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脑静脉和静脉窦血栓形成(CVST)是一种相当少见的疾病,仅占所有卒中的不到1%。由于其临床症状谱广且常呈亚急性或迁延起病,因此往往被漏诊或延误诊断。目前在临床实践中采取的治疗措施包括:抗凝药,如剂量调整的静脉肝素或体质量调整皮下注射低分子肝素(LMWH);溶栓治疗;对症治疗,包括控制癎性发作和降低颅内压。我们通过MEDLINE(美国国立医学图书馆)、Cochrane对照试验注册中心资料库和Cochrane数据库进行了文献检索,对支持这些治疗措施的证据强度进行了评价,并在现有最佳证据基础上制定了CVST治疗的推荐意见。综述性文献和书籍章节内容亦被包括在内。通过共识达成推荐意见。当缺乏证据但能达成明确的共识时,我们将自己的观点表述为良好临床实践要点(GPP)。无抗凝禁忌证的CVST患者应接受体质量调整皮下注射LMWH或剂量调整静脉肝素治疗(GPP)。伴发CVST相关性颅内出血不是肝素治疗的禁忌证。急性期后口服抗凝药的最佳疗程尚不清楚。如果CVST继发于可迅速消退的危险因素,口服抗凝治疗可持续3个月;对于原发性CVST和存在轻度遗传性血栓形成倾向的患者,则需要治疗6～12个月;对于有过≥2次CVST以及有过1次CVST但存在严重遗传性血栓形成倾向的患者,应考虑永久性抗凝治疗(GPP)。尚无充分的证据支持对CVST患者进行全身或局部溶栓治疗。如果充分抗凝治疗后患者仍然出现病情恶化并且排除了其他导致恶化的因素,溶栓治疗可作为一种治疗选择,尤其是对于那些无颅内出血的病例(GPP)。在重症CVST患者中,关于降低增高的颅内压(伴脑组织移位)的某些治疗措施的风险和益处尚无对照资料。抗水肿治疗应作为挽救生命的干预措施,包括过度通气、渗透性利尿药和颅骨切除术(GPP)。
Cerebral venous and sinus thrombosis (CVST) is a relatively rare disease accounting for less than 1% of all strokes. Due to its wide range of clinical symptoms and often subacute or delayed onset, it is often missed or delayed diagnosis. Current treatments in clinical practice include: anticoagulants, such as dose-adjusted intravenous heparin or subcutaneous low molecular weight heparin (LMWH) for body weight adjustment; thrombolytic therapy; symptomatic treatment including controlling seizures and reducing intracranial Pressure We conducted a literature search through the MEDLINE (National Library of Medicine), Cochrane Central Register of Controlled Trials and Cochrane Database, evaluated the strength of evidence to support these therapies and developed CVST based on the best evidence available Recommended treatment. Summary literature and book chapters are also included. Reach recommendations through consensus. When there is a lack of evidence but a clear consensus can be reached, we present our own opinion as a Good Clinical Practice Point (GPP). CVST patients without anticoagulation contraindications should receive body weight adjusted subcutaneous injection of LMWH or dose-adjusted intravenous heparin (GPP). CVST-related intracranial hemorrhage is not a contraindication to heparin therapy. The best course of oral anticoagulation after acute phase is not clear. Oral anticoagulant therapy lasts for 3 months if CVST is secondary to a rapidly declining risk factor and 6 to 12 months for primary CVST and patients with a mild genetic thrombophilia; Permanent anticoagulation therapy (GPP) should be considered in patients who have had ≥2 CVSTs and who have had 1 CVST but have a predisposition to severe hereditary thrombosis. There is insufficient evidence to support systemic or local thrombolysis in patients with CVST. Thrombolytic therapy may be used as a treatment option, especially for those with no intracranial hemorrhage (GPP) if the patient remains experiencing worsening after adequate anticoagulation and excluding other causes of worsening. In critically ill CVST patients, there is no controlled data on the risks and benefits of some of the therapies that reduce elevated intracranial pressure (with brain tissue displacement). Anti-edema treatment should be used as life-saving interventions, including hyperventilation, osmotic diuretics and craniotomy (GPP).