Cerebral Venous Thrombosis: Reviewing Pathophysiology, Diagnosis, and Treatment Strategies

AbstractThis review discusses cerebral venous thrombosis (CVT), including diagnosis and treatment strategies, a rare class of stroke that, if unrecognized or untreated, can have devastating effects. Thrombosis of one or many cerebral veins leads to propagation of thrombosis and impaired cerebral venous drainage. Diagnosis is made using a combination of history and imaging, particularly computed tomography (CT) venogram, which demonstrates thrombosis. Currently, acute treatment consists of heparin infusion with transition to long-term oral anticoagulation. Further research, especially on prevention, endovascular therapy, and the role of newer anticoagulants (direct oral anticoagulants [DOACs]) is necessary and ongoing.

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Cerebral Venous Thrombosis Case Series at a Tertiary Care Hospital: Exploring Treatment Safety and Efficacy of Direct Oral Anticoagulants

Blood ◽

10.1182/blood-2019-128406 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3658-3658

Author(s):

Mohammed Abdullah Alsheef ◽

Mukhtar Alomar ◽

Abdul Rehman Z. Zaidi ◽

Ghaydaa Juma Kullab ◽

Mohammed AlHazzaa ◽

...

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Tertiary Care ◽

Case Series ◽

Case Report Form ◽

Care Hospital ◽

Safety And Efficacy ◽

Number Of Patients

Background: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults and children. Initial treatment with heparin followed by wafarin is the mainstay of treatment. Only insufficient experience is available for direct oral anticoagulants (DOACs). Aims: The study aims to demonstrate the efficacy and safety of DOACs such as (Rivaroxaban and Dabigatran) in patients with objectively confirmed CVT. Methods: Data of 46 cases of CVT collected using a standardized case report form. Inclusion criteria were patients diagnosed with CVT, confirmed by CT or MRI imaging. Results: The total number of patients was 46 (9 males and 37 females). The mean age of the patients was 35.2± 5 years. The most common clinical manifestations among our patients were headache followed by seizure. 52% of cases were unprovoked, while 48% were provoked by pregnancy and oral contraceptive pills. Superior sagittal sinus (55%) and transverse sinus (44.9%) were the most common sites. Involvement of more than three venous sinuses was 34.8%. Thrombophilic abnormality was detected in 21.7% of patients. Initiation of anticoagulation (AC) was mostly low molecular weight heparin (LMWH) (80%), followed by unfractionated heparin (UFH) (17.7%) and fondaparinex (2%). Maintenance AC with Rivaroxaban after heparin (LMWH/UFH) was in 63% of our patients, the rest were switched from Warfarin to Rivaroxaban (34.8%), and one was treated by Dabigatran (2%). CVT recurrence was observed in one patient. Major bleeding (according to ISTH criteria) was not reported in our case series. Conclusions: DOACs demonstrated good safety and efficacy profile and can potentially replace warfarin in CVT patients. Disclosures No relevant conflicts of interest to declare.

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Recurrent Cerebral Venous Thrombosis Treated with Direct Oral Anticoagulants in a Japanese Man with Hereditary Protein C Deficiency

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.105320 ◽

2021 ◽

Vol 30 (1) ◽

pp. 105320

Author(s):

Kazuyuki Saito ◽

Kazuyuki Ishii ◽

Konosuke Furuta ◽

Masaki Kobayashi ◽

Yoshiaki Wada ◽

...

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Protein C ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Protein C Deficiency

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Preliminary findings regarding the use of direct oral anticoagulants in cerebral venous thrombosis

Clinical Neurology and Neurosurgery ◽

10.1016/j.clineuro.2020.106204 ◽

2020 ◽

Vol 198 ◽

pp. 106204

Author(s):

Andrew Hsu ◽

Hetal Mistry ◽

Nupur Lala ◽

John L. Reagan

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants

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Emerging anticoagulant strategies

Blood ◽

10.1182/blood-2016-09-692996 ◽

2017 ◽

Vol 129 (2) ◽

pp. 147-154 ◽

Cited By ~ 30

Author(s):

James C. Fredenburgh ◽

Peter L. Gross ◽

Jeffrey I. Weitz

Keyword(s):

Secondary Prevention ◽

Venous Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Treatment Strategies ◽

Arterial Injury ◽

Standards Of Care ◽

Factor Xii ◽

New Anticoagulants ◽

Novel Treatment Strategies

Abstract Despite the introduction of direct oral anticoagulants (DOACs), the search for more effective and safer antithrombotic strategies continues. Better understanding of the pathogenesis of thrombosis has fostered 2 new approaches to achieving this goal. First, evidence that thrombin may be as important as platelets to thrombosis at sites of arterial injury and that platelets contribute to venous thrombosis has prompted trials comparing anticoagulants with aspirin for secondary prevention in arterial thrombosis and aspirin with anticoagulants for primary and secondary prevention of venous thrombosis. These studies will help identify novel treatment strategies. Second, emerging data that naturally occurring polyphosphates activate the contact system and that this system is critical for thrombus stabilization and growth have identified factor XII (FXII) and FXI as targets for new anticoagulants that may be even safer than the DOACs. Studies are needed to determine whether FXI or FXII is the better target and to compare the efficacy and safety of these new strategies with current standards of care for the prevention or treatment of thrombosis. Focusing on these advances, this article outlines how treatment strategies for thrombosis are evolving and describes the rationale and approaches to targeting FXII and FXI. These emerging anticoagulant strategies should address unmet needs and reduce the systemic underuse of anticoagulation because of the fear of bleeding.

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Use of direct oral anticoagulants in cerebral venous thrombosis: a systematic review

Blood Coagulation & Fibrinolysis ◽

10.1097/mbc.0000000000000958 ◽

2020 ◽

Vol 31 (8) ◽

pp. 501-505

Author(s):

Sen Sheng ◽

Krishina Nalleballe ◽

Naga V. Pothineni ◽

Rohan Sharma ◽

Aliza Brown ◽

...

Keyword(s):

Systematic Review ◽

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants

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Direct Oral Anticoagulants for the Treatment of Cerebral Venous Thrombosis

Cerebrovascular Diseases ◽

10.1159/000502454 ◽

2019 ◽

Vol 48 (1-2) ◽

pp. 32-37 ◽

Cited By ~ 5

Author(s):

Antoine Lurkin ◽

Laurent Derex ◽

Alexandra Fambrini ◽

Laurent Bertoletti ◽

Magali Epinat ◽

...

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Randomized Clinical Trials ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Individual Risk ◽

University Hospitals ◽

Imaging Results ◽

Venous Recanalization

Background: Cerebral venous thrombosis (CVT) is an uncommon neurological condition usually treated with heparin followed by oral vitamin K antagonists (VKAs). In patients with venous thromboembolism (VTE), compared to VKAs, direct oral anticoagulants (DOACs) offer several advantages. However, there is little data concerning their use in managing CVT. Aims: This retrospective observational study pursued 2 objectives: (1) to investigate clinical characteristics of CVT patients treated with heparin + DOACs vs. heparin + standard treatment; (2) to compare clinical outcomes. Methods: Consecutive CVT patients recruited from January 2016 to March 2018 in 2 French university hospitals (Lyon, Saint-Etienne), and treated with DOACs or VKAs were identified. Radiological evolution, VTE, hemorrhagic events, and antithrombotic medication were recorded. Functional outcome was assessed by the modified Rankin scale score and venous recanalization was assessed by magnetic resonance imaging. Results: Overall, 41 patients were included: 25 (61%) received VKAs and 16 (39%) DOACs. We identified no clinical or radiological features explaining the physicians’ preference for a specific anticoagulation treatment, and age, initial clinical presentation, radiological severity, and individual risk factors thus unlikely guided the choice of anticoagulant. No DOAC patient exhibited clinical or radiological thrombosis aggravation, and the thrombosis completely vanished in 6 (40%). Two of the VKA-treated patients (28.6%) demonstrated complete venous recanalization, whereas 3 others experienced clinical or radiological aggravation versus baseline. There was no major bleeding leading to hospitalization in both groups. Conclusion: The collected data on DOAC efficacy and safety in CVT management appear encouraging, yet needs to be confirmed by larger prospective randomized clinical trials.

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