EFNS guideline on the treatment of cerebral venous and sinus thrombosis

Abstract

Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed due to the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence, but consensus was clear we stated our opinion as good practice points. Patients with CVST without contraindications for anticoagulation should be treated either with body weight-adjusted subcutaneous LMWH or dose-adjusted intravenous heparin (good practice point). Concomitant intracranial haemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulation after the acute phase is unclear. Oral anticoagulation may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with ÔmildÕ hereditary thrombophilia. Indefinite anticoagulation (AC) should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and ÔsevereÕ hereditary thrombophilia (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial haemorrhage (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. Antioedema treatment (including hyperventilation, osmotic diuretics and craniectomy) should be used as life saving interventions (good practice point).Background and objectives

Persistent headache after earache

“…Box 1 outlines some of the differential diagnoses we considered for our patient. [1][2][3][4][5][6] Headache, which occurs in 90% of patients, 1 is frequently severe and diffuse in nature and often precedes the onset of neurologic symptoms. 5 Behavioural symptoms, such as delirium, amnesia and mutism, can occur if the deep venous system is involved.…”

“…7 Focal or generalized seizure, central motor deficits, sensory deficits, aphasia or hemianopia develops in 40%-60% of patients. 6 A multicentre prospective observational study involving more than 600 patients reported that 39.3% had seizures at presentation. 8 Alternating focal deficits are rare but characteristic of cerebral venous sinus thrombosis.…”

“…1 Twenty to forty per cent of patients may present with isolated intracranial hypertension and symptoms of headache, vomiting and blurred vision due to papilledema, in the absence of localizing neurologic findings. 6 Elderly patients tend to have a distinctive clinical presentation with depressed consciousness or changes in mental status as opposed to isolated intracranial hypertension. 7 Focal or generalized seizure, central motor deficits, sensory deficits, aphasia or hemianopia develops in 40%-60% of patients.…”

“…The best approach is the combination of MRI showing an abnormal signal in a sinus (Figure 4) in conjunction with magnetic resonance venography showing a corresponding absence of blood flow ( Figure 5). 1,6,9,10 During the first few days, the thrombus appears isointense on T 1 -weighted images and hypointense on T 2 -weighted images. Magnetic resonance venography is needed to rule out patency and show the absence of blood flow.…”

Stroke pathophysiology: management challenges and new treatment advances

“…According to the American and European Guidelines, the use of anticoagulants should be restricted to special cases, such as cerebral venous sinus thrombosis and possibly arterial dissections (2,13,19,20,54,62,66). Several studies have shown no benefit of anticoagulation in acute ischemic stroke (1,3,11,12,67).…”