MENA Regional Endovascular Intervention for Venous Cerebral Venous Sinus Thrombosis (REVIVE-CVST)

REVIVE-CVST: A Multicenter, Prospective, Randomized, Open-Label, Blinded-Endpoint (PROBE) Trial of Endovascular Thrombectomy Plus Standard Medical Care Versus Standard Medical Care Alone in Adults With Acute or Subacute Cerebral Venous Sinus Thrombosis at High Risk of Poor Outcome in the Middle East and North Africa Region

REVIVE-CVST is a multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) trial evaluating whether early endovascular thrombectomy (EVT) combined with standard anticoagulation improves outcomes compared to anticoagulation alone in patients with severe cerebral venous sinus thrombosis (CVST).

The study targets adult patients (aged 18 years or older) presenting within 14 days of symptom onset with imaging-confirmed CVST and at least one severity marker, such as a Glasgow Coma Scale score of 14 or below, intracerebral hemorrhage, venous infarction, or deep venous system involvement.

Participants will be randomly assigned in a 1:1 ratio to either the intervention arm (EVT plus anticoagulation) or the control arm (anticoagulation alone). The primary endpoint is functional outcome at 180 days as measured by the modified Rankin Scale (mRS), using a shift analysis across all mRS categories.

The trial aims to enroll 440 participants across approximately 15 centers in the Middle East, North Africa, South Asia, and Turkey (MENA-SINO network). The study duration is approximately 42 months, including 18 months of enrollment and 12 months of follow-up for the last enrolled patient.

Study Overview

• Status: Not yet recruiting
• Conditions: Cerebral Venous Sinus Thrombosis
• Intervention / Treatment: Procedure: Endovascular Thrombectomy; Drug: Anticoagulation Therapy

Detailed Description

BACKGROUND: Cerebral venous sinus thrombosis (CVST) accounts for approximately 0.5-1% of all strokes and disproportionately affects younger patients, particularly women. While anticoagulation remains the standard of care, approximately 15% of patients experience poor outcomes despite treatment. Endovascular thrombectomy (EVT) has emerged as a potential adjunctive therapy for severe CVST, but high-quality evidence from randomized controlled trials is lacking, particularly from the Middle East, North Africa, and South Asia regions where CVST prevalence may be higher.

STUDY DESIGN: This is a multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) trial. Participants are randomized 1:1 to either EVT plus anticoagulation (intervention) or anticoagulation alone (control). Randomization is stratified by site and presence of intracerebral hemorrhage.

INTERVENTION ARM: Patients receive endovascular thrombectomy using mechanical thrombectomy devices, aspiration catheters, or balloon-assisted techniques, performed within 24 hours of randomization. All patients also receive standard anticoagulation therapy.

CONTROL ARM: Patients receive standard anticoagulation therapy alone, consisting of intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin, followed by oral anticoagulation for 3-12 months per guidelines.

FOLLOW-UP: Assessments are conducted at 30 days, 90 days, and 180 days post-randomization. The primary endpoint assessment occurs at 180 days. Follow-up includes clinical assessments (mRS, NIHSS), quality of life measures (EQ-5D-5L), and imaging at 90 days.

STATISTICAL ANALYSIS: The primary analysis uses ordinal logistic regression (shift analysis) of the mRS at 180 days. The study is powered at 80% to detect a common odds ratio of 1.5 with a two-sided alpha of 0.05, requiring 440 participants (220 per arm) including a 10% attrition allowance.

SAFETY: An independent Data Safety Monitoring Board (DSMB) will conduct interim analyses after enrollment of 25%, 50%, and 75% of participants. Pre-specified stopping rules are based on the Haybittle-Peto boundary.

• Study Type: Interventional
• Enrollment (Estimated): 440
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Egypt
  • Alexandria, Egypt
    • Alexandria University, Smouha Comprehensive Stroke Center
    • Contact: Ossama Mansour, MD, PhD; Phone Number: +20-3-4282929; Email: ossama.mansour@alexmed.edu.eg
  • Cairo, Egypt
    • Cairo University
  • Cairo, Egypt
    • Ain Shams University
  • Cairo, Egypt
    • Neurology Department, Al-Azhar University
• Jordan
  • Amman, Jordan
    • Amman Specialized IR Center
• Morocco
  • Rabat, Morocco
    • Centre Hospitalier Universitaire Ibn Sina de Rabat
• Pakistan
  • Karachi, Pakistan
    • Aga Khan University
• Qatar
  • Doha, Qatar
    • Weill Cornell Medicine-Qatar
• Saudi Arabia
  • Abhā, Saudi Arabia
    • King Khalid University
  • Jeddah, Saudi Arabia
    • King Abdulaziz Medical City
  • Mecca, Saudi Arabia
    • King Abdullah Medical City
• Tunisia
  • Tunis, Tunisia
    • Institut National de Neurologie
• Turkey (Türkiye)
  • Eskişehir, Turkey (Türkiye)
    • Department of Neurology, Eskisehir Osmangazi University
  • Istanbul, Turkey (Türkiye)
    • Neurology Department, Dr. Lutfi Kirdar City Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 18-65 years, inclusive
• Radiologically confirmed cerebral venous sinus thrombosis (CVST) by CT venography (CTV), MR venography (MRV), or digital subtraction angiography (DSA), with thrombosis of at least one major dural sinus
• Acute or subacute presentation with symptom onset within 21 days of randomization
• MRI phase characterization confirming acute or subacute phase
• At least one risk factor for poor outcome: symptoms of intracranial hypertension (severe headache, papilledema, visual obscurations), focal neurological deficit, seizures, altered consciousness (GCS 9-14), intracranial hemorrhage from venous congestion, or deep venous system thrombosis
• Significant venous outflow obstruction on imaging
• Written informed consent from patient or legally authorized representative

Exclusion Criteria:

• Isolated cortical vein thrombosis without dural sinus involvement
• Isolated cavernous sinus thrombosis
• Chronic-phase CVST on MRI phase characterization
• Pre-morbid modified Rankin Scale (mRS) score greater than 2
• Glasgow Coma Scale (GCS) score less than 9 at randomization
• Imminent risk of transtentorial herniation requiring emergent decompressive craniectomy
• Massive cerebral edema with midline shift greater than 10 mm requiring surgical intervention
• Active systemic bleeding or hemorrhagic diathesis
• Severe allergy to iodinated contrast media
• CVST secondary to active hematological malignancy or life expectancy less than 12 months
• Pregnancy
• Participation in another interventional clinical trial within 30 days
• Any condition rendering the patient unsuitable for study participation per investigator judgment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Endovascular Thrombectomy Plus Anticoagulation; Participants in this arm will receive endovascular thrombectomy (EVT) within 24 hours of randomization, in addition to standard anticoagulation therapy. EVT techniques may include mechanical thrombectomy, aspiration thrombectomy, or balloon-assisted techniques at the discretion of the treating interventionalist. Standard anticoagulation consists of intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin, followed by oral anticoagulation for 3-12 months per guidelines.	Procedure: Endovascular Thrombectomy; Endovascular thrombectomy (EVT) performed within 24 hours of randomization. Techniques include mechanical thrombectomy using stent retrievers, aspiration thrombectomy, balloon-assisted thrombectomy, or a combination approach at the discretion of the treating neurointerventionalist. The procedure is performed under general anesthesia or conscious sedation via femoral venous access with navigation to the affected cerebral venous sinus.; Drug: Anticoagulation Therapy; Standard anticoagulation therapy consisting of intravenous unfractionated heparin (UFH) or subcutaneous low-molecular-weight heparin (LMWH) during the acute phase, followed by oral anticoagulation with warfarin (target INR 2.0-3.0) or direct oral anticoagulants (DOACs) for 3-12 months as per current AHA/ASA and ESO guidelines. Both arms receive this intervention.
Active Comparator: Anticoagulation Alone; Participants in this arm will receive standard anticoagulation therapy alone. Treatment consists of intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin during the acute phase, followed by oral anticoagulation (warfarin or direct oral anticoagulants) for 3-12 months as per current guidelines. No endovascular intervention will be performed.	Drug: Anticoagulation Therapy; Standard anticoagulation therapy consisting of intravenous unfractionated heparin (UFH) or subcutaneous low-molecular-weight heparin (LMWH) during the acute phase, followed by oral anticoagulation with warfarin (target INR 2.0-3.0) or direct oral anticoagulants (DOACs) for 3-12 months as per current AHA/ASA and ESO guidelines. Both arms receive this intervention.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Proportion of patients achieving functional independence (mRS 0-2) at 12 months	The primary efficacy endpoint is the proportion of patients achieving a modified Rankin Scale (mRS) score of 0-2 at 12 months after randomization, assessed by a blinded central adjudication committee. The mRS is a 7-point disability scale ranging from 0 (no symptoms) to 6 (death). A score of 0-2 indicates functional independence.	12 months after randomization

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Venous sinus recanalization rate at Day 7	Proportion of patients achieving partial or complete recanalization of the affected venous sinuses at Day 7, assessed by CT venography (CTV) or MR venography (MRV). Recanalization is graded as no recanalization, partial recanalization, or complete recanalization by a blinded central imaging core lab.	7 days after randomization
Modified Rankin Scale (mRS) ordinal shift analysis	Ordinal shift analysis of the full modified Rankin Scale (mRS) distribution at 6 and 12 months, comparing the distribution of scores between the two treatment arms using ordinal logistic regression. The mRS ranges from 0 (no symptoms) to 6 (death).	6 and 12 months after randomization
All-cause mortality	All-cause mortality at 30 days and 12 months after randomization.	30 days and 12 months after randomization
Time to clinical improvement	Time from randomization to clinical improvement, defined as a reduction of 2 or more points on the National Institutes of Health Stroke Scale (NIHSS) or discharge from hospital, whichever occurs first.	Up to 12 months after randomization
Health-related quality of life (EQ-5D-5L)	Health-related quality of life assessed using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) instrument at 6 and 12 months after randomization. The EQ-5D-5L measures health across five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.	6 and 12 months after randomization
Cognitive function (Montreal Cognitive Assessment)	Cognitive function assessed using the Montreal Cognitive Assessment (MoCA) at 6 and 12 months after randomization. The MoCA is a 30-point screening tool for mild cognitive dysfunction, with scores ranging from 0 to 30. Higher scores indicate better cognitive function; a score of 26 or above is considered normal.	6 and 12 months after randomization
Seizure frequency	Frequency and type of seizures (focal or generalized) occurring during the follow-up period, documented at each study visit.	Up to 12 months after randomization

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Safety composite: sICH and major procedural complications (co-primary safety endpoint)	Co-primary safety endpoint comprising: (1) symptomatic intracranial hemorrhage (sICH) within 72 hours, defined as new or worsening hemorrhage on imaging with clinical deterioration (increase of 4 or more points on NIHSS); and (2) major procedural complications within 30 days, including vessel perforation, dissection, or device-related events requiring intervention.	72 hours (sICH) and 30 days (procedural complications) after randomization

Collaborators and Investigators

• Sponsor: Middle East North Africa Stroke and Interventional Neurotherapies Organization

Study record dates

Study Major Dates

• Study Start (Estimated): July 1, 2026
• Primary Completion (Estimated): January 1, 2029
• Study Completion (Estimated): January 1, 2030

Study Registration Dates

• First Submitted: April 16, 2026
• First Submitted That Met QC Criteria: April 16, 2026
• First Posted (Actual): April 23, 2026

Study Record Updates

• Last Update Posted (Actual): April 23, 2026
• Last Update Submitted That Met QC Criteria: April 16, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: anticoagulation; endovascular thrombectomy; CVST
• Additional Relevant MeSH Terms: Therapeutics; Bridge Therapy; Anticoagulation Bridge
• Other Study ID Numbers: MENASINO-REVIVE-2026-01

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No