Sequential Escalation of Therapy in "Malignant'' Cerebral Venous and Sinus Thrombosis

Background The best treatment of fulminant or progressive cerebral venous and sinus thrombosis (CVST) despite dose-adjusted heparin remains controversial. Local thrombolysis has been successfully performed in several cases. In cases of impending herniation hemicraniectomy has been suggested as ultima ratio. We describe sequential escalation of therapy in "malignant'' CVST. Methods Case report. Results We report a case of fulminant CVST in whom sequential escalation of therapy with intravenous heparin, local thrombolysis, and hemicraniectomy was necessitated by the progressive clinical course. The patient survived with a relatively good outcome. Conclusions This first description on the combined treatment with local thrombolysis and hemicraniectomy illustrates that even in severely affected individuals, therapeutic nihilism is unwarranted and that all available therapeutic options including local thrombolysis and hemicraniectomy should be taken into consideration.