What is the treatment for Cerebral Venous Sinus Thrombosis (CVST)?

Treatment of Cerebral Venous Sinus Thrombosis (CVST)

Start immediate anticoagulation with either intravenous unfractionated heparin (UFH) or subcutaneous low-molecular-weight heparin (LMWH) as soon as CVST is diagnosed, even when intracranial hemorrhage is present on imaging. 1, 2

Initial Anticoagulation Protocol

The presence of hemorrhagic transformation is NOT a contraindication to anticoagulation - this is a critical point that distinguishes CVST from other stroke types, as the hemorrhage results from venous congestion and anticoagulation prevents thrombus propagation. 1, 2, 3

First-Line Anticoagulation Options:

LMWH is preferred over UFH due to superior efficacy: 2

• Enoxaparin: 1.0 mg/kg subcutaneously twice daily OR 1.5 mg/kg once daily 2
• Dalteparin: 200 U/kg subcutaneously once daily 2

UFH is appropriate when: 2

• LMWH is contraindicated or unavailable
• Severe renal failure (creatinine clearance <30 mL/min) is present
• Thrombolytic therapy may be needed
• Dosing: 5000 IU bolus, then continuous infusion of ~30,000 IU over 24 hours, adjusted to maintain aPTT at 1.5-2.5 times baseline 2

Admission and Monitoring:

• Admit all patients to a stroke unit for specialized care and close neurological monitoring 1, 3
• Monitor for signs of deterioration: worsening consciousness, new focal deficits, seizures 2

Transition to Oral Anticoagulation

Begin oral anticoagulants early while continuing parenteral anticoagulation for minimum 5 days AND until INR ≥2.0 for at least 24 hours. 2

Oral Anticoagulation Options:

Vitamin K antagonists (warfarin): 2

• Target INR: 2.0-3.0 (goal 2.5)
• Preferred in: mechanical heart valves, antiphospholipid syndrome, severe renal impairment 2

Direct oral anticoagulants (DOACs): 2

• Can be used in most other cases
• Avoid in the specific conditions listed above

Duration of Anticoagulation

The duration depends on the underlying cause - this is not arbitrary but evidence-based: 1, 2

Provoked CVST (transient risk factor like infection, pregnancy, oral contraceptives):

• 3-6 months 2, 4, 5

Idiopathic CVST or mild hereditary thrombophilia:

• 6-12 months 4, 5

Antiphospholipid syndrome or severe thrombophilia:

• Indefinite (lifelong) anticoagulation 2, 4, 5

Recurrent CVST (≥2 episodes):

• Indefinite anticoagulation 4

Cancer-associated CVST:

• Continue anticoagulation throughout duration of anti-cancer treatment 2

Management of Complications

Seizure Control:

• Use anticonvulsants for acute seizures, particularly in patients with supratentorial lesions 1, 5
• Consider prophylactic anticonvulsants in patients with supratentorial hemorrhagic lesions or motor deficits 5

Elevated Intracranial Pressure:

• Therapeutic lumbar puncture can reduce pressure in patients with severe headache and papilledema 5
• 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 1
• Do NOT use dexamethasone routinely in asymptomatic patients without significant mass effect 1

Refractory Cases:

If patient deteriorates despite adequate anticoagulation: 2, 6

• Mechanical thrombectomy with or without local thrombolysis is an option in experienced centers
• Decompressive hemicraniectomy may be lifesaving in patients with severe mass effect or large intracerebral hemorrhage causing progressive neurological deterioration 2

Essential Workup and Follow-up

Investigate underlying prothrombotic conditions immediately as this determines treatment duration: 1, 3

• Thrombophilia screening
• Malignancy workup if indicated
• Autoimmune conditions (especially Behçet's syndrome)

Discontinue oral contraceptives permanently in affected patients to prevent recurrence 1

Imaging follow-up: 2

• CT venography or MR venography at 3-6 months to assess recanalization in stable patients

Clinical follow-up: 1

• Neurological and ophthalmological monitoring, especially during first year
• Risk of visual loss from increased intracranial pressure persists
• Monitor for cognitive and neurological sequelae requiring rehabilitation

Critical Pitfalls to Avoid

Never delay anticoagulation due to presence of intracranial hemorrhage - this is the most common and dangerous error, as hemorrhage in CVST results from venous congestion, not arterial rupture. 1, 2, 3

Do not use thrombolysis as first-line therapy - insufficient evidence supports routine use; reserve for deteriorating patients despite adequate anticoagulation in experienced centers only. 4, 6

Do not stop monitoring after discharge - patients can develop delayed complications including visual loss from persistent intracranial hypertension requiring lumboperitoneal shunt. 5