AHA issues statement on cerebral venous thrombosis diagnosis, management

The American Heart Association (AHA)/American Stroke Association last week issued a scientific statement on the diagnosis, treatment and management of cerebral venous thrombosis (CVT).

CVT is uncommon, representing 0.5% to 1% of all strokes, and usually affects individuals younger than age 50. Diagnosis and management can be difficult because of the diverse underlying risk factors, and the lack of uniformity in treatment, the statement said. Recommendations for diagnosis and treatment include the following:

• In patients with suspected CVT, perform routine blood studies comprising complete blood count, chemistry panel, prothrombin time and activated partial thromboplastin time (Class I, Level C evidence).In patients with headache associated with atypical features, perform imaging of the cerebral venous system to exclude CVT (Class IIa, Level C evidence).Although a plain computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is useful in the initial evaluation of patients with suspected CVT, a negative plain CT or MRI doesn't rule out CVT. If CVT is suspected and either scan is negative, perform a venographic study. The study should also be performed to define the extent of CVT, when CT or MRI suggests the condition. (Class I, Level C evidence).For patients with CVT, use initial anticoagulation with adjusted-dose unfractionated heparin or weight-based low-molecular-weight heparin in full anticoagulant doses, followed by vitamin K antagonists, whether or not intracerebral hemorrhage is present (Class IIa, Level C evidence).It's reasonable to admit patients with CVT to a stroke unit for treatment and to prevent clinical complications (Class IIa, Level C evidence).

For long-term management of CVT, the statement authors recommend the following:Test for prothrombotic conditions, including protein C, protein S, antithrombin deficiency, antiphospholipid condition, prothrombin G20210A mutation and factor V Leiden. Testing for proteins C and S and antithrombin deficiency is generally indicated two to four weeks after completing anticoagulation. The value of testing is very limited in patients taking warfarin or in the acute setting (Class IIa, Level B evidence).Patients with provoked CVT (associated with a transient risk factor) can continue with vitamin K antagonists for three to six months, with a target INR of 2.0 to 3.0. Patients with unprovoked CVT can continue vitamin K antagonists for six to 12 months, with the same target INR (Class IIb, Level C evidence).In patients with recurrent CVT, venous thromboembolism (VTE) after CVT, or first CVT with severe thrombophilia, consider indefinite anticoagulation with a target INR of 2.0 to 3.0.Consider consultation with a physician expert in thrombosis to aid in prothrombotic testing and care of CVT patients (Class IIb, Level C evidence).

The recommendations also include evaluation and management of CVT during pregnancy. The statement was published online Feb. 3 by Stroke. Its educational value has been affirmed by the American Academy of Neurology, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons. The Ibero-American Stroke Society and the Society of NeuroInterventional Surgery have endorsed the recommendations, as well.