What is the initial management for a patient with cerebral venous thrombosis, assuming no contraindications to anticoagulation?

Initial Management of Cerebral Venous Thrombosis

Immediate anticoagulation with either low-molecular-weight heparin (LMWH) or intravenous unfractionated heparin (UFH) should be initiated as soon as the diagnosis is confirmed, even in the presence of intracranial hemorrhage. 1, 2

Diagnostic Confirmation First

Before initiating treatment, confirm the diagnosis using:

• MRI with MR venography as the preferred imaging modality 2
• CT venography if MRI is unavailable or contraindicated 2
• Catheter angiography may be needed in select cases with high clinical suspicion but negative initial imaging 3, 2

Immediate Anticoagulation Protocol

First-Line Options

Low-Molecular-Weight Heparin (Preferred):

• Enoxaparin: 1.0 mg/kg twice daily or 1.5 mg/kg once daily 1
• Dalteparin: 200 U/kg once daily 1
• LMWH is preferred over UFH due to superior efficacy 1

Unfractionated Heparin (Alternative):

• Initial bolus: 5000 IU, followed by continuous infusion of approximately 30,000 IU over 24 hours 1
• Adjust to maintain aPTT at 1.5-2.5 times baseline 1
• Use UFH when LMWH is contraindicated, unavailable, in severe renal failure (creatinine clearance <30 mL/min), or when thrombolytic therapy may be needed 1

Critical Pitfall to Avoid

The presence of intracranial hemorrhage related to CVT is explicitly NOT a contraindication for anticoagulation. 1, 4 This is a common error—hemorrhagic venous infarction is an indication FOR anticoagulation, not against it, as the risk of thrombus propagation outweighs bleeding concerns. 1, 4

Acute Care Setting and Monitoring

• Admit all patients to a stroke unit or neurocritical care setting for close monitoring 2, 4
• Monitor neurological status every 2-4 hours for signs of deterioration including worsening consciousness, new focal deficits, or seizures 1, 4
• Perform regular neurological assessments to detect clinical deterioration requiring escalation of care 1

Supportive Management

All patients require:

• Management of seizures if present with aggressive antiepileptic medications 3, 4
• Control of elevated intracranial pressure 3, 2
• Prevention of complications through general supportive care 3

Transition to Oral Anticoagulation

• Initiate oral anticoagulants early while continuing parenteral anticoagulation for a minimum of 5 days and until INR is ≥2.0 for at least 24 hours 1
• For vitamin K antagonists (warfarin), maintain therapeutic INR range of 2.0-3.0 (target INR of 2.5) 1

Duration of Initial Anticoagulation

Minimum 3 months of anticoagulation is required for all patients. 1, 2 Extended duration depends on underlying etiology:

• 3-6 months for transient/reversible risk factors 1, 2
• 6-12 months for idiopathic CVT or mild thrombophilia 2, 5
• Indefinite anticoagulation for severe thrombophilia, antiphospholipid syndrome, or recurrent thrombosis 1, 2

Escalation of Care for Deteriorating Patients

If patients deteriorate despite adequate anticoagulation:

• Consider endovascular therapy (with or without mechanical thrombectomy) in patients with absolute contraindications to anticoagulation or failure of initial therapeutic anticoagulation 3, 1
• Decompressive hemicraniectomy may be lifesaving in patients with severe mass effect, large intracerebral hemorrhage, or impending herniation 1, 4

Follow-Up Imaging

• Perform follow-up CT venography or MR venography at 3-6 months after diagnosis to assess for recanalization in stable patients 1, 2
• Earlier imaging is indicated if persistent or evolving symptoms despite treatment 4

Special Populations

• Severe renal failure (CrCl <30 mL/min): Use UFH followed by early vitamin K antagonists or LMWH adjusted to anti-Xa concentration 1
• Behçet's syndrome with CVT: Add high-dose glucocorticoids followed by tapering, with anticoagulants for a short duration 1
• Cancer-associated CVT: Continue anticoagulation as long as anti-cancer treatment is given 1
• Mechanical heart valves, antiphospholipid syndrome, or severe renal impairment: Warfarin is preferred over direct oral anticoagulants 1