CEREBRAL VENOUS SINUS THROMBOSIS
General therapy and acute anticoagulation in cerebral venous thrombosis
Created 08/04/2021, last revision 17/01/2023
General therapy
- in the acute stage, the patient should be monitored in the ICU
- order bed rest with a slightly elevated upper body position
- start general therapy and acute anticoagulation
- search for the underlying cause (hypercoagulable state, infection, etc.)
- with extensive 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
Content available only for logged-in subscribers (registration will be available soon) |
- 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
- bromazepam (1.5mg / 3mg tablet)
- 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)
Anticoagulation in the acute stage
Content available only for logged-in subscribers (registration will be available soon) |