Cerebral venous thrombosis

Because of its wide range of presentations, its highly variable mode of onset, its numerous causes, and its unpredictable outcome, cerebral venous thrombosis (CVT) remains a diagnostic and therapeutic challenge. Treatment of CVT consists primarily of symptomatic treatment of seizures and intracranial hypertension, antithrombotics, and etiologic treatment whenever possible. Heparin remains the first line of treatment for CVT; although its systematic use remains debated, recent studies have confirmed its safety even in patients with large hemorrhagic infarctions. The addition of local thrombolysis is indicated for patients with clinical worsening related to extension of the venous thrombosis, despite adequate anticoagulation and optimal symptomatic and etiologic treatment. In contrast to arterial stroke, complete recovery of prolonged or severe neurologic deficit is possible, justifying initiation of anticoagulation and eventually thrombolysis, even when the clinical situation seems desperate. New techniques using mechanical devices disrupting the clot may be used in addition to thrombolysis in rare cases. Ventricular drainage is indicated in cases of cerebellar infarction or deep venous thrombosis associated with hydrocephalus. Decompressive craniotomy may be performed acutely in patients with untractable intracranial hypertension and herniation.