Advances in the treatment of cerebral venous thrombosis.
Patients with recent cerebral venous sinus thrombosis (CVT) should be fully anticoagulated with heparin as soon as the diagnosis is confirmed, even in the presence of cerebral hemorrhagic venous infarcts. Fixed-dose subcutaneous low-molecular-weight heparins (LMWH) in therapeutic dosage have a better safety profile and are probably more effective than dose-adjusted intravenous unfractionated heparin. After the patient is stabilized , oral anticoagulant treatment is started, aimed at an INR value between 2.0 and 3.0 for at least three months after the acute phase. Since about 40 % of patients with CVT have epileptic seizures at onset or during the first days, many require treatment with anti-epileptics. Prophylactic anti-epileptic treatment is an option, but its efficacy has not been investigated. If no new seizures occur after the acute phase, anti-epileptics can be tapered after three to six months. The efficacy of endovascular treatment, with mechanical and/or pharmacologic thrombolysis, has only been published in small case series, and cannot be regarded as proven effective treatment for CVT. Its theoretical advantage of more rapid clearance of thrombi may be offset by severe bleeding complications, and the limited availability and higher cost of the procedure. Patients who deteriorate because of large space-occupying venous infarcts have a high risk of dying from cerebral herniation. In such cases an emergent decompressive hemicraniectomy is often life-saving. Experience from different centers with this procedure shows a good clinical outcome in the majority of these patients. Patients with CVT may develop - and sometimes present with - chronic intracranial hypertension with headache and papilledema. In such patients the priority is prevention of visual function loss; intracranial hypertension should be controlled with acetazolamide, and occasionally with repeated lumbar punctures if vision is threatened. Refractory cases will need a CSF shunting procedure.
Department of Neurology of the Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands, j.coutinho@amc.uva.nl.
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Coutinho
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Middeldorp
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Stam