What is the treatment for transverse sinus thrombosis?

Treatment of Transverse Sinus Thrombosis

Anticoagulation therapy is the cornerstone of treatment for transverse sinus thrombosis and should be initiated immediately, even in the presence of hemorrhagic changes. 1

Initial Management

• Anticoagulation therapy:

  • Start immediately upon diagnosis, even with hemorrhagic infarction present
  • Options include:
    • Intravenous unfractionated heparin (UFH)
    • Subcutaneous low molecular weight heparin (LMWH)
  • LMWH is preferred in pregnancy-associated cases 1
  • Consider non-heparin anticoagulants if heparin-induced thrombocytopenia is suspected 1

• Duration of anticoagulation:

  • Minimum of 3 months for the treatment phase (Strong recommendation, Low-certainty evidence) 2
  • Longer duration based on underlying cause:
    • 3 months for transient risk factors
    • 6-12 months for idiopathic thrombosis or mild thrombophilia
    • Lifelong for high-risk thrombophilia, recurrent events, or antiphospholipid syndrome 1

Management of Complications

• Increased intracranial pressure:

  • Antiedematous agents (mannitol or hypertonic saline)
  • Consider external ventricular drain for hydrocephalus 1

• Seizures:

  • Initiate anticonvulsant therapy (approximately 40% of patients develop seizures) 1

• Hemorrhagic infarction:

  • Occurs in approximately 40% of cases
  • Continue anticoagulation despite hemorrhagic changes 1
  • Surgical intervention may be considered for significant mass effect or neurological deterioration 1

Advanced Interventions

• Standard approach: Anticoagulation alone is recommended over thrombolysis for most patients 2

• Consider thrombolytic therapy in specific circumstances:

  • Neurological deterioration despite anticoagulation
  • Massive thrombosis with severe symptoms
  • Recent thrombus (less than 10 days old)
  • Low bleeding risk 1

• Endovascular interventions may be considered in severe cases with:

  • Rapid neurological deterioration despite anticoagulation
  • Extensive thrombosis
  • Poor response to standard therapy 2

Follow-up and Monitoring

• Imaging follow-up:

  • Early follow-up CTV or MRV for patients with persistent or evolving symptoms
  • Follow-up imaging at 3-6 months to assess recanalization 1, 2

• Anticoagulation monitoring:

  • For warfarin: Target INR of 2.0-3.0 3
  • Adjust dosage based on patient's PT/INR response 3

Special Considerations

• Pediatric patients:

  • Anticoagulation is recommended for cerebral sinus venous thrombosis even with hemorrhage 2
  • Duration typically 3-6 months depending on risk factors 2

• Underlying causes:

  • Treat any underlying infection (e.g., sinusitis may require functional endoscopic sinus surgery) 1
  • Evaluate for thrombophilia, antiphospholipid syndrome, and other risk factors

Prognosis

Despite modern treatment, transverse sinus thrombosis carries significant morbidity, with less than half of patients recovering completely. Poor prognostic factors include female gender, sudden onset, and extension of thrombosis into cortical veins 1.

Common Pitfalls

• Delayed diagnosis: Symptoms can be nonspecific and variable
• Inadequate anticoagulation: Fear of hemorrhagic complications may lead to insufficient anticoagulation
• Missing underlying causes: Failure to identify and address predisposing factors can lead to recurrence
• Discontinuing anticoagulation too early: Premature cessation increases risk of recurrence

Remember that anticoagulation remains the mainstay of treatment even in the presence of hemorrhagic changes, as the hemorrhage is typically due to venous congestion rather than the anticoagulation itself.