Management of Cerebral Vein Thrombosis in a Canadian Tertiary Hospital

Introduction: Cerebral vein thrombosis (CVT) is an uncommon cause of stroke and is more likely to affect young adults and children. Women have a three-fold increased risk compared to men, owing to gender specific factors such as oral contraceptive use (OCP), pregnancy, and hormone replacement therapies. The presenting symptoms of CVT are non-specific and include headache, seizure, focal neurological deficits, or coma as the most severe presentation. The rarity and variable symptoms of the disease leads to delayed diagnosis and implementation of treatment. With improved imaging techniques and increased awareness in recent years, CVT is now more often recognized.

Aim: To evaluate patients admitted to The Ottawa Hospital with diagnosis of CVT including demographics, symptoms at presentation, risk factors for CVT, management practices during hospital stay, and discharge disposition. Where available, 12-month follow-up information is provided.

Methods: A retrospective chart review of patients admitted to The Ottawa Hospital with diagnosis of CVT between January 2010 - December 2017. Patients were identified using ICD-10 codes from the Ottawa Hospital Data Warehouse.

Results: 123 patients were identified in the Data Warehouse and manual chart review confirmed 61 patients diagnosed with CVT. The mean age was 46 years, and 44 (72%) were women. The average hospital stay was 10 days (range 1-66 days) and 25 patients (40%) were admitted to a monitored setting during hospitalization. Only 4 patients had prior history of venous thrombosis. 38 patients (62%) had provoking risk factors for CVT including: surgery (n=6); cancer (5); pregnancy/peripartum (5); oral contraceptive use (21); the remaining 23 patients were unprovoked CVT events. Imaging findings at diagnosis showed 17 patients (28%) had intracranial hemorrhage such as subarachnoid hemorrhage and intraparenchymal bleeding; 17 (28%) had infarction; and 13 (21%) had cerebral edema.

All patients received parenteral anticoagulation at time of CVT diagnosis: 54 (89%) with IV unfractionated heparin and the remainder received low molecular weight heparins. One patient received catheter directed thrombolysis, one patient had mechanical embolectomy, two patients underwent decompressive craniectomy, and one patient had both catheter directed thrombolysis and decompression surgery. Four patients died during hospital stay, one directly related to CVT and another due to anticoagulation associated intracranial hemorrhage. More than half of patients were started on warfarin at the time of hospital discharge and no patients were discharged on direct oral anticoagulants (DOACs). 48 patients (79%) were discharged home, 7 (12%) were discharged to rehabilitation programs, and 1 patient (2%) required transfer to nursing home facility. During 12-month follow-up 45 patients (74%) had been transitioned to warfarin and 3 (5%) were on DOACs.

Summary: In this cohort of patients admitted with CVT to a large Canadian academic hospital, many were young women and were related to hormonal therapies or peripartum state. All patients received parenteral anticoagulation in hospital and warfarin was the most common oral anticoagulant prescribed. Patients with severe CVT required invasive intervention, with two deaths attributed to CVT or complications from anticoagulation. Most patients returned home within 12-months of discharge from hospital.