What is the treatment for cerebral venous thrombosis?

Treatment of Cerebral Venous Thrombosis

Anticoagulation therapy is the cornerstone of treatment for cerebral venous thrombosis (CVT) and should be initiated immediately upon diagnosis, even in the presence of hemorrhagic lesions. 1, 2

Diagnosis

• CVT accounts for 0.5-1% of all strokes, primarily affecting young individuals under 50 years of age 3
• Diagnosis requires neuroimaging, with MRI with MR venography being the preferred initial imaging modality 2
• CT venography can be used if MRI is not readily available in emergency settings 2
• Gradient echo T2 susceptibility-weighted images combined with MR venography can improve diagnostic accuracy 3
• Catheter cerebral angiography may be necessary in patients with inconclusive CTV or MRV results but high clinical suspicion 3

Initial Management

Anticoagulation Protocol

• Immediate anticoagulation should be started with either:
  • Intravenous unfractionated heparin (UFH) 3, 2
  • Subcutaneous low-molecular-weight heparin (LMWH) 3, 2
• The presence of intracerebral hemorrhage related to CVT is NOT a contraindication to anticoagulation 3, 2
• Anticoagulation prevents thrombus propagation, increases recanalization, and reduces mortality and severe disability 1

Hospitalization

• All patients should be admitted to a stroke unit for close monitoring and specialized care 2
• Management in a stroke unit optimizes care and minimizes complications 3

Treatment Algorithm

1. Confirm diagnosis with MRI/MRV or CT/CTV 2

2. Initiate anticoagulation with IV heparin or subcutaneous LMWH if no major contraindications 3, 1

3. Monitor neurological status:

   • If stable or improving: Continue anticoagulation and transition to oral anticoagulants 2
   • If deteriorating: Consider advanced interventions 3

4. For patients with neurological deterioration:

   • Evaluate for severe mass effect or ICH on repeat imaging 3
   • Consider endovascular therapy for patients with severe or refractory symptoms 3
   • Decompressive hemicraniectomy may be considered as a life-saving procedure in cases with significant mass effect 3

Duration of Anticoagulation

• For transient reversible risk factors: 3-6 months of oral anticoagulation 3, 2
• For idiopathic CVT or mild thrombophilia: 6-12 months 3, 2
• For high-risk inherited thrombophilia or recurrent events: Consider indefinite (lifelong) anticoagulation 3, 2

Special Considerations

Cerebral Venous Thrombosis in Behçet's Syndrome

• The first episode should be treated with high-dose glucocorticoids followed by tapering 3
• Anticoagulants may be added for a short duration 3
• Screening for vascular disease at extracranial sites is recommended 3

Management of Complications

• Seizures should be treated aggressively with antiepileptic medications 3
• For elevated intracranial pressure, treatments may include:
  • Dexamethasone (4-8 mg/day oral or IV) for patients with significant white matter edema causing mass effect 1
  • Note: Dexamethasone should not be used routinely in all CVT cases 1

Follow-up Imaging

• A follow-up CTV or MRV at 3-6 months after diagnosis is reasonable to assess for recanalization of the occluded cortical vein/sinuses in stable patients 3
• Early follow-up imaging is recommended in patients with persistent or evolving symptoms despite medical treatment 3

Common Pitfalls and Caveats

• Diagnostic challenges include anatomic variants that may mimic sinus thrombosis, including sinus atresia/hypoplasia and asymmetrical sinus drainage 3
• Long-term use of dexamethasone (>3 weeks) is associated with significant toxicity and should be avoided 1
• Steroid doses should be tapered as quickly as the clinical situation allows to minimize side effects 1
• Failure to recognize deterioration can occur in some patients, particularly those with cerebral venous sinus thrombosis, requiring vigilant monitoring 2