PONE-D-23-36251Factors associated with venous collaterals in patients with cerebral venous thrombosisPLOS ONE

Dear Dr. Korathanakhun,

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Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Authors,

Please find the reviewers comment and address these issues before we reconsider for publication.

Reviewer 1

The authors present a study on venous collaterals in VST. The paper is fairly novel and interesting study, although the paper is limited by small sample size, retrospective nature, not uniform approach to assessing collaterals. The discussion is well-written, although some portions such as the introduction need to be clearly written. I have several specific comments below:

In abstract, ensure that similar decimal places are used throughout (needs to be consistent)

Line 33 – the authors should be more specific, ie. In a cohort of patients with CVT, the frequency of collateral was …

Line 38 – would rephrase this, many would not consider VST a type of stroke.

Line 39 – this is redundant and out of place, please omit

Line 45 – should say that it can lead to hemorrhage.

Line 57 – the authors need to clearly state why this study is being done, despite so many prior studies on VST and collaterals. What is unique about this study? What are the knowledge gaps and how does this study seek to fulfill the gap?

Line 65 – why not CTV?

Line 85 – needs reference

Line 156 – please include frequency of patients with collaterals as well

- Why was malignancy not included as a risk factor?

- Was traumatic VST included? If not, the authors should clarify these are spontaneous

- Was is the interrater reliability of grading these collaterals?

- Not using gold standard uniform imaging in all patients should also be listed as limitation. For example, it likely easier to see collateral on DSA vs MRI.

Reviewer 2

Thank you very much for your submission to the PLOS ONE journal. This descriptive study sought to determine clinical and radiologic factors associated with the presence of venous collaterals in patients with cerebral venous thrombosis. I was impressed that you carried out a 20-year retrospective study to collect data for several different variables about 79 patients diagnosed with cerebral venous thrombosis (20 with venous collaterals and 59 without). Based on this, you determined that patients with venous collaterals were more likely to have CVT located in the superior sagittal sinus, and more likely to have had hormonal exposure. Overall, I found that your study was thorough, your methodology and data analyses sound, and your manuscript well-organized and clearly written. I believe that your manuscript could benefit from some revisions particularly to strengthen your discussion prior to resubmitting. Please find below some of my suggestions for your consideration.

Major comments

1. Your study describes some differences between patients with venous collaterals and those without, although you also mention how both the presentation and clinical outcomes in these two groups are not significantly different. May you elaborate on the clinical significance of the factors you identified as different between your two groups? How do you foresee the findings from your study being applied by neuroradiologists and neurologists evaluating patients with suspected or confirmed CVT?

2. You mention that the prevalence of venous collaterals in your population was much lower than that seen in previous studies, including a study that used the same classification system as your study (the Qureshi classification) but found a prevalence of 88% (versus 25% in your study). Are there specific differences between the characteristics of your populations that would be expected to account for such a major difference in prevalence, or how can we best reconcile these differences?

Thank you.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors present a study on venous collaterals in VST. The paper is fairly novel and interesting study, although the paper is limited by small sample size, retrospective nature, not uniform approach to assessing collaterals. The discussion is well-written, although some portions such as the introduction need to be clearly written. I have several specific comments below:

In abstract, ensure that similar decimal places are used throughout (needs to be consistent)

Line 33 – the authors should be more specific, ie. In a cohort of patients with CVT, the frequency of collateral was …

Line 38 – would rephrase this, many would not consider VST a type of stroke.

Line 39 – this is redundant and out of place, please omit

Line 45 – should say that it can lead to hemorrhage.

Line 57 – the authors need to clearly state why this study is being done, despite so many prior studies on VST and collaterals. What is unique about this study? What are the knowledge gaps and how does this study seek to fulfill the gap?

Line 65 – why not CTV?

Line 85 – needs reference

Line 156 – please include frequency of patients with collaterals as well

- Why was malignancy not included as a risk factor?

- Was traumatic VST included? If not, the authors should clarify these are spontaneous

- Was is the interrater reliability of grading these collaterals?

- Not using gold standard uniform imaging in all patients should also be listed as limitation. For example, it likely easier to see collateral on DSA vs MRI

Reviewer #2: Thank you very much for your submission to the PLOS ONE journal. This descriptive study sought to determine clinical and radiologic factors associated with the presence of venous collaterals in patients with cerebral venous thrombosis. I was impressed that you carried out a 20-year retrospective study to collect data for several different variables about 79 patients diagnosed with cerebral venous thrombosis (20 with venous collaterals and 59 without). Based on this, you determined that patients with venous collaterals were more likely to have CVT located in the superior sagittal sinus, and more likely to have had hormonal exposure. Overall, I found that your study was thorough, your methodology and data analyses sound, and your manuscript well-organized and clearly written. I believe that your manuscript could benefit from some revisions particularly to strengthen your discussion prior to resubmitting. Please find below some of my suggestions for your consideration.

Major comments

1. Your study describes some differences between patients with venous collaterals and those without, although you also mention how both the presentation and clinical outcomes in these two groups are not significantly different. May you elaborate on the clinical significance of the factors you identified as different between your two groups? How do you foresee the findings from your study being applied by neuroradiologists and neurologists evaluating patients with suspected or confirmed CVT?

2. You mention that the prevalence of venous collaterals in your population was much lower than that seen in previous studies, including a study that used the same classification system as your study (the Qureshi classification) but found a prevalence of 88% (versus 25% in your study). Are there specific differences between the characteristics of your populations that would be expected to account for such a major difference in prevalence, or how can we best reconcile these differences?

Thank you again for your submission and I hope that my comments will be helpful to your group.

**********

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Reviewer #1: Yes: Alvin Das

Reviewer #2: No

**********

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Factors associated with venous collaterals in patients with cerebral venous thrombosis

PONE-D-23-36251R1

Dear Dr. Korathanakhun,

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Kind regards,

Suraj Shrestha, MBBS, DiMM

Academic Editor

PLOS ONE

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