Decompressive craniectomy for cerebral venous thrombosis

To the Editor

We read with great interest the recent article by Richard et al. [1], in which the authors presented a case of cerebral venous thrombosis (CVT) due to essential thrombocythemia and worsened by heparin-induced thrombocytopenia and thrombosis. The authors successfully treated the patient by the discontinuance of heparin and the administration of danaparoid. However, the patient underwent decompressive craniectomy for progression of intracranial hypertension and improved.

We would like to comment on the treatment strategies of refractory CVT. Decompressive craniectomy was reported to be useful as an additional therapeutic method for refractory CVT [2]. We previously reported a case of refractory CVT associated with thrombocythemia [3]. Despite treatment with intravenous heparin, oral warfarin, and local thrombolysis, the patient's high intracranial pressure (ICP) continued. At that time, we considered that decompressive craniectomy might be useful to decrease ICP. However, cerebral angiography revealed prominent collateral venous systems draining into the dura, skull, and scalp. As we considered that craniectomy might cause aggravation of the patient due to injury to important draining systems to the dura, skull, or scalp, the patient was instead treated with barbiturate coma therapy and continuous spinal drainage. Developing collateral venous systems and draining to the skull or the scalp may be observed in cases of CVT [4]. Decompressive craniectomy should be performed in an area free from collateral draining veins because compromising these veins can result in serious sequelae. We suppose that decompressive craniectomy without evaluation of cerebral circulation may be hazardous. If possible, we suggest that patients of refractory CVT should be evaluated for collateral venous systems draining to the dura, skull, or scalp prior to craniectomy.