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Abstract
<p class="first" id="d3012264e219">The current proposal for cerebral venous thrombosis
guideline followed the Grading
of Recommendations, Assessment, Development, and Evaluation system, formulating relevant
diagnostic and treatment questions, performing systematic reviews of all available
evidence and writing recommendations and deciding on their strength on an explicit
and transparent manner, based on the quality of available scientific evidence. The
guideline addresses both diagnostic and therapeutic topics. We suggest using magnetic
resonance or computed tomography angiography for confirming the diagnosis of cerebral
venous thrombosis and not screening patients with cerebral venous thrombosis routinely
for thrombophilia or cancer. We recommend parenteral anticoagulation in acute cerebral
venous thrombosis and decompressive surgery to prevent death due to brain herniation.
We suggest to use preferentially low-molecular weight heparin in the acute phase and
not using direct oral anticoagulants. We suggest not using steroids and acetazolamide
to reduce death or dependency. We suggest using antiepileptics in patients with an
early seizure and supratentorial lesions to prevent further early seizures. We could
not make recommendations due to very poor quality of evidence concerning duration
of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic
lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest
that in women who suffered a previous cerebral venous thrombosis, contraceptives containing
oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but
use of prophylactic low-molecular weight heparin should be considered throughout pregnancy
and puerperium. Multicentre observational and experimental studies are needed to increase
the level of evidence supporting recommendations on the diagnosis and management of
cerebral venous thrombosis.
</p>
The natural history and long-term prognosis of cerebral vein and dural sinus thrombosis (CVT) have not been examined previously by adequately powered prospective studies. We performed a multinational (21 countries), multicenter (89 centers), prospective observational study. Patients were followed up at 6 months and yearly thereafter. Primary outcome was death or dependence as assessed by modified Rankin Scale (mRS) score >2 at the end of follow-up. From May 1998 to May 2001, 624 adult patients with CVT were registered. At the end of follow-up (median 16 months), 356 patients (57.1%) had no symptom or signs (mRS=0), 137 (22%) had minor residual symptoms (mRS=1), and 47 (7.5%) had mild impairments (mRS=2). Eighteen (2.9%) were moderately impaired (mRS=3), 14 (2.2%) were severely handicapped (mRS=4 or 5), and 52 (8.3%) had died. Multivariate predictors of death or dependence were age >37 years (hazard ratio [HR]=2.0), male sex (HR=1.6), coma (HR=2.7), mental status disorder (HR=2.0), hemorrhage on admission CT scan (HR=1.9), thrombosis of the deep cerebral venous system (HR=2.9), central nervous system infection (HR=3.3), and cancer (HR=2.9). Fourteen patients (2.2%) had a recurrent sinus thrombosis, 27 (4.3%) had other thrombotic events, and 66 (10.6%) had seizures. The prognosis of CVT is better than reported previously. A subgroup (13%) of clinically identifiable CVT patients is at increased risk of bad outcome. These high-risk patients may benefit from more aggressive therapeutic interventions, to be studied in randomized clinical trials.
To assess the safety and efficacy of low-molecular-weight heparins (LMWHs) for thromboprophylaxis and treatment of venous thromboembolism (VTE) in pregnancy, a systematic review of studies to the end of 2003 was undertaken. Data on VTE recurrence and side effects were extracted and cumulative incidences of VTE and adverse effects calculated. Of 81 reports identified, 64 reporting 2777 pregnancies were included. In 15 studies (174 patients) the indication for LMWH was treatment of acute VTE, and in 61 studies (2603 pregnancies) it was thromboprophylaxis or adverse pregnancy outcome. There were no maternal deaths. VTE and arterial thrombosis (associated with anti-phospholipid syndrome) were reported in 0.86% (95% confidence interval [CI], 0.55%-1.28%) and 0.50% (95% CI, 0.28%-0.84%) of pregnancies, respectively. Significant bleeding, generally associated with primary obstetric causes, occurred in 1.98% (95% CI, 1.50%-2.57%), allergic skin reactions in 1.80% (95% CI, 1.34%-2.37%), heparin-induced thrombocytopenia in 0%, thrombocytopenia (unrelated to LMWH) in 0.11% (95% CI, 0.02%-0.32%), and osteoporotic fracture in 0.04% (95% CI, < 0.01%-0.20%) of pregnancies. Overall, live births were reported in 94.7% of pregnancies, including 85.4% in those receiving LMWH for recurrent pregnancy loss. LMWH is both safe and effective to prevent or treat VTE in pregnancy.
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