CEREBRAL VENOUS SINUS THROMBOSIS
Management in the subacute phase of cerebral venous thrombosis
David Goldemund M.D.
Updated on 12/03/2024, published on 08/04/2021
Anticoagulant therapy
Drug choice
- acute parenteral therapy (usually using LMWH) is switched to oral anticoagulant therapy after 5-15 days (AHA guidelines, 2024)
- 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
- 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 women who are pregnant or breastfeeding (contraindication)
- in individuals with antiphospholipid syndrome (higher risks of recurrent thromboembolic events)
- 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 |
|
Antiplatelet agents after discontinuation of oral anticoagulation
- studies focused on secondary prevention of VTE showed that aspirin was more effective than placebo
- potential benefits should be carefully considered (based on risk factors); optimal duration of therapy is unknown ⇒ temporary antiplatelet therapy may be considered
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) → stroke-related epilepsy and seizures
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)