General therapy and acute anticoagulation in cerebral venous thrombosis

Created 08/04/2021, last revision 19/04/2022

General therapy

  • in the acute stage, the patient should be monitored in the ICU
  • order bed rest with slightly elevated upper body position
  • start general therapy and acute anticoagulation
  • search for the underlying cause (hypercoagulable state, infection, etc.)
  • with large or progressive thrombosis, consider early endovascular treatment
  • thanks to anticoagulant therapy, no specific strategy is necessary
  • Intermittent Pneumatic Compressions (IPC) may be added →  VTE prevention
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  • it is beneficial to combine analgesics with anxiolytics; consider regular administration every 6-8h
  • anxiolytics:
    • bromazepam (1.5mg / 3mg tablet)

      • the recommended starting dose of bromazepam for adults ranges from 3-6 mg, divided into 3 doses
      • if needed, escalate the dose
      • the maximum adult dose is 30 mg/day
    • alprazolam (0.25 mg/0,5 mg/1mg tablet)

      • the starting dose for anxiety is 0.25 mg, taken 2-3 times a day
      • gradually increase until anxiety is controlled
      • elderly patients may start with a lower dose of 0.125 mg taken 2-3 times a day
      • the usual maximum dose is 3 mg/day
    • diazepam (5mg/10 mg tablet)
      • 2.5-10 mg, taken 2-4 times daily
  • peroral analgesics:
    • paracetamol
    • metamizol gtt
    • tramadol
  • intravenous analgesics:
    • paracetamol
    • tramadol
    • dolsin
    • sufentanyl
  • seizures in the acute stage are called acute symptomatic seizures (ASS)
    • ASS occur at the time of a systemic insult or in close temporal association with a documented brain insult
  • seizures ↑ intracranial pressure and may potentiate secondary brain damage
  • antiepileptic drugs (AEDs) are indicated in all patients after the first seizure  (ESO guidelines 2017)
  • prophylactic treatment in the first 7-14 days after diagnosing CVST can be considered (according to cohort results from the ICSVT study)
    • patients with hemiparesis and parenchymal lesions are at higher risk of ASS
    • prophylactic treatment does not reduce the risk of post-CVST epilepsy
  • choice of antiepileptic drug
    • in the acute phase, choose VPA or LEV (they allow rapid parenteral titration)
    • the trouble with PHE is possible interaction with anticoagulants
    • long-term medication, if indicated: CBZ, VPA, LEV

→ see intracranial hypertension treatment

  • actively search for and treat the infection that could be a potential cause of thrombosis
    • a facial furuncle can be the source of cavernous sinus thrombosis
    • in sigmoid and transverse sinus thromboses, search for middle ear inflammation

Anticoagulation in the acute stage

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  • continuous HEPARIN (1 amp=25000 IU/5ml)  → heparinization protocol
  • 5-10 days, until the patient is clinically stable; maintain aPTT at the 2-2.5x upper limit of the norm
  • in case of significant ischemia or secondary hemorrhage, do not start with bolus
  • use UFH if LMWHs are contraindicated (renal insufficiency) or when a rapid withdrawal is required (e.g., anticipated neurosurgical procedure)
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