Treatment of cerebral venous thrombosis: a review

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke. COVID-19 infection and vaccination have been associated with CVT. Fibrinolysis and mechanical thrombectomy may play an emerging role in management. We conducted a literature review summarizing current evidence on use of antiplatelets, anticoagulants, thrombolysis, and mechanical thrombectomy for the management of CVT and COVID-19 related CVT. This was achieved through a review of MEDLINE, PubMed, and Cochrane Reviews databases, performed using the search terms CVT AND "antiplatelets' aspirin", "ticagrelor", "clopidogrel", "eptifibatide", "Low-molecular-weight-heparin (LMWH)", "Unfractionated heparin (UH)", "warfarin", "DOACs", "rivaroxaban", "apixaban", "dabigatran", "fibrinolysis", "intra-sinus thrombolysis", "mechanical thrombectomy", and "craniectomy". We found that LMWH and UH are safe and effective for the management of acute CVT and should be considered first line. Warfarin may be used in the sub-acute phase for secondary prevention but has weak evidence. DOACs are potentially a safe warfarin alternative, but only warfarin is currently recommended in international guidelines. Antiplatelets show little evidence for the prevention or management of CVT, but studies are currently limited. COVID-19 related CVT is treated similarly to non-COVID-19 CVT; however, vaccine-related CVT is a newly recognised disease with a different pathophysiology and is treated with a combination of non-heparin anticoagulants, immunotherapy, and steroids. Decompressive craniectomy may be used to reduce intracranial pressure in life-threatening cases. There is a small body of evidence for endovascular therapy in complex cases but should be reserved for complex cases in specialist centres. This paper is of relevance to clinical practice since the safe and effective management of CVT is important to reduce the risk of disability.