Endovascular Therapy for Severe Cerebral Venous Sinus Thrombosis: Time is Vein?

Treatment of cerebral venous sinus thrombosis (CVST) can be deceptively complex. On one hand, it is clear that prompt initiation of anticoagulation is essential as the only treatment of proven efficacy and that the majority of patients treated in this way will have good outcomes [1]. Unfortunately, there is an important minority of severely affected patients in whom anticoagulation alone does not arrest progression of the condition and in whom poor outcomes, including a high risk of death, are common [2]. What more should be done to help such patients is not clear. Endovascular therapy (EVT) aimed at reducing clot burden and improving flow in the affected venous sinuses using mechanical means and/or targeted thrombolysis is frequently considered. Yet, support for this treatment rests on biological plausibility and low-quality clinical evidence, leaving unanswered the questions of if, how, and when to deploy it [1]. In this issue of Neurocritical Care, Bucke and colleagues [3] attempt to narrow this knowledge gap by addressing the question of whether the timing of EVT affects outcomes in CVST. …