What is the initial treatment for cerebral sinus venous thrombosis?

Initial Treatment for Cerebral Sinus Venous Thrombosis (CVST)

Anticoagulation therapy is the recommended initial treatment for cerebral venous sinus thrombosis, regardless of the presence of hemorrhagic conversion. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with appropriate imaging:

• MRI with MR venography is the preferred initial imaging modality 1
• CT venography can be used if MRI is not readily available 1
• Catheter angiography may be needed in select cases with high clinical suspicion but negative initial imaging 1

Initial Anticoagulation Protocol

1. First-line therapy: Immediate anticoagulation with either:

   • Intravenous unfractionated heparin (UFH) with dose adjustment to achieve an activated partial thromboplastin time twice the pretreatment value 1
   • Subcutaneous low-molecular-weight heparin (LMWH) dosed based on body weight (e.g., nadroparin 180 anti-factor Xa units/kg daily in 2 divided doses) 1

2. Important note: The presence of intracerebral hemorrhage related to CVST is NOT a contraindication to anticoagulation 1

Treatment Algorithm

For patients with neurological stability or improvement:

• Continue anticoagulation with oral anticoagulants after initial heparin therapy 1
• Duration of anticoagulation depends on underlying etiology:
  • 3-6 months for transient risk factors (e.g., infection, pregnancy) 1, 2
  • 6-12 months for idiopathic CVST or mild thrombophilia 1, 2
  • Indefinite (lifelong) anticoagulation for severe thrombophilia or recurrent thrombosis 1, 2

For patients with neurological deterioration despite anticoagulation:

• Consider endovascular therapy (thrombolysis with or without mechanical disruption) in:
  • Patients with contraindications to anticoagulation 1
  • Patients who fail to improve with anticoagulation 1
• Consider decompressive hemicraniectomy for severe mass effect or hemorrhage causing impending herniation 1

Management of Complications

• Seizures: Administer antiepileptic drugs for patients with acute seizures, particularly those with supratentorial lesions 2
• Intracranial hypertension: Consider therapeutic lumbar puncture to reduce pressure and relieve symptoms in patients with severe headache and papilledema 2
• Monitoring: All patients should be admitted to a stroke unit for close monitoring and specialized care 1

Evidence Supporting Anticoagulation

• Two randomized controlled trials (though small, with a total of 79 patients) showed that anticoagulation is associated with:
  • Reduced risk of death (relative risk 0.33,95% CI 0.08 to 1.21) 3
  • Reduced risk of death or dependency (relative risk 0.46,95% CI 0.16 to 1.31) 3
  • No new symptomatic intracerebral hemorrhages in either study 3

Potential Pitfalls and Caveats

• Rebleeding risk: While anticoagulation is generally safe, close monitoring is essential, especially in patients with pre-existing hemorrhage 4
• Diagnostic delays: CVST can mimic other neurological conditions, leading to treatment delays; maintain high clinical suspicion in young adults with unusual headache patterns or neurological deficits 5
• Incomplete evaluation: Always investigate underlying prothrombotic conditions, as this affects treatment duration 1
• Failure to recognize deterioration: Some patients with CVST, particularly those with cerebral venous sinus thrombosis, may experience rapid deterioration after appearing clinically well 1