We thank Coutinho and colleagues for their comments on our manuscript. They state that the 4% mortality associated with noninvasive anticoagulant treatment in the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) is superior to our observed mortality rate of 15% (2 of 13 patients). The ISCVT is a large prospective trial, which is detailed in the Discussion of our article. A direct comparison of mortality rates between ISCVT and our small case series is not meaningful. In our series the 15% mortality rate was related to the damage that was already done by venous sinus thrombosis. These patients were already neurologically devastated before our intervention—their deaths were not a result of the procedure. It is even possible that outcomes would have been better had we intervened in those patients sooner. We have been involved in several cases where patients were managed with anticoagulation initially for some time but continued to worsen. By the time mechanical thrombectomy was brought to the table, they were already devastated. Coutinho and colleagues state that in the absence of additional risk factors for a poor prognosis, they would not treat any patients with endovascular therapy. However, they do not consider the problems associated with long-term refractory headaches often experienced by sinus thrombosis patients. In our series all 6 patients who presented primarily with severe headaches experienced complete and immediate resolution of their headaches after mechanical thrombectomy. Coutinho et al. also point out that there was no control group in our series and that follow up was incomplete. These issues of course reflect the retrospective nature of this case series; it was not a randomized controlled trial. The key point of our report is that endovascular therapy for venous sinus thrombosis can be performed with minimal risk in experienced hands. Mechanical intervention markedly reduces the volume of thrombus and quickly restores flow. Once flow is established, the residual thrombus responds more completely and more quickly to systemic anticoagulation. We believe this approach greatly reduces the duration and severity of symptoms and can shorten hospital stays and the required convalescence period.
Shervin R. Dashti, M.D. Louisville, Kentucky Cameron G. McDougall, M.D. Phoenix, Arizona
Conflict of Interest: