What is the management of venous sinus thrombosis?

Management of Venous Sinus Thrombosis

Immediate anticoagulation with heparin or low molecular weight heparin (LMWH) is the cornerstone of treatment for venous sinus thrombosis, regardless of the presence of hemorrhagic changes. 1

First-Line Treatment

Anticoagulation

• Initial therapy options:
  • Intravenous unfractionated heparin
  • Subcutaneous low molecular weight heparin (LMWH)
  • Important: Intracranial hemorrhage associated with venous sinus thrombosis is NOT a contraindication to anticoagulation 1
  • Consider non-heparin based anticoagulants if there is concern for heparin-induced thrombocytopenia 1

Duration of Anticoagulation

• Transient risk factors: 3 months 1, 2
• Idiopathic venous thrombosis or mild thrombophilia: 6-12 months 1
• Severe thrombophilia, recurrent events, or antiphospholipid syndrome: Lifelong anticoagulation 1, 2

Management of Complications

Increased Intracranial Pressure

• For severe headache and papilledema: Therapeutic lumbar puncture 2
• For persistent symptoms: Consider repeated lumbar punctures or lumboperitoneal shunt 2

Seizures

• Antiepileptic drugs for:
  • Patients with acute seizures and supratentorial lesions
  • Consider prophylactic use for patients with risk factors 2

Neurological Deterioration Despite Anticoagulation

1. Repeat imaging to assess for progression 1
2. Consider endovascular therapy for severe cases or patients who fail to improve on anticoagulation 1, 2
   • Local thrombolysis with or without mechanical thrombectomy
   • Note: Not useful in patients with large infarcts and impending herniation 1
   • Complete recanalization is not always necessary for good clinical outcomes 3
   • Risk of post-procedural hemorrhage (32% in one study) 4
3. Decompressive hemicraniectomy may be lifesaving in patients with parenchymal lesions leading to herniation 1, 2

Special Considerations

Safety of Anticoagulation with Hemorrhage

While anticoagulation is generally considered safe in venous sinus thrombosis with hemorrhagic lesions, careful monitoring is essential as rebleeding has been reported in some cases 5. The Cochrane review found no new symptomatic intracerebral hemorrhages in patients treated with anticoagulants in the two small trials analyzed 6.

Diagnostic Imaging

• Preferred: MRI with MRV (92.5% sensitivity, 100% specificity) 1
• Alternative: CT with CT venography when MRI is contraindicated or unavailable 1
• Caution: Normal anatomic variants can be misinterpreted as thrombosis 1
• Follow-up imaging: MRV or CTV at 3-6 months to assess recanalization 1

Treatment Algorithm

1. Confirm diagnosis with MRI/MRV or CT/CTV
2. Start anticoagulation immediately (heparin or LMWH)
3. Monitor neurological status closely
4. For patients who deteriorate:
   • Repeat imaging
   • Consider endovascular therapy or decompressive surgery
5. Transition to oral anticoagulation (target INR 2-3.5) for long-term management
6. Determine duration based on underlying etiology and risk factors
7. Follow-up imaging at 3-6 months to assess recanalization

Despite limited evidence from small trials, anticoagulant treatment for cerebral venous sinus thrombosis appears to be safe and is associated with a potentially important reduction in the risk of death or dependency 6.