Unfractionated heparin vs LMWH for CVT

[Neurologo]

An interesting debate is ongoing between neurologists and neuroIRs at our hospital regarding the choice between unfractionated heparin vs. LMWH (lovenox) to best treat Cerebral venous thrombosis (CVT).

It would be interesting to hear your views. What do you prefer at your institutions?

Little more background story:
Several large and small prospective, meta analysis and small randomized studies showed superiority of Lovenox in terms of rate of hemorrhages and thrombus resolution. Thus, I proposed to use Lovenox. The neuroIR's view is that heparin is easier to reverse in case of bleed and intervention. My response to that is first, even if ICH occurs, anticoagulation should be continued in CVT rather than reversed since the bleed is due to venous pooling. Second, lovenox can be reversed w/ protamine as well. Lastly, IR intervention in CVT is not proven to be safe nor effective as of yet. AHS/ASA 2014 recommends either heparin or lovenox.

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[typhoonegator]

I'd only use LMWH if guided by Xa levels in CVST. I tend to use heparin. Some data for LMWH exists but I don't consider it conclusive. Depends to some degree on the etiology of the CVST as well.

 

[Neurologo]

I'd only use LMWH if guided by Xa levels in CVST. I tend to use heparin. Some data for LMWH exists but I don't consider it conclusive. Depends to some degree on the etiology of the CVST as well.

Thank you for sharing your view. Could you elaborate on the etiologies affecting your choice between the two?

My view is that since LMWH is not inferior to unfractionated heparin, and since there are some data pointing to possible superiority, it may be worthwhile to prefer LMWH.

 

[typhoonegator]

If they're in DIC with a SSS thrombosis then I'd rather use heparin in case they start bleeding somewhere else. While you can reverse LMWH, giving someone protamine who is already bleeding and clotting is a no-win situation. Easier to turn off the heparin and provide supportive care.

If there is a chance the patient will need to go to angio for attempted thrombectomy of their CVST, there may be a desire to use an alternative agent like integrillin during the case. It's easier to manage clotting times with a heparin drip in that case than trying to deal with LMWH. Anti-Xa activity with LMWH is not actually steady throughout the 12 hour period. Endovascular treatment may not be proven effective, but when a patient is dying in front of me on a heparin drip, I offer it as a salvage option.