What is the workup and treatment for cerebral venous thrombosis (CVT) during pregnancy?

Jenn

Pyralis

@jenn In the pregnant patient, cerebral venous thrombosis (CVT) is as common a cause of stroke as cerebral ischemia or cerebral hemorrhage is. CVT is often encountered after delivery. The main symptoms and findings are headache, stroke in a venous distribution, or both. The clinical challenges are as follows:

To identify CVT in patients presenting with headache alone before it progresses

To recognize CVT as the correct cause of stroke in a patient presenting in the peripartum period

Without treatment, CVT may lead to emergence or progression of stroke, exacerbation of dysfunction, worsening of increased intracranial pressure (ICP) that leads to vision impairment, and persistence of a headache that is difficult to treat.

Therapy for CVT consists of anticoagulation with heparin, which after delivery is switched to warfarin. In rare cases, elevated ICP must be treated. However, acetazolamide is a category C drug (meaning that data about risks in humans are not available), and its risks in infants and children have not been studied. Hence, its use must be preceded by a clear definition of goals and by discussions with the patient and her obstetricians. CVT usually, but not always, resolves. Analgesia is permitted, in accordance with usual obstetric practice.

The underlying genetic or acquired risk factors for a hypercoagulable state are often sought. Little is known about the yield of such a search in patients who have no other history of venous thrombosis or of previous fetal loss. However, the presence or absence of risk factors for hypercoagulability may contribute to decision-making with regard to the duration of warfarin therapy. At present, no data are available to guide recommendations about how long the patient should take warfarin.

The question of the optimal duration of warfarin treatment acquires particular relevance for patients who developed CVT during pregnancy and who wish to become pregnant again, in that warfarin is a category X drug. Reports describe birth malformations in children born to mothers who were treated with warfarin during pregnancy. Furthermore, the drug passes through the placental barrier and may cause fatal hemorrhage in utero.

Consequently, if the decision has been made that the patient requires anticoagulation in her next pregnancy, warfarin should be discontinued and fractionated or unfractionated heparin should be used instead. All therapeutic decisions must be individualized after discussions with the patient.