Thrombolytics

Thrombolytics aim at rapid restoration of venous outflow by clot destruction. Local thrombolysis restores flow more often and faster than heparin by itself. Multiple cases with administration of urokinase or recombinant tissue-type plasminogen activator (rtPA) plus heparin have been reported. No randomized trials have been reported, only case reports and small series of thrombolysis administration in patients with CVT (level IV evidence). In a review of all published information regarding thrombolytics (n = 169 patients, 76% treated with urokinase; dependency at discharge in 7%, 95% CI, 3-12%; 5% mortality, 95% CI, 2-9%; ICH in 17%), the treatment appears safe with relatively few serious hemorrhagic complications (32). However, as no controlled studies have been reported, no good scientific evidence exists to strongly endorse routine use in standard clinical practice.

In one study (33), intrathrombus rtPA and intravenous heparin combined in patients with CVT demonstrated rapid flow restoration and improved clinical outcome in the majority of patients who did not have ICH prior to treatment. In patients with hemorrhagic CVT, the risk of bleeding is high with this therapy. Thrombolysis seems useful in patients with no ICH resulting from treatment, but the numbers of patients treated until now is still much less than the number of patients treated with heparin (2,7). Additionally, the location of the ICH, whether it is deep or on a convexity, influences the efficiency of thrombolytic treatment. The use of local thrombolysis is currently indicated if the patient worsens after medical and heparin therapy (7). No randomized trials have been reported showing that the clinical outcome is better with the use of thrombolytics compared to anticoagulants; however, thrombolytics appear to restore flow faster than heparin alone.

A few cases have been reported in which direct thrombectomy was used within the cerebral venous sinuses (15). In experimental SSS thrombosis in rats, abciximab, a GPIIb/IIIa platelet antagonist, resulted in the best clinical outcomes (residual sinus occlusion of 36% at 1 week), although the highest recanalization rates were seen with rtPA (34). A randomized clinical trial of thrombolysis for CVT is urgently needed (35) and would probably have to be multicentered and international to obtain an adequate sample size.

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