The Source for Neurovascular News and Education

June 06, 2020

Simple scoring system helps identify the high-risk patients who can benefit from early treatment before clinical worsening sets in.

 

An easy-to-calculate score based on imaging evidence of collateral drainage appears to effectively identify patients with dural venous sinus thrombosis who are likely to worsen over time, according to a small study.

The hope is that identifying high-risk patients early will allow treatment to be initiated before clinical worsening sets in, rather than relying on the presence of worsening to identify patients who need to be treated.

“It’s a tricky disease, because we see it and we don’t know what to do with it,” said lead author Sunil A. Sheth, MD (UT Health McGovern School of Medicine, Houston, TX), in an interview with Neurovascular Exchange. Potential outcomes range all the way from complete recovery without intervention to death. Traditionally, prognosis has depended on clinical parameters such as patient demographics, clinical presentation, and medications used, but these approaches often overlooked patients destined to worsen. Relying on these parameters also means that clinicians must wait for clinical signs to appear before initiating treatment.

Once a reliable method for identifying high-risk patients is established, he said, there are treatment options that can prevent clinical decline, including anticoagulation with drugs like heparin or endovascular clot removal.

“The idea has been around for a while that collaterals influence outcomes,” Sheth noted. Thus, he and his colleagues devised a scale based on imaging findings, known as the Venous Collateral Scale (VCS), in an effort to determine if they could identify “which patients are going to get worse and which are going to be ok,” he explained.

For their study published online March 6, 2017, ahead of print in the Journal of NeuroInterventional Surgery, Sheth et al used their institutional database to identify the 27 patients (median age 42 years; 52% women) with dural venous sinus thrombosis revealed on dedicated venous imaging between January 2010 and July 2016. Next, two blinded reviewers calculated a VCS score from venous imaging at presentation, and the investigators looked at how well it predicted clinical worsening.

Patients’ 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%.

The VCS, which is rated on a scale of 0-2, was designed to be as simple as possible to calculate, Sheth said. Clinically speaking, the most important determinant is whether or not the score is a 2, which refers to the presence of “cortical venous drainage from affected region with anastomosis into a patent sinus.” These are the lowest risk patients. “That distinction is pretty easy to do,” he said. “Anyone with experienced at looking at neurovascular imaging should be able to do easily.”

VCS was calculated to be 0 in 11% of patients, 1 in 37%, and 2 in 52%. A lower VCS was significantly associated with clinical worsening both from time of initial symptom onset and during hospitalization (table 1).

Outcomes by Venous Collateral Scale

 

VCS 0-1

VCS 2

P Value

Worsening from Time of initial Symptom Onset

77%

29%

< 0.05

Worsening During Hospitalization

62%

0

< 0.01


Multivariate analysis revealed that a lower VCS was associated with in-hospital worsening (OR = 2.0; 95% CI 1.5-2.8). No other presenting factor showed a similar association.

Potential as Clinical and Research Tool

Antonio Arauz, MD (Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico), described the findings as “unexpected” in an email to Neurovascular Exchange. “Previous studies failed to find an independent effect of collaterals on the type of brain damage, clinical manifestations, or prognosis [associated with dural venous sinus thrombosis],” he wrote.

Before the VCS is used clinically, the findings require confirmation in larger prospective trials, he said. But if such confirmation is forthcoming, Arauz predicted the tool “could help to identify patients early who are at high risk for neurological deterioration and who need closer surveillance and more aggressive treatment.” In addition, the findings also provide further “understanding of the hemodynamic behavior of the venous system” in dural venous sinus thrombosis, he said, which could in turn inform future research.

That is exactly in line with Sheth’s thinking. He acknowledged that a small, single-center, and retrospective study requires validation using prospective designs with more patients in multiple centers. If such a trial would yield similar results, “that would cement the finding,” he said.

 


Source:

Sheth SA, Trieu H, Liebeskind DS, et al. Venous collateral drainage patterns predict clinical worsening in dural venous sinus thrombosis. J NeurInterv Surg. 2017;Epub ahead of print.

 

Disclosures:

Sheth and Arauz report no relevant conflicts of interest.