Clinical Analysis With Improved Scheme Versus Systemic Anticoagulation For Cerebral Venous And Sinus Thrombosis

Objective: To compare the safety and efficacy of improved scheme and systemic anticoagulation for the treatment of cerebral venous and sinus thrombosis(CVST).Method: A retrospective review of 126 consecutive inpatients with CVST from 2005.01 to 2010.12 was undertaken in our hospital. Ten were excluded. At last, 116 were included (Male=32,Female=84,M:F=1:2.63). All of them were divided into two groups named improved scheme group (ISG) and systemic anticoagulation group (SAG) according to the different theropies. SAG(n=86) received low molecular weight heparin, some of whom were also treated with fibrinolysin or batroxobin. ISG(n=30) received improved local urokinase thrombolysis which provided unremitting microdosis injection into the venous sinus followed by low molecular weight heparin anticoagulation. The duration of thrombolysis was decided by the course of disease. Medical records, including age, sex, clinical manifestations and findings of neuroimaging were analyzed retrospectively in 116 cases with CVST. Neurological deficits before and after treatment were graded on the National Institute of Health Stroke Scale (NIHSS), functional outcome when discharged on the modified Rankin Scale (mRS). Compared the effectiveness and complication of the two kinds of treatments.Results: Basic characteritics such as age(P=0.73), ratio of sex(P=0.73) have no difference between groups. Of the 116 CVST patients, eight-six have definite risk factors while 30 have not. The most common risk factor is blood hypercoagulability such as gestation, puerperium, etc. associated with female hormone. Infection is the second cause. Clinical manifestations of CVST are divided into four kinds according to an international agreement: (1)Isolated intracranial hypertension: totally 51 cases ( ISG 18 cases, SAG 33 cases); (2)Focal deficits/ seizures: totally 48 cases ( ISG 8 cases, SAG 40 cases);(3)Subacute encephalopathy: totally 13 cases ( ISG 4 cases, SAG 9 cases);(4)Cavernous sinus thrombosis: totally 4 cases (all of them are in the SAG). According to magnetic resonance venography (MRV) or digital subtraction angiography (DSA), dural sinus affected most is lateral sinus (including transverse sinus and sigmoid sinus) and superior sagittal sinus. Usually more than one dural sinus are affected. It is not common to see only one sinus involved. Nineteen(63.33%) of ISG have undergone a CT scan before treatment, and the number of SAG is seventy (81.40%). There is no difference of intracerebral hemorrhage (ICH) between groups before treatment (P=0.163). Neurological deficit before treatment (NIHSS score) is 3.93 (range, 0–19 days) in ISG and 3.70 (range, 0–17 days) in SAG. No significant difference between groups is seen (P=0.636). Mean duration of infusion is 4.5 days (range, 2–7 days) in ISG. The dosage of urokinase is 200,000-3,750,000 Units (mean 898,000 Unit). After treatment, ISG (sixteen improvement, thirteen no apparent improvement, one worse) get better recovery (P=0.047) than SAG (thirty-one improvement, forty-two no apparent improvement, thirteen worse). NIHSS scores before and after treatment are compared for each case. Statistical difference is seen (P=0.048). Outcome is classified according to the mRS as complete recovery (mRS 0 to 1); partial recovery, independent (mRS 2); dependent (mRS 3 to 5); and death (mRS 6). ISG: complete recovery 24 cases; partial recovery, independent 3 cases; dependent 3 cases; no death. SAG: complete recovery 52 cases; partial recovery, independent 14 cases; dependent 16 cases; 4 death. The mRS scores of the two groups when discharged have significant difference (P=0.046). Nine (30%) of ISG have complications including two ICH, three hemorrhagic tendency (one hemorrhage of endotracheal intubation and nose and two of puncture sites), one ache of head and neck, one phlebothrombosis of leg and two catheter displacements. One patient (1.16%) of SAG has complication as intracerebral hemorhage. ISG have more complications than SAG (P<0.001). The incidence of ICH between groups has no difference (P=0.164). Conclusions: Improved scheme is better than systemic anticoagulation in neurological function improvement and recovery. Improved scheme group has more complications than systemic anticoagulation. However, the rate of intracerebral hemorhage of the two group has no significant difference.