Cerebral venous sinus thrombosis treatment

Cerebral venous sinus thrombosis treatment

Hydration with IV fluids and IV anticoagulation are part of the initial treatment for cranial sinus thrombosis (CST). Prior to initiation of treatment, blood for hypercoagulopathy tests is drawn.

Severity of cerebral venous thrombosis (CVT) may require the transfer to intensive care unit (ICU).

Treatment is with anticoagulants and rarely thrombolysis (enzymatic destruction of the blood clot).


Batroxobin may promote venous sinus recanalization and attenuate CVT-induced stenosis. Further randomized study of this promising drug may be warranted to better delineate the amount of benefit 1).

Timing

Current guidelines recommend anticoagulation after cerebral venous sinus thrombosis (CVT) even in the setting of intracranial hemorrhage, but the timing of initiation is unclear.

A literature review demonstrated a wide variation of timing for anticoagulation initiation in patients with CVT and intracranial hemorrhage. Most started anticoagulation within 24 hours of admission with similar functional neurological recovery. Current guidelines on the treatment of CVT, even with intracranial hemorrhage, recommend anticoagulation. Most reports in the literature state initiation of anticoagulation within 24 hours. However, the literature does not definitively state when to initiate anticoagulation in a patient with CVT, intracranial hemorrhage, thrombectomy, and decompressive hemicraniectomy 2).

Given that there is usually an underlying cause for the disease, tests may be performed to look for these. The disease may be complicated by raised intracranial pressure, which may warrant surgical intervention such as the placement of a shunt.

There are several other terms for the condition, such as cerebral venous and sinus thrombosis, (superior) sagittal sinus thrombosis, dural sinus thrombosis and intracranial venous thrombosis as well as the older term cerebral thrombophlebitis.

Indications for endovascular intervention

● Persistent ischemic symptoms despite anticoagulation therapy.

● Contraindication to anticoagulation and/or anti-platelet therapy including hemorrhagic infarct 3).

● Impending risk of stroke.

Endovascular treatment

Chemical Thrombolysis: A catheter may be advanced to the involved sinus or close to it, through the femoral vein. The advantage of local administration is that, a larger amount of tPA actually reaches the clot vs systemic administration through a peripheral vein. Usually, 2–5mg are administered through the thrombus and then an infusion started at a rate of 1 mg/hr, usually for 12 hours. If clot burden is still there on angiography, the infusion may be continued for longer, until the clot resolves.

For CST, the infusion may be prepared in a concentration of 1 mg/10 ml (0.1 mg/ml), for a rate of 10 ml/hr.

Mechanical Thrombolysis: Similar to arterial embolic stroke, devices such as Stentriever or Penumbra may be used for clot extraction. Additionally, devices intended for other sites e.g., clot extraction from dialysis fistula, have also been used in cranial sinuses 4).

The challenge during endovascular intervention is negotiating the sigmoid-transverse sinus junction especially when using bulkier catheters e.g., AngioJet.

References

1)

Ding JY, Pan LQ, Hu YY, Rajah GB, Zhou D, Bai CB, Ya JY, Wang ZA, Jin KX, Guan JW, Ding YC, Ji XM, Meng R. Batroxobin in combination with anticoagulation may promote venous sinus recanalization in cerebral venous thrombosis: A real-world experience. CNS Neurosci Ther. 2019 May;25(5):638-646. doi: 10.1111/cns.13093. Epub 2019 Jan 23. PubMed PMID: 30675757; PubMed Central PMCID: PMC6488911.
2)

Pizzi MA, Alejos DA, Siegel JL, Kim BY, Miller DA, Freeman WD. Cerebral Venous Thrombosis Associated with Intracranial Hemorrhage and Timing of Anticoagulation after Hemicraniectomy. J Stroke Cerebrovasc Dis. 2016 Jun 16. pii: S1052-3057(16)30098-2. doi: 10.1016/j.jstrokecerebrovasdis.2016.05.025. [Epub ahead of print] PubMed PMID: 27321968.
3) , 4)

Khan SH, Adeoye O, Abruzzo TA, Shutter LA, Ringer AJ. Intracranial dural sinus thrombosis: novel use of a mechanical thrombectomy catheter and review of management strategies. Clin Med Res. 2009; 7:157– 165

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