Decompressive craniectomy for severe cerebral venous sinus thrombosis: a 15-year Swedish multicentre case-series

BACKGROUND: Cerebral venous sinus thrombosis (CVT) is a rare condition that, in severe cases, can cause refractory intracranial hypertension. Despite limited evidence, decompressive craniectomy (DC) is endorsed as a rescue treatment. We aimed to describe indications, surgical characteristics, and outcomes of DC for severe CVT in a near-nationwide Swedish cohort. METHODS: This multicentre retrospective case-series included all CVT patients treated with DC (n = 13) at five Swedish neurosurgical centres between 2008-2022. Demographic, clinical, radiological, and surgical variables, and six-month modified Rankin Scale (mRS) were extracted from medical records and radiological imaging. Favourable outcome was defined as mRS 0-3. RESULTS: Median age was 53 years (IQR 32-62), and 77% were female. At admission, the median GCS Motor score (GCS M) was 6 (5-6) and all patients had reactive pupils. Preoperatively, GCS M declined to 5 (1-5), and only 46% had reactive pupils. Midline shift was 9 mm (6-11) and all patients had compressed basal cisterns before DC. Postoperatively, midline shift decreased to 2 mm (0-5), and basal cisterns were open in 85% of cases. Eleven patients (85%) developed external brain herniation, one patient (8%) had subdural hygroma requiring surgery, and 4 (31%) developed a postoperative intracranial haematoma, one of which (8%) was evacuated. No postoperative infections or reoperations due to DC-extension occurred. At follow-up, 62% had recovered favourably, while 15% were deceased. CONCLUSIONS: DC was an effective last-tier treatment of intracranial hypertension in selected severe CVT cases. Most patients recovered favourably, with low mortality and complication rates.