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Intracranial venous and venous sinus thrombosis (CVST) accounts for about 0.
5% to 1.
0% of all strokes, and is more common in pregnant women, women taking oral contraceptives, and young people <45 years old
.
In China, although CVST is clinically rare, it is often misdiagnosed or missed because of its diverse forms of incidence and different clinical manifestations, and has a high disability and mortality rate.
Existing clinical treatment methods and evaluation methods lack uniform standards
.
Based on this situation, the expert group jointly formulated guidelines for the treatment of CVST
.
Come and learn about the latest norms of diagnosis and treatment
.
Diagnosis is generally based on clinical manifestations, laboratory tests, and imaging findings
.
Imaging recommendations are as follows
.
➤Although unenhanced CT or MRI is helpful in the initial evaluation of patients with suspected CVST, a negative result does not rule out CVST
.
For patients with suspected CVST, venography (CTV or MRV) is recommended if the CT scan or MRI results are negative, or if the CT scan or MRI has suggested CVST to determine the extent of CVST
.
(Class I recommendation, level of evidence C)
.
➤ For CVST patients with persistent or progressive symptoms despite medical treatment, or with signs of thrombus expansion, CTV or MRV examinations are recommended for early follow-up
.
(Class I recommendation, level of evidence C)
.
➤ For patients with clinical symptoms of recurrent CVST and a clear history of CVST, it is recommended to review CTV or MRV
.
(Class I recommendation, level C evidence)
.
➤ Gradient echo T2 sensitivity-weighted images combined with MR help to improve the accuracy of CVST diagnosis
.
(Class IIa recommendation, level B evidence)
.
➤For patients with a high clinical suspicion of CVST, but with uncertain CTV or MRI results, further whole-brain angiography is recommended to confirm the diagnosis
.
(Class IIa recommendation, level of evidence C)
.
➤In stable patients, it is reasonable to perform CTV or MRV 3 to 6 months after diagnosis to assess recanalization of occluded cortical veins or venous sinuses
.
(Class IIa recommendation, level of evidence C)
.
Treatment ➤ Basic treatment ➤ Depressing intracranial pressure: For patients with mild to moderate cerebral edema, anticoagulant therapy can improve venous return and does not require other antihypertensive drug therapy
.
Dehydration drugs such as mannitol can be used in patients with severe intracranial hypertension; there are no randomized controlled studies evaluating the effect of carbonic anhydrase inhibitors or diuretics on the outcome of patients with CVST, so acetazolamide is not recommended for patients with acute CVST To prevent death or improve functional outcomes; acetazolamide may be considered if relatively safe for isolated high intracranial pressure secondary to CVST causing severe headache or visual impairment
.
➤ Seizure control: About 30% to 40% of CVST patients can have epileptic seizures in the early stage.
For acute CVST patients with supratentorial lesions and seizures, it is recommended to use antiepileptic drugs to treat and prevent early seizures.
and recurrence; no recommendations are made for the prevention of long-term seizures
.
➤Anticoagulation therapy ➤Actions and deficiencies ➤Action: It can prevent the occurrence of venous thrombosis, prevent the continued development of thrombus, promote the opening of collateral circulation, and prevent deep vein thrombosis and pulmonary embolism
.
➤Insufficient: cannot dissolve already formed thrombus
.
➤Indications and contraindications ➤Indications: Subcutaneous low-molecular-weight heparin or intravenous heparin anticoagulation should be given to conscious patients with CVST.
CVST with intracranial hemorrhage is not a contraindication to heparin therapy
.
➤Contraindications: patients with severe coagulation dysfunction; critically ill, late stage of brain herniation, brain tonic
.
➤ Drugs and usage of anticoagulation Early oral warfarin, control the patient's international normalized ratio (INR) to 2.
0 ~ 3.
0 (plasma prothrombin time to 2 times the normal value)
.
For patients with clear etiology and clinical improvement, warfarin can be used for 3 months; for patients with unidentified hypercoagulable state, warfarin can be used for 6 to 12 months; for patients with recurrent CVST, lifelong anticoagulation can be considered
.
The 2017 version of the European guidelines pointed out that rivaroxaban and dabigatran can effectively treat CVST without obvious complications, but there are shortcomings such as no effective indicators to monitor the efficacy, short clinical application time, and long-term complications are not yet clear
.
➤Recommendations ➤Monitor the INR value and adjust the warfarin dose, with a target value of 2.
0 to 3.
0
.
➤ It is necessary to monitor platelet count and coagulation, and provide antagonists such as vitamin K1 and protamine sulfate
.
➤ Intracranial hemorrhage is not a contraindication to anticoagulation therapy.
The volume of hemorrhage can be evaluated, the dose of anticoagulant drugs can be adjusted, and anticoagulant drugs can be discontinued in severe cases
.
➤ Duration of anticoagulation: Warfarin can be used for 3 months for patients with clear etiology and improved clinical symptoms; warfarin can be used for 6 to 12 months for hypercoagulable state of unknown etiology; if the hypercoagulable state cannot be corrected , lifelong anticoagulation is recommended; lifelong anticoagulation may be considered for patients with recurrent CVST
.
➤Thrombolytic therapy ➤Indications and contraindications ➤Indications: Thrombolysis or thrombectomy can be used for patients with coma, venous infarction and/or hemorrhage, epilepsy, and patients whose condition worsens despite anticoagulation therapy
.
➤Contraindications: patients with severe coagulation disorders who cannot tolerate treatment; critically ill, advanced brain herniation, and brain tonic removal
.
➤ Intravenous infusion of systemic intravenous thrombolytic thrombolytics, through blood circulation to the intracranial venous sinus to dissolve the thrombus in the sinus to recanalize the venous sinus.
This treatment method is fast, simple, and relatively low in treatment cost.
The thrombolytic effect of recombinant tissue plasminogen activator is exact
.
But the premise is that there must be enough (equivalent) dose of thrombolytic agent into the sinus to contact with the thrombus, in order to play a thrombolytic effect
.
If the thrombus in the venous sinus has completely occluded the venous sinus, the blood flow in the sinus is slow or even no blood flow, and the thrombolytic drugs are often backflowed through the collateral route after intravenous infusion, resulting in a very low local thrombolytic drug concentration in the sinus thrombus, and the patient will be lysed.
The plug effect is reduced or even ineffective
.
➤Thrombolytic drugs: urokinase 500,000 to 1.
5 million U/d, used for 5 to 7 days, and fibrinogen ≥1.
0g detected at the same time; recombinant tissue plasminogen activator 0.
6～0.
9mg/kg, total amount ≤50mg
.
➤ Venous sinus contact thrombolysis The microcatheter is placed in the thrombus through the femoral vein approach, which on the one hand significantly increases the concentration of thrombolytic drugs in the thrombus; In patients, the microcatheter is placed at the distal end of the thrombus, and urokinase is pumped slowly and continuously for thrombolytic therapy, so that urokinase is repeatedly circulated for thrombolysis, which can improve the rate of venous sinus recanalization and shorten the time of venous sinus recanalization
.
Urokinase 500,000 to 1.
5 million U/d, intravenous drip, 2 to 4 times/d, 3 to 7 days.
The specific medication time is determined according to the improvement of the patient's clinical symptoms and whether the venous sinus is basically unobstructed by imaging studies
.
➤Recommendations ➤At present, there is insufficient evidence to support systemic intravenous thrombolysis in patients with CVST, and small-scale case series studies support venous sinus contact thrombolysis
.
➤ For some patients with CVST who have been treated with adequate anticoagulation but whose disease is still progressing, excluding other conditions that cause deterioration, sinus contact thrombolysis can be considered.
Systemic intravenous thrombolysis requires stricter case selection (especially for those without patients with intracranial hemorrhage or massive hemorrhagic infarction at risk of brain herniation)
.
➤Arterial thrombolysis: Arterial thrombolysis is used for deep vein or venous thrombosis, as well as thrombus that cannot be reached by venous sinus thrombolysis
.
The transarterial thrombolysis method can deliver the thrombolytic drugs antegradely to the venous end, which can effectively dissolve the thrombus in the cortex and deep veins, and can promote the establishment of collateral circulation and open collaterals when the main draining vein is not smooth.
Venous return route
.
➤Specific dosage of urokinase: through carotid artery puncture, 100,000 U/d, 1 time/d, 5-7d, slowly inject for 10-25min, alternately puncture the carotid artery
.
Through the femoral artery approach, the total amount of thrombolysis should be 500,000
U.
➤Other treatments ➤Mechanical opening: At present, there are guide wires, balloons, protective umbrellas, and stent-type thrombectomy devices at home and abroad for mechanical thrombectomy, and intermediate guide catheters or thrombectomy devices for thrombectomy
.
Each medical unit can be carefully selected according to the patient's condition, personal experience and unit conditions
.
➤Stent angioplasty: For patients with regular treatment for >6 months, chronic thrombosis, local stenosis, no improvement in symptoms, and pressure difference between the distal and proximal ends >10 mmHg, stenting can be considered
.
➤Recommendations ➤At present, there is insufficient evidence to support arterial thrombolysis in patients with CVST
.
➤ Mechanical thrombectomy and stenting are supported by case reports and small case series
.
When the patient still has clinical deterioration after anticoagulation therapy, or the patient has mass effect due to venous infarction, or the patient has increased intracranial pressure due to cerebral hemorrhage, and the conventional medical treatment method is ineffective, the above interventional treatment measures should be considered.
.
Yimaitong compiled from: National Health Commission of the People's Republic of China.
Guidelines for the diagnosis and treatment of intracranial venous and venous sinus thrombosis in China (2021 edition) [J].
Clinical and Education of General Medicine, 2022,20(1):4- 7.
5% to 1.
0% of all strokes, and is more common in pregnant women, women taking oral contraceptives, and young people <45 years old
.
In China, although CVST is clinically rare, it is often misdiagnosed or missed because of its diverse forms of incidence and different clinical manifestations, and has a high disability and mortality rate.
Existing clinical treatment methods and evaluation methods lack uniform standards
.
Based on this situation, the expert group jointly formulated guidelines for the treatment of CVST
.
Come and learn about the latest norms of diagnosis and treatment
.
Diagnosis is generally based on clinical manifestations, laboratory tests, and imaging findings
.
Imaging recommendations are as follows
.
➤Although unenhanced CT or MRI is helpful in the initial evaluation of patients with suspected CVST, a negative result does not rule out CVST
.
For patients with suspected CVST, venography (CTV or MRV) is recommended if the CT scan or MRI results are negative, or if the CT scan or MRI has suggested CVST to determine the extent of CVST
.
(Class I recommendation, level of evidence C)
.
➤ For CVST patients with persistent or progressive symptoms despite medical treatment, or with signs of thrombus expansion, CTV or MRV examinations are recommended for early follow-up
.
(Class I recommendation, level of evidence C)
.
➤ For patients with clinical symptoms of recurrent CVST and a clear history of CVST, it is recommended to review CTV or MRV
.
(Class I recommendation, level C evidence)
.
➤ Gradient echo T2 sensitivity-weighted images combined with MR help to improve the accuracy of CVST diagnosis
.
(Class IIa recommendation, level B evidence)
.
➤For patients with a high clinical suspicion of CVST, but with uncertain CTV or MRI results, further whole-brain angiography is recommended to confirm the diagnosis
.
(Class IIa recommendation, level of evidence C)
.
➤In stable patients, it is reasonable to perform CTV or MRV 3 to 6 months after diagnosis to assess recanalization of occluded cortical veins or venous sinuses
.
(Class IIa recommendation, level of evidence C)
.
Treatment ➤ Basic treatment ➤ Depressing intracranial pressure: For patients with mild to moderate cerebral edema, anticoagulant therapy can improve venous return and does not require other antihypertensive drug therapy
.
Dehydration drugs such as mannitol can be used in patients with severe intracranial hypertension; there are no randomized controlled studies evaluating the effect of carbonic anhydrase inhibitors or diuretics on the outcome of patients with CVST, so acetazolamide is not recommended for patients with acute CVST To prevent death or improve functional outcomes; acetazolamide may be considered if relatively safe for isolated high intracranial pressure secondary to CVST causing severe headache or visual impairment
.
➤ Seizure control: About 30% to 40% of CVST patients can have epileptic seizures in the early stage.
For acute CVST patients with supratentorial lesions and seizures, it is recommended to use antiepileptic drugs to treat and prevent early seizures.
and recurrence; no recommendations are made for the prevention of long-term seizures
.
➤Anticoagulation therapy ➤Actions and deficiencies ➤Action: It can prevent the occurrence of venous thrombosis, prevent the continued development of thrombus, promote the opening of collateral circulation, and prevent deep vein thrombosis and pulmonary embolism
.
➤Insufficient: cannot dissolve already formed thrombus
.
➤Indications and contraindications ➤Indications: Subcutaneous low-molecular-weight heparin or intravenous heparin anticoagulation should be given to conscious patients with CVST.
CVST with intracranial hemorrhage is not a contraindication to heparin therapy
.
➤Contraindications: patients with severe coagulation dysfunction; critically ill, late stage of brain herniation, brain tonic
.
➤ Drugs and usage of anticoagulation Early oral warfarin, control the patient's international normalized ratio (INR) to 2.
0 ~ 3.
0 (plasma prothrombin time to 2 times the normal value)
.
For patients with clear etiology and clinical improvement, warfarin can be used for 3 months; for patients with unidentified hypercoagulable state, warfarin can be used for 6 to 12 months; for patients with recurrent CVST, lifelong anticoagulation can be considered
.
The 2017 version of the European guidelines pointed out that rivaroxaban and dabigatran can effectively treat CVST without obvious complications, but there are shortcomings such as no effective indicators to monitor the efficacy, short clinical application time, and long-term complications are not yet clear
.
➤Recommendations ➤Monitor the INR value and adjust the warfarin dose, with a target value of 2.
0 to 3.
0
.
➤ It is necessary to monitor platelet count and coagulation, and provide antagonists such as vitamin K1 and protamine sulfate
.
➤ Intracranial hemorrhage is not a contraindication to anticoagulation therapy.
The volume of hemorrhage can be evaluated, the dose of anticoagulant drugs can be adjusted, and anticoagulant drugs can be discontinued in severe cases
.
➤ Duration of anticoagulation: Warfarin can be used for 3 months for patients with clear etiology and improved clinical symptoms; warfarin can be used for 6 to 12 months for hypercoagulable state of unknown etiology; if the hypercoagulable state cannot be corrected , lifelong anticoagulation is recommended; lifelong anticoagulation may be considered for patients with recurrent CVST
.
➤Thrombolytic therapy ➤Indications and contraindications ➤Indications: Thrombolysis or thrombectomy can be used for patients with coma, venous infarction and/or hemorrhage, epilepsy, and patients whose condition worsens despite anticoagulation therapy
.
➤Contraindications: patients with severe coagulation disorders who cannot tolerate treatment; critically ill, advanced brain herniation, and brain tonic removal
.
➤ Intravenous infusion of systemic intravenous thrombolytic thrombolytics, through blood circulation to the intracranial venous sinus to dissolve the thrombus in the sinus to recanalize the venous sinus.
This treatment method is fast, simple, and relatively low in treatment cost.
The thrombolytic effect of recombinant tissue plasminogen activator is exact
.
But the premise is that there must be enough (equivalent) dose of thrombolytic agent into the sinus to contact with the thrombus, in order to play a thrombolytic effect
.
If the thrombus in the venous sinus has completely occluded the venous sinus, the blood flow in the sinus is slow or even no blood flow, and the thrombolytic drugs are often backflowed through the collateral route after intravenous infusion, resulting in a very low local thrombolytic drug concentration in the sinus thrombus, and the patient will be lysed.
The plug effect is reduced or even ineffective
.
➤Thrombolytic drugs: urokinase 500,000 to 1.
5 million U/d, used for 5 to 7 days, and fibrinogen ≥1.
0g detected at the same time; recombinant tissue plasminogen activator 0.
6～0.
9mg/kg, total amount ≤50mg
.
➤ Venous sinus contact thrombolysis The microcatheter is placed in the thrombus through the femoral vein approach, which on the one hand significantly increases the concentration of thrombolytic drugs in the thrombus; In patients, the microcatheter is placed at the distal end of the thrombus, and urokinase is pumped slowly and continuously for thrombolytic therapy, so that urokinase is repeatedly circulated for thrombolysis, which can improve the rate of venous sinus recanalization and shorten the time of venous sinus recanalization
.
Urokinase 500,000 to 1.
5 million U/d, intravenous drip, 2 to 4 times/d, 3 to 7 days.
The specific medication time is determined according to the improvement of the patient's clinical symptoms and whether the venous sinus is basically unobstructed by imaging studies
.
➤Recommendations ➤At present, there is insufficient evidence to support systemic intravenous thrombolysis in patients with CVST, and small-scale case series studies support venous sinus contact thrombolysis
.
➤ For some patients with CVST who have been treated with adequate anticoagulation but whose disease is still progressing, excluding other conditions that cause deterioration, sinus contact thrombolysis can be considered.
Systemic intravenous thrombolysis requires stricter case selection (especially for those without patients with intracranial hemorrhage or massive hemorrhagic infarction at risk of brain herniation)
.
➤Arterial thrombolysis: Arterial thrombolysis is used for deep vein or venous thrombosis, as well as thrombus that cannot be reached by venous sinus thrombolysis
.
The transarterial thrombolysis method can deliver the thrombolytic drugs antegradely to the venous end, which can effectively dissolve the thrombus in the cortex and deep veins, and can promote the establishment of collateral circulation and open collaterals when the main draining vein is not smooth.
Venous return route
.
➤Specific dosage of urokinase: through carotid artery puncture, 100,000 U/d, 1 time/d, 5-7d, slowly inject for 10-25min, alternately puncture the carotid artery
.
Through the femoral artery approach, the total amount of thrombolysis should be 500,000
U.
➤Other treatments ➤Mechanical opening: At present, there are guide wires, balloons, protective umbrellas, and stent-type thrombectomy devices at home and abroad for mechanical thrombectomy, and intermediate guide catheters or thrombectomy devices for thrombectomy
.
Each medical unit can be carefully selected according to the patient's condition, personal experience and unit conditions
.
➤Stent angioplasty: For patients with regular treatment for >6 months, chronic thrombosis, local stenosis, no improvement in symptoms, and pressure difference between the distal and proximal ends >10 mmHg, stenting can be considered
.
➤Recommendations ➤At present, there is insufficient evidence to support arterial thrombolysis in patients with CVST
.
➤ Mechanical thrombectomy and stenting are supported by case reports and small case series
.
When the patient still has clinical deterioration after anticoagulation therapy, or the patient has mass effect due to venous infarction, or the patient has increased intracranial pressure due to cerebral hemorrhage, and the conventional medical treatment method is ineffective, the above interventional treatment measures should be considered.
.
Yimaitong compiled from: National Health Commission of the People's Republic of China.
Guidelines for the diagnosis and treatment of intracranial venous and venous sinus thrombosis in China (2021 edition) [J].
Clinical and Education of General Medicine, 2022,20(1):4- 7.
