From the Guidelines
Isolated cortical venous thrombosis should be treated with anticoagulation, typically involving low molecular weight heparin or unfractionated heparin, followed by oral anticoagulation with warfarin or direct oral anticoagulants for 3-6 months, as this approach has been shown to improve outcomes and reduce the risk of permanent neurological deficits 1.
Treatment Approach
The treatment of isolated cortical venous thrombosis involves anticoagulation to prevent the propagation of the thrombus and to reduce the risk of recurrent venous thromboembolism.
- Anticoagulation with low molecular weight heparin (such as enoxaparin 1mg/kg twice daily) or unfractionated heparin (targeting aPTT 1.5-2.5 times normal) is recommended as the initial treatment.
- Oral anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants like rivaroxaban (15-20mg daily) can be used for long-term anticoagulation.
Supportive Care
Supportive care is crucial in the management of isolated cortical venous thrombosis, including:
- Managing increased intracranial pressure with elevation of the head of bed, adequate hydration, and possibly osmotic agents like mannitol or hypertonic saline if needed.
- Seizure prophylaxis with levetiracetam (500-1000mg twice daily) is recommended for patients who present with seizures.
Clinical Considerations
The condition results from hypercoagulable states, infections, inflammatory conditions, or trauma causing clot formation in cortical veins, leading to venous congestion, localized edema, and potential hemorrhagic transformation.
- Prompt diagnosis and treatment are essential as early intervention significantly improves outcomes and reduces the risk of permanent neurological deficits.
- In cases with severe symptoms or clinical deterioration despite anticoagulation, endovascular thrombolysis or thrombectomy may be considered 1.
From the Research
Clinical Presentation
- Isolated cortical venous thrombosis (ICoVT) is a rare condition with non-specific clinical presentations, making it challenging to diagnose 2, 3.
- The most common symptoms are headache, seizures, and focal neurological deficits, with headache and seizures being the most common presentations 4, 3, 5.
- Papilledema is not commonly reported, and increased cerebrospinal fluid pressure is rare 4.
- Infection, pregnancy or puerperium, and oral contraceptive use are common risk factors, especially in women 4.
Diagnosis
- MRI techniques are essential in the diagnosis of ICoVT, with susceptibility-weighted imaging (SWI) being a sensitive imaging technique 3, 5.
- CT cord sign and filling defects on contrast-enhanced CT can also be used to diagnose ICoVT, but are less sensitive than MRI 3.
- A high index of clinical suspicion and a thorough understanding of neurovascular anatomy are required to diagnose this rare entity 3.
Treatment and Outcome
- Correction of predisposing factors for venous thrombosis and anticoagulation is the therapy of choice for most patients 2.
- Direct oral anticoagulants (DOACs) have similar efficacy and safety compared to vitamin K antagonists (VKAs) in the treatment of cerebral venous thrombosis, including ICoVT 6.
- Anticoagulation therapy can lead to complete resolution of symptoms in most patients 5.
- The overall prognosis with adequate and timely therapy is very good, with a low in-hospital mortality rate 2, 4.