What is the treatment for a patient presenting with symptoms of basilar artery cerebral venous thrombosis (CVT)?

Treatment of Basilar Artery Cerebral Venous Thrombosis (CVT)

For patients presenting with basilar artery cerebral venous thrombosis, immediate anticoagulation with either intravenous heparin or subcutaneous low-molecular-weight heparin is the first-line treatment, even in the presence of intracerebral hemorrhage related to the CVT. 1

Diagnostic Confirmation

• Venographic study (either CT venography or MR venography) should be performed to confirm the diagnosis of CVT when plain CT or MRI is negative or to define the extent of CVT 1
• Gradient echo T2 susceptibility-weighted MR images combined with MRV improve the accuracy of CVT diagnosis 1
• Catheter cerebral angiography can be useful in patients with inconclusive CTV or MRV when clinical suspicion remains high 1

Initial Management

• Patients should be admitted to a stroke unit for specialized care and monitoring 1
• Anticoagulation therapy should be initiated immediately upon diagnosis to:
  • Prevent thrombus growth
  • Facilitate recanalization
  • Prevent deep vein thrombosis or pulmonary embolism 1
• Choice of anticoagulant:
  • Intravenous unfractionated heparin (dose-adjusted) OR
  • Subcutaneous low-molecular-weight heparin (body weight-adjusted) 1, 2

Important Clinical Consideration

• Intracranial hemorrhage related to CVT is NOT a contraindication for anticoagulation therapy 1, 2
• This differs from arterial stroke management, where anticoagulation is typically avoided in hemorrhagic transformation 1

Management of Complications

For Patients with Elevated Intracranial Pressure:

• Antiedema treatments may be necessary as life-saving interventions, including:
  • Hyperventilation
  • Osmotic diuretics
  • Surgical decompression (craniectomy) in severe cases 1, 2

For Patients with Seizures:

• Anticonvulsant therapy should be administered 1

For Patients with Neurological Deterioration Despite Anticoagulation:

• Early follow-up CTV or MRV is recommended for patients with persistent or evolving symptoms despite medical treatment 1
• If deterioration occurs despite adequate anticoagulation and other causes have been ruled out, thrombolysis may be considered in selected cases, particularly those without intracranial hemorrhage 2

Long-term Management

• Oral anticoagulation after the acute phase:
  • 3 months if CVT was secondary to a transient risk factor
  • 6-12 months for idiopathic CVT or "mild" hereditary thrombophilia
  • Indefinite anticoagulation for patients with multiple episodes or "severe" hereditary thrombophilia 2
• Follow-up CTV or MRV at 3-6 months is reasonable to assess recanalization of the occluded veins/sinuses 1

Special Considerations for Basilar Artery Occlusion (Arterial)

It's important to note that basilar artery occlusion (BAO) is different from basilar venous thrombosis. If the patient actually has basilar artery occlusion (arterial):

• Endovascular thrombectomy is indicated within 12 hours of symptom onset for patients with NIHSS ≥6, PC-ASPECTS ≥6, and age 18-89 years 1
• Thrombectomy is reasonable within 12-24 hours from last known well 1
• For very mild symptoms (NIHSS 0-5), intravenous thrombolysis alone may be associated with better outcomes than endovascular treatment 3

Monitoring and Follow-up

• Serial imaging to assess for thrombus resolution is recommended 1, 4
• Follow-up at 3-6 months to assess for recanalization 1, 4
• Monitor for development of dural arteriovenous fistula, which may complicate CVT in the delayed setting 1