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Q) When should we consider endovascular treatment (EVT) for patient with cerebral venous thrombosis (CVT)? 

A) The Society of Neurointerventional Surgery (SNIS) guideline in 2018 recommends that EVT can be considered in patients with the following conditions: 

• Clinical deterioration despite anticoagulation
• Contraindication to anticoagulation
• Coma (GCS <9)
• Deep cerebral venous thrombosis
• Posterior fossa involvement
• Intracerebral hemorrhage (ICH)


     According to SNIS guideline, exact indications for neurointerventional procedures
require further validation. Currently, we do not have strong evidence to support EVT for severe CVT patients. A large systemic review of 185 cases who received EVT in CVT demonstrated 95% of recanalization (partial & complete) with good clinical outcomes in 84% of cases. The mortality and new or increase ICH of 12% and 10% respectively. However, This study is based on a retrospective case report and case series, therefore it is prone to publication bias and under - reporting of poor-outcomes.

     The only randomized trial of EVT in severe CVT was TO-ACT trial (67 patients) which failed to show the benefit of EVT in severe CVT patients in 12 month follow up. The mortality was higher in EVT group (12% vs 3%, P=0.2) but major hemorrhagic complication was higher in control group (24% vs 18%, P= 0.59).

     From TO-ACT paper discussion, “Although the point estimate of the primary end point in the trial did not point toward a beneficial effect of EVT in CVT (RR ratio, 0.99), the large width of the 95% CI (0.71-1.38) indicates that a clinically meaningful treatment effect cannot be excluded. Similarly, we cannot exclude the possibility that EVT was effective in a subgroup of patients (for instance, to those in a coma) because the number of patients in such groups was small”.

     We really need more studies in this topic! Using new devices in future trials might change the outcome of EVT.


     1) Lee SK, Mokin M, Hetts SW, et al. Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg. 2018;10 (8) : 803-810.
     2) Coutinho JM, Zuurbier SM, Bousser MG, et al. Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial [published online ahead of print, 2020 May 18]. JAMA Neurol. 2020;e201022.
     3) Siddiqui FM, Dandapat S, Banerjee C, et al. Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases. Stroke. 2015;46(5):1263-1268.
     4) Siddiqui FM, Weber MW, Dandapat S, et al. Endovascular Thrombolysis or Thrombectomy for Cerebral Venous Thrombosis: Study of Nationwide Inpatient Sample 2004-2014. J Stroke Cerebrovasc Dis. 2019;28(6):1440 -1447.

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