CEREBRAL VENOUS SINUS THROMBOSIS

Management in the subacute phase of cerebral venous thrombosis

David Goldemund M.D.
Updated on 21/03/2024, published on 08/03/2023

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)    ACTION-CVT trial
    • DOACs are not recommended:
      • in women who are pregnant or breastfeeding (contraindication)
      • in individuals with antiphospholipid syndrome (higher risks of recurrent thromboembolic events)
  • 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 duration of anticoagulant therapy should be decided based on individual hereditary and provoking factors, along with 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
  • transient risk factors (e.g., oral contraceptives, puerperium, infection)
6-12 months
  • idiopathic (unprovoked) thrombosis
  • mild thrombophilia (e.g., heterozygous Leiden V or MTHFR), then switch to aspirin  (AHA/ASA 2014 IIa/C)
  • some clinicians use repeated venous imaging to guide the duration of therapy
long-term anticoagulation
  • recurrent venous thrombosis
  • severe thrombophilia (e.g., Leiden homozygote, prothrombin G20210A mutation, protein C and S deficiency, antiphospholipid antibodies)

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
  • 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 ~ 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

Chronic headache

  • up to 14% of patients experience chronic headache
  • in cases of atypical presentation or intensity, thrombosis recurrence must be excluded (brain CT/MRI + venography + D-Dimer test)

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Management in the subacute phase of cerebral venous thrombosis
link: https://www.stroke-manual.com/cerebral-venous-thrombosis-subacute-therapy/