When to Start Acitrom in CSVT Patients
Anticoagulation should be started immediately after the diagnosis of cerebral sinovenous thrombosis (CSVT), even if intracranial hemorrhage is present. 1
Initial Anticoagulation Approach
- Begin anticoagulation immediately after confirming CSVT diagnosis with appropriate imaging (CT venography or MR venography) 1
- Either intravenous heparin or subcutaneous low molecular weight heparin (LMWH) can be used as initial therapy 1
- The presence of intracranial hemorrhage related to CSVT is not a contraindication for anticoagulation therapy 1
- Initial anticoagulation should be maintained during the acute phase of CSVT 1
Transition to Oral Anticoagulation
- After the initial phase with heparin or LMWH, transition to oral anticoagulation (such as acitrom/warfarin) 1
- Target INR should be in the therapeutic range of 2.0-3.0 (target 2.5) 1
- Maintain parenteral anticoagulation until the INR is ≥2.0 for at least 24 hours 1
Duration of Anticoagulation
The duration of anticoagulation therapy should be determined based on the underlying cause:
- For CSVT secondary to a transient risk factor: 3 months of anticoagulation 1, 2
- For idiopathic CSVT or mild thrombophilia: 6-12 months of anticoagulation 2, 3
- For recurrent CSVT or severe thrombophilia: indefinite anticoagulation 2, 3
Special Considerations
Pediatric Patients
- In children with CSVT, anticoagulation is recommended for a minimum of 3 months 1
- For children with ongoing symptoms or persistent occlusion after 3 months, consider an additional 3 months of therapy 1
- In children with recurrent risk factors (e.g., nephrotic syndrome), prophylactic anticoagulation should be considered during periods when risk factors recur 1
Patients with Intracranial Hemorrhage
- Despite the presence of hemorrhagic conversion or intracranial hemorrhage at diagnosis, anticoagulation should still be initiated 1
- In cases with severe hemorrhage, consider initial radiologic monitoring at 5-7 days and start anticoagulation if thrombus extension is noted 1
- Recent evidence suggests that even in patients with traumatic intracranial hematomas and CSVT, anticoagulation with LMWH at approximately 50% of therapeutic dose can be effective without increasing the risk of hematoma expansion 4
Monitoring and Follow-up
- A follow-up venographic study (CTV or MRV) at 3-6 months after diagnosis is reasonable to assess recanalization of the occluded sinuses 1
- Early follow-up imaging is recommended for patients with persistent or evolving symptoms despite medical treatment 1
- Monitor for signs of thrombus progression or venous infarct, especially if there is delay in initiating anticoagulation 4
Pitfalls and Caveats
- Delaying anticoagulation may increase the risk of thrombus progression and venous infarct 4
- Insufficient anticoagulation dosing (below 50% of therapeutic levels) may lead to thrombotic complications 4
- Do not withhold anticoagulation solely due to the presence of intracranial hemorrhage if it is related to venous congestion from CSVT 1
- Recognize that CSVT can be associated with infections, particularly head and neck infections in younger patients, which should be treated concurrently 5