Background Dural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. The condition of approximately 23% of patients with DVST will worsen after initial presentation, as a result of restricted venous outflow and venous hypertension, but early identification of this subset is challenging. A venous collateral scale (VCS) that grades alternative drainage routes may improve prediction of clinical deterioration.
Objective To examine the ability of the VCS system to accurately identify patients with DVST who will experience clinical worsening, based on their imaging at presentation.
Methods From our institutional database, we identified patients with DVST on dedicated venous imaging between January 2010 and July 2016. A VCS was created and calculated from venous imaging at presentation by two reviewers blinded to subsequent data.
Results The 27 patients who met the inclusion criteria for this study had a median age of 42 years and 14 (52%) were female. Initial symptoms included headache without hemorrhage in 30% and focal deficit in 30%. Transverse sinus occlusion was present in 70% and superior sagittal sinus occlusion in 41%. VCS was 0 in 11%, 1 in 37%, and 2 in 52%. A lower VCS was significantly associated with clinical worsening both from time of initial symptom onset (77% vs 29%, VCS 0–1 vs 2, p<0.05) and during hospitalization (62% vs 0%, VCS 0–1 vs 2, p<0.01). In multivariate analysis, VCS but no other presenting features was significantly associated with in-hospital worsening (OR=2, p<0.01).
Conclusions The type and quality of venous collaterals influence outcome in DVST. VCS helps to identify patients whose condition is likely to deteriorate and may need additional aggressive interventions.
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Contributors SAS, HT, and GD: substantial contributions to the conception and design of the work, drafting and critically revising it and its final approval. He agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. DSL, JLS, VS, RJ, and ST: acquisition of data, revising the article and its final approval. The authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This work has not been presented in part or whole at any prior conference or submitted to another journal for publication.
Funding This work was supported by the Society for NeuroInterventional Surgery Foundation Pilot Research Award (principal investigator (PI): SAS) and the American Heart Association/American Academy of Neurology/American Brain Foundation Lawrence Brass Stroke Research Award (PI: SAS, award number 15CRP22900006).
Competing interests DSL: consulting fees from Stryker, Covidien, and Zoll (modest). ST: consulting fees from Penumbra, Covidien, Stryker, and Reverse Medical. RJ: consulting fees from Covidien and Stryker.
Ethics approval Institutional review board.
Provenance and peer review Not commissioned; externally peer reviewed.