General therapy and acute anticoagulation in cerebral venous thrombosis

• thanks to anticoagulant therapy, no specific strategy is necessary
• Intermittent Pneumatic Compressions (IPC) may be added → VTE prevention

• it is beneficial to combine analgesics with anxiolytics; consider regular administration every 6-8 hours
• 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 phase 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 injury
• antiepileptic drugs (AEDs) are indicated in all patients after the first seizure  (ESO guidelines 2017)
• prophylactic treatment in the first 7-14 days after diagnosis of CVST may 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 problem with PHE is possible interaction with anticoagulants
  • long-term medication, if indicated: CBZ, VPA, LEV

→ see intracranial hypertension treatment

• mannitol (MANNITOL / OSMITROL)
• furosemide (FUROSEMIDE / LASIX)
• acetazolamide (DIAMOX)  (according to ESO guidelines 2017, consider in a case of severe headache or visual compromise)
• steroids are not recommended [Canhão, 2008]
  • steroids can be administered only in CVST associated with Behcet’s disease or other inflammatory diseases (e.g., SLE) (ESO guidelines 2017)
• consider decompressive craniectomy for severe refractory intracranial hypertension

• actively search for and treat the infection that may be causing the thrombosis
  • a facial furuncle may be the source of cavernous sinus thrombosis
  • in sigmoid and transverse sinus thromboses, look for middle ear inflammation (otitis media)