What are the AHA/ASA guidelines on stroke prevention in women with cerebral venous thrombosis (CVT)?

Updated: Jan 10, 2016
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Answer

Answer

Because cerebral venous thrombosis (CVT) is related to hormonal factors (primarily oral contraceptives) and pregnancy, over 70% of cases are in women. The greatest risk periods for CVT include the third trimester and the first month postpartum, with 73% of CVT in women occurring in the puerperium. The AHA/ASA guidelines address the management of CVT with the following recommendations [12] :

  • Screen for potential prothrombotic conditions that may predispose a woman to CVT (eg, use of contraceptives, underlying inflammatory disease, infectious process) in the initial clinical assessment (class I).
  • Testing for prothrombotic conditions (protein C, protein S, or antithrombin deficiency; antiphospholipid syndrome; prothrombin G20210A mutation; and factor V Leiden) can be beneficial for the management of patients with CVT. Testing for protein C, protein S, and antithrombin deficiency is indicated 2 to 4 weeks after completion of anticoagulation. There is a very limited value of testing in the acute setting or in patients taking warfarin (class IIa).
  • For provoked CVT (associated with a transient risk factor): Vitamin K antagonists may be continued for 3-6 months, with a target international normalized ratio INR) of 2.0 to 3.0 (class IIb).
  • For unprovoked CVT: Vitamin K antagonists may be continued for 6 to 12 months, with a target INR of 2.0 to 3.0 (Class IIb).
  • For recurrent CVT, INR of 2.0 to 3.0 (Class IIb).
  • For CVT during pregnancy: Low-molecular-weight heparin (LMWH) in full anticoagulant doses throughout pregnancy, and LMWH or vitamin K antagonist with a target INR of 2.0 to 3.0 should be continued for ≥6 weeks postpartum (for a total minimum duration of therapy of 6 months) (class I).
  • For acute CVT during pregnancy: Full-dose LMWH rather than unfractionated heparin (class IIa).
  • Future pregnancy is not contraindicated in women with a history of CVT. Further investigations regarding the underlying cause and a formal consultation with a hematologist or maternal fetal medicine specialist are reasonable (class IIa).
  • For women with a history of CVT: prophylaxis with LMWH during future pregnancies and the postpartum period. (class IIa).

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