New European Guidelines for Cerebral Venous Thrombosis

September 15, 2017

New guidelines for the diagnosis and treatment of cerebral venous thrombosis (CVT) have been issued by the European Stroke Organisation.

The guidelines, published in the European Journal of Neurology, have also been endorsed by the European Academy of Neurology. 

"There has been a lot of uncertainty about the best treatments for CVT and several therapies used are unproven with little safety data," lead author of the new guidelines, Jose Ferro, MD, Hospital de Santa Maria, Lisbon, Portugal, told Medscape Medical News. "These new guidelines therefore provide recommendations for good standardized care."

He pointed out that the new guidelines also differ from previous ones in that they are totally based on systematic reviews of the evidence base and do not include expert consensus.

'We used the GRADE [Grading of Recommendations, Assessment, Development and Evaluation] system, which increases objectivity and decreases bias by only considering a systematic review of available scientific evidence. It also makes the rating of advice given much simpler, classifying each recommendation as either strong, weak or no recommendation. We think this is easier for clinicians to understand and use to make decisions," he said.

Dr Ferro reported that central venous thrombosis is an uncommon cause of stroke, with an incidence similar to that of bacterial meningitis or cerebral hemorrhage. "A large center may see 15 to 20 cases a year in higher-income countries, whereas in lower- to middle-income countries there are more cases probably because of worse management of women in the perinatal period and ear, nose, and throat infections, two common situations when CVT can occur."

Unlike strokes caused by arterial thrombosis, CVT often occurs in young people, with the average age being 37 years, and the condition has a high morbidity/mortality rate. "As CVT affects individuals often at the peak of their productive lives, and can often be fatal or lead to major complications, accurate diagnosis and correct treatment is vital," Dr Ferro commented. 

He summarized the main highlights of the new guidelines as follows:

Diagnostic Recommendations

  • The diagnostic recommendations are based on the impact of diagnostic procedures on patient outcome and not on process indicators.

  • For the diagnosis of CVT, computed tomographic venography, magnetic resonance venography, or intra-arterial venography can be used because these techniques have similar accuracies.

  • Prothrombotic and cancer screening are not recommended as a routine.

Therapeutic Recommendations

  • All patients with acute CVT should be anticoagulated parentally, preferably with low-molecular-weight heparin (LMWH).

  • Patients with large hemisphere lesions with impending herniation should be offered decompressive surgery.

  • Seizure prophylaxis with anticonvulsants is indicated in patients who experience an acute symptomatic seizure and have a venous infarct or hemorrhage.

  • Non–vitamin K anticoagulants (novel oral anticoagulants) are not recommended, particularly in the acute phase, because of the limited experience and unknown safety.

  • No recommendations could be made regarding acute endovascular treatment because of the very low quality of available evidence, pending the publication of the final results of the TO-ACT trial, which was prematurely terminated for futility this year.

  •  Pregnancy is not contraindicated after CVT, and subcutaneous LMWH is suggested during pregnancy to prevent recurrent venous thrombotic events.

 

Evidence Slowly Accumulating

The guidelines paper points out that as for other relatively rare diseases, evidence to support diagnostic and therapeutic decisions in CVT is slowly accumulating but is still rather scarce. Regarding diagnostic procedures, studies have looked mostly at accuracy and predictive values. There is very little information on the influence of performing a diagnostic test and of its results on patient outcome, the authors note.

They report that, regarding treatments, few randomized controlled trials have been performed in CVT, and most of the available randomized controlled trials had small sample sizes and other methodologic problems. Most of the evidence had to be derived from observational studies, whose bias to evaluate the efficacy of interventions is well known.

But the authors add that: "Recent efforts have led to important multicentre registries and trials…[and] in the next few years numerous observational studies and treatment trials on several uncertain issues (e.g. thrombectomy, direct oral anticoagulants, decompressive surgery, pregnancy after CVT, duration of oral anticoagulation) will increase the level of evidence that currently supports the management of CVT."

Eur J Neurol. Published online August 20, 2017.  Full text 

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