title: Decompressive surgery for malignant cerebral venous sinus thrombosis: a retrospective case series from Pakistan and comparative literature review.
abstract: BACKGROUND
  Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke in the West; however, it is prevalent in Asia and the Middle East. CVST is treated with dose-adjusted heparin or heparinoid followed by warfarin to facilitate recanalization of venous sinuses. For those with progressive malignant cerebral edema, the role of decompressive surgery has been reported from developed countries. We present data on decompressive craniectomy from a tertiary care stroke center in a developing country and compare our results and population with that described in the international literature.
  
  
  METHODS
  We retrospectively analyzed data of all patients who underwent a decompressive hemicraniectomy for CVST at the Aga Khan University Hospital, Karachi, Pakistan from 1999 till 2011. A record review of the Aga Khan University Hospital was performed as decompressive hemicraniectomy for malignant CVST is not being performed elsewhere in the country and the hospital is a major referral center. Using the International Classification of Diseases, Ninth Edition codes for CVST, we identified a total of 7 patients. Patients are presented along with descriptions of their presentation, neuroimaging, intraoperative findings, and long-term outcomes. Pearson chi-square test was done to identify features that predicted survival. A comparative literature review was also done through PubMed to identify all other reports of surgery for CVST.
  
  
  RESULTS
  During a 12-year review, 134 patients were diagnosed with CVST. Of these, 7 received intervention. The age range of the patients was 15-60 years. Four of the 7 patients had an excellent outcome, 2 of 7 died, and 1 of 7 left against medical advice (in a comatose state) and was lost to follow-up. Patients presented alert but progressively deteriorated preoperatively. All those patients who had preoperative reactive pupils with low Glasgow Coma Scale scores made a complete neurologic recovery, and patients with fixed, dilated, and nonreactive pupils preoperatively died in the first postoperative week (P = .05).
  
  
  CONCLUSIONS
  Patients who received decompressive hemicraniectomy in Pakistan for CVST had excellent outcomes in all cases when intervention was performed with intact preoperative pupillary reflexes. Of the data reviewed, most reported (two-third) patients show the same prognosticators; however, one third show that even with nonreactive pupils complete recovery is possible.
authors.affiliation: Medical College, Aga Khan University, Karachi, Pakistan.
authors.forename: Emmon
authors.initials: E
authors.lastname: Raza
authors.affiliation: Neurosurgery Section, Department of Surgery, Aga Khan University, Karachi, Pakistan.
authors.forename: Muhammad Shahzad
authors.initials: MS
authors.lastname: Shamim
authors.affiliation: Neurovascular Clinical Fellowship, The International Cerebrovascular Translational Clinical Research Training Program, Stroke Service, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan.
authors.forename: Muhammad Faisal
authors.initials: MF
authors.lastname: Wadiwala
authors.affiliation: Epidemiology and Biostatistics, Aga Khan University, Karachi, Pakistan.
authors.forename: Bilal
authors.initials: B
authors.lastname: Ahmed
authors.affiliation: Stroke Service, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan. Electronic address: ayeesha.kamal@aku.edu.
authors.forename: Ayeesha Kamran
authors.initials: AK
authors.lastname: Kamal
mesh_terms: D000293:Adolescent; D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D056424:Decompressive Craniectomy / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D059906:Neuroimaging; D019635:Neurosurgical Procedures / Q000379:methods*; D010154:Pakistan; D010291:Paresis / Q000209:etiology; D012189:Retrospective Studies; D012851:Sinus Thrombosis, Intracranial / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000925:Anticoagulants
keywords: Cerebral venous sinus thrombosis; blood disorders; decompressive hemicraniectomy; developing countries; stroke