gms | German Medical Science

Objective: Decompressive craniectomy (DC) is an evidenced-based treatment option for ischemic stroke and traumatic brain injury. However, its role in the management of severe cerebral venous sinus thrombosis is less clearly characterised. We present a systematic literature review of clinical studies.

Methods: In August 2021, a PubMed search for the terms “venous sinus thrombosis” combined with “craniectomy”, “decompressive craniectomy” and “hemicraniectomy” yielded 158, 53 and 23 results, respectively. After exclusion of duplicates and manual selection, 30 relevant publications were included. The overall Oxford level of evidence is 4, i.e. studies without control group.

Results: We performed a pooled analysis of 220 patients (150 female, 63 male, 7 not reported). Median age was 36 (15-60) years. Median time between onset and therapy was 48 (3-192) hours. Pregnancy/puerperium (N=23) was commonly reported as the predisposing condition. Of note, 4 cases of Covid19-vaccination within the previous 8 (2-12) days were included. These patients had raised D-dimer and low platelets/fibrinogen. Median GCS prior to DC was 7 and, among studies reporting on pupillary findings, 87% had at least unilateral mydriasis. The most commonly occluded sinus was the superior sagittal sinus (N=95). In addition to venous infarction/oedema, haemorrhage was reported in 136 cases. Hemicraniectomy was the main surgical procedure, combined with hematoma evacuation (N=18) or open thrombectomy (N=4). Neurointerventional thrombectomy was reported in 10 cases. The most common anticoagulation strategy was heparin/LMWH in the acute and vitamin K antagonist/direct oral anticoagulant in the postacute phase. Good outcome (mRS 0-2) was reported in 57% (N=108), poor outcome (mRS 3-5) in 15% (N=29) and death (mRS 6) in 27% (N=51). Of note, all 4 patients with previous Covid19-vaccination died. Postoperative infection was the main complication (N=18), whereas postsurgical hematoma was rarely reported (N=2).

Conclusion: In this pooled cohort, the typical patient was young and presented with coma and abnormal pupils due to haemorrhagic venous infarction. Hemicraniectomy was the most common neurosurgical procedure. Despite common perioperative anticoagulation, haemorrhagic complications were rarely reported. Outcome appears to be better, compared to ischemic stroke studies. Of note, outcome of the few reported patients with cerebral venous sinus thrombosis and low platelets after Covid19-vaccination was dismal.