Cerebral venous thrombosis: another heparin controversy.

R esults from clinical studies and advances in radiological diagnosis during the past 20 years have significantly altered the management of patients with cerebral venous thrombosis (CVT), with resultant improvement in overall prognosis and decreased mortality. Although the efficacy of anticoagulation in CVT has not been unequivocally proven, it is widely used as the mainstay therapy. There is a pathophysi-ological rationale to recommend the use of anticoagulation in CVT. Occlusion of cerebral venous system impairs blood outflow from the brain, resulting in increased intracranial and capillary pressure and subsequently intracerebral hemorrhage (ICH). The use of anticoagulation can theoretically prevent thrombus propagation, facilitate recanalization of the occluded venous sinus, and improve venous outflow. Scattered case reports and series in the literature described the successful use of heparin in CVT since the 1940s. In the early 1990s, Einhäupl et al 3 performed the first randomized controlled study: 20 patients with CVT were randomized to a placebo versus heparin. Patients treated with heparin showed significant improvement; all of the heparin-treated patients survived, and 80% had a complete clinical recovery after 3 months. No new cases of ICH occurred after initiation of heparin. Einhäupl et al 3 also reported their retrospective experience in 43 patients with CVT with ICH; 27 patients were treated with intravenous heparin after the ICH. Of these, 15% of patients died compared with 69% of patients who did not receive heparin, and 52% of patients completely recovered. The authors concluded that anticoagulation is an effective treatment in patients with CVT, and that ICH is not a contra-indication to anticoagulation. De Bruijn and Stam 4 followed up by a larger randomized double-blinded placebo-controlled multicenter trial; 30 patients were randomized to subcutane-ous nadroparin (180 U/kg per 24 hours), and 29 patients were treated to matching placebo for 3 weeks, followed by 3 months of oral anticoagulation in nadroparin-treated patients. Twenty percent of patients in the nadroparin group versus 24% in the placebo group had poor outcomes after 3 weeks. After 3 months, 13% in the nadroparin group and 21% in the placebo group had poor outcomes, defined as death or Oxford Handicap Score ≥3 (95% confidence interval, –26%–12%; NS). There were no new cases of symptomatic ICH. However, a patient in the nadroparin group had major gastrointestinal bleeding, and a patient in the placebo group died from pulmonary embolism. The authors concluded that patients with CVT treated with anticoagulants had a favorable …