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Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the AHA
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- This updated scientific statement from the American Heart Association summarizes the clinical presentation (headache, transient visual obscurations, seizures, and/or focal neurological deficits), predisposing factors (oral contraceptive use or hormone replacement therapy, pregnancy, malignancy, or thrombophilia), long-term symptoms (cognitive impairment, mood issues, fatigue, headache, and epilepsy), recurrence risk (1%–4%), diagnostic/imaging approach (CTV or MRV [better sensitivity for cortical vein thrombosis than CTV]), medical management (3–12 months of DOAC or VKA use after the initial parenteral anticoagulation [subcutaneous low molecular–weight heparin preferred to unfractionated heparin]), consideration of interventions such as endovascular treatment (for clinical/imaging progression despite appropriate anticoagulation) or decompressive hemicraniectomy (for impending herniation) in patients with cerebral venous thrombosis.
- This most up-to-date scientific statement from the American Heart Association highlights the important clinical aspects of cerebral venous sinus thrombosis.
abstract
This abstract is available on the publisher's site.
Access this abstract nowCerebral venous thrombosis accounts for 0.5% to 3% of all strokes. The most vulnerable populations include young individuals, women of reproductive age, and patients with a prothrombotic state. The clinical presentation of cerebral venous thrombosis is diverse (eg, headaches, seizures), requiring a high level of clinical suspicion. Its diagnosis is based primarily on magnetic resonance imaging/magnetic resonance venography or computed tomography/computed tomographic venography. The clinical course of cerebral venous thrombosis may be difficult to predict. Death or dependence occurs in 10% to 15% of patients despite intensive medical treatment. This scientific statement provides an update of the 2011 American Heart Association scientific statement for the diagnosis and management of cerebral venous thrombosis. Our focus is on advances in the diagnosis and management decisions of patients with suspected cerebral venous thrombosis. We discuss evidence for the use of anticoagulation and endovascular therapies and considerations for craniectomy. We also provide an algorithm to optimize the management of patients with cerebral venous thrombosis and those with progressive neurological deterioration or thrombus propagation despite maximal medical therapy.
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Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association
Stroke 2024 Mar 01;55(3)e77-e90, G Saposnik, C Bushnell, JM Coutinho, TS Field, KL Furie, N Galadanci, W Kam, FC Kirkham, ND McNair, AB Singhal, V Thijs, VXD YangFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Although cerebral venous thrombus (CVT) is an uncommon cause of ischemic and hemorrhagic stroke, its incidence has continued to rise. In this report by Saposnik et al, the authors provide an encompassing review regarding the epidemiology, diagnosis, and management of CVT. The article represents an update to the 2011 AHA scientific statement and reflects many of the interim changes in the field.
In this report, the authors note that new predisposing factors of obesity, COVID-19, and vaccine-induced thrombocytopenia have been identified since the last guideline. Importantly, initial treatment of CVT with parenteral anticoagulation is still recommended. However, after the acute period, and with proven stability of CVT, direct oral anticoagulants (DOACs) have now largely replaced vitamin K antagonists for subacute CVT treatment as both a convenient and safe treatment option. Important exceptions to this are pregnancy, during which low–molecular weight heparin is used for the safety of the fetus, and antiphospholipid antibody syndrome, for which DOACs are ineffective. In the statement, the authors advocate for DOACs as a reasonable alternative to warfarin based on two randomized controlled trials (RESPECT-CVT studying dabigatran1 and SECRET studying rivaroxaban2) and a large multicenter retrospective study (ACTION-CVT3) comparing DOACs and warfarin and demonstrating similar recurrence and recanalization rates and potentially lower rates of hemorrhage. The article further highlights EINSTEIN-JR,4 a study on rivaroxaban versus warfarin for pediatric venous thromboembolism, which showed comparable outcomes in children with CVT. The optimal timing of initiation of oral anticoagulation and the ultimate duration of treatment are uncertain; despite evidence that the majority of recanalization occurs before 3 months after initiation of anticoagulation,5 it is not yet known whether prolonged treatment with anticoagulation in patients who do not achieve earlier recanalization would achieve later recanalization or improve outcomes.
The evidence surrounding endovascular therapy (EVT) for CVT remains controversial. Although several series and meta-analyses have found technical success with high rates of recanalization, it is unclear whether this translates to improved patient outcomes. The authors highlight the recent TO-ACT trial,6 a randomized controlled trial on EVT versus best medical management in patients with CVT and severe presentations or risk factors for deterioration. Even in this selected population, EVT was not associated with improved functional outcomes or decreased mortality rates. In spite of the lack of evidence, the authors advise that EVT can be considered a potential rescue therapy in patients with CVT with worsening thrombosis or neurologic deterioration despite anticoagulation.
Finally, in addition to the above management recommendations, the authors provide a clear algorithm for etiological evaluation, acute management, and follow-up in patients with CVT. In summary, the statement by Saposnik et al offers a thorough overview of CVT, incorporating emerging risk factors and updated treatment strategies while acknowledging ongoing uncertainties in management and highlighting the need for further research on this complex condition.
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