Treatment of cerebral venous and sinus thrombosis

Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for less than 1% of all strokes. 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, the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We reviewed the strength of evidence reported in the literature to support these interventions and provide treatment recommendations based on the best available evidence. Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous low molecular weight heparin or dose-adjusted intravenous heparin. Concomitant intracranial hemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral AC after the acute phase is unclear. Oral AC 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 'mild' hereditary thrombophilia. Indefinite AC should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and 'severe' hereditary thrombophilia. There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial hemorrhage. 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. Anti-edema treatment (including hyperventilation, osmotic diuretics, craniectomy) should be used as life-saving interventions.