What is the immediate treatment for a patient diagnosed with Cerebral Venous Thrombosis (CVT)?

Immediate Treatment for Cerebral Venous Thrombosis (CVT)

Begin anticoagulation immediately with either intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin (LMWH) as soon as CVT is confirmed by imaging, even if intracranial hemorrhage is present. 1, 2

Initial Anticoagulation Strategy

The cornerstone of acute CVT management is prompt anticoagulation, which prevents thrombus propagation, increases recanalization rates, and reduces mortality and severe disability. 3

Choice of anticoagulant:

• Low-molecular-weight heparin (LMWH) is preferred as first-line therapy 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 once daily 2

• Intravenous unfractionated heparin (UFH) is an appropriate alternative when 2:

  • LMWH is contraindicated or unavailable
  • Severe renal failure is present (creatinine clearance <30 mL/min)
  • Thrombolytic therapy may be needed
  • 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

Critical Management Principle: Hemorrhage is NOT a Contraindication

The presence of intracranial hemorrhage related to CVT is explicitly NOT a contraindication to anticoagulation. 4, 1, 2, 3 This is because the hemorrhage results from venous congestion and infarction, not arterial bleeding, and the risk of thrombus propagation outweighs bleeding concerns. 2 Multiple studies confirm that anticoagulation does not increase hemorrhage volume or worsen clinical outcomes in patients with hemorrhagic CVT. 5, 6

Supportive Care and Monitoring

All patients should be admitted to a stroke unit for close monitoring and specialized care. 3 Concurrent management includes:

• Seizure management: Treat acute seizures aggressively with antiepileptic medications, particularly in patients with supratentorial lesions 3, 7
• Elevated intracranial pressure: Consider therapeutic lumbar puncture for severe headache and papilledema 3, 7
• Regular neurological assessment: Monitor for signs of deterioration including worsening consciousness, new focal deficits, or increased mass effect 2

Transition to Oral Anticoagulation

Early initiation of oral anticoagulants should begin during the acute phase 2:

• Continue parenteral anticoagulation for minimum 5 days AND until INR ≥2.0 for at least 24 hours 1, 2
• Target INR range: 2.0-3.0 (target 2.5) for vitamin K antagonists 1, 2

When to Escalate Treatment

Consider endovascular therapy or decompressive hemicraniectomy if 4, 2:

• Neurological deterioration or coma despite medical treatment
• Absolute contraindications to anticoagulation exist
• Failure of initial therapeutic anticoagulation
• Severe mass effect or large intracerebral hemorrhage causing progressive deterioration

Common Pitfalls to Avoid

• Do not delay anticoagulation due to presence of hemorrhage on imaging—this is the most common error 2, 3
• Do not withhold treatment while waiting for thrombophilia workup; anticoagulation should begin immediately upon diagnosis 1
• Do not use prolonged dexamethasone (>3 weeks) as it is associated with significant toxicity 3
• For patients with temporal lobe hemorrhage, enlarging hematomas, or midline shift, exercise greater caution and consider delaying anticoagulation until clinical stability is achieved for at least 24 hours 6