What is the management and treatment approach for dural venous thrombosis?

Dural Venous Thrombosis Management

Low molecular weight heparin (LMWH) is the first-line treatment for dural venous thrombosis, followed by oral anticoagulation for at least 3-6 months, with consideration for extended therapy in high-risk cases. 1

Diagnosis and Initial Assessment

• Confirm diagnosis through urgent compression ultrasound or appropriate neuroimaging
• Evaluate the extension of the thrombus and assess risk of complications
• Assess hemodynamic stability and bleeding risk
• Consider CT pulmonary angiography or echocardiography if pulmonary embolism is suspected

Acute Treatment Phase

Initial Anticoagulation

• LMWH is preferred over unfractionated heparin (UFH) for initial treatment due to:

  • Superior efficacy in reducing mortality
  • Lower risk of major bleeding
  • Fixed dosing regimen requiring less monitoring
  • Once or twice daily subcutaneous administration 2, 1

• Recommended LMWH dosing:

  • Enoxaparin: 1 mg/kg twice daily or 1.5 mg/kg once daily
  • Dalteparin: 200 U/kg once daily for the first month, then 150 U/kg once daily
  • Tinzaparin: 175 U/kg once daily 1

• Consider UFH in specific situations:

  • Severe renal impairment (creatinine clearance <25-30 ml/min)
  • When rapid reversal may be needed
  • Administer as bolus of 5000 IU, followed by continuous infusion of ~30,000 IU over 24h
  • Adjust to maintain aPTT 1.5-2.5 times baseline 2, 1

Special Considerations

• Thrombolytic therapy should be considered for:

  • Severe cases with neurological deterioration
  • Patients with massive thrombosis at risk for serious complications
  • Cases where rapid venous decompression is desirable 2, 3

• Inferior vena cava filter should be considered when:

  • Anticoagulation is contraindicated due to active bleeding
  • Recurrent thromboembolism occurs despite adequate anticoagulation 2

Long-Term Management

Transition to Oral Anticoagulation

• Start vitamin K antagonist (warfarin) within 24 hours of initiating heparin
• Continue full-dose heparin for at least 5 days and until INR >2.0 for at least 2 consecutive days
• Target INR: 2.0-3.0 2, 1, 4

Duration of Anticoagulation

• For DVT secondary to transient risk factors: 3-6 months 2, 4
• For unprovoked/idiopathic DVT: 6-12 months minimum, with consideration for extended therapy 1, 4
• For recurrent DVT: Extended therapy (>12 months or indefinite) 2, 4
• For DVT associated with active cancer: Continue until cancer is no longer active 2, 4

Special Patient Populations

• Cancer patients:

  • LMWH is preferred over vitamin K antagonists for long-term therapy
  • Recommended schedule: 75-80% of initial dose for 6 months 2

• Pregnant women:

  • Avoid vitamin K antagonists due to teratogenicity
  • Use LMWH or unfractionated heparin as neither crosses the placenta 2

Management of Complications

Recurrent VTE While on Anticoagulation

• If recurrence occurs with subtherapeutic INR: Retreat with UFH or LMWH until therapeutic anticoagulation is achieved
• If recurrence occurs with therapeutic INR, options include:
  • Switch to alternative anticoagulation method (LMWH or UFH)
  • Increase INR target to 3.5
  • Resume full-dose LMWH (200 U/kg once daily) 2

Prevention of Post-Thrombotic Syndrome

• Compression stockings should be used:
  • Begin within 1 month of diagnosis
  • Continue for minimum of 1 year (ideally 2 years)
  • Significantly reduces incidence and severity of post-thrombotic syndrome 2, 1

Management of Increased Intracranial Pressure

• For severe headache and papilledema, consider therapeutic lumbar puncture
• Hemicraniectomy may be lifesaving in patients with parenchymal lesions leading to herniation
• Persistent symptoms may require repeated lumbar punctures or lumboperitoneal shunt 3

Monitoring

• Regular INR monitoring for patients on warfarin to maintain target 2.0-3.0
• Monitor hemoglobin, hematocrit, and platelet count every 2-3 days for first 14 days, then every 2 weeks
• Assess for signs of bleeding or recurrent thrombosis

Reversal of Anticoagulation in Emergency

• For major bleeding on warfarin: Administer vitamin K and 4-factor prothrombin complex concentrate
• For DOACs: Use specific reversal agents when available (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1

By following this structured approach to the management of dural venous thrombosis, clinicians can optimize outcomes while minimizing complications. The evidence strongly supports initial LMWH therapy followed by appropriate duration of oral anticoagulation based on individual risk factors.