Cerebral Venous Thrombosis: Focus on Five Hot Issues NCN 2021

*It is only for medical professionals to read and explain, not to be missed! Cerebral venous thrombosis (CVT) refers to the formation of intracranial vein or venous sinus thrombosis caused by various causes, obstructed blood return or cerebrospinal fluid circulation, which is a characteristic of intracranial hypertension and focal brain damage.
Class cerebrovascular disease
.

In clinical practice, there are often problems such as missed diagnosis, high rate of misdiagnosis, and untimely treatment
.

At the 24th National Neurology Conference (NCN) of the Chinese Medical Association, Professor Zeng Jinsheng from the Department of Neurology of the First Affiliated Hospital of Sun Yat-sen University gave a wonderful report on "Several Hot Issues in the Diagnosis and Treatment of Cerebral Venous Thrombosis" ! Figure 1: Professor Zeng Jinsheng’s report 1 Today's form: New coronary pneumonia and CVT Since the beginning of 2020, new coronary pneumonia has spread all over the world and has brought serious impact on people's lives
.

In today's anti-epidemic and epidemic prevention environment, there is also a close relationship between COVID-19 and CVT
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A meta-analysis published in the European Journal of Neurology in 2021 showed that the incidence of CVT was 0.
001% of all patients with COVID-19, and it accounted for 0.
02%-1.
00% of all 17,799 COVID-19 patients hospitalized
.

For CVT, this is not a small proportion
.

Figure 2: A meta-analysis published in the European Journal of Neurology.
In addition, related studies suggest that the total incidence of headaches after various new crown vaccines is 16.
4%, of which the possibility of CVT should be vigilant
.

2 Imaging diagnosis: CTV vs MRV Professor Zeng Jinsheng introduced that CT plain scan/enhanced, MRI routine series (enhanced), CTV and MRV have their own diagnostic value in the clinical diagnosis of thrombosis
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▌ Conventional imaging examination (CT/MRI) indirect signs: cerebral edema, ischemic infarction, hemorrhagic infarction, ventricular obstruction or obstructive hydrocephalus in the corresponding vein/venous window drainage area; direct signs: cord sign ), dense triangle sign; venous imaging can show thrombus in the venous window, showing filling defect-like lesions, superior sagittal dense thrombosis visible characteristic empty triangle sign (empty triangle sign); for the diagnosis of CVT , CT and MRI have their own advantages and disadvantages, but both can be used as the preferred imaging methods, with a sensitivity of 75%-100% and a specificity of 81%-100%
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See Table 1 for specific comparison
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Table 1: Comparison of the advantages and disadvantages of CT and MRI ▌ DSA: accurate diagnosis during endovascular treatment Professor Zeng Jinsheng introduced that DSA can show the occluded venous sinus is not visible or filling defect, delayed cerebral venous sinus development, prolonged capillary phase, and collateral drainage Vein dilation, increased scalp veins around the affected vein, and reversal of the direction of venous blood flow
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It can further confirm the existence of thrombus, the extent of involvement, the softness of thrombus and the changes in the pressure of various segments in the sinus
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In the past, DSA was considered to be the main method for diagnosing CVT.
However, due to the continuous improvement and wide application of CT and MRI and its vascular imaging technology and the invasive nature of DAS, it is now only when other tests cannot confirm the diagnosis, or it is decided to perform intravascular interventional treatment at the same time.
At that time, DSA examination was performed to confirm the diagnosis
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3 Anticoagulation treatment: New oral anticoagulation drugs have a tendency to replace warfarin.
Domestic guidelines: According to the Chinese Guidelines for the Diagnosis and Treatment of Intracranial Vein Thrombosis in 2019, anticoagulation is still the main treatment for CVT
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Guideline recommendations: The efficacy and safety of the new oral anticoagulant dabigatran is similar to that of warfarin, but it is easier to use than warfarin (level II recommendation, level C evidence)
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Recanalization of occluded veins (sinuses) as a basis for stopping oral anticoagulation therapy is not yet clear (level III recommendation, level C evidence)
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Figure 3: The 2019 Chinese Guidelines Foreign Research: The latest research of JAMA Neurology suggests that the recurrence rate of the two drugs is low, and the bleeding risk is similar.
The new oral anticoagulant needs further research to establish its safety and effectiveness
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Figure 4: Study 4 published in JAMA Neurology.
Endovascular treatment is important for vascular recanalization in critically ill patients.
The guideline introduces that the endovascular treatment of CVT mainly includes local thrombolysis, balloon dilatation, mechanical thrombectomy and intravascular stent implantation.
Into treatment
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Clinically, two or more treatment methods are sometimes used in combination
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In 2013, a Chinese study found that 52 severe CVT patients received endovascular treatment (thrombectomy + thrombolytic urokinase 10 to 1.
5 million units), 87% (45/52) were completely recanalized, and 6% (3/52) were partially recanalized.
7% (4/52) had no recanalization, 11.
5% (6/52) died in hospital
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In 2015, 42 studies were systematically analyzed, 185 patients, 71% had intravascular treatment, 60% had intracranial hemorrhage before thrombus removal, and 47% were unconscious
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Finally, 10% had bleeding during the perioperative period, 84% had a good prognosis, and 12% died
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It is not clear whether to combine arterial thrombolysis
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In 2017, in a large retrospective study of 152 cases in the United States, 73 cases (49%) received endovascular treatment, especially for cerebral edema, disturbance of consciousness, aphasia, obvious paralysis, obvious intracranial hypertension, headache, vision When the disorder or disease progresses, endovascular treatment is considered safe and effective
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Therefore, for the intravascular treatment of CVT, the recommended opinion is: in general, it is recommended to choose carefully
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5 Treatment of Intracranial Hypertension in Severe Patients According to Professor Zeng Jinsheng, according to the 2019 guidelines, there are the following recommendations for the management of intracranial hypertension in severely ill patients: 1.
For patients with intracranial hypertension, dehydration can be used to reduce intracranial pressure; however, excessive dehydration should be prevented.
Factors such as hemoconcentration aggravate the condition of CVT (level II recommendation, level C evidence)
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2.
Conventional use of glucocorticoids for CVT is not beneficial unless needed for treatment of underlying diseases.
CVT patients with no brain parenchymal lesions found on CT/MRI should avoid the use of glucocorticoids (level III recommendation, level B evidence)
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3.
Patients with severe intracranial hypertension or early brain herniation should be treated urgently.
If necessary, decompressive craniectomy or ventricular-abdominal shunt therapy can be performed (level II recommendation, level C evidence)
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4.
For patients with intracranial hypertension with progressive vision loss, optic nerve sheath decompression can be used to save vision (level II recommendation, level C evidence)
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Summary: 1.
For patients with neo-coronary pneumonia or headaches after neo-coronary vaccine injection, they should be alert to the possibility of cerebral venous thrombosis; 2.
Imaging diagnosis is the main basis for cerebral venous thrombosis.
Both CTV and MRV can be used as diagnostic methods; 3.
Anticoagulation is still the main treatment measure, and new oral anticoagulation drugs have a tendency to replace warfarin; 4.
Endovascular treatment is of great significance for recanalization of critically ill patients; 5.
Surgical treatment (decompressive craniectomy) can be As a means of saving lives with severe intracranial hypertension
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References: [1] Zeng Jinsheng, Liu Ming, Cui Liying, etc.
, Chinese Guidelines for the Diagnosis and Treatment of Intracranial Vein Thrombosis 2019, [J] Chinese Journal of Neurology, September 2020, Volume 53, Issue 9, 648-663