Saudi Stroke Standards

Cerebral Venous Thrombosis Purpose To ensure that patients presenting with suspected Cerebral venous thrombosis (CVT) are diagnosed and treated promptly to improve their prognosis. 12 https://professional.heart.org/idc/groups/ahamah- public/@wcm/@sop/@smd/documents/downloadable/ucm_460163.pdf 13 https://www.ncbi.nlm.nih.gov/pubmed?term=3975967 Rationale  CVT is an uncommon and frequently unrecognized type of stroke, it is more common in younger stroke patients14.  In a series of intracerebral hemorrhage (ICH) in young people, CVT explained 5% of all cases15.  Neurologic worsening may occur in 23% of the patients, even several days after diagnosis Standards 1. Routine blood studies consisting of a complete blood count, chemistry panel, prothrombin time and activated partial thromboplastin time should be performed for patients presenting with suspected CVT. 2. In patients with lobar intracerebral hemorrhage of otherwise unclear etiology or with cerebral infarction crossing typical arterial boundaries, imaging of the cerebral venous system should be performed. 3. In patients with the clinical features of idiopathic intracranial hypertension, imaging of the cerebral venous system should be performed. 4. A venographic study (either CT or MR venogram) should be performed in suspected CVT if the plain CT or MRI is negative, or, to define the extent of CVT if the plain CT or MRI suggests CVT. A plan CT or MRI does not rule out CVT. 5. Repeat CT or MR venogram should be performed in patients presenting with recurrent symptoms of CVT. 6. In patients with CVT and a single seizure with parenchymal lesions, early initiation of anti-epileptic drugs for a defined duration should be performed. 7. Patients with CVT and a suspected bacterial infection should receive appropriate antibiotics and surgical drainage of purulent collections of infectious sources associated with CVT when appropriate. 8. In patients with CVT, visual fields should be monitored for progressive deterioration and when this is observed, increased intracranial pressure should be urgently treated. 9. In patients with a past history of CVT who complain of new, persisting or severe headache, evaluation for CVT recurrence and intracranial hypertension should be considered. 10. For patients with CVT, initial anticoagulation with adjusted-dose unfractionated heparin or weight-based low molecular weight heparin in full anticoagulant doses should be considered, followed by vitamin K antagonists, regardless of the presence of intracerebral hemorrhage. 11. For women with CVT during pregnancy, LMWH in full anticoagulant doses should be continued throughout pregnancy, and LMWH or vitamin K antagonist with a target INR 2.0-3.0 should be continued for at least 6 weeks post-partum (for a total minimum duration of therapy of 6 months). 14 https://www.ncbi.nlm.nih.gov/pubmed/14976332 15 https://www.ahajournals.org/doi/full/10.1161/01.STR.0000117571.76197.26 QM