Hatim Attar, MD

Zuurbier SM, Hiltunen S, Lindgren E, Silvis SM, Jood K, Devasagayam S, et al. Cerebral Venous Thrombosis in Older Patients. Stroke. 2018

Although uncommon, cerebral venous thrombosis (CVT) is an established cause of stroke and is often skipped on initial diagnostics. Understanding the patient profile and high-risk clinical features would definitely allow physicians to maintain a higher index of suspicion. Authors Zuurbier et al have sought to do that: define patient population characteristics and contrast them in old and young patients. This becomes increasingly relevant with the ever expanding geriatric population and the differences across the age groups identified by this study.

Patients were pooled into a registry supported by 5 major academic centers of consecutive CVTs, totaling 843 patients. Comparisons were drawn for demographics, clinical manifestations and outcomes. The uppermost quartile for age distribution was the older patients group, age > 55 (n= 222), while the lower three quartiles were clubbed together for the younger patients, age < 55 (n= 621). While most patients aged < 55 were women (71%), the gender disparity did not exist in the older patients.

Amongst the clinical symptoms from CVT, headaches retained the majority among both age groups. However, the report of headache at presentation was not as common in the older patients (62.9%) as compared with the younger patients (87.4%). The remainder of symptoms like neurological deficits, seizures or coma were not significantly different. Another notable difference between the age groups was increased use of hormonal therapy in the older patients. Lastly, history of cancer was markedly more in the older patients, 24.4% vs. 9.3% in the younger group of patients. Of the total number of patients with cancer, half of them (52/111) had the diagnosis of cancer at CVT detection, and 35/52 were diagnosed within a year of CVT. It is interesting that this association was noted with solid tumors, not with hematological malignancies. The risk of poor outcome, defined as a modified Rankin Scale 3-6, was increased in patients aged >55 years, adjusted odds ratio 2.68.

This study has focused on key differences in CVT etiology, presentation and prognosis across different age groups. The gender representation equalized over aged 55 is expected with decrease in female hormonal effects. A major differentiating factor between the groups is incidence of cancer, which is the largest risk factor in the elderly population – specifically solid tumor. Not unexpected, as cancer is known to cause hypercoagulable states and is frequently associated with deep venous thromboses and pulmonary embolism. The only other comparable study is the post hoc analysis of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). The results of both are consistent; both relay the decreased incidence of headaches in the aged. The mortality rate was higher in the ISCVT population, 27% vs. 13% in this study. To explain this discrepancy, the authors point out that ISCVT had the older population defined over age 65, and several newer treatment options have been developed since ISCVT, like decompressive surgery. The changing practices and improved treatment options have decreased mortality and improved outcomes.

Although this study reviewed patient characteristics, certain key points need to be addressed. The locations of the depicted patient profile were the Netherlands, Finland, Australia, Canada, and Sweden. All of these countries have some form of universal healthcare. These systems encourage individuals to seek preventive healthcare services that facilitate lifestyle modification disease prevention strategies, thereby making this patient subset different from the U.S. patient population – who often present late with more severe co-morbidities. Additionally, the demographics and ethnic profile of U.S. patients is different.

This study has thrown light on the varying clinical presentations of CVT across different ages. A diagnosis of CVT often hinges on the sneaking suspicions of providers. This study provides evidence that the commonly associated symptomatology such as headaches are not always present, and their absence should not eliminate them from the differential.

CVT diagnosis and management is definitely being evaluated more closely, right from identifying genes and biomarkers for diagnosis, to evaluating patients for decompressive surgery. New directions do warrant mention of TO-ACT, evaluating efficacy and safety of endovascular treatment, duration of anticoagulation in EXCOA-CVT, as well as efficacy and safety of NOACs in RE-SPECT. By redefining clinical characteristics and patient profiles, this paper has benefited clinicians who would be able to better evaluate patients and triage them appropriately for early management and consideration for advanced therapies.