Should we start anticoagulant in intracerebral bleed? Which subset of patient needs one? This case highlights one of the subset which requires anticoagulation even if it is complicated by haemorrhage.
We had a 33 years old staff nurse who was on long-term contraceptive pills presenting with a sudden altered behavior. She was not answering question coherently and appears confused. She had a left sided headache and vomiting for the past five days but had no limb or facial weakness.
Contrasted CT scan showed a left tempero - parietal infarct complicated with haemorrhage. Dense clot sign of left transverse sinus was identified. Initial diagnosis of left parieto-occipito-temporal haemorrhage due to cerebral venous thrombosis was made. MRI, MR Angiogram Cerebral and MR Venography Cerebral confirmed the diagnosis. Subcutaneous clexane was initially started for six days before she was put on long term warfarin. She had a complete resolution of symptoms within one week.
Cerebral venous thrombosis (CVT) is a rare cause of stroke that poses diagnostic, therapeutic and prognostic challenges. Mainstay of treatment is systemic anticoagulant but may also promote further haemorrhages.
European Stroke Guideline 2017 advocates the use of anticoagulant, preferably low molecular weight heparin, for CVT even with haemorrhagic complication. It is based on the two randomized trials, which were also analysed in a recently updated Cochrane review, with a total of 79 adult patients. It showed that anticoagulation with heparin was associated with a reduction in poor outcome [relative risk (RR) for death or dependency, 0.46; 95% CI, 0.16–1.31; RR for death, 0.33; 95% CI, 0.08–1.21]. No new symptomatic intracerebral haemorrhages were observed in these cohorts.
Anticoagulant should be given in patient with infarction secondary cerebral venous thrombosis with or without haemorrhagic complications.
cerebral venous thrombosis