Decompressive Surgery for Malignant Cerebral Venous Sinus Thrombosis: A Retrospective Case Series from Pakistan and Comparative Literature Review


      Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke in the West; however, it is prevalent in Asia and the Middle East. CVST is treated with dose-adjusted heparin or heparinoid followed by warfarin to facilitate recanalization of venous sinuses. For those with progressive malignant cerebral edema, the role of decompressive surgery has been reported from developed countries. We present data on decompressive craniectomy from a tertiary care stroke center in a developing country and compare our results and population with that described in the international literature.


      We retrospectively analyzed data of all patients who underwent a decompressive hemicraniectomy for CVST at the Aga Khan University Hospital, Karachi, Pakistan from 1999 till 2011. A record review of the Aga Khan University Hospital was performed as decompressive hemicraniectomy for malignant CVST is not being performed elsewhere in the country and the hospital is a major referral center. Using the International Classification of Diseases, Ninth Edition codes for CVST, we identified a total of 7 patients. Patients are presented along with descriptions of their presentation, neuroimaging, intraoperative findings, and long-term outcomes. Pearson chi-square test was done to identify features that predicted survival. A comparative literature review was also done through PubMed to identify all other reports of surgery for CVST.


      During a 12-year review, 134 patients were diagnosed with CVST. Of these, 7 received intervention. The age range of the patients was 15-60 years. Four of the 7 patients had an excellent outcome, 2 of 7 died, and 1 of 7 left against medical advice (in a comatose state) and was lost to follow-up. Patients presented alert but progressively deteriorated preoperatively. All those patients who had preoperative reactive pupils with low Glasgow Coma Scale scores made a complete neurologic recovery, and patients with fixed, dilated, and nonreactive pupils preoperatively died in the first postoperative week (P = .05).


      Patients who received decompressive hemicraniectomy in Pakistan for CVST had excellent outcomes in all cases when intervention was performed with intact preoperative pupillary reflexes. Of the data reviewed, most reported (two-third) patients show the same prognosticators; however, one third show that even with nonreactive pupils complete recovery is possible.

      Key Words

      To read this article in full you will need to make a payment


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stam J.
        Thrombosis of the cerebral veins and sinuses.
        N Engl J Med. 2005; 352 (PubMed PMID: 15858188. Epub 2005/04/29. eng): 1791-1798
        • Saposnik G.
        • Barinagarrementeria F.
        • Brown Jr., R.D.
        • et al.
        Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2011; 42 (PubMed PMID: 21293023. Epub 2011/02/05. eng): 1158-1192
        • Khealani B.A.
        • Wasay M.
        • Saadah M.
        • et al.
        Cerebral venous thrombosis: a descriptive multicenter study of patients in Pakistan and Middle East.
        Stroke. 2008; 39 (PubMed PMID: 18635853. Epub 2008/07/19. eng): 2707-2711
        • Rajan Vivakaran T.T.
        • Srinivas D.
        • Kulkarni G.B.
        • et al.
        The role of decompressive craniectomy in cerebral venous sinus thrombosis.
        J Neurosurg. 2012; 117 (PubMed PMID: 22920956. Epub 2012/08/28. eng): 738-744
        • Wasay M.
        • Kamal A.K.
        Cerebral venous thrombosis: recent advances and need for an Asian registry.
        J Pak Med Assoc. 2006; 56 (PubMed PMID: 17183970. Epub 2006/12/23. eng): 483-484
        • Kojan S.
        • Al-Jumah M.
        Infection related cerebral venous thrombosis.
        J Pak Med Assoc. 2006; 56 (PubMed PMID: 17183974. Epub 2006/12/23. eng): 494-497
        • Khealani B.A.
        • Mapari U.U.
        • Sikandar R.
        Obstetric cerebral venous thrombosis.
        J Pak Med Assoc. 2006; 56 (PubMed PMID: 17183973. Epub 2006/12/23. eng): 490-493
        • Lath R.
        • Kumar S.
        • Reddy R.
        • et al.
        Decompressive surgery for severe cerebral venous sinus thrombosis.
        Neurol India. 2010; 58 (PubMed PMID: 20644266. Epub 2010/07/21. eng): 392-397
        • Ferro J.M.
        • Crassard I.
        • Coutinho J.M.
        • et al.
        Decompressive surgery in cerebrovenous thrombosis: a multicenter registry and a systematic review of individual patient data.
        Stroke. 2011; 42 (PubMed PMID: 21799156. Epub 2011/07/30. eng): 2825-2831
        • Dentali F.
        • Gianni M.
        • Crowther M.A.
        • et al.
        Natural history of cerebral vein thrombosis: a systematic review.
        Blood. 2006; 108 (PubMed PMID: 16609071. Epub 2006/04/13. eng): 1129-1134
        • Medel R.
        • Monteith S.J.
        • Crowley R.W.
        • et al.
        A review of therapeutic strategies for the management of cerebral venous sinus thrombosis.
        Neurosurg Focus. 2009; 27 (PubMed PMID: 19883208. Epub 2009/11/04. eng): E6
        • Bentley J.N.
        • Figueroa R.E.
        • Vender J.R.
        From presentation to follow-up: diagnosis and treatment of cerebral venous thrombosis.
        Neurosurg Focus. 2009; 27 (PubMed PMID: 19877795. Epub 2009/11/03. eng): E4
        • Ferro J.M.
        • Canhao P.
        • Stam J.
        • et al.
        Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT).
        Stroke. 2004; 35 (PubMed PMID: 14976332. Epub 2004/02/21. eng): 664-670
        • Preter M.
        • Tzourio C.
        • Ameri A.
        • et al.
        Long-term prognosis in cerebral venous thrombosis. Follow-up of 77 patients.
        Stroke. 1996; 27 (PubMed PMID: 8571417. Epub 1996/02/01. eng): 243-246
        • Khan M.
        • Kamal A.K.
        Surgical interventions for malignant middle cerebral infarction—saving lives and functionality or increasing disabled survivors?.
        J Pak Med Assoc. 2010; 60 (PubMed PMID: 20527622): 405-406
        • Rieke K.
        • Schwab S.
        • Krieger D.
        • et al.
        Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial.
        Crit Care Med. 1995; 23 (PubMed PMID: 7664561. Epub 1995/09/01. eng): 1576-1587
        • Vahedi K.
        • Hofmeijer J.
        • Juettler E.
        • et al.
        Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials.
        Lancet Neurol. 2007; 6 (PubMed PMID: 17303527): 215-222
        • Juttler E.
        • Schwab S.
        • Schmiedek P.
        • et al.
        Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial.
        Stroke. 2007; 38 (PubMed PMID: 17690310): 2518-2525
        • Hofmeijer J.
        • Kappelle L.J.
        • Algra A.
        • et al.
        Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial.
        Lancet Neurol. 2009; 8 (PubMed PMID: 19269254): 326-333
        • Enam S.A.
        Role of surgery in cerebral venous sinus thrombosis.
        J Pak Med Assoc. 2006; 56 (PubMed PMID: 17183988. Epub 2006/12/23. eng): 543-547
        • Mohindra S.
        • Umredkar A.
        • Singla N.
        • et al.
        Decompressive craniectomy for malignant cerebral oedema of cortical venous thrombosis: an analysis of 13 patients.
        Br J Neurosurg. 2011; 25 (PubMed PMID: 21615250. Epub 2011/05/28. eng): 422-429
        • Théaudin M.
        • Crassard I.
        • Bresson D.
        • et al.
        Should decompressive surgery be performed in malignant cerebral venous thrombosis?: a series of 12 patients.
        Stroke. 2010; 41 (PubMed PMID: 20185780. Epub 2010/02/27. eng): 727-731
        • Zuurbier S.M.
        • Coutinho J.M.
        • Majoie C.B.
        • et al.
        Decompressive hemicraniectomy in severe cerebral venous thrombosis: a prospective case series.
        J Neurol. 2011; 259 (PubMed PMID: 22119770. Epub 2011/11/29. Eng): 1099-1105
        • Siddiqui F.M.
        • Kamal A.K.
        Incidence and epidemiology of cerebral venous thrombosis.
        J Pak Med Assoc. 2006; 56 (PubMed PMID: 17183971. Epub 2006/12/23. eng): 485-487
        • Stefini R.
        • Latronico N.
        • Cornali C.
        • et al.
        Emergent decompressive craniectomy in patients with fixed dilated pupils due to cerebral venous and dural sinus thrombosis: report of three cases.
        Neurosurgery. 1999; 45 (discussion 9-30. PubMed PMID: 10493383. Epub 1999/09/24. eng): 626-629
        • Coutinho J.M.
        • Hama-Amin A.D.
        • Vleggeert-Lankamp C.
        • et al.
        Decompressive hemicraniectomy followed by endovascular thrombosuction in a patient with cerebral venous thrombosis.
        J Neurol. 2011; 259 (PubMed PMID: 21822935. Epub 2011/08/09. Eng): 562-564
        • Ebke M.
        • Jurgens K.U.
        • Tomandl B.
        • et al.
        Surgical treatment of space occupying edema and hemorrhage due to cerebral venous thrombosis during pregnancy.
        Neurocrit Care. 2011; 15 (PubMed PMID: 20524080): 166-169
        • Dohmen C.
        • Galldiks N.
        • Moeller-Hartmann W.
        • et al.
        Sequential escalation of therapy in “malignant” cerebral venous and sinus thrombosis.
        Neurocrit Care. 2010; 12 (PubMed PMID: 19898967. Epub 2009/11/10. eng): 98-102
        • Coutinho J.M.
        • Majoie C.B.
        • Coert B.A.
        • et al.
        Decompressive hemicraniectomy in cerebral sinus thrombosis: consecutive case series and review of the literature.
        Stroke. 2009; 40 (PubMed PMID: 19372443. Epub 2009/04/18. eng): 2233-2235
        • Lanterna L.A.
        • Gritti P.
        • Manara O.
        • et al.
        Decompressive surgery in malignant dural sinus thrombosis: report of 3 cases and review of the literature.
        Neurosurg Focus. 2009; 26 (PubMed PMID: 19485718. Epub 2009/06/03. eng): E5
        • Pfeilschifter W.
        • Neumann-Haefelin T.
        • Hattingen E.
        • et al.
        [Cortical venous thrombosis after a diagnostic lumbar puncture].
        Der Nervenarzt. 2009; 80 (PubMed PMID: 19707734): 1219-1221
        • Galarza M.
        • Gazzeri R.
        Cerebral venous sinus thrombosis associated with oral contraceptives: the case for neurosurgery.
        Neurosurg Focus. 2009; 27 (PubMed PMID: 19877796. Epub 2009/11/03. eng): E5
        • Lin H.S.
        • Lin J.F.
        • Chang C.K.
        • et al.
        Cerebral sinus thrombosis with intracerebral hemorrhage in pregnancy: a case report.
        Acta neurologica Taiwanica. 2008; 17 (PubMed PMID: 18975526): 189-193
        • Zeng L.
        • Derex L.
        • Maarrawi J.
        • et al.
        Lifesaving decompressive craniectomy in ‘malignant’ cerebral venous infarction.
        Eur J Neurol. 2007; 14 (PubMed PMID: 17222086. Epub 2007/01/16. eng): e27-e28
        • Armonda R.A.
        • Vo A.H.
        • Bell R.
        • et al.
        Multimodal monitoring during emergency hemicraniectomy for vein of Labbe thrombosis.
        Neurocrit Care. 2006; 4 (PubMed PMID: 16757831): 241-244
        • Keller E.
        • Pangalu A.
        • Fandino J.
        • et al.
        Decompressive craniectomy in severe cerebral venous and dural sinus thrombosis.
        Acta Neurochir Suppl. 2005; 94 (PubMed PMID: 16060260. Epub 2005/08/03. eng): 177-183
        • Weber J.
        • Spring A.
        [Unilateral decompressive craniectomy in left transverse and sigmoid sinus thrombosis].
        Zentralbl Neurochir. 2004; 65 (PubMed PMID: 15306978. Epub 2004/08/13): 135-140
        • Barbati G.
        • Dalla Monta G.
        • Coletta R.
        • et al.
        Post-traumatic superior sagittal sinus thrombosis. Case report and analysis of the international literature.
        Minerva Anestesiol. 2003; 69 (PubMed PMID: 14743123. Epub 2004/01/27. eng ita): 919-925
        • Kuroki K.
        • Taguchi H.
        • Sumida M.
        • et al.
        Dural sinus thrombosis in a patient with protein S deficiency—case report.
        Neurologia medico-chirurgica. 1999; 39 (PubMed PMID: 10658454): 928-931