(631) Evaluation of Acute Anticoagulation of Cerebral Venous Thrombosis

Introduction: Anticoagulation is critical to the management of cerebral venous thrombosis (CVT) and is recommended by national treatment guidelines, but a lack of specific recommendations for anticoagulant choice, dosing intensity, or timing of initiation leads to heterogeneity of practice. Unfractionated heparin (UFH) is commonly used for acute CVT despite limited evidence on appropriate dosing and monitoring. European Stroke Organization (ESO) guidelines recommend anticoagulation with low molecular weight heparins (LMWH) over UFH, but it is unknown whether the use of UFH over alternative anticoagulation strategies in the acute setting impacts early goals or safety events.

Methods: This was a single-center retrospective study performed at Yale New Haven Hospital. Adult patients admitted with an imaging confirmed diagnosis of CVT between 2013 and 2021 and managed with UFH were included. Patients were excluded if they received initial endovascular treatment. Baseline demographics, disease characteristics, and anticoagulation dosing and monitoring strategies were assessed. The primary objective was to describe time to therapeutic anticoagulation (AC). The secondary objective was to assess hemorrhage risk.

Results: Twenty-nine patients were included in the analysis. The median initial rate of UFH was 900 units/hr (12 units/kg/hr). Six (21%) patients received a bolus of UFH and 23 (79%) patients received UFH no initial bolus. The median bolus was 4190 units (57 units/kg). The median time to initiation of anticoagulation from diagnosis was 7.5 hours (h). The median time from UFH initiation to the first therapeutic aPTT was 27.2 h. In patients receiving > 12 units/kg/hr the median time to therapeutic AC was 18.6 h compared to 29.8 h in those receiving ≤ 12 units/kg/hr, p=0.17. Five (17%) patients had hemorrhagic expansion at follow up imaging. Of these five patients, one (20%) received a bolus of UFH and four (80%) did not receive a bolus. No significant difference in hemorrhage was found when comparing patients receiving a bolus (1/6) to those not receiving a bolus (5/23), p=0.96.

Conclusions: Time to therapeutic anticoagulation is delayed when conservative UFH dosing is used as the initial anticoagulation strategy for CVT. More aggressive dosing or use of LMWH may improve time to therapeutic anticoagulation.