What is the management of central venous sinus thrombus?

Management of Central Venous Sinus Thrombosis

Anticoagulation with therapeutic doses of low-molecular-weight heparin (LMWH) is the first-line treatment for central venous sinus thrombosis (CVST), even in patients with intracranial hemorrhage related to the thrombosis. 1

Initial Management Algorithm

Immediate Treatment

1. Anticoagulation therapy:

   • Start with therapeutic dose LMWH (e.g., enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily) 1, 2
   • For patients with severe renal impairment (CrCl <30 mL/min), use intravenous unfractionated heparin (UFH) with continuous infusion (initial bolus 5000 IU, followed by ~30,000 IU/24h) with target aPTT 1.5-2.5 times baseline 2

2. Assess for mass effect and intracranial hemorrhage (ICH):

   • Presence of ICH is NOT a contraindication to anticoagulation 1, 3
   • In the 1991 randomized controlled trial, patients with CVST treated with heparin had better outcomes despite the presence of ICH 3

Management Based on Severity

• Mild to moderate symptoms with no or mild mass effect:

  • Continue anticoagulation therapy
  • Monitor with repeat imaging

• Severe symptoms with significant mass effect or clinical deterioration despite anticoagulation:

  • Consider endovascular therapy (mechanical thrombectomy and/or thrombolysis) 1, 4, 5
  • Consider decompressive hemicraniectomy in cases of life-threatening cerebral edema 1

Long-term Management

Duration of Anticoagulation

• Transient risk factor: 3-6 months of anticoagulation 1
• Unprovoked/idiopathic CVST: 6-12 months of anticoagulation 1
• High-risk thrombophilia or recurrent VTE: Consider lifelong anticoagulation 1

Transition to Oral Anticoagulation

• After 5-7 days of initial LMWH treatment, transition to:
  • Vitamin K antagonists (VKAs) with target INR 2.0-3.0 2
  • Continue parenteral anticoagulation until INR ≥2.0 for at least 24 hours 2
  • Direct oral anticoagulants (DOACs) may be considered as an alternative to warfarin 2

Special Populations

Cancer Patients

• Continue LMWH for at least 6 months rather than transitioning to VKAs 1, 2
• After the first month, reduce LMWH dose to 75-80% of the initial dose 2

Pregnant Women

• Avoid vitamin K antagonists due to teratogenicity 1, 2
• Use LMWH or unfractionated heparin throughout pregnancy 1, 2

Prevention of Complications

Post-Thrombotic Syndrome Prevention

• Start compression stockings within 1 month of diagnosis 1
• Continue for a minimum of 1 year (ideally 2 years) 1, 2

Monitoring and Follow-up

1. Laboratory monitoring:

   • Complete blood count, renal and hepatic function panel at baseline
   • Monitor hemoglobin, hematocrit, and platelet count every 2-3 days for the first 14 days, then every 2 weeks 2
   • For patients on warfarin, regular INR monitoring to maintain target INR of 2.0-3.0 2

2. Imaging follow-up:

   • MRI/MRV at 3-6 months to assess recanalization 2

Management of Treatment Failure

Recurrence or Clinical Deterioration

• If deterioration occurs with therapeutic anticoagulation:
  1. Consider endovascular therapy (mechanical thrombectomy using devices like the Penumbra System) 4, 5
  2. Local thrombolysis may be considered in severe cases 1, 6
  3. For patients with severe symptoms, coma, or extensive thrombosis at presentation, more aggressive approaches may be needed as these patients carry an increased risk of death despite standard anticoagulation 7

Anticoagulation Complications

• For major bleeding on warfarin: administer vitamin K and 4-factor prothrombin complex concentrate 2
• For DOACs: specific reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 2

Key Considerations and Pitfalls

1. Do not withhold anticoagulation due to presence of hemorrhagic infarction or ICH - evidence shows better outcomes with anticoagulation even in these cases 1, 3

2. Ensure adequate anticoagulation intensity - subtherapeutic levels are associated with treatment failure and poor outcomes 7

3. Consider early endovascular intervention for patients with:

   • Coma
   • Deep cerebral venous system thrombosis
   • Large space-occupying lesions
   • Clinical deterioration despite adequate anticoagulation 6

4. Monitor closely for signs of increased intracranial pressure - may require specific management strategies including osmotic therapy, head elevation, and in severe cases, decompressive surgery 1