AHA/ASA Issues Statement on Cerebral Venous Thrombosis

February 15, 2011—In Stroke, the American Heart Association/American Stroke Association (AHA/ASA) has published a statement that provides an overview of cerebral venous thrombosis (CVT) and recommendations for its diagnosis, management, and treatment. The intended audience is physicians and other health care providers who are responsible for the diagnosis and management of patients with CVT.

The panel summarized its findings by noting that management dilemmas in CVT can be complex, and health care providers managing these patients may require assistance from appropriate subspecialists given that there is no strong literature evidence to guide some of these challenging clinical decisions. The present statement is unlikely to end the debate about the management of CVT. Rather, its content should be seen as a compilation of the best available evidence at the present time. Through a process of innovative research and systematic evaluation, diagnosis, management, and therapeutic alternatives will continue to evolve and consequently lead to better outcomes for patients with CVT.

The chair of the writing panel was Gustavo Saposnik, MD. The AHA Stroke Council's Scientific Statement Oversight Committee appointed the members of the panel, each representing different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 1966 and used the AHA levels-of-evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the AHA Science Advisory and Coordinating Committee.

Evidence-based recommendations are provided for the diagnosis, management, and prevention of recurrence of CVT. Recommendations on the evaluation and management of CVT during pregnancy and in the pediatric population are provided. Considerations for the management of clinical complications (seizures, hydrocephalus, intracranial hypertension, and neurological deterioration) are also summarized. An algorithm for diagnosis and management of patients with CVT is described.

The statement provides an extensive and critical review of the literature related to the diagnosis and management of CVT and its most common complications.

CVT accounts for 0.5% to 1% of all strokes, mostly affecting young individuals and women of childbearing age. Patients with CVT commonly present with headache, although some develop a focal neurological deficit, decreased level of consciousness, seizures, or intracranial hypertension without focal neurological signs. Uncommonly, an insidious onset may create a diagnostic challenge. A prothrombotic factor or a direct cause is identified in approximately two-thirds of patients with sinus thrombosis. The diagnosis is usually made by computed tomographic or magnetic resonance venography studies to demonstrate obstruction of the venous sinuses or cerebral veins by thrombus. Management of CVT includes treatment of the underlying condition; symptomatic treatment; the prevention or treatment of complications of increased intracranial pressure, ICH, or venous infarction; and, typically, anticoagulation therapy.

According to the statement, diagnostic and therapeutic techniques in stroke are in continuous evolution. Important advances have been made in the understanding of the pathophysiology of cerebral sinus thrombosis. However, promising techniques (endovascular procedures, hemicraniectomy for the management of refractory intracranial hypertension in the context of mass effect or intracerebral hemorrhage, etc.) need to be evaluated rigorously before they are widely adopted.

The statement advised that despite substantial progress in the study of CVT in recent years, much of the literature remains descriptive. The CVT writing group made an effort to highlight areas that require further study (eg, larger randomized clinical trials to determine the benefit of therapeutic interventions) and provided suggestions that reflect the current standard practice. The results of TO-ACT (Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis), an ongoing randomized clinical trial aimed at comparing the benefit of anticoagulation therapy versus endovascular thrombolysis, may contribute to improving the acute management of patients with CVT.