A review of therapeutic strategies for the management of cerebral venous sinus thrombosis

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Although initially described in the 19th century, cerebral venous sinus thrombosis (CVST) remains a diagnostic and therapeutic dilemma. It has an unpredictable course, and the propensity for hemorrhagic infarction produces significant consternation among clinicians when considering anticoagulation. It is the purpose of this review to analyze the evidence available on the management of CVST and to provide appropriate recommendations.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A thorough literature search was conducted through MEDLINE and PubMed, with additional sources identified through cross-referencing. A classification and level of evidence assignment is provided for recommendations based on the American Heart Association methodologies for guideline composition.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Of the publications identified, the majority were isolated case reports or small case series. Few prospective trials have been conducted. Existing data support the use of systemic anticoagulation as an initial therapy in all patients even in the presence of intracranial hemorrhage. Chemical and/or mechanical thrombectomy, in conjunction with systemic anticoagulation, is an alternative strategy in patients with progressive deterioration on heparin therapy or in those who are moribund on presentation. Mechanical thrombectomy is probably preferred in patients with preexisting intracranial hemorrhage.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Effective treatments exist for the management of CVST, and overall outcomes are more favorable than those for arterial stroke. Further research is necessary to determine the role of individual therapies; however, the rarity of the condition poses a significant limitation.</jats:p></jats:sec>

Two cases of venous sinus thrombosis in women taking the oral contraceptive pill, Yaz (dropirenone/ ethinyl estradiol), and review of the literature

“…Complications from thrombolytic treatment included extracranial hemorrhage, intracranial hemorrhage. Recanalization occurred in most patients and was less likely to occur in those patients treated with systemic thrombolytics [39,[41][42][43][44]. Based on these studies, thrombolytics may benefit some patients for which anticoagulation therapy does not prove sufficient treatment.…”

“…Mortality rates reported in the literature range from 2% -8% and 65% -90% of patients make a complete recovery with minimal neurologic deficit [1][2][3]13,14,16,22,34,53,54]. In multiple studies, poor prognosis correlated with male gender, older age, coma, malignnancy, CNS infection, and worsening exam after admission [44,53]. Pregnancy, peurperium, and oral contraceptive use are associated with a better outcome than those patients with systemic disease such as malignancy or inherited thrombophilia [4,16].…”

Superior sagittal sinus and transverse sagittal sinus thrombus secondary to occult meningioma

“…Systemic anticoagulation is the first-line treatment for cerebral venous thrombosis, but identifying and managing the underlying and contributing factor (s) are more important. 12,13 In patients not responding to anticoagulation treatment, endovascular thrombolysis may be warranted.…”

Acute Neurological Issues in Pregnancy and the Peripartum

“…In small series and case studies in aggregate, there is a trend toward favorable outcomes in severe cases of CVT that were treated with thrombolytics and/or thrombectomy. 41,42 Many of these studies include CVT patients with significant complications including ICH on systemic anticoagulation therapy and outcomes do not appear significantly different in this high-risk population. 41,42 Additionally, surgical decompression has been attempted in a small series of patients with elevated ICP related to CVT complicated by ICH 43 and represents a possible therapeutic option in severely affected patients.…”

“…41,42 Many of these studies include CVT patients with significant complications including ICH on systemic anticoagulation therapy and outcomes do not appear significantly different in this high-risk population. 41,42 Additionally, surgical decompression has been attempted in a small series of patients with elevated ICP related to CVT complicated by ICH 43 and represents a possible therapeutic option in severely affected patients. At this point, if interventional therapies are available and the patient is declining clinically, these should probably be considered, regardless of pregnancy status.…”