What is the treatment for superior sagittal sinus thrombosis?

Treatment of Superior Sagittal Sinus Thrombosis

Anticoagulation therapy should be initiated immediately for superior sagittal sinus thrombosis, even in the presence of hemorrhagic changes, as the primary treatment approach. 1, 2

Initial Management

1. Immediate Anticoagulation

   • First-line options:
     • Intravenous unfractionated heparin (UFH)
     • Subcutaneous low molecular weight heparin (LMWH)
   • Anticoagulation should be started even if hemorrhagic changes are present on imaging 2
   • Non-heparin anticoagulants should be considered if there's concern for heparin-induced thrombocytopenia 2

2. Neurological Monitoring

   • Close monitoring during the acute phase is essential 2
   • Serial neurological examinations to detect clinical deterioration

3. Imaging

   • Initial diagnosis typically made with:
     • CT with CT venography (CTV) - quick (5-10 minutes), readily available 2
     • MRI with MR venography (MRV) - superior for detecting early ischemic changes and micro/macrobleed 2
   • Follow-up imaging at 3-6 months to assess recanalization 2

Advanced Treatment Options

1. Thrombolytic Therapy

   • Consider in specific circumstances:
     • Massive thrombosis with severe symptoms
     • Recent thrombus (less than 10 days old)
     • Low bleeding risk
     • Progressive neurological deterioration despite adequate anticoagulation 2
   • Options include:
     • Systemic thrombolytics
     • Direct thrombolysis via selective venography (catheter-directed) 3

2. Management of Complications

   • For increased intracranial pressure:
     • Antiedematous agents (mannitol, hypertonic saline) 4
     • Consider external ventricular drain for hydrocephalus 1
   • For seizures:
     • Anticonvulsant therapy (approximately 40% of patients develop seizures) 1, 4

3. Surgical Intervention

   • Rarely needed but may be considered for:
     • Significant mass effect from hemorrhagic infarction
     • Evacuation of hematoma in cases of neurological deterioration 1

Duration of Anticoagulation

Based on underlying cause of thrombosis 2:

• 3 months for transient risk factors
• 6-12 months for idiopathic thrombosis or mild thrombophilia
• Lifelong for:
  • High-risk thrombophilia
  • Recurrent thrombotic events
  • Antiphospholipid syndrome

Special Considerations

1. If associated with infection (e.g., sinusitis)

   • Initiate broad-spectrum antibiotics immediately 2
   • Consider surgical drainage of primary infection site 2

2. Underlying medical conditions

   • Investigate and treat potential causes (e.g., dehydration, hematologic disorders, thyrotoxicosis) 5

3. Pregnancy-associated cases

   • LMWH is preferred over UFH during pregnancy 3
   • Direct thrombolysis may be considered in severe cases with rapid deterioration 3

Prognosis

Despite modern treatment, superior sagittal sinus thrombosis carries significant morbidity, with less than half of patients recovering completely 2. Poor prognostic factors include:

• Female gender
• Sudden onset (<24 hours)
• Posterior 1/3 occlusion of the superior sagittal sinus 6
• Extension of thrombosis from superior sagittal sinus into cortical veins 6

Early diagnosis and prompt initiation of anticoagulation are critical to improve outcomes and prevent further thrombus propagation.