Management of CVST with Hemorrhagic Transformation
Anticoagulation should be initiated immediately in CVST patients even when hemorrhagic transformation is present, as intracerebral hemorrhage occurring as a consequence of CVST is not a contraindication to anticoagulation. 1, 2, 3
Initial Anticoagulation Strategy
Start anticoagulation without delay regardless of hemorrhagic lesions present on imaging. The presence of hemorrhagic transformation does not change the fundamental treatment approach, as the risk of thrombus propagation outweighs bleeding concerns in this specific context. 1, 2, 3
Preferred Initial Agent
Low-molecular-weight heparin (LMWH) is the preferred first-line agent over unfractionated heparin due to superior efficacy and significantly lower hospital mortality. 2, 4
Dosing options for LMWH: 2
- Enoxaparin: 1.0 mg/kg twice daily OR 1.5 mg/kg once daily
- Dalteparin: 200 U/kg once daily
Alternative Initial Agent
Intravenous unfractionated heparin (UFH) is appropriate when: 2
- LMWH is contraindicated or unavailable
- Severe renal failure present (creatinine clearance <30 mL/min)
- Thrombolytic therapy may be needed
UFH dosing: Initial bolus of 5000 IU, followed by continuous infusion of approximately 30,000 IU over 24 hours, adjusted to maintain aPTT at 1.5-2.5 times baseline. 2
Clinical Monitoring During Acute Phase
Admit all patients to a stroke unit for specialized monitoring to detect neurological deterioration early. 2, 3
- Monitor for signs of increased mass effect: worsening consciousness, new focal deficits, seizures. 1, 3
- Perform regular neurological assessments to identify clinical deterioration requiring escalation of care. 2
- Control seizures with anticonvulsants if they occur. 3
Transition to Oral Anticoagulation
Begin oral anticoagulants early after clinical stabilization: 2
- Continue parenteral anticoagulation for minimum 5 days AND until INR ≥2.0 for at least 24 hours. 2
- Target INR range of 2.0-3.0 (target 2.5) for vitamin K antagonists. 2
Duration of Anticoagulation
Minimum 3 months of anticoagulation is required for all CVST patients. 2, 3
- 3-6 months for provoked CVST (transient reversible risk factors). 1, 2
- 3-12 months or lifelong depending on underlying etiology (high-risk thrombophilia, recurrent events). 1, 5
- Indefinite anticoagulation for antiphospholipid syndrome. 2
Escalation Strategies for Deteriorating Patients
If patients deteriorate neurologically despite adequate anticoagulation:
Endovascular Therapy
- Consider mechanical thrombectomy in patients with absolute contraindications to anticoagulation OR failure of initial therapeutic anticoagulation. 1, 6
- The Penumbra System has been used successfully even in hemorrhagic CVST cases. 7, 6
Surgical Decompression
- Decompressive hemicraniectomy may be lifesaving in patients with severe mass effect or large ICH causing progressive neurological deterioration. 1
- This is reserved for patients with no or mild mass effect improvement on repeated imaging despite medical management. 1
Special Considerations
Dexamethasone (4-8 mg/day oral or IV) may be considered only in specific scenarios with significant white matter edema causing mass effect and neurological deterioration, but should not be used routinely. 3
Discontinue oral contraceptives in all affected patients to reduce recurrence risk. 3
Follow-Up Imaging
Obtain CT venography or MR venography at 3-6 months after diagnosis to assess recanalization of occluded sinuses in stable patients. 2, 5
Critical Pitfall to Avoid
The most common error is withholding anticoagulation due to fear of hemorrhagic transformation. The hemorrhage in CVST is venous congestion-related, not arterial, and anticoagulation prevents further thrombosis that would worsen venous hypertension and bleeding. 1, 2 Research demonstrates that LMWH results in significantly lower hospital mortality compared to UFH (0% vs 18.8% mortality in one RCT), and anticoagulation reduces absolute risk of death or dependency by 13%. 3, 4