What is the management approach for Cerebral Venous Thrombosis (CVT)?

Management of Cerebral Venous Thrombosis (CVT)

Immediate anticoagulation with either intravenous unfractionated heparin (UFH) or subcutaneous low-molecular-weight heparin (LMWH) is the first-line treatment for cerebral venous thrombosis, even in the presence of hemorrhagic lesions. 1, 2, 3

Diagnostic Confirmation

• MRI with T2*-weighted imaging plus MR venography is the preferred diagnostic method for confirming CVT 1, 2
• CT venography can be used if MRI is not readily available 1, 2
• Catheter angiography may be needed in select cases with high clinical suspicion but negative initial imaging 1, 4

Initial Management Algorithm

1. Immediate Anticoagulation:

   • Start anticoagulation with either IV unfractionated heparin or subcutaneous LMWH 1, 3
   • The presence of intracranial hemorrhage related to CVT is NOT a contraindication to anticoagulation 1, 3, 5
   • Monitor patients closely in a stroke unit or neurocritical care setting 4

2. Management Based on Neurological Status:

   • If neurologically stable or improving:

     • Continue anticoagulation and transition to oral therapy 1
     • Duration depends on underlying etiology (see long-term management) 2, 3

   • If neurologically deteriorating despite medical treatment:

     • Perform repeat neuroimaging to assess for worsening 1
     • Consider decompressive hemicraniectomy for severe mass effect (lifesaving procedure) 1, 3
     • Consider endovascular therapy in patients with absolute contraindications for anticoagulation or failure of initial anticoagulant therapy 1, 6

Supportive Care

• Provide symptomatic therapy for seizures and increased intracranial pressure 1
• For severe headache and papilledema, therapeutic lumbar puncture may relieve symptoms 7
• Antiepileptic drugs should be prescribed for patients with acute seizures and supratentorial lesions 7, 8

Long-term Management

• After initial heparin therapy, transition to oral anticoagulation 2, 3
• Duration of anticoagulation depends on underlying etiology:
  • 3-6 months for transient risk factors (e.g., infection, pregnancy) 2, 3, 7
  • 6-12 months for unprovoked CVT or low-risk thrombophilia 1, 2
  • Indefinite (lifelong) anticoagulation for severe thrombophilia or recurrent thrombosis 2, 3, 7

Special Considerations

• Direct oral anticoagulants (DOACs) have shown similar efficacy and safety compared to vitamin K antagonists in recent studies, with potentially better recanalization rates, but are not yet recommended in current guidelines 9, 8
• Women with previous CVT should avoid contraceptives containing estrogens 8
• Subsequent pregnancies are generally safe, but prophylactic LMWH should be considered throughout pregnancy and puerperium 8

Prognostic Factors and Pitfalls

• Decreased consciousness and extensive infarction (more than two-thirds of a hemisphere) are associated with poorer outcomes 5
• Failure to recognize neurological deterioration can occur in some patients with CVT 4
• Underlying prothrombotic conditions should be investigated as this affects treatment duration 4

Follow-up

• Follow-up imaging at 3-6 months after diagnosis is reasonable to assess for recanalization 2