在过去的几年里,在脑静脉和硬脑膜窦血栓形成(CVT)的诊断和管理的多个方面积累了新的证据,包括识别新的危险因素,关于介入治疗以及直接口服抗凝剂治疗的研究。基于欧洲卒中组织关于该主题的指南的GRADE问题,德国关于CVT的新准则是奥地利专家代表之间的共识,德国和瑞士。新的建议包括:•在SARS-CoV-2接种载体疫苗后的最初几周发生的CVT可能与严重的血小板减少症有关,表明存在血栓前免疫原性原因(疫苗诱导的免疫性血栓性血小板减少症;VITT)。•不推荐排除CVT的D-二聚体测试,因此不应常规进行。•通常不建议对CVT患者进行血栓形成筛查。应该在年轻患者中考虑,在自发CVT中,在复发性血栓形成和/或静脉血栓栓塞家族史阳性的情况下,如果治疗的改变是由积极的发现引起的。•CVT患者在急性期应优选用低分子量肝素(LMWH)代替普通肝素治疗。在个人基础上,对于在充分抗凝治疗下恶化的患者,可以考虑在神经介入中心进行血管内再通.尽管总体证据水平较低,CVT患者应进行手术减压,实质病变(充血性水肿和/或出血)和即将发生的嵌顿以防止死亡。•在急性期之后,用直接口服抗凝药代替维生素K拮抗剂的口服抗凝药治疗3~12个月,以增强血管再通,防止CVT复发和脑静脉血栓形成.•患有与使用联合激素避孕药或妊娠有关的既往CVT的妇女应避免继续或重新开始使用雌激素-孕激素组合的避孕,因为如果不再使用抗凝药物,复发的风险会增加。•既往CVT且无禁忌症的女性应在怀孕期间和产后至少6周接受LMWH预防。尽管支持这些建议的证据水平大多较低,深静脉血栓形成的证据以及当前的临床经验可以证明新的建议是合理的.本文是德语准则的节略翻译,可在线获得。
Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization
guideline on this topic, the new German
guideline on CVT is a
consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German
guideline, which is available online.