What is the treatment for cerebral venous thrombosis?

Treatment of Cerebral Venous Thrombosis

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

Diagnosis

• MRI with MR venography is the preferred initial imaging modality for diagnosing cerebral venous thrombosis (CVT) 1, 2
• CT venography can be used if MRI is not readily available in emergency settings 1, 3
• Gradient echo T2 susceptibility-weighted images combined with MR venography improve diagnostic accuracy 1
• Catheter cerebral angiography may be necessary for patients with inconclusive results but high clinical suspicion 1, 2

Initial Management

• Start anticoagulation immediately upon diagnosis with either:
  • Intravenous unfractionated heparin (UFH), OR
  • Subcutaneous low-molecular-weight heparin (LMWH) 1, 2, 3
• The presence of intracerebral hemorrhage related to CVT is NOT a contraindication to anticoagulation 1, 2, 3
• All patients should be admitted to a stroke unit for close monitoring and specialized care 1, 3

Treatment Duration

Anticoagulation duration depends on the underlying etiology:

• For transient reversible risk factors: 3-6 months of oral anticoagulation 1, 2, 3
• For idiopathic CVT or mild thrombophilia: 6-12 months 1, 2
• For high-risk inherited thrombophilia or recurrent events: Consider indefinite (lifelong) anticoagulation 1, 2, 3

Management of Complications

• Seizures should be treated aggressively with antiepileptic medications 1
• 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: Long-term use of dexamethasone (>3 weeks) should be avoided due to significant toxicity 1
• For patients with Behçet's Syndrome, high-dose glucocorticoids followed by tapering is recommended, with anticoagulants added for a short duration 1

Advanced Interventions

• If patients deteriorate despite adequate anticoagulation, thrombolysis may be considered in selected cases, particularly those without intracranial hemorrhage 4
• Mechanical thrombectomy may be considered in patients with neurological deterioration despite intensive medical treatment 5

Follow-up

• A follow-up CTV or MRV at 3-6 months after diagnosis is reasonable to assess for recanalization 1, 2
• Early follow-up imaging is recommended in patients with persistent or evolving symptoms despite medical treatment 1

Common Pitfalls

• Diagnostic challenges include anatomic variants that may mimic sinus thrombosis, including sinus atresia/hypoplasia and asymmetrical sinus drainage 1
• CVT can present in various ways, with headache being the most common symptom, followed by focal neurologic deficit, seizure, and altered mental status 6
• CVT accounts for only 0.5-1% of all strokes but primarily affects young individuals under 50 years of age 1, 7
• Failure to recognize neurological deterioration can occur in some patients with CVT, highlighting the need for close monitoring 2