Current Treatment Options in Neurology

, Volume 2, Issue 4, pp 343–352

Cerebral venous thrombosis

  • Philippe Niclot
  • Marie Germaine Bousser

Opinion statement

  • Cerebral venous thrombosis is a rare disorder with highly variable and nonspecific clinical presentations. For these reasons, specific treatment should be given only when the diagnosis has been firmly established. Etiologic diagnosis should begin in the emergency department to identify underlying conditions that require specific treatment.

  • The mainstay of treatment is anticoagulation with heparin, even in the case of cerebral hemorrhage, followed as soon as possible by oral anticoagulant administration. The optimal duration of oral anticoagulation has not been established. By analogy with systemic venous thrombosis, it should be prolonged 3 to 6 months. When a high risk of recurrence is present, treatment should be continued until the risk disappears.

  • In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation even when the clinical situation seems desperate. For the same reason, aggressive treatment of intracranial hypertension and seizures or status epilepticus is warranted.

  • Screening for extraneurologic venous thrombosis should be done by means of clinical examination and, if necessary, specific imaging procedures.

  • Local thrombolysis is not yet of proven efficacy and safety. It can be used in patients with clinical worsening related to documented extension of the venous thrombosis despite anticoagulation and in the absence of cerebral hematoma.

  • Surgical treatment is limited to external ventricular drainage and suboccipital craniotomy in the very rare cases of cerebellar vein thrombosis with edematous cerebellar infarct.


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References and Recommended Reading

  1. 1.
    Bousser MG, Chiras J, Bories J, Castaigne P: Cerebral venous thrombosis—a review of 38 cases. Stroke 1985, 16:199–213. This is a reference article describing the various clinical, neuroimaging, and outcomes patterns in CVT and the good tolerance of anticoagulant treatment.PubMedGoogle Scholar
  2. 2.
    Bousser MG: Cerebral Venous Thrombosis. Philadelphia: W.B. Saunders Co.; 1997. The only recent reference book on CVT, describing pathophysiology, clinical presentation, diagnosis, prognosis, and treatment of all known forms of CVT.Google Scholar
  3. 3.
    Crawford SC, Digre KB, Palmer CA, et al.: Thrombosis of the deep venous drainage of the brain in adults. Arch Neurol 1995, 52:1101–1108. A precise clinical and radiologic description of seven cases of a rare but sometimes devastating form of CVT, diagnosis of which can often be suspected on unenhanced CT scanning.PubMedGoogle Scholar
  4. 4.
    DiNubile MJ: Septic thrombosis of the cavernous sinuses. Arch Neurol 1988, 45:567–572.PubMedGoogle Scholar
  5. 5.
    Kuehnen J, Schwartz A, Neff W, et al.: Cranial nerve syndrome in thrombosis of the transverse/sigmoid sinuses. Brain 1998, 121:381–388.PubMedCrossRefGoogle Scholar
  6. 6.
    Jacobs K, Moulin T, Bogousslavsky J, et al.: The stroke syndrome of cortical venous thrombosis. Neurology 1996, 47:376–382.PubMedGoogle Scholar
  7. 7.
    Lafitte F, Boukobza M, Guichard JP, et al.: Deep cerebral venous thrombosis: imaging in eight cases. Neuroradiology 1999, 41:410–418.PubMedCrossRefGoogle Scholar
  8. 8.
    Ozsvath RR, Casey SO, Lustrin ES, et al.: Cerebral venography: comparison of CT and MR projection venography. Am J Roentgenol 1997, 169:1699–1707. A rigorous comparative study showing that CT venography is at least as efficient as magnetic resonance venography in the diagnosis of CVT; it is possibly superior in the differential diagnosis of hypoplastic sinus with low-flow phenomenon and dural sinus thrombosis.Google Scholar
  9. 9.
    Rosendaal FR: Venous thrombosis: a multicausal disease. Lancet 1999, 353:1167–1173. An excellent review of the multifactorial pathogenesis of venous thrombosis, with several references to CVT.PubMedCrossRefGoogle Scholar
  10. 10.
    De Bruijn SFTM, Stam J, Koopman MMW, et al.: Casecontrol study of risk of cerebral sinus thrombosis in oral contraceptive users who are carriers of hereditary prothrombotic conditions. BMJ 1998, 316:589–592.PubMedGoogle Scholar
  11. 11.
    Martinelli I, Sacchi E, Landi G, et al.: High risk of cerebralvein thrombosis in carriers of a prothrombingene mutation and in users of oral contraceptives. N Engl J Med 1998, 338:1793–1797. A case-control study showing the high incidence of two congenital thrombophilia (factor V Leiden and prothrombin) mutations in idiopathic CVT and their interaction with oral contraceptive agents.PubMedCrossRefGoogle Scholar
  12. 12.
    Zuber M, Toulon P, Marnet L, et al.: Factor V Leiden mutation in cerebral venous thrombosis. Stroke 1996, 27:1721–1723.PubMedGoogle Scholar
  13. 13.
    Ludemann P, Nabavi DG, Junker R, et al.: Factor V Leiden mutation is a risk factor for cerebral venous thrombosis: a case-control study of 55 patients. Stroke 1998, 29:2507–2510.PubMedGoogle Scholar
  14. 14.
    Reuner KH, Ruf A, Grau A, et al.: Prothrombin gene G20210®A transition is a risk factor for cerebral venous thrombosis. Stroke 1998, 29:1765–1769.PubMedGoogle Scholar
  15. 15.
    Christopher R, Nagaraja D, Dixit NS, et al.: Anticardiolipin antibodies: a study in cerebral venous thrombosis. Acta Neurol Scand 1999, 99:121–124.PubMedGoogle Scholar
  16. 16.
    Wilder-Smith E, Kothbauer-Margreiter I, Lämmle B, et al.: Dural puncture and activated protein C resistance: risk factors for cerebral venous thrombosis. J Neurol Neurosurg Psychiatry 1997, 63:351–356.PubMedGoogle Scholar
  17. 17.
    Brucker AB, Vollert-Rogenhofer H, Wagner M, et al.: Heparin treatment in acute cerebral sinus venous thrombosis: a retrospective clinical and MR analysis of 42 cases. Cerebrovasc Dis 1998, 8:331–337.PubMedCrossRefGoogle Scholar
  18. 18.
    Einhäupl KM, Villringer A, Meister W, et al.: Heparin treatment in sinus venous thrombosis. Lancet 1991, 338:597–600. The first randomized controlled trial in CVT, showing a diminution in deaths and handicapping together with good tolerance of heparin in CVT complicated by cerebral hemorrhage.PubMedCrossRefGoogle Scholar
  19. 19.
    Bergui M, Bradac GB, Danielle D: Brain lesions due to cerebral venous thrombosis do not correlate with sinus involvement. Neuroradiology 1999, 41:419–424. A multimodal radiologic study showing that parenchymatous lesions in CVT correlate with the involvement of cerebral veins, not the dural sinus.PubMedCrossRefGoogle Scholar
  20. 20.
    Hirsh J, Dalen JE, Anderson DR, et al.: Oral anticoagulants. Mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest 1998, 114:445S-469S.PubMedGoogle Scholar
  21. 21.
    Einhäupl KM, Masuhr F: Cerebral venous and sinus thrombosis: an update. Eur J Neurol 1994, 1:109–126.Google Scholar
  22. 22.
    De Bruijn SFTM, Stam J: Randomized, placebo-controlled trial of anticoagulant treatment with lowmolecular-weight heparin for cerebral sinus thrombosis. Stroke 1999, 30:484–488. A randomized controlled trial of nadroparin versus placebo in CVT that was negative despite fewer deaths in the group receiving nadroparin.PubMedGoogle Scholar
  23. 23.
    Bousser MG: Cerebral venous thrombosis. Nothing, heparin, or local thrombolysis? Stroke 1999, 30:481–483. A critical editorial on the various therapeutic options in CVT with analysis of the literature.PubMedGoogle Scholar
  24. 24.
    Raschke RA, Reilly BM, Guidry JR, et al.: The weightbased heparin dosing nomogram compared with a “standard-care” nomogram. A randomized controlled trial. Ann Intern Med 1993, 119:874–881. Description of a weight-based nomogram and of a randomized controlled trial showing its efficiency and safety.PubMedGoogle Scholar
  25. 25.
    Pohl C, Klockgether T, Greinacher A, et al.: Neurological complications in heparin-induced thrombocytopenia. Lancet 1999, 353:1678–1679.PubMedCrossRefGoogle Scholar
  26. 26.
    Schulman S, Rhedin AS, Lindmaker P, et al.: A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. N Engl J Med 1995, 332:1661–1665.PubMedCrossRefGoogle Scholar
  27. 27.
    Preter M, Tzourio C, Ameri A, et al.: Long-term prognosis in cerebral venous thrombosis. Follow-up of 77 patients. Stroke 1996, 27:243–246.PubMedGoogle Scholar
  28. 28.
    Hyers TM, Agnelli G, Hull RD, et al.: Antithrombotic therapy for venous thromboembolic disease. Chest 1998, 114:561S-578S.PubMedGoogle Scholar
  29. 29.
    Horowitz M, Purdy P, Unwin H, et al.: Treatment of dural sinus thrombosis using selective catheterization and urokinase. Ann Neurol 1995, 38:58–67.PubMedCrossRefGoogle Scholar
  30. 30.
    Gordon Smith A, Cornblath WT, Deveikis JP: Local thrombolytic therapy in deep cerebral venous thrombosis. Neurology 1997, 48:1613–1619.Google Scholar
  31. 31.
    Kasner SE, Gurian JH, Grotta JC: Urokinase treatment of sagittal sinus thrombosis with venous hemorrhagic infarction. J Stroke Cerebrovasc Dis 1998, 7:421–425.CrossRefPubMedGoogle Scholar
  32. 32.
    Philips MF, Bagley LJ, Sinson GP, et al.: Endovascular thrombolysis for symptomatic cerebral venous thrombosis. J Neurosurg 1999, 90:65–71.PubMedCrossRefGoogle Scholar
  33. 33.
    Frey JL, Muro GJ, McDougall CG, et al.: Cerebral venous thrombosis. Combined intrathrombus rtPA and intravenous heparin. Stroke 1999, 30:489–494.PubMedGoogle Scholar
  34. 34.
    Corvol JC, Oppenheim C, Manaï R, et al.: Diffusionweighted magnetic resonance imaging in a case of cerebral venous thrombosis. Stroke 1998, 29:2649–2652.PubMedGoogle Scholar
  35. 35.
    Keller E, Flacke S, Urbach H, et al.: Diffusion- and perfusion-weighted magnetic resonance magnetic imaging in deep cerebral venous thrombosis. Stroke 1999, 30:1144–1146. A case report discussing the pathophysiology of the neurologic manifestations of CVT and its exploration with new magnetic resonance imaging techniques.PubMedGoogle Scholar
  36. 36.
    Hsu LC, Lirng JF, Fuh JL, et al.: Proton magnetic resonance spectroscopy in deep cerebral venous thrombosis. Clin Neurol Neurosurg 1998, 100:27–30.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2000

Authors and Affiliations

  • Philippe Niclot
    • 1
  • Marie Germaine Bousser
    • 1
  1. 1.Service de NeurologieHôpital LariboisièreFrance

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