What is the recommended treatment for cerebral vein thrombosis?

Treatment of Cerebral Vein Thrombosis

For patients with cerebral vein thrombosis (CVT), anticoagulation therapy is strongly recommended for at least the first 3 months of treatment over no anticoagulant therapy. 1

Initial Anticoagulation

• Low-molecular-weight heparin (LMWH) is preferred as the initial treatment option due to its superior efficacy compared to unfractionated heparin (UFH) 2, 3
• LMWH dosing recommendations:
  • Enoxaparin: 1.0 mg/kg twice daily or 1.5 mg/kg once daily 2
  • Dalteparin: 200 U/kg once daily 2
• Intravenous UFH is an appropriate alternative when LMWH is contraindicated, unavailable, in cases of severe renal failure, or when thrombolytic therapy may be needed 2
• UFH dosing: Initial bolus of 5000 IU, followed by continuous infusion of approximately 30,000 IU over 24 hours, adjusted to maintain aPTT at 1.5-2.5 times baseline 2
• The presence of intracerebral hemorrhage related to CVT is not a contraindication for anticoagulation therapy 1, 4

Duration of Anticoagulation

• Minimum duration of anticoagulation should be 3 months (treatment phase) 1
• After 3 months, duration depends on underlying etiology:
  • 3 months if CVT was associated with a transient risk factor 5
  • 6-12 months for idiopathic CVT or with mild hereditary thrombophilia 5
  • Indefinite anticoagulation should be considered for patients with:
    • Two or more episodes of CVT 5
    • Severe hereditary thrombophilia 5

Transition to Oral Anticoagulation

• Early initiation of oral anticoagulants is recommended, with continuation of parenteral anticoagulation for a minimum of 5 days and until INR is ≥2.0 for at least 24 hours 2
• For patients treated with vitamin K antagonists (VKA), maintain a therapeutic INR range of 2.0-3.0 (target INR of 2.5) 1

Special Considerations

• For patients with Behçet's syndrome and CVT, high-dose glucocorticoids followed by tapering is recommended, with anticoagulants added for a short duration 1
• For patients with CVT associated with cancer, anticoagulation should be continued as long as anti-cancer treatment is given 1
• Patients with decreased consciousness or infarction extending to more than two-thirds of a hemisphere may have a worse clinical course and require closer monitoring 4

Management of Deteriorating Patients

• If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be considered in selected cases, particularly in those without intracranial hemorrhage 5
• For patients with elevated intracranial pressure and brain displacement, antiedema treatments (including hyperventilation, osmotic diuretics, and craniectomy) should be used as life-saving interventions 5

Follow-up

• A follow-up CT venography or MR venography at 3-6 months after diagnosis is reasonable to assess for recanalization of the occluded cortical vein/sinuses in stable patients 1
• Regular neurological assessment is necessary to detect clinical deterioration 2

Pitfalls to Avoid

• Delaying anticoagulation due to presence of hemorrhagic lesions is not recommended, as this is not a contraindication 2, 4
• Inadequate duration of anticoagulation based on underlying risk factors should be avoided 2
• Failing to recognize that patients with decreased consciousness may have a worse clinical course 4

The evidence supporting anticoagulation in CVT is strong despite the presence of intracranial hemorrhage in many patients at presentation. Studies have shown that anticoagulation is associated with reduced mortality and disability without increasing the risk of new hemorrhages 1, 6.