From the Guidelines
Management of cerebral venous sinus thrombosis (CVST) requires prompt anticoagulation therapy, typically with low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily or unfractionated heparin with an initial bolus of 80 units/kg followed by continuous infusion targeting an aPTT of 1.5-2.5 times normal, as recommended by the most recent guidelines 1. This approach is supported by the latest evidence, which suggests that anticoagulation therapy is beneficial in preventing thrombus propagation and facilitating recanalization, even in patients with hemorrhagic infarction.
Key Considerations
- Anticoagulation should be initiated immediately upon diagnosis, regardless of the presence of hemorrhagic conversion, as it has been shown to improve outcomes 1.
- After initial heparin therapy, transition to oral anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants (DOACs) like rivaroxaban 20 mg daily or apixaban 5 mg twice daily is recommended.
- Anticoagulation should be continued for 3-12 months depending on the underlying cause; lifelong treatment may be necessary for patients with persistent prothrombotic conditions.
- Supportive measures include managing increased intracranial pressure with acetazolamide 250-1000 mg daily in divided doses, adequate hydration, and head elevation.
- For severe cases with impending herniation, osmotic therapy with mannitol or hypertonic saline, or decompressive hemicraniectomy may be necessary.
- Seizure prophylaxis with levetiracetam 500-1000 mg twice daily is often used in patients with parenchymal lesions.
- Endovascular intervention with mechanical thrombectomy or local thrombolysis should be considered in patients deteriorating despite anticoagulation.
- Identifying and treating underlying causes such as infections, autoimmune disorders, or prothrombotic conditions is essential for preventing recurrence, as highlighted in previous guidelines 1.
From the Research
Management of Cerebral Venous Sinus Thrombosis (CVST)
The management of CVST includes:
- Treatment of the underlying condition
- Antithrombotic treatment
- Symptomatic treatment
- Prevention or treatment of complications 2 Antithrombotic treatment options include:
- Intravenous heparin
- Subcutaneous low-molecular-weight heparin (LMWH) 2, 3, 4, 5
- Oral anticoagulant therapy, with a target International Normalized Ratio (INR) of 2-3.5 2, 5
Anticoagulation Therapy
Anticoagulation therapy is recommended for patients with CVST, even in the presence of intracranial hemorrhage 2, 3, 4, 5 The optimal duration of anticoagulation therapy is unclear, but guidelines suggest:
- 3 months for patients with transient risk factors 2, 3, 4
- 6-12 months for patients with idiopathic CVST or mild thrombophilia 2, 3, 4
- Indefinite anticoagulation for patients with severe thrombophilia or recurrent CVST 2, 3, 4
Thrombolysis and Endovascular Treatment
Thrombolysis and endovascular treatment are experimental and should only be considered in severe cases or patients who fail to improve on anticoagulation 2, 3, 4, 5 These treatments may be associated with severe bleeding complications and are not proven to be effective 5
Symptomatic Treatment
Symptomatic treatment options include:
- Control of seizures and elevated intracranial pressure 2, 3, 4
- Anti-epileptic drugs for patients with seizures or at risk of seizures 2, 5
- Decompressive hemicraniectomy for patients with large space-occupying venous infarcts 5
- Treatment of chronic intracranial hypertension with acetazolamide, repeated lumbar punctures, or CSF shunting procedures 5