Intracranial venous thrombosis (CVT) refers to a type of cerebrovascular disease characterized by intracranial venous or venous sinus thrombosis caused by various causes, which impede blood return or cerebrospinal fluid circulation disorders, resulting in intracranial hypertension and focal brain damage. "China's Diagnosis and Treatment Guidelines for Intracranial Venous Thrombosis in China" was revised based on the 2015 version of the guideline. Regarding the treatment of CVT, the new version of the guideline mainly contains the following recommendations.
1. Cause treatment
(1) Infectious thrombosis should be treated with sensitive antibiotics in a timely and sufficient manner; surgical treatment can be performed if necessary to clear the source of infection (Level I recommendation).
(2) oral contraceptive pills and other related CVTs should be discontinued immediately (Level I recommendation; this article is a new recommendation for this time).
2. Anticoagulation treatment
(1) CVT patients without anticoagulation contraindications should receive anticoagulation treatment as early as possible, use low molecular weight heparin in the acute phase, with a dose of 90~100 IU/kg, and be injected twice a day; or use ordinary heparin for treatment, the time of partial thromboplastin should be extended by 1.5~2.5 times. The course of treatment can last for 1 to 4 weeks (Level II recommendation, Level B evidence).
(2) low molecular weight heparin is slightly better than ordinary heparin (grade II recommendation, grade B evidence).
(3) small amount of intracranial hemorrhage and increased intracranial pressure accompanied by CVT are not absolute contraindications for anticoagulant treatment (Level II recommendation, Level B evidence).
(4) Oral anticoagulant drugs should be continued after the acute phase, warfarin is often used, and the target PT‑INR value remains between 2 and 3 (Level II recommendation, C-level evidence).
(5) For CVT that can quickly control risk factors, such as pregnancy and oral hormone contraceptive drugs, anticoagulation treatment can be within 3 months; for CVT with unknown risk factors or mild hereditary thrombosis tend to form , oral anticoagulation treatment should last for 6 to 12 months; for CVT with more than 2 episodes or with severe hereditary thrombosis tendency, long-term anticoagulation treatment can be considered (Level II recommendation, Level B evidence; this article is a new recommendation for this time).
(6) There is currently no evidence to support imaging-proven occlusion venous (sinus) recanalization, which can be used as a basis for cessation of oral anticoagulation therapy (Level III recommendation, Level C evidence). The efficacy and safety of the new oral anticoagulant dabigatran is similar to warfarin, but it is easier to use than warfarin (Level II recommendation, Level B evidence; this article is the recommended opinion for this revision).
3. Anticoagulant treatment for special cases
(1) For patients with CVT related to head, face and neck infection, the efficacy of anticoagulant treatment is not clear, but it increases the risk of intracranial hemorrhage (Level III recommendation, C-level evidence; this article is a new recommendation for this time).
(2) For patients with CVT during pregnancy, it is recommended to use low molecular weight heparin anticoagulation throughout the entire pregnancy (grade II recommendation, grade C evidence; this article is a new recommendation for this time).
4. Anti- platelet and lower fiber treatment
unless required for underlying disease treatment, there is no supporting evidence for routine anti-platelet or lower fiber treatment to treat CVT (Level III recommendation, Level C evidence).
5. Intravenous thrombolysis treatment
Currently, there is a lack of evidence to support systemic venous thrombolysis treatment of CVT (Level III recommendation, Level C evidence).
6. Endovascular treatment
(1) The safety and effectiveness of CVT endovascular treatment needs to be further evaluated (Level III recommendation, Level C evidence; this article is a new recommendation opinion).
(2) Severe patients who have been ineffective with sufficient anticoagulant treatment and have no serious intracranial hemorrhage can carefully implement local thrombolysis treatment under strict supervision (Level III recommendation, Level C evidence; this article is the recommended opinion for this revision).
(3) For patients with acute or subacute CVT who have been ineffective in treating intracranial hemorrhage or other methods, transcatheter mechanical thrombectomy or balloon dilation can be used as an alternative treatment method in hospitals with neurointerventional treatment conditions (Level III recommendation, Level C evidence; this article is the recommended opinion for this revision).
(4) For patients with venous sinus stenosis and intracranial hypertension caused by chronic thrombosis, hospitals with conditions can strictly select cases and consider intravenous sinus stent implantation in the stenosis site, but the long-term efficacy and safety still need further evaluation (Level III recommendation, Level C evidence; this article is the recommended opinion for this revision).
(5) Antithrombotic scheme after endovascular treatment shall be individually selected according to the treatment measures and patient's condition (Level III recommendation, Level C evidence; this article is a new recommendation opinion added this time).
7. The treatment of Dural Artificial and Venous Fistula secondary to CVT
CVT can refer to the general principles of Dural Artificial and Venous Fistula, but special attention should be paid to the establishment and protection of cerebral venous reflux (Level II recommendation, C-level evidence).
8. Glucocorticoid
Unless the treatment of underlying diseases requires the treatment of underlying diseases, routine use of glucocorticoids is not beneficial. Patients with CVT who have not found parenchymal lesions in CT/MRI should avoid using glucocorticoids (Level II recommendation, C-level evidence).
9. Reduce intracranial high pressure and optic nerve protection
(1) For intracranial high pressure caused by CVT, dehydration can be used to reduce cranial pressure; however, excessive dehydration should be prevented from aggravating the CVT condition (Level II recommendation, C-level evidence).
(2) For severe intracranial hypertension or early brain hernia, emergency treatment should be carried out. If necessary, bone flap surgery decompression or cerebrospinal fluid shunt treatment can be performed (Level II recommendation, Grade C evidence; this article is the recommended opinion for this revision).
(3) For intracranial hypertension with progressive visual acuity, optic nerve sheath decompression can be performed to save vision (Level II recommendation, Level C evidence; this article is the recommended opinion for this revision).
10. Anti-epileptic treatment
(1) For CVT patients with first epilepsy seizure, anti-epileptic drugs should be used as early as possible to control the seizure (Level I recommendation, Level B evidence).
(2) For patients with anaesthetic seizures, preventive use of antiepileptic drugs is not recommended (Level II recommendation, Level C evidence; this article is the recommended opinion for this revision).
The above content is excerpted from: Neurology Branch of the Chinese Medical Association, Cerebrovascular Medicine Group of the Neurology Branch of the Chinese Medical Association. Guidelines for Diagnosis and Treatment of Intracranial Venous Thrombosis in China 2019 [J]. Chinese Journal of Neurology , 2020, 53 (09): 648-663.
