CBV ratio threshold and the relative CBV lesion volume threshold that were associated with the best prediction of PH. The optimal lesion criteria were an relative CBV ratio <0.42 and a volume ≥3.55 mL, categorizing 44 patients as VLCBV positive and 47 patients as VLCBV negative. Almost 40% of patients with VLCBV (n=17) developed PH, all of which occurred in patients who experienced reperfusion (n=36) of the VLCBV territory. Although the overall risk for PH was relatively higher in recombinant tissue-type plasminogen activator (r-tPA)-treated patients (60%) as compared with patients who had not received r-tPA (31%), this did not reach statistical significance. After adjustment, VLCBV and use of r-tPA were independent predictors of PH. Separate modeling indicated that reperfusion of the VLCBV territory was most predictive of PH (odds ratio, 53; 95% confidence interval, 6–440; P<0.001) with a borderline association with a poor functional outcome (odds ratio, 2.9; 95% confidence interval, 1–8.5; P=0.05). In summary, this study highlights that VLCBV is well suited to predict PH in the setting of regional reperfusion. One of the key questions is whether the defined lesion criteria are independent of the occlusion duration. If so, this could be large step forward to individually define a therapeutic window for recanalization based on biological imaging markers rather than an arbitrarily chosen time window. See p 1245.
Multivitamin Use and Risk of Stroke Mortality: The Japan Collaborative Cohort Study
Despite its immense popularity, the use of vitamins to promote health and prevent cardiovascular disease has been largely disappointing. Hence, many studies seek to define which patient and medical condition benefits the most from routine supplementation. Dong et al hypothesized that multivitamin supplementation (MVI) associated benefit may vary among stroke subtypes and subject characteristics. They specifically sought to examine the association between MVI use and risk of death as stratified according to ischemic versus hemorrhagic stroke among participants of the prospective Japan Collaborative Cohort (JACC) study. Among 72 180 studied participants, 13.1% (n=9483) used MVI. Although MVI users had a lower body mass index, higher level of education, and higher level of physical activity, they also had more stroke risk factors, such as male sex, current smoking, and current alcohol use, as well as more frequently have a history of diabetes mellitus and higher mental stress. Regular MVI users were more likely to be older, have a history of hypertension and diabetes mellitus, and have higher mental stress. During a median follow-up of 19.1 years, there were 2087 deaths from stroke (1148 ischemic, 877 hemorrhagic, and 62 unspecified). Most important, after adjustment there was only a marginal, nonsignificant benefit with MVI use to reduce death from total stroke, an effect driven by ischemic stroke (hazard ratio, 0.80; 95% confidence interval, 0.63–1.01; P=0.06). Further subgroup analyses suggested that MVI use was associated with a significantly lower risk of total stroke mortality in participants with lower intake of fruits and vegetables—a result that was also driven by a reduced ischemic (but not hemorrhagic) stroke mortality. Similar to other studies, the presented results do not support routine MVI use in unselected subjects to reduce stroke-related mortality. Yet, at the same time there may be a specific target population that may gain some benefit. Further, the chosen end point (death) may not be well suited to detect small differences conferred by MVI use. A more detailed analysis of functional outcomes after stroke (as a surrogate for reduced stroke burden) may provide better insight into the potential benefit from MVI. Lastly, a lot more information is required regarding stroke mortality among different ischemic stroke subtypes. Considering the reported baseline differences in MVI users versus nonusers, there may have well been differences in stroke subtype distribution (such as lacunar versus cardioembolic strokes), which significantly impact poststroke mortality. Thus, the verdict is still out which patient and medical condition benefits the most from MVI supplementation. See p 1167.
- © 2015 American Heart Association, Inc.