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Cerebral Venous Thrombosis (CVT) in Adults

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General Information

Description

  • rare form of stroke, characterized by formation or presence of a blood clot in the dural sinus and/or cerebral veins1
    • superior sagittal sinus in 62%
    • transverse (lateral) sinus in 41%-45%
    • straight sinus in 18%
    • cortical veins in 17%
    • internal jugular in 12%
    • deep venous system (including internal cerebral vein, vein of Galen, and straight sinus) in 11%

Also called

  • cerebral venous sinus thrombosis (CVST)
  • dural venous sinus thrombosis (DVST)
  • sinovenous thrombosis
  • cerebral sinovenous thrombosis
  • cavernous sinus thrombosis
  • venous sinus thrombosis

References

General references used

  1. Saposnik G, Barinagarrementeria F, Brown RD Jr, et al; American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Apr;42(4):1158-92OpenInNewfull-textOpenInNew, commentary can be found in Stroke 2011 Jul;42(7):e408OpenInNew
  2. Gulati D, Strbian D, Sundararajan S. Cerebral venous thrombosis: diagnosis and management. Stroke. 2014 Feb;45(2):e16-8OpenInNew full-textOpenInNew
  3. Piazza G. Cerebral venous thrombosis. Circulation. 2012 Apr 3;125(13):1704-9OpenInNewfull-textOpenInNew
  4. Einhäupl K, Stam J, Bousser MG, et al; European Federation of Neurological Societies. EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients. Eur J Neurol. 2010 Oct;17(10):1229-35OpenInNew
  5. Bushnell C, Saposnik G. Evaluation and management of cerebral venous thrombosis. Continuum (Minneap Minn). 2014 Apr;20(2 Cerebrovascular Disease):335-51OpenInNew

Recommendation grading systems used

  • American Heart Association/American Stroke Association (AHA/ASA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • British Society for Haematology (BSH) GRADE system
    • strength of recommendation
      • Grade 1
        • strong recommendations made when there is confidence that benefits do or do not outweigh harm and burden
        • can be applied uniformly to most patients
        • regard as "recommend"
      • Grade 2
        • weak recommendations made where magnitude of benefit or not is less certain
        • require judicious application to individual patients
        • regard as "suggest"
    • quality of evidence
      • A - high
        • further research very unlikely to change confidence in estimate of effect
        • current evidence derived from randomized clinical trials without important limitations
      • B - moderate
        • further research may well have important impact on confidence in estimate of effect and may change estimate
        • current evidence derived from randomized clinical trials with important limitations or very strong evidence from observational studies or case series
      • C - low
        • further research likely to have important impact on confidence in estimate of effect and likely to change estimate
        • current evidence from observational studies, case series, or just opinion
    • Reference - BSH Grading of Recommendations Assessment, Development and Evaluation (GRADE) system PDFPictureAsPdf
  • Infectious Diseases Society of America (IDSA) grading system for recommendations
    • strength of recommendation grades
      • Grade A - good evidence to support recommendation for or against use
      • Grade B - moderate evidence to support recommendation for or against use
      • Grade C - poor evidence to support recommendation
    • quality of evidence ratings
      • I - evidence from ≥ 1 properly randomized, controlled trial
      • II - evidence from ≥ 1 well-designed nonrandomized clinical trial; from cohort or case-controlled analytic studies (preferably from > 1 center); from multiple time series; or from dramatic results from uncontrolled studies
      • III - evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
    • Reference - IDSA clinical practice guideline on treatment of methicillin-resistant Staphylococcus aureus infections in adults and children (21208910Clin Infect Dis 2011 Feb;52(3):e18OpenInNew), correction can be found in Clin Infect Dis 2011 Aug 1;53(3):319, commentary can be found in 25609680Clin Infect Dis 2015 Apr 15;60(8):1290OpenInNew
  • European Federation of Neurological Societies (EFNS) grading system
    • levels of recommendation
      • Level A - established as useful/predictive or not useful/predictive, requires at least 1 convincing Class I study or at least 2 consistent, convincing Class II studies
      • Level B - established as probably useful/predictive or not useful/predictive, requires at least 1 convincing Class II study or overwhelming Class III evidence
      • Level C - established as possibly useful/predictive or not useful/predictive
      • Good Practice Point - supported primarily by expert opinion
    • evidence classification
      • Class I - prospective study in broad spectrum of persons with suspected condition, using 'gold standard' for case definition, where test is applied in blinded evaluation, and enabling assessment of appropriate tests of diagnostic accuracy
      • Class II - prospective study of narrow spectrum of persons with suspected condition, or well-designed retrospective study of broad spectrum of persons with established condition (by 'gold standard') compared with broad spectrum of controls, where test is applied in blinded evaluation, and enabling assessment of appropriate tests of diagnostic accuracy
      • Class III - retrospective study where either persons with established condition or controls are of narrow spectrum, and where test is applied in blinded evaluation
      • Class IV - test not applied in blinded evaluation OR evidence provided by expert opinion alone or in descriptive case series (without controls)
    • Reference - EFNS guideline on treatment of cerebral venous and sinus thrombosis in adult patients (20402748Eur J Neurol 2010 Oct;17(10):1229OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • George Stohr, DO (Assistant Clinical Professor, Department of Diagnostic Imaging and Therapeutics, University of Connecticut School of Medicine; Attending Radiologist, Saint Francis Hospital and Medical Center; Radiology Associates of Hartford, PC; Connecticut, United States)
  • Dr. Stohr declares no relevant financial conflicts of interest.
  • Esther Jolanda van Zuuren, MD (Head of Allergy, Dermatology, and Venereology, Leiden University Medical Centre; Netherlands)
  • Dr. van Zuuren declares no relevant financial conflicts of interest.
  • Peter Oettgen MD, FACC, FAHA, FACP (Editor in Chief; Cardiologist, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School, Massachusetts, United States)
  • Dr. Oettgen declares no relevant financial conflicts of interest.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116508, Cerebral Venous Thrombosis (CVT) in Adults; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116508. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Likely risk factors

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • Clinical presentation

    • KeyboardArrowRight

      History

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

    • KeyboardArrowRight

      Physical

      • General physical

      • HEENT

      • Neuro

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Blood tests

    • KeyboardArrowRight

      Imaging studies

      • Noninvasive imaging

      • Invasive imaging

    • Cerebrospinal fluid (CSF) analysis

  • KeyboardArrowRight

    Management

    • Management overview

    • Treatment setting

    • KeyboardArrowRight

      Medications

      • KeyboardArrowRight

        Anticoagulation

        • Anticoagulation in adults

        • Anticoagulation in pregnancy

      • Thrombolytics

      • Antiepileptic drugs

      • Antibiotics

      • Corticosteroids

    • Surgery and procedures

    • Consultation and referral

    • Other management

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

  • Prevention and Screening

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • United States guidelines

      • United Kingdom guidelines

      • European guidelines

      • Asian guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

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