From the Guidelines
Cerebral venous sinus thrombosis (CVST) requires prompt anticoagulation therapy as the primary management approach, with initial treatment typically involving low molecular weight heparin or unfractionated heparin, followed by oral anticoagulation with warfarin or direct oral anticoagulants for at least 3-6 months. The main causes of CVST include prothrombotic conditions, oral contraceptives, pregnancy/puerperium, infections, inflammatory diseases, malignancy, and dehydration 1.
Management Approach
The management of CVST involves:
- Initial anticoagulation with low molecular weight heparin such as enoxaparin 1mg/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
- Transition to oral anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants like rivaroxaban 15-20mg daily for at least 3-6 months
- Consideration of endovascular thrombectomy or thrombolysis for severe cases with neurological deterioration
- Supportive measures including managing increased intracranial pressure with acetazolamide, mannitol, or in extreme cases, decompressive craniectomy
Causes of CVST
The causes of CVST can be categorized into:
- Prothrombotic conditions (Factor V Leiden, protein C/S deficiency, antiphospholipid syndrome)
- Oral contraceptives
- Pregnancy/puerperium
- Infections (particularly of the head and neck)
- Inflammatory diseases
- Malignancy
- Dehydration
Rationale for Anticoagulation
Anticoagulation is effective in preventing further thrombus propagation and allowing for natural thrombolytic processes to dissolve the existing clot, while the extensive collateral venous drainage in the brain often allows for compensation during recovery 1. The use of anticoagulation with heparin or low molecular weight heparin given acutely in the setting of CVT is recommended, regardless of the presence of hemorrhagic conversion 1.
Duration of Anticoagulation
The duration of anticoagulation therapy for CVST is typically at least 3-6 months, with longer periods considered for patients with inherited thrombophilia or unprovoked CVT 1.
From the Research
Causes of Cerebral Venous Sinus Thrombosis (CVST)
- CVST is a rather rare disease that accounts for less than 1% of all strokes 2, 3
- The causes of CVST can be due to various factors, including transient risk factors, idiopathic factors, and hereditary thrombophilia 2, 3, 4
Management of CVST
- Anticoagulation therapy is the current recommended treatment for CVST, which can be achieved through the use of dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH) 5, 2, 3, 4
- Anticoagulant therapy is associated with a potentially important reduction in the risk of death or dependency, although the evidence is limited 5
- Concomitant intracranial hemorrhage related to CVST is not a contraindication for heparin therapy, but the safety of anticoagulant therapy in patients with early intracranial hemorrhage associated with CVST is still uncertain 2, 6, 3
- The optimal duration of oral anticoagulation after the acute phase is unclear, but it may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST, and indefinitely in patients with recurrent episodes of CVST or severe hereditary thrombophilia 2, 3, 4
- Thrombolysis may be a therapeutic option in selected cases, possibly in those without large intracranial hemorrhage and threatening herniation 2, 3, 4
- Symptomatic therapy, including control of seizures and elevated intracranial pressure, is also important in the management of CVST 2, 3, 4
Treatment Options
- Intravenous heparin or subcutaneous low-molecular-weight heparin can be used to prevent thrombus propagation and pulmonary embolism and to increase the chances of recanalization 4
- Endovascular thrombolysis (with or without mechanical thrombus disruption) is an experimental treatment for severe cases or patients who fail to improve on anticoagulation 4
- Local thrombolysis is not useful in patients with large infarcts and impending herniation 4
- Hemicraniectomy may be lifesaving in patients with parenchymal lesions leading to herniation 4
- Antiepileptic drugs should be prescribed in patients with acute seizures and supratentorial lesions, and prophylactic use of these drugs can also be considered for patients with one of these risk factors 4