Anticoagulation is the mainstay of treatment of cerebral venous sinus thrombosis, irrespective of whether associated venous hemorrhage is present. Anticoagulant selection is variable, with physicians opting for unfractionated heparin (UFH) about 72% of the time in one international study. However, recent evidence favors the use of low-molecular-weight heparin (LMWH), with meta-analytic data showing trends towards lower mortality rates and improved functional outcomes in LMWH cohorts. UFH is often viewed more favorably due to the ability to rapidly discontinue the infusion in the event of major bleeding; however, risk of major bleeding complications were actually found to be lower in patients treated with LMWH compared to UFH. Further, LMWH has many pharmacological and practical benefits compared to UFH, including more predictable pharmacokinetics, reduced risk of heparin-induced thrombocytopenia (HIT), lack of need for frequent aPTT monitoring, ease of administration (daily subcutaneous injection), and ease of transition to outpatient therapy. 

Takeaway: Consider LMWH (1.5mg/kg subcutaneously once daily) as first-line treatment for CVST in patients with acceptable renal function.

References

1. Coutinho, J. M., Ferro, J. M., Canhao, P., Barinagarrementeria, F., Bousser, M. G., & Stam, J. (2010). Unfractionated or low–molecular weight heparin for the treatment of cerebral venous thrombosis. Stroke, 41(11), 2575-2580.
2. Xu, W., Gao, L., Li, T., Shao, A., & Zhang, J. (2018). Efficacy and risks of anticoagulation for cerebral venous thrombosis. Medicine, 97(20), e10506.
3. Qureshi, A., & Perera, A. (2017). Low molecular weight heparin versus unfractionated heparin in the management of cerebral venous thrombosis: a systematic review and meta-analysis. Annals of Medicine and Surgery, 17, 22-26.
4. Ferro, J. M., Canhão, P., Stam, J., Bousser, M. G., & Barinagarrementeria, F. (2004). Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke, 35(3), 664-670.