What is the treatment for superior sagittal sinus thrombosis?

Treatment of Superior Sagittal Sinus Thrombosis

The treatment of superior sagittal sinus thrombosis should begin with immediate therapeutic anticoagulation using low molecular weight heparin (LMWH) or unfractionated heparin (UFH), even in the presence of intracranial hemorrhage. 1

Diagnostic Confirmation

• Diagnosis must be confirmed with MRI/MRV or CT/CTV before initiating treatment 1
• Time-of-flight MRV or contrast-enhanced MRV are preferred techniques for visualizing venous structures and confirming thrombosis 2, 1
• Imaging should evaluate for secondary signs such as cerebral swelling, edema, and/or hemorrhage 1
• In cases where MRV or CTV results are inconclusive, cerebral angiography or direct cerebral venography may be necessary 2

Initial Management

• Begin therapeutic anticoagulation immediately upon diagnosis 1
  • LMWH is preferred over UFH for initial treatment 1
  • Anticoagulation should be initiated even in the presence of intracranial hemorrhage, as the benefits of preventing thrombus progression outweigh bleeding risks 1
• Monitor for signs of increased intracranial pressure 1
• Perform regular neurological assessments to detect early signs of deterioration 1

Anticoagulation Protocol

• Initial phase: LMWH or UFH 1
• Treatment phase (at least 3 months): Transition to adjusted-dose vitamin K antagonists (target INR 2.5) 1
• Direct oral anticoagulants (DOACs) are not recommended as first-line therapy for cerebral venous thrombosis 1

Management of Increased Intracranial Pressure

• For patients with signs of increased intracranial pressure, consider osmotic therapy with mannitol or hypertonic saline 1
• In cases of neurological deterioration despite medical therapy, surgical decompression with hematoma evacuation may be necessary 1

Management of Hemorrhagic Complications

• If intracranial hemorrhage develops or worsens during anticoagulation, temporary discontinuation may be necessary 1, 3
• However, anticoagulation should be resumed once the patient is stabilized to prevent thrombus progression 1
• The risk of rebleeding must be carefully weighed against the risk of thrombus progression 3

Advanced Interventions for Severe Cases

• In patients with severe neurological deterioration despite anticoagulation, endovascular interventions may be considered 4, 5
• Local thrombolysis with urokinase has shown better neurological outcomes compared to systemic heparin alone in non-randomized studies 4
• Mechanical thrombectomy techniques may be employed in cases with extensive clot burden 5

Monitoring and Follow-up

• Follow-up imaging (MRV or CTV) should be performed to assess recanalization 1
• Continue monitoring for signs of post-thrombotic syndrome 1
• In patients with persistent or progressive symptoms despite medical treatment, repeated neuroimaging may help identify new ischemic lesions, hemorrhage, edema, or thrombus propagation 2

Pitfalls and Caveats

• Delaying anticoagulation due to fear of hemorrhagic complications can lead to thrombus progression and worse outcomes 1
• While anticoagulation is generally safe, there is limited evidence specifically for patients with significant intracranial hemorrhage at baseline 3
• The extension of thrombus from the superior sagittal sinus into cortical veins is associated with worse outcomes and requires prompt intervention 6
• Sudden onset of symptoms (<24 hours) and posterior 1/3 occlusion are associated with poorer outcomes 6