A uniform approach to cerebral venous sinus thrombosis management

ABSTRACT

Background: Cerebral venous sinus thrombosis (CVST) is an important cause of stroke with a generally favourable prognosis if diagnosed and treated early. Despite advances over recent years, the management remains variable. The current trend for initial treatment is a dose-adjusted intravenous heparin infusion or low-molecular-weight-heparin (LMWH) such as enoxaparin. Once the patient has stabilized, they are transitioned to longterm anticoagulation such as warfarin therapy or direct oral anticoagulants (DOAC) for 3-6 months, depending on risk factors. The use of a heparin infusion brings many known difficulties and complexities impacting on patient care and length of stay within hospital. Current literature suggests that enoxaparin may be superior to heparin in the treatment of CVST. Aim(s) To conduct an internal audit of patients diagnosed with CVST over a twelve-month period at the Princess Alexandra Hospital. This audit will provide foundation to develop an evidence-based hospital protocol for CVST management. Method(s) A search through the hospital imaging system identified all relevant patients. Information was collected on the initial treatment, specifically comparing the use of heparin to enoxaparin and the duration. Consideration of risk factors, aetiology and complications were summarized. During the recent era of COVID-19, we also collected data on COVID-related CVST and COVID vaccine-related CVST. Finally, we recorded the maintenance anticoagulation treatment that was commenced. Result(s) The purpose of this audit is to critically reflect on current hospital practice with a view to improve patient outcomes, safety, satisfaction, and cost-effective care. We hypothesise that in select cases, it will be a safe and preferable alternative to use enoxaparin as initial therapy over a heparin infusion. Furthermore, with appropriate patient selection, DOACs may be an appropriate maintenance therapy. Conclusion(s) The evidence for medical management of CVST is continuously evolving. This evidence must be carefully evaluated before being widely adopted at a local level.