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Editor,—A recent review article in your journal gives the impression that the case for heparinisation of all patients with cerebral venous sinus thrombosis (CVST) is proved.1 The largest and most robust study did not come to this conclusion and its results did not achieve statistical significance.2 Given that CVST has a spectrum of presentations from headache to coma and death, a blanket approach to treatment in the absence of good evidence and continued debate3 does not seem sensible.
The author responds:
I acknowledge Dr Lewis' comment with respect to the Dutch CVST Study Group trial.1-1 Nevertheless I feel this study in combination with an earlier study by Einhäupl et al 1-2 allows the conclusion that intravenous heparin should be first line treatment of CVST. The Dutch trial differed in several points from the German study, which may explain its neutral outcome. They are the altogether smaller number of poor outcomes; the larger proportion of patients with isolated intracranial hypertension and hence a much better prognosis anyway; finally a different treatment modality using subcutaneous low molecular weight heparin instead of the intravenous route.
I would agree with Bousser that heparin confers a clinically relevant benefit,1-3 justifying the use of this treatment as long as we remain unable to predict the outcome in the individual patient with CVST.
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