What is the recommended treatment for cerebral venous thrombosis?

Treatment of Cerebral Venous Thrombosis

The recommended first-line treatment for cerebral venous thrombosis (CVT) is immediate anticoagulation with low-molecular-weight heparin (LMWH), which is preferred over unfractionated heparin (UFH) due to its superior efficacy and safety profile. 1, 2, 3

Initial Anticoagulation

• LMWH is the preferred initial treatment option with recommended dosing of enoxaparin 1.0 mg/kg twice daily or 1.5 mg/kg once daily, or dalteparin 200 U/kg once daily 1, 3
• Intravenous UFH is an appropriate alternative when LMWH is contraindicated, unavailable, in cases of severe renal failure, or when thrombolytic therapy may be needed 1, 3
• The presence of intracerebral hemorrhage related to CVT is NOT a contraindication for anticoagulation therapy 1, 2, 4
• A randomized controlled trial showed significantly lower hospital mortality in patients treated with LMWH compared to UFH (0 vs 6 deaths, P = 0.01) 5

Duration of Anticoagulation

• The minimum duration of anticoagulation should be 3 months (treatment phase) 1
• For patients with transient risk factors, anticoagulation for 3-6 months is recommended 2, 3
• For patients with idiopathic CVT or mild hereditary thrombophilia, 6-12 months of anticoagulation is suggested 1, 4
• Indefinite (lifelong) anticoagulation should be considered for patients with:
  • Two or more episodes of CVT 4
  • One episode of CVT with severe hereditary thrombophilia 4
  • Ongoing risk factors such as cancer 1, 2

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 1, 3
• For patients treated with vitamin K antagonists (VKA), a therapeutic INR range of 2.0-3.0 (target INR of 2.5) is recommended 1

Management of Complications

• All patients should be admitted to a stroke unit for close monitoring and specialized care 2
• Regular neurological assessment is necessary to detect clinical deterioration 1, 3
• Antiedema treatment (including hyperventilation, osmotic diuretics) should be used as life-saving interventions in cases of elevated intracranial pressure 4
• In severe cases with brain displacement and failure to respond to medical therapy, decompressive craniectomy may be considered 4

Special Considerations

• For patients with decreased consciousness, more careful monitoring is required as this is associated with worse clinical outcomes 6
• Patients with extensive infarction (more than two-thirds of a hemisphere) may have a different clinical course and require closer monitoring 6
• For patients with Behçet's syndrome and CVT, high-dose glucocorticoids followed by tapering is recommended, with anticoagulants added for a short duration 1
• In patients with severe renal failure (creatinine clearance <30 mL/min), UFH followed by early vitamin K antagonists or LMWH adjusted to anti-Xa concentration is suggested 7

Follow-up

• A follow-up CT venography or MR venography at 3-6 months after diagnosis is recommended to assess for recanalization of the occluded cortical vein/sinuses 1
• Investigation of underlying prothrombotic conditions is important, as this affects treatment duration 2, 3

Pitfalls to Avoid

• Delaying anticoagulation due to presence of hemorrhagic lesions (this is not a contraindication) 1, 2, 4
• Using UFH when LMWH is available (LMWH has been shown to be more effective with fewer complications) 8, 5
• Inadequate duration of anticoagulation based on underlying risk factors 3
• Failure to recognize clinical deterioration despite appropriate treatment 2, 3