What are the admission criteria and management for great sphenoid vein occlusion?

Admission Criteria for Great Sphenoid Vein Occlusion

Patients with great sphenoid vein occlusion should be admitted to the hospital when presenting with neurological deficits, as urgent revascularization is indicated in these cases. 1

Diagnostic Evaluation

• Initial imaging should include non-contrast CT to rule out hemorrhage and estimate the ischemic core using Alberta Stroke Program Early CT Score (ASPECTS) 1
• This should be immediately followed by multiphase CT angiography (mCTA) to detect and localize the occlusion, estimate treatment risks and benefits, and allow for procedural planning 1
• For patients presenting within 6 hours of symptom onset, CT perfusion (CTP) is not necessary for clinical decision-making 1
• For patients with unknown onset time or presenting >6 hours from symptom onset, CTP may be considered to determine ischemic core volume 1

Admission Criteria

• Presence of neurological deficit requires urgent hospital admission and revascularization 1
• In the absence of neurological deficit, revascularization should be considered within hours after initial imaging on a case-by-case basis, which typically requires admission 1
• Patients with thrombus protruding into the common femoral vein should be admitted for anticoagulation and monitoring 2
• Patients with high-risk features on imaging (e.g., poor collaterals, large ischemic core) should be admitted for close monitoring 1

Management Approach

• Heparin and analgesics should be initiated as soon as possible 1
• For patients with acute occlusion and neurological deficits, urgent revascularization is the standard of care 1
• For patients with chronic occlusion, management depends on the underlying cause:
  • If related to sinistral hypertension (splenic vein occlusion), splenic vein recanalization may be considered 1
  • If related to portal hypertension, transjugular intrahepatic portosystemic shunt (TIPS) may be beneficial 1

Special Considerations

• In patients with venous occlusion associated with gastric varices, cross-sectional imaging (CT or MRI) is critical to determine the presence of portal or splenic vein occlusion 1
• For patients with splenic vein occlusion causing sinistral hypertension, restoration of venous patency through transjugular recanalization has shown resolution of symptoms at a median follow-up of 17.5 months 1
• Patients with thrombus extension into the common femoral vein may require anticoagulation and temporary inferior vena cava filter placement if there is a floating thrombus 2

Monitoring and Follow-up

• Early duplex scanning is recommended in all patients after endovenous procedures to assess for thrombus extension 2
• DVT prophylaxis should be considered in patients >50 years old 2
• Follow-up imaging should be performed to confirm resolution of thrombus extension into the common femoral vein 2

By following these admission criteria and management approaches, clinicians can optimize outcomes for patients with great sphenoid vein occlusion while minimizing morbidity and mortality.