What is the treatment for superior sagittal sinus thrombosis?

Treatment of Superior Sagittal Sinus Thrombosis

Anticoagulation therapy is the first-line treatment for superior sagittal sinus thrombosis (SSST), even in the presence of intracranial hemorrhage. 1

Diagnostic Approach

• Diagnosis should be confirmed with MRI/MRV or CT/CTV before initiating treatment 1
• MRV techniques (time-of-flight or contrast-enhanced) are preferred for visualizing venous structures and confirming thrombosis 1
• Look for secondary signs including cerebral swelling, edema, and/or hemorrhage on imaging 1

Initial Management

• Begin therapeutic anticoagulation immediately upon diagnosis 1
• Low molecular weight heparin (LMWH) or unfractionated heparin (UFH) should be initiated as soon as the diagnosis is confirmed 1
• Continue anticoagulation for at least the first 3 months (treatment phase) 1
• Anticoagulation is recommended even in the presence of intracranial hemorrhage, as the benefits of preventing thrombus progression outweigh bleeding risks 1

Anticoagulation Options

• Direct oral anticoagulants (DOACs) are not recommended for cerebral venous thrombosis; adjusted-dose vitamin K antagonists (target INR 2.5) are preferred 1
• For the initial treatment phase, LMWH is preferred over vitamin K antagonists 1
• Maintain anticoagulation for at least 3 months 1

Management of Increased Intracranial Pressure

• Monitor for signs of increased intracranial pressure which may require additional interventions 1
• For patients with severe increased intracranial pressure:
  • Consider osmotic therapy (mannitol or hypertonic saline) 1
  • In cases of deterioration despite medical therapy, surgical decompression with hematoma evacuation may be necessary 1
  • External ventricular drainage may be required in cases with hydrocephalus or severe mass effect 1, 2

Special Considerations for Hemorrhagic Complications

• In patients who develop intracranial hemorrhage while on anticoagulation:
  • Temporary discontinuation of anticoagulation may be necessary 1, 3
  • Once stabilized, anticoagulation should be resumed as the risk of thrombus progression is high 1
  • Close neurological monitoring is essential during this period 3

Thrombolytic Therapy

• Local thrombolytic therapy should be considered in patients with:
  • Clinical deterioration despite adequate anticoagulation 1, 4
  • Extensive thrombosis with severe neurological deficits 4
  • Superior vena cava syndrome with poorly tolerated symptoms 1
• Direct thrombolysis via selective venography with tissue plasminogen activator (t-PA) may be effective in the acute phase 4

Monitoring and Follow-up

• Regular neurological assessment to detect early signs of deterioration 1
• Follow-up imaging (MRV or CTV) to assess recanalization 1
• Monitor for signs of post-thrombotic syndrome which may require additional interventions 1

Pitfalls and Caveats

• Delaying anticoagulation due to fear of hemorrhagic complications can lead to thrombus progression and worse outcomes 1
• Misdiagnosis is common - headache may be mistaken for migraine, leading to delayed treatment 1
• Rebleeding risk exists with anticoagulation but is generally outweighed by the benefits of preventing thrombus progression 3
• Avoid using DOACs as first-line therapy as evidence for their efficacy in cerebral venous thrombosis is limited 1