What is the treatment for venous sinus thrombosis?

Treatment of Venous Sinus Thrombosis

The cornerstone of treatment for venous sinus thrombosis is immediate anticoagulation with heparin or low molecular weight heparin (LMWH), regardless of whether hemorrhagic changes are present. 1

Initial Management

Anticoagulation

• First-line therapy:

  • Intravenous unfractionated heparin OR
  • Subcutaneous low molecular weight heparin (LMWH)
  • Note: Intracranial hemorrhage associated with venous sinus thrombosis is NOT a contraindication to anticoagulation 2

• Transition to oral anticoagulation:

  • Vitamin K antagonists (e.g., warfarin) with target INR 2.0-3.0 1
  • Non-heparin based anticoagulants should be considered if there is concern for heparin-induced thrombocytopenia 2

Monitoring

• Close neurological monitoring during acute phase
• Follow-up imaging with MRV or CTV at 3-6 months to assess recanalization 1

Duration of Anticoagulation

Duration depends on underlying etiology:

• 3 months: If thrombosis is related to a transient risk factor (e.g., infection, pregnancy) 2, 3
• 6-12 months: For idiopathic venous thrombosis or thrombosis associated with "mild" thrombophilia 3
• Lifelong anticoagulation: For patients with:
  • High-risk inherited thrombophilia
  • Recurrent thrombotic events
  • Antiphospholipid antibody syndrome 2, 3

Management of Complications

Intracranial Hypertension

• Therapeutic lumbar puncture for severe headache and papilledema 3
• For persistent symptoms of increased intracranial pressure:
  • Repeated lumbar punctures or
  • Lumboperitoneal shunt 3

Neurological Deterioration

For patients with neurological deterioration despite anticoagulation:

1. Repeat imaging to assess for progression
2. Consider endovascular therapy (with or without mechanical thrombus disruption) in:
   • Severe cases
   • Patients who fail to improve on anticoagulation
   • Note: Local thrombolysis is not useful in patients with large infarcts and impending herniation 2, 3
3. Consider decompressive hemicraniectomy for patients with parenchymal lesions leading to herniation 2, 3

Seizure Management

• Antiepileptic drugs should be prescribed for patients with acute seizures and supratentorial lesions
• Prophylactic use can be considered for patients with supratentorial hemorrhagic lesions or motor deficits 3

Special Considerations

Hemorrhagic Lesions

• Despite traditional concerns, evidence supports that anticoagulation is safe in patients with venous sinus thrombosis even when hemorrhagic lesions are present 2, 4
• However, careful monitoring is essential as rebleeding has been reported in some cases 5

Endovascular Treatment

• Reserved for:
  • Severe cases not responding to anticoagulation
  • Patients with contraindications to anticoagulation
  • Should only be performed in experienced centers 3, 6

Diagnostic Imaging

• MRI with MR venography (MRV) is the preferred imaging modality (sensitivity 92.5%, specificity 100%) 1
• CT with CT venography is a reasonable alternative when MRI is contraindicated or unavailable 1

Pitfalls to Avoid

1. Delaying anticoagulation due to presence of hemorrhagic lesions
2. Relying solely on non-contrast CT for diagnosis (only 30% are abnormal in cerebral venous thrombosis) 1
3. Misinterpreting normal anatomic variants (e.g., asymmetrical lateral sinuses) as thrombosis 1
4. Failing to consider endovascular therapy or decompressive surgery in deteriorating patients despite anticoagulation

The evidence supporting anticoagulation comes from limited trials, but the potential benefits in reducing mortality and dependency outweigh the risks 4. Early recognition and prompt treatment are critical to improve outcomes and reduce morbidity and mortality.