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PRIORITY-CVT

Early Recanalization in Patients With Cerebral Venous Thrombosis Treated With Anticoagulation

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Year of Publication: 2020

Authors: Diana Aguiar de Sousa, MD; Lia Lucas Neto, MD, ..., PhD; José M. Ferro

Journal: Stroke

Citation: Stroke. 2020;51:1174-1181.

Link: https://doi.org/10.1161/STROKEAHA.119.028532

PDF: https://www.ahajournals.org/doi/reader/1...EAHA.119.028532

Clinical Question

In patients with acute cerebral venous thrombosis (CVT) treated with standard anticoagulation, what is the rate of early venous recanalization, and is it associated with the evolution of brain lesions and clinical outcomes?

Bottom Line

In this prospective cohort study of CVT patients, venous recanalization began within 8 days of starting anticoagulation in the majority of patients (74%). Early recanalization was associated with a significantly lower risk of nonhemorrhagic lesion progression and a higher chance of lesion regression. However, early recanalization status was not significantly associated with headache persistence or functional outcome at 90 days.

Major Points

  • PRIORITY-CVT was a multicenter, prospective cohort study including 68 patients with newly diagnosed CVT treated with standard anticoagulation.
  • At an early follow-up (day 8), 74% of patients had achieved at least partial recanalization of the thrombosed vessels.
  • Early recanalization was associated with a significantly lower risk of worsening of nonhemorrhagic lesions (OR, 0.11; P=0.023) and a higher likelihood of lesion improvement (OR, 8.40; P=0.028).
  • Reversal of venous infarction (lesions with cytotoxic edema) was observed in 83% of surviving patients, and all of these patients had shown early venous recanalization.
  • There was no significant association between early recanalization and the progression of hemorrhagic lesions, persistence of headache, or functional outcome at 90 days.

Design

Study Type: Multicenter, prospective, cohort study.

Randomization:

Blinding: Not applicable (prospective cohort study).

Enrollment Period: May 2014 to April 2018.

Follow-up Duration: 90 days.

Centers: 5

Countries: Portugal, Mexico

Sample Size: 68

Analysis: Prospective cohort analysis with standardized imaging and clinical assessments at baseline, day 8, and day 90.

Inclusion Criteria

  • Adult patients (aged ≥18 years) with a new diagnosis of CVT confirmed by imaging.
  • Enrollment within 24 hours of starting therapeutic anticoagulation.

Exclusion Criteria

  • Medical comorbidities with high risk of short-term death.
  • Other intracranial conditions hindering analysis (e.g., brain tumors).
  • Contraindication to anticoagulant therapy.
  • Patients undergoing any type of endovascular intervention.
  • Contraindication to MRI assessment.

Baseline Characteristics

CharacteristicControlActive
Age (mean)40 (±14) years
Female (%)82%
...Not applicable, single-arm cohort study.
Headache at presentation (%)94%
Parenchymal lesions at baseline (%)44%
Parenchymal hemorrhage at baseline (%)29%
Venous infarction at baseline (%)19%
Stupor or coma at baseline (%)7%

Arms

FieldStandard Anticoagulation
InterventionTherapeutic anticoagulation with heparin (low-molecular-weight heparin or unfractioned heparin) started at diagnosis, followed by oral anticoagulation (primarily vitamin K antagonists).
DurationAt least 90 days.

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Early worsening of nonhemorrhagic lesion, defined as enlargement of a baseline lesion or development of a new lesion on MRI at day 8. This analysis compares patients who achieved early recanalization versus those who did not.Primary63% (5/8) [in patients with no early recanalization]16% (3/19) [in patients with early recanalization]0.110.023
Early improvement of non-hemorrhagic lesion at day 8Secondary25% (2/8) [in patients with no early recanalization]74% (14/19) [in patients with early recanalization]OR 8.400.028
Favorable functional outcome (mRS 0-1) at 90 daysSecondary74% [in patients with partial or no recanalization]85% [in patients with full recanalization]OR 2.00.30
Headache at 90 daysSecondary42% [in patients with partial or no recanalization]42% [in patients with full recanalization]No significant difference
Unfavorable functional outcome (mRS > 1) at 90 daysAdverse26% [in patients with partial or no recanalization]15% [in patients with full recanalization]OR 2.00.30

Subgroup Analysis

Younger age was significantly associated with achieving early recanalization (OR, 0.62 per 10-year increase; P=0.035).

Criticisms

  • The most severe clinical presentations of CVT were likely underrepresented due to the exclusion of medically unstable patients unable to undergo acute MRI.
  • Early imaging reassessment at day 8 was not possible in 7% of the included patients.
  • There was a lack of information on the time in therapeutic range for patients treated with vitamin K antagonists.
  • The 8-day time point for early assessment was arbitrarily defined.

Funding

Fundação AstraZeneca-Faculdade de Medicina Universidade de Lisboa and D. Manuel de Mello grant, Fundação Amélia de Mello.

Based on: PRIORITY-CVT (Stroke, 2020)

Authors: Diana Aguiar de Sousa, MD; Lia Lucas Neto, MD, ..., PhD; José M. Ferro

Citation: Stroke. 2020;51:1174-1181.

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