CEREBRAL VENOUS SINUS THROMBOSIS
Management in the subacute phase of cerebral venous thrombosis
Created 08/04/2021, last revision 16/11/2023
Anticoagulant therapy
Drug choice
- acute parenteral therapy (usually using LMWH) is replaced by oral anticoagulant therapy
- WARFARIN with a target INR 2-3 → see here
- DOACs seem to have similar efficacy and better safety profiles [Geisbüsch, 2014]
- positive results of the RE-SPECT CVT trial
- n=120 (dabigatran 2x150mg vs. warfarin with INR 2-3), treatment duration 24 weeks
- 5-15 days pretreatment with parenteral heparin, major bleeding 1 vs. 2 (warfarin), no thrombotic events
- the ACTION-CVT (2022) trial showed equal efficacy of DOACs and warfarin, with DOACs having a lower risk of major bleeding (HR 0.35)
- DOACs are not recommended in the acute phase (ESO guidelines 2017)
- positive results of the RE-SPECT CVT trial
- therapy of CVST provoked by VITT (Vaccine-induced Immune Thrombotic Thrombocytopenia)
- DOACs are preferred (American Society of Hematology guidelines for HIT therapy – 2018)
- switch to oral anticoagulation is advised only after normalization of platelet count
warfarin | LMWH | DOAC |
antiphospholipid syndrome (APL) hypercoagulable states (Leiden, etc.) |
pregnancy active cancer |
active cancer VITT (Vaccine-induced Immune Thrombotic Thrombocytopenia) other causes of CSVT |
Duration of the anticoagulant therapy
- the decision regarding the duration of anticoagulant therapy is based on individual hereditary and provoking factors, as well as the potential bleeding risks associated with long-term treatment (Einhäupl, 2006]
- sinus recanalization most commonly occurs within the first 3-4 months; the rate of rethrombosis is low
- regular follow-up visits should be conducted after discontinuing anticoagulant therapy
- patients should be educated about early signs of potential relapse (most commonly headache)
3-6 months |
|
6-12 months |
|
long-term anticoagulation |
|
Hormonal contraceptives and pregnancy
- avoid estrogen-containing contraceptives (ESO guidelines 2017)
- an intrauterine contraceptive device (IUD) is advised
- an intrauterine contraceptive device (IUD) is advised
- in the absence of a hypercoagulable state or a history of previous thromboembolism, recurrent venous thrombotic events during subsequent pregnancy are rare [Sousa, 2017]
- educate patients about the increased risk of CVST and/or VTE
- reviews indicate no increased incidence of miscarriage after the previous CVST
- no clear consensus exists on the prophylactic administration of LMWH during pregnancy and puerperium; data are weak and mostly from observational studies
- prophylactic LMWH seems appropriate (unless contraindicated or full anticoagulation is indicated) (ESO guidelines 2017)
- in the U.S., LMWH is administered from the 3rd trimester to the 8th week postpartum
- patients on warfarin should plan pregnancy with a switch to LMWH (due to warfarin´s teratogenicity)
Antiseizure medication
- optimal duration of antiseizure medication (ASM) is unknown
- risk of epilepsy is approx. 5-11% (higher in patients with parenchymal hemorrhages and focal neurological deficits)
- most late-onset seizures occur within the first year
- late-onset seizures are more common in patients with early symptomatic seizures
- duration should be guided by the presence and extent of parenchymal lesions, EEG findings, and the timing of epileptic seizures (early x late)
- no strict recommendation; an individualized approach is advised to avoid unnecessary long-term ASM use
- isolated symptomatic seizure (<2 weeks after CVT onset) without parenchymal lesion ⇒ AED therapy can be gradually tapered within 2-4 weeks after the acute phase
- isolated symptomatic seizure or multiple ASS with parenchymal lesion and/or pathological EEG ⇒ continue ASM treatment for up to 12 months
- post-CVT epilepsy (at least two seizures > 2 weeks after CVT onset) ⇒ long-term ASM is reasonable
- isolated symptomatic seizure (<2 weeks after CVT onset) without parenchymal lesion ⇒ AED therapy can be gradually tapered within 2-4 weeks after the acute phase
Neuropsychiatric disorders
- anxiety
- depression (SSRI)
- vascular cognitive deficit or impaired symbolic functions in patients with parenchymal lesions
Chronic headache
- up to 14% of patients experience chronic headache
- for atypical presentation or intensity, thrombosis recurrence must be excluded (CT/MR venography + D-Dimer)