Safety of thrombolysis in cerebral venous thrombosis. A systematic review of the literature.

Internal Medicine, Department of Clinical Medicine, University of Insubria Ospedale di Circolo, Varese, Italy.
Thrombosis and Haemostasis (Impact Factor: 6.09). 09/2010; 104(5):1055-62. DOI:10.1160/TH10-05-0311
Source: PubMed

ABSTRACT Several small series have suggested the efficacy of thrombolysis in patients with cerebral vein thrombosis (CVT). However, since no randomised controlled trials have compared the use of thrombolysis with anticoagulant treatment in these patients, the risk to benefit ratio of this approach remains uncertain. The aim of this study is therefore to assess the safety of thrombolysis in CVT estimating mortality and major bleeding complications. MEDLINE and EMBASE databases were searched up to June 2010. Two reviewers performed study selection independently. Studies providing data on mortality and/or on the incidence of major bleeding complications were potentially eligible for the study. Two reviewers independently extracted data on study and population characteristics, type, dose and administration route of thrombolytic treatment; use and dose of concomitant heparin. Weighted mean proportion of the mortality rate and of the rate of major and non-major bleeding complications were calculated. Fifteen studies for a total of 156 patients were included. Twelve patients died after thrombolysis (weighted mean 9.2%; 95% CI 4.3, 15.7%) and 15 patients had a major bleeding complication (weighted mean 9.8%; 95% CI 5.3, 15.6%). Twelve haemorrhages were intracranial (weighted mean 7.6%; 95% CI 3.5, 13.1%), and seven of these patients died (58.3%; 95% CI 32.0, 80.7%). Our results suggest that thrombolysis is associated with a non-negligible incidence of major bleeding complications, including intracranial bleeding potentially affecting patients outcome. Future studies are necessary to evaluate the safety of thrombolysis in comparison to more conservative strategies.

0 0
  • [show abstract] [hide abstract]
    ABSTRACT: Cerebral venous thrombosis (CVT) is a rare form of stroke found most often in young women of reproductive age, often associated with oral contraceptive use, genetic or acquired thrombophilia, pregnancy, dehydration, or infection. CVT should be considered in any young patient who presents with an unexplained headache in combination with known hypercoagulable state, focal neurologic deficits, seizure, lobar hemorrhage, or bilateral thalamic or basal ganglionic edema. Acute treatment is with unfractionated heparin or low-molecular-weight heparin. It is important to provide supportive treatment. Outcomes are good compared with other types of stroke. Pediatric patients, excluding neonates, have similar presentation, treatment, and outcomes as adults.
    Neurologic Clinics 08/2013; 31(3):765-83. · 1.34 Impact Factor
  • Source
    [show abstract] [hide abstract]
    ABSTRACT: Cerebral venous thrombosis (CVT) is a potentially serious disease, with nonspecific clinical symptoms and an unpredictable outcome. Despite adequate anticoagulation, a patient's clinical condition can rapidly deteriorate. The aim of this study was to evaluate the efficacy of local thrombolysis in these patients. Consecutive patients with progressive cerebral venous thrombosis between October 2008 and January 2011 were enrolled prospectively. Progressive CVT was defined as the persistence of neurologic findings (headache, blurred vision, and visual field defects) despite at least four days (or 48 hours in patients with involvement of more than one sinus) on full anticoagulation therapy with heparin and development of focal neurologic deficits or cortical hemorrhage. We excluded patients with large hematomas and predisposing malignancies like leukemia. All patients underwent local thrombolysis with 30 mg recombinant tissue plasminogen activator (rtPA). Overall, 26 patients were enrolled with a mean age of 35.5 years (range 18 to 56 years). Six patients (23%) were male and twenty patients (77%) were female. The most common presenting feature was headache and the most common neurologic finding was papilledema, which was present in all patients. Eighty-five percent of women had a history of oral contraceptive pill consumption. Successful recanalization was achieved in all patients except one (96.2%). Neurological examinations and follow-up assessments were based on a modified Rankin scale (mRS). Favorable outcome and recovery was defined as a mRS score of 0-1. Follow-up assessments at the third week showed that 25 out of 26 recovered, with 18 having a mRS score of 0 and 7 with a mRS score of 1. There were no procedure-related neurological complications. Our results show that local thrombolysis is a safe and effective treatment modality for patients suffering from progressive CVT.
    Interventional Neuroradiology 03/2012; 18(1):89-96. · 0.77 Impact Factor
  • [show abstract] [hide abstract]
    ABSTRACT: Cerebral venous and sinus thrombosis is a still underdiagnosed cause of stroke, with an incidence of about 2.8 events per 100,000 person-years in young women and about 1.3 events per 100,000 person-years in the general population. Puerperium, oral hormonal contraception, and coagulation disorders remain the most frequently identified risk factors. Initial treatment with heparin is the only proven therapy, although the evidence is based on only two randomized placebo-controlled trials which together included 79 patients. In the case of clinical deterioration under anticoagulation, local thrombolysis and mechanical thrombectomy may be considered, but clinical efficacy is supported only by case reports. Patients with imminent lateral herniation due to large hemorrhagic infarctions should be treated with prompt surgical decompression. Following the acute phase, oral anticoagulation is recommended for 3-12 months, and only patients suffering from a severe coagulopathy or with recurrent cerebral venous and sinus thrombosis should be considered for long-term anticoagulation. Only insufficient experience is available for novel anticoagulants such as thrombin inhibitors or factor Xa antagonists.
    Current Neurology and Neuroscience Reports 01/2014; 14(1):417. · 3.78 Impact Factor