Cerebral venous thrombosis: Current management, recent advances and future directions

Cerebral venous thrombosis (CVT) is an uncommon but increasingly recognized cause of stroke.Despite its lower incidence than arterial stroke, CVT can cause substantial functional disability and mortality and mainly affects younger adults. This review summarizes current treatment strategies, recent advances, and potential future directions.

Anticoagulation remains the cornerstone of CVT treatment. While vitamin K antagonists (VKAs) have long been the standard, direct oral anticoagulants (DOACs) have recently been demonstrated to be equally safe and effective, and are increasingly used in routine practice. Endovascular therapy is reserved for selected severe cases unresponsive to anticoagulation, although data from randomized trials remain limited. The recently completed DECOMPRESS2 study has provided high-quality data on the outcomes of patients with severe CVT that underwent decompressive surgery. Novel scoring systems, such as DIAS3 and SI(2)NCAL(2)C, have helped facilitate individualized prediction of seizures and long-term outcomes.

The diagnostic work-up of CVT could be further improved if clinical decision rules, in combination with biomarkers, are developed and validated. Similarly, Artificial Intelligence algorithms that are able to detect signs of CVT on imaging, even when CVT is not suspected, could help to speed up diagnosis of CVT, allowing faster treatment. Novel anticoagulant and fibrinolytic treatments hold promise to rapidly and safely achieve recanalization of the venous system. Finally, multicenter studies should address novel ways to measure outcome after CVT, beyond the modified Rankin Scale. As with all CVT research, international collaboration through academic consortia will be the key to produce evidence-based answers to the burning clinical questions, with the ultimate goal to reduce the global burden of this condition.