Comment on “Cerebral venous thrombosis: A comprehensive narrative review” – The need for integrating neuromonitoring and intracranial pressure management

Dear Editor, We read with considerable interest the comprehensive narrative review on cerebral venous thrombosis (CVT) by Almegren,[1] which presents a well-structured synthesis of current understanding related to CVT epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment. The author deserves commendation for this timely work, particularly in light of the rising awareness of CVT in the post-COVID-19 era. While the review serves as a valuable reference for clinicians and researchers alike, we believe two essential aspects of CVT management are underrepresented: The role of advanced neuromonitoring A structured approach to intracranial pressure (ICP) management. Both are critical to optimizing outcomes, particularly in patients who are severely ill or neurologically deteriorating. The review mentions that ultrasonography has limited utility in CVT, but this does not reflect the expanding role of multimodal neuromonitoring, which now includes promising noninvasive methods. For instance, optic nerve sheath diameter (ONSD) has emerged as a dynamic bedside surrogate for ICP. In their case series, Wang et al.[2] demonstrated its utility in two patients, one with venous sinus stenosis and another with venous sinus thrombosis. The authors showed that ONSD values decreased in parallel with ICP reduction after treatment, highlighting its potential as a quantitative, noninvasive method for monitoring intracranial hypertension from venous sinus pathology. Ultrasound-based neuromonitoring has also been used to assess cerebral blood flow dynamics and autoregulation. Sharma et al.[3] have demonstrated that CVT disrupts carbon dioxide (CO2) reactivity, implying that hyperventilation, a traditionally used strategy to control raised ICP, may not effectively reduce cerebral blood volume or ICP in these patients. Thus, blind reliance on PaCO2 manipulation may be counterproductive or even harmful. Cerebral autoregulation impairment is another key concern. Chen et al.[4] used transcranial Doppler to assess autoregulatory capacity in CVT patients and observed pressure-passive cerebral blood flow in a significant proportion, making them vulnerable to both hypoperfusion and hyperemia depending on systemic blood pressure. These findings support the use of autoregulation-informed blood pressure targets, rather than fixed, protocolized thresholds. In one of the most clinically impactful studies to date, Hejdenberg et al.[5] employed invasive neuromonitoring in CVT patients and found frequent impairment in the pressure reactivity index (PRx), a surrogate for cerebral autoregulation. They further showed that the proportion of eligible monitoring time spent above ICP thresholds (e.g., > 20 mmHg) and poor PRx values were both associated with unfavorable outcomes. These results underscore the importance of individualized ICP and cerebral perfusion pressure targets guided by autoregulation metrics. Other modalities such as near-infrared spectroscopy have also shown promise. Venkateswaran et al. reported that patients with malignant CVT had lower ipsilateral regional cerebral oxygen saturation, which improved significantly after decompressive craniectomy,[6] highlighting another window into monitoring real-time cerebral physiology in these patients. These data suggest that multimodal neuromonitoring is no longer a research-only concept, but increasingly a cornerstone in intensive care management of CVT. Its omission from an otherwise comprehensive review overlooks a significant evolution in CVT care paradigms. Second, while the review appropriately emphasizes anticoagulation as the cornerstone of treatment, it lacks a dedicated discussion on ICP management, which remains a parallel therapeutic priority. Raised ICP is a central feature of CVT pathophysiology and contributes substantially to morbidity and mortality. A tiered management algorithm is often employed, especially in neurocritical care settings. The importance of early decompressive surgery is further emphasized by the meta-analysis cited by the author,[7] which found that urgent craniectomy within 48 h of CVT diagnosis improved both survival and functional outcomes. These results reinforce the need to view ICP not merely as a complication but as a coprimary treatment target alongside anticoagulation. This is even more important, considering that neuromonitoring and ICP management are synergistic, not mutually exclusive. Neuromonitoring informs the trajectory and response to ICP-lowering interventions, facilitates timely escalation of care, and provides prognostic insight, thus completing the loop of personalized neurocritical care in CVT. In conclusion, we once again congratulate the author on a timely and well-articulated review of CVT. To enhance comprehensiveness and relevance to current practice, we propose that future reviews incorporate the expanding role of multimodal neuromonitoring, and a structured, tiered approach to ICP management. Author contributions Concept and design: PS and AR; Drafting the original manuscript: PS; Critical Revision: AR. Ethical policy and institutional review board statement Not applicable. Data availability statement Data sharing is not applicable to this article as no datasets were generated and/or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.