To the Editor:

In response to the article by Razier and DeAngelis,1 I was pleasantly surprised that the authors covered such a significant complication seen in cancer patients succinctly. Unfortunately, in their study of 20 patients identified retrospectively (9 with hematologic and 11 with solid tumors), no mention was made of those patients with primary CNS tumors who also possibly harbored cerebral sinus thrombosis (CST). The incidence of hypercoagulable states in patients with high-grade glioma2 and meningioma3 has been previously recognized. In those patients with primary CNS tumors, early diagnosis of CST by MRI and MR venography is very important, as it may determine the necessity for a surgical option prior to medical management of the CST. MRI and MR venography can noninvasively detail the site of CST and identify important collateral venous circulation and venous flow dynamics, which are critical in formulating therapeutic options (whether surgical or medical). The surgical resection of a parasagittal, falx meningioma or a metastatic solid tumor that has precipitated a CST can effectively remove the compressive mechanism immediately and reduce or prevent the occurrence of intracranial hypertension or venous infarction. Patients with meningioma (at presentation or recurrent) adjacent to a major cerebral sinus can be offered surgical resection with adjuvant stereotactic radiosurgery for residual tumor for control of local disease. However, tumor invasion of the sinus, as identified by MRI and MR venography, may require sacrifice of the involved sinus itself.

The authors are to be congratulated for their review; however, the noninclusion of primary CNS tumors (or other CNS diseases that may predispose to CST) by such a wealthy neurologic database needs to be addressed in this important and timely review.