Treatment of Cerebral Venous Thrombosis
Immediate Anticoagulation is the Cornerstone of Treatment
Initiate anticoagulation immediately with either low-molecular-weight heparin (LMWH) or intravenous unfractionated heparin (UFH), even in the presence of intracerebral hemorrhage, as hemorrhagic transformation from CVT is not a contraindication to anticoagulation. 1
Initial Anticoagulation Regimen
LMWH is the preferred first-line agent due to superior efficacy compared to UFH 1:
- Enoxaparin: 1.0 mg/kg subcutaneously twice daily OR 1.5 mg/kg once daily 1
- Dalteparin: 200 U/kg once daily 1
Intravenous UFH is an appropriate alternative when 1:
- LMWH is contraindicated or unavailable
- Severe renal failure is present (creatinine clearance <30 mL/min)
- Thrombolytic therapy may be needed
- Dosing: 5000 IU bolus, followed by continuous infusion of approximately 30,000 IU over 24 hours, adjusted to maintain aPTT at 1.5-2.5 times baseline 1
Critical Point: Hemorrhage is NOT a Contraindication
The presence of intracranial hemorrhage occurring as a consequence of CVT does not contraindicate anticoagulation therapy, as the risk of thrombus propagation outweighs bleeding concerns in this specific context. 2, 1 This is a common pitfall—physicians often hesitate to anticoagulate when seeing blood on imaging, but in CVT, anticoagulation prevents further venous congestion and hemorrhagic transformation. 3
Transition to Oral Anticoagulation
Begin oral anticoagulants early (same day as parenteral therapy) and continue parenteral anticoagulation for a minimum of 5 days AND until INR ≥2.0 for at least 24 hours. 1
For vitamin K antagonists (warfarin): Target INR of 2.5 (therapeutic range 2.0-3.0) 1
Duration of Anticoagulation
The duration depends on the underlying etiology 2, 1:
- Provoked CVT (transient reversible factor such as infection): 3-6 months 1
- Idiopathic CVT or low-risk thrombophilia: 6-12 months 4
- High-risk/inherited thrombophilia or recurrent CVT: Consider indefinite anticoagulation 1, 4
- Antiphospholipid syndrome: Indefinite anticoagulation 1
- Cancer-associated CVT: Continue as long as anti-cancer treatment is given 1
Minimum duration in all cases is 3 months. 1
Management of Neurological Deterioration
If patients deteriorate despite adequate anticoagulation 2, 1:
Monitor for signs requiring escalation:
- Worsening consciousness
- New focal deficits
- Seizures
- Severe mass effect on repeat imaging
Consider escalation of care 2, 1:
- Endovascular therapy (with or without mechanical thrombectomy) in patients with absolute contraindications to anticoagulation or failure of initial therapeutic anticoagulation
- Decompressive hemicraniectomy may be lifesaving in patients with severe mass effect or large intracerebral hemorrhage causing progressive neurological deterioration
Supportive Care
All patients require 2:
- Management of seizures if present
- Control of elevated intracranial pressure
- Prevention of complications (DVT prophylaxis with compression devices if not anticoagulated, aspiration precautions)
Follow-Up Imaging
Perform CT venography or MR venography at 3-6 months after diagnosis to assess for recanalization of the occluded cortical vein/sinuses in stable patients. 1
Special Populations
Behçet's syndrome with CVT: High-dose glucocorticoids followed by tapering, with anticoagulants added for a short duration 1
Severe renal failure (CrCl <30 mL/min): UFH followed by early vitamin K antagonists OR LMWH adjusted to anti-Xa concentration 1
Mechanical heart valves or severe renal impairment: Warfarin is preferred over direct oral anticoagulants 1
Common Pitfalls to Avoid
- Withholding anticoagulation due to hemorrhage on imaging—this is the most critical error, as hemorrhagic venous infarction is an indication FOR, not against, anticoagulation 2, 1, 3
- Delaying anticoagulation while awaiting complete diagnostic workup
- Inadequate duration of treatment (stopping before 3 months minimum)
- Failing to investigate underlying thrombophilia, which determines duration of therapy 4