Cerebral Venous Thrombosis Treatment & Management

  • Author: W Alvin McElveen, MD; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: Nov 14, 2011
 

Medical Care

Medical management of the patient with cerebral venous thrombosis (CVT) is similar to that of patients with arterial stroke as far as stabilizing the patient is concerned.

  • Patients with altered mental status or hemiplegia should be given nothing by mouth to prevent aspiration. Intravenous fluids should not be hypotonic solutions. Normal saline is recommended at a rate of approximately 1000 mL in 24 hours. To decrease intracranial pressure, the head should be elevated 30-40° at all times. In the treatment of stroke patients, supplemental oxygen has not been shown to be beneficial unless level of consciousness is decreased.
  • Seizures should be treated with appropriate anticonvulsants. Fosphenytoin is recommended for treatment of seizures in those patients who require a parenteral formulation. Alternatively, phenobarbital or sodium valproate injection may be utilized if the patient has allergy to phenytoin. Diazepam or lorazepam may be used to treat status epilepticus, but the patient also should be given an anticonvulsant with a longer duration of action to prevent recurrent seizures.
  • Specific therapy for CVT involves anticoagulation or thrombolytic therapy.[22, 23] Use of anticoagulation in CVT has been a subject of some debate among neurologists. Concern has been expressed over the possibility of increasing hemorrhage in patients treated in this manner.[22] Studies by de Bruijn and Stam in 1999[24] and by Einhaupl in 1991[25] indicated that anticoagulation could be used safely in this condition. The question of effectiveness of anticoagulation is not clear, but most articles tend to point toward improved outcome with utilization of anticoagulation.
    • Thrombolytic therapy has been described in several case reports as beneficial in cases of CVT. These patients were treated with infusion of a thrombolytic agent into the dural venous sinus utilizing microcatheter technique. This treatment at present is limited to specialized centers but should be considered for patients with significant deficit.
    • A recent report describes the use of a rheolytic catheter device in a patient who had not responded to microcatheter instillation of urokinase. The rheolytic catheter was designed for use in the coronary circulation and delivers 6 high-velocity saline jets through a halo device at the tip of the catheter. This leads to a Bernoulli effect that breaks up the thrombus. In addition, the particulate debris is directed into an effluent lumen for collection into a disposable bag. The catheter was advanced into the sagittal sinus, resulting in restoration of venous flow and reduction of intracranial pressure.
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Surgical Care

In cases of severe neurologic deterioration, open thrombectomy and local thrombolytic therapy have been described as beneficial. Patients selected for these procedures have progressed despite adequate anticoagulation and intensive medical care.[22, 26, 23] Ekseth described 3 such patients who all returned to normal lives following this procedure.[27]

Herniation attributable to unilateral mass effect is the major cause of death in cerebral venous thrombosis (CVT). In CVT patients with large parenchymal lesions causing herniation, decompressive surgery has been lifesaving and often results in good functional outcome, even in patients with severe clinical conditions.[28]

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Consultations

  • Consultation with a neurosurgeon is indicated in patients with subdural empyema or brain abscess. Consultation should also be considered for patients who have severe deterioration despite aggressive medical management.
  • Consultation with an infectious disease specialist is to be considered for patients with cerebral venous thrombosis who have associated infection such as meningitis or sinusitis.
  • Consultation with an otolaryngologist may be helpful in patients with associated sinusitis.
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Contributor Information and Disclosures
Author

W Alvin McElveen, MD  Director, Stroke Unit, Lakewood Ranch Medical Center; Neurologist, Manatee Memorial Hospital

W Alvin McElveen, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Society of Neuroimaging, American Stroke Association, and Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ralph F Gonzalez, MD  Private Practice, Bradenton Neurology, Inc; Consulting Staff, Department of Neurology, Blake Hospital, Lakewood Ranch Medical Center, Manatee Memorial Hospital

Ralph F Gonzalez, MD is a member of the following medical societies: American Academy of Neurology and Florida Medical Association

Disclosure: Nothing to disclose.

Andrew P Keegan, MD  Private Practice, Bradenton Neurology, Inc; Consulting Staff, Department of Neurology, Manatee Memorial Hospital, Lakewood Ranch Medical Center, Blake Medical Center

Andrew P Keegan, MD is a member of the following medical societies: American Academy of Neurology and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Norman C Reynolds Jr, MD  Neurologist, Veterans Affairs Medical Center of Milwaukee; Clinical Professor, Medical College of Wisconsin

Norman C Reynolds Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, Movement Disorders Society, Sigma Xi, and Society for Neuroscience

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Howard S Kirshner, MD  Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

References

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Case 1: Left lateral sinus thrombosis demonstrated on MR venography. This 42-year-old woman presented with sudden onset of headache. Physical examination revealed no neurological abnormalities.
Case 1: One week after treatment with heparin, the MR venogram displayed increased flow in the left lateral sinus consistent with early recanalization of the sinus; headache had resolved at this point.
Magnetic resonance venogram - axial view; A = lateral (transverse) sinus; B = sigmoid sinus; C = confluence of sinuses; and D = superior sagittal sinus.
Magnetic resonance venogram - sagittal view; A = lateral (transverse) sinus; C = confluence of sinuses; D = superior sagittal sinus; and E = straight sinus.
Case 2: CT scan demonstrates a left posterior temporal hematoma in a 38-year-old woman on oral contraceptives (the only identified risk factor).
Case 2: Contrast-enhanced MRI showing lack of filling of left transverse sinus.
Case 2: Axial view of MR venogram demonstrating lack of flow in transverse sinus.
Case 2: Coronal view of MR venogram demonstrating lack of flow in the left transverse and sigmoid sinuses.
Table. Patients With Cerebral Venous Thrombosis Treated With Heparin and Local Infusion of Urokinase vs Nontreated Group
Treated Group, % (n = 12)Nontreated Group, % (n = 21)
Full recovery62.529
Mild disability12.513
Severe disability12.59.6
Fatal outcome12.548
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