Practice-pattern variation in anticoagulation intensity in acute cerebral venous thrombosis: A two-center experience

Background and purpose: Cerebral venous thrombosis (CVT) requires acute anticoagulation. Heparin is commonly used but specific recommendations on intensity and timing are lacking. We sought to characterize practice-pattern variation in the use of unfractionated heparin (UFH) for acute CVT treatment across multiple centers.

Methods: This was a two-center retrospective study performed at Yale New Haven Hospital and Massachusetts General Hospital. Adult patients with CVT between 2013 and 2021 initially managed with parenteral anticoagulation and without endovascular therapy were included. The co-primary objectives were variation in UFH dosing and time to therapeutic anticoagulation by dosing intensity. Dosing intensity was defined as high intensity (≥12 units/kg/hr) or low intensity (<12 units/kg/hr), with or without initial boluses.

Results: Seventy-two patients were included; 62 patients (86 %) received initial anticoagulation with UFH. The median initial UFH rate was 12 (IQR 11-14) units/kg/hr and 17 (27 %) patients received initial boluses (77 units/kg, IQR 40-80). Time to therapeutic anticoagulation was 11 (IQR 6-21) hours with high intensity UFH with a bolus (n = 13) and was 27 h (IQR 20-29) with low intensity UFH with a bolus (n = 4), while time to therapeutic anticoagulation was 30 (IQR 13-35) and 30 (IQR 23-39) hours with high (n = 21) and low intensity (n = 18) UFH without a bolus, respectively. Initial boluses reduced time to therapeutic anticoagulation overall (20 vs 30 h, p = 0.003).

Conclusions: Practice-pattern variation in UFH dosing leads to delays in time to therapeutic anticoagulation for CVT. Bolus dosing and high intensity UFH likely reduces the time to therapeutic anticoagulation.