Dural venous sinus thrombosis due to cranial trauma

Classification of traumatic injury to the dural venous sinus using CT venography

BACKGROUND AND PURPOSE

Cerebral venous sinus thrombosis (CVST) is an underrecognized cause of morbidity in acute traumatic brain injury (TBI). Radiologic diagnosis is challenging in the setting of concurrent extra-axial injury and a lack of standardized diagnostic criteria. The prevalence of traumatic thrombosis versus compression is unknown. Treatment with anticoagulation is often determined by the appropriate classification of the type of traumatic venous injury.

METHODS

We developed a two-part radiologic grading method for standardized assessment of traumatic CVST based on (1) the degree of flow limitation through the affected sinus and (2) the location of venous pathology (ie, external compression vs. intrinsic thrombosis) based on computed tomography venography. We applied this grading method to a retrospective cohort of TBI patients presenting to a Level 1 Trauma center. Chart review was performed to identify potential clinical correlates. A senior neuroradiologist graded the entire cohort and a random subsample was selected for blinded rating by two independent neuroradiologists.

RESULTS

Seventy-six of 221 patients were identified for inclusion after excluding nontraumatic mechanisms. Seven unique grades were employed to characterize the full extent of venous injuries. The plurality of patients from the cohort (43/76 = 43.4%) suffered compressive injuries. Inter-rater reliability was moderate for the combined grade, kappa = 0.48, p<.05, and substantial for the flow limitation component, kappa = 0.69, p<.05.

CONCLUSIONS

We introduce a standardized two-part classification system for traumatic venous sinus injury with moderate-substantial inter-rater reliability. Compressive injuries were more common than thrombotic injuries. Further prospective work is needed to validate the clinical significance of this classification system.

Post traumatic cerebral sinovenous thrombosis in children: A retrospective and multicenter study

CONTEXT

Cerebral sinovenous thrombosis (CSVT) is a rare but life-threatening condition in the pediatric population and there is no pediatric guidelines regarding anticoagulation for post traumatic CSVT.

OBJECTIVE

This study aims to describe a cohort of children with post traumatic CSVT and the use of anticoagulant therapy in this population.

METHODS

A multicenter retrospective study. Patients admitted with post traumatic CSVT in the six participating Pediatric Intensive Care Unit were included.

RESULTS

Overall, 29 patients (median age 8.2 years [IQR 4.8-14.6], n = 22 (76%) males) were included in the study (Table 1). CSVT was observed within the first 24 h after admission for a half of the patients (n = 14, 50%). Anticoagulation was initiated in 18 patients (62%). No patient received thrombolytic therapy or endovascular treatment. The presence of epidural hematoma was associated with the absence of anticoagulation (n = 0 versus n = 10, p = 0.003). One patient (3%) died of extracranial injury (not related with adverse event of anticoagulation) and in survivors, median Pediatric Overall Performance Category Outcome (POPC) score at discharge from PICU was 2 [IQR 2-4] (i.e., mild disability). Regarding the outcomes of patients, we found no association according to the anticoagulation status (p = 1). Overall, 23 patients (79%) had a follow-up cerebral imaging with a median delay of 42 days [IQR 6-63] after admission. CSVT was still seen in 9 patients (31%). We found no difference regarding the persistence of CSVT between patients according to the anticoagulation status (p = 0.36). The median duration of anticoagulant treatment was 58 days [IQR 44-91] and one patient (3%) experienced adverse event related to anticoagulation.

CONCLUSION

There were minimal adverse events in patients with post traumatic CSVT treated with therapeutic anticoagulation. However, the effect of anticoagulation on outcomes needs to be confirmed in further studies.

Venous sinus thrombosis in traumatic brain injury: a major trauma centre experience

BACKGROUND

This study explores the presentation, management and outcomes of traumatic venous sinus thrombosis (VST) and identifies risk factors associated with poor outcomes.

METHODS

This study is a retrospective review of all patients with VST secondary to trauma who presented to a major trauma centre, between April 2015 and January 2020. VST was confirmed by CT venogram and a consultant neuroradiologist.

RESULTS

Forty-six patients were identified (38 male), mean age of 43 (range 12-78) and median follow-up 10.2 months (range 0.7-39.1). Fifty-two percent presented as a severe traumatic brain injury, and all had an associated skull fractures overlying the sinus. Ninety-six percent had cerebral contusions, 96% had an intracranial haematoma, 91% had traumatic subarachnoid haemorrhage (tSAH) and 22% had acute cerebral infarction. Thirty-seven percent of the VSTs were occlusive. Fifty-eight percent had sustained, unprovoked intracranial pressure (ICP) spikes (> 20 mmHg). Fifty percent underwent surgical intervention-20% external ventricular drain and 46% craniotomy/craniectomy. Nine percent were treated with anticoagulation and 4% with antiplatelets, at a median of 13.5 days and 9.5 days post-injury, with no additional complications. Age > 60 was associated with poor outcome (GOS of 3-5) (p = 0.0098). On follow-up CT, 52% of the VSTs remained unchanged, 29% re-canalised, 14% improved and 5% worsened, independent of treatment.

CONCLUSIONS

This study demonstrated a higher incidence of VST in severe TBI and strong associations with skull fractures, cerebral contusions, tSAH, raised ICP and surgical intervention. Management was inconsistent, with no difference in outcome with or without anticoagulation. Larger, prospective cohort studies are needed to better understand this condition and establish evidence-based guidelines.

Pediatric cerebral venous sinus thrombosis or compression in the setting of skull fractures from blunt head trauma

OBJECTIVE Pediatric cerebral venous sinus thrombosis has been previously described in the setting of blunt head trauma; however, the population demographics, risk factors for thrombosis, and the risks and benefits of detection and treatment in this patient population are poorly defined. Furthermore, few reports differentiate between different forms of sinus pathology. A series of pediatric patients with skull fractures who underwent venous imaging and were diagnosed with intrinsic cerebral venous sinus thrombosis or extrinsic sinus compression is presented. METHODS The medical records of patients at 2 pediatric trauma centers were retrospectively reviewed. Patients who were evaluated for blunt head trauma from January 2003 to December 2013, diagnosed with a skull fracture, and underwent venous imaging were included. RESULTS Of 2224 pediatric patients with skull fractures following blunt trauma, 41 patients (2%) underwent venous imaging. Of these, 8 patients (20%) had intrinsic sinus thrombosis and 14 patients (34%) displayed extrinsic compression of a venous sinus. Three patients with intrinsic sinus thrombosis developed venous infarcts, and 2 of these patients were treated with anticoagulation. One patient with extrinsic sinus compression by a depressed skull fracture underwent surgical elevation of the fracture. All patients with sinus pathology were discharged to home or inpatient rehabilitation. Among patients who underwent follow-up imaging, the sinus pathology had resolved by 6 months postinjury in 80% of patients with intrinsic thrombosis as well as 80% of patients with extrinsic compression. All patients with intrinsic thrombosis or extrinsic compression had a Glasgow Outcome Scale score of 4 or 5 at their last follow-up. CONCLUSIONS In this series of pediatric trauma patients who underwent venous imaging for suspected thrombosis, the yield of detecting intrinsic thrombosis and/or extrinsic compression of a venous sinus was high. However, few patients developed venous hypertension or infarction and were subsequently treated with anticoagulation or surgical decompression of the sinus. Most had spontaneous resolution and good neurological outcomes without treatment. Therefore, in the setting of pediatric skull fractures after blunt injury, venous imaging is recommended when venous hypertension or infarction is suspected and anticoagulation is being considered. However, there is little indication for pervasive venous imaging after pediatric skull fractures, especially in light of the potential risks of CT venography or MR venography in the pediatric population and the unclear benefits of anticoagulation.

Dural sinus obstruction following head injury: a diagnostic and clinical study

OBJECTIVE The aim of this study is to describe the clinical characteristics of patients with skull fracture adjacent to a dural venous sinus (DVS) and evaluate the role of CT venography (CTV) in the diagnosis of the effect of this fracture on the involved DVS. METHODS The study comprised patients with vault or skull base fracture adjacent to a DVS who were admitted to 1 medical center during a 2-year period. The medical records were reviewed for the clinical and radiographic characteristics. All patients had undergone CTV to evaluate potential DVS pathology. The clinical and radiological findings of the patients with DVS pathology were compared with those of the patients with normal DVS. The groups were compared using the chi-square and t-tests for categorical and continuous data, respectively. The potential risk for poor outcome among the patients with DVS pathology was also investigated. RESULTS Of 434 patients with skull fractures, 41 (9.4%) had fractures adjacent to a DVS. DVS pathology was detected in 51% of patients (21 of 41 patients). For 9 (43%) patients, obstruction was extraluminal without thrombosis, and 12 (57%) patients had dural sinus thrombosis (DST). In patients with a positive-CTV scan, the severity of injury according to the Glasgow Coma Scale score at presentation was correlated with the presence of DST (p = 0.007). The sensitivity of noncontrast CT (NCCT) for DVS involvement was 38% among the patients with positive-CTV scans. For patients with DVS pathology, poor outcome was correlated with DST (intraluminal), rather than extraluminal obstruction without thrombosis (p = 0.02), and superior sagittal sinus (SSS) involvement (p = 0.05). CONCLUSIONS NCCT is not sensitive enough to detect DVS obstruction in patients with skull fracture adjacent to a DVS, and CTV should be performed in order to rule it out. A correlation was found between the severity of injury and the presence of DST, rather than extraluminal obstruction. The authors' findings suggest that DST and SSS involvement may be indicators of poor outcome in patients with skull fracture adjacent to DVS.

Early Spontaneous Recanalization of Sigmoid Sinus Thrombosis Following a Closed Head Injury in a Pediatric Patient : A Case Report and Review of Literature

Cerebral venous sinus thrombosis (CVST) following a closed head injury in pediatric patients is a rare condition, and an early spontaneous recanalization of this condition is extremely rare. A 10-year-old boy was admitted with a mild, intermittent headache and nausea five days after a bicycle accident. The brain computed tomography showed an epidural hematoma at the right occipital area with pneumocephalus due to a fracture of the occipital skull bone. The brain magnetic resonance imaging and the magnetic resonance venography demonstrated a flow signal loss from the right sigmoid sinus to the right jugular vein. The diagnosis was sigmoid sinus thrombosis, so close observations were selected as a treatment for the patient because of his gradually improving symptoms; however, he complained of vomiting 14 days the after conservative treatment. The patient was readmitted for a further examination of his symptoms. The laboratory and the gastroenterological examinations were normal. Due to concern regarding the worsening of the sigmoid sinus thrombosis, the brain magnetic resonance venography was rechecked and it revealed the recanalization of the venous flow in the sigmoid sinus and in the jugular vein.

Cerebral sinus thrombosis in a 6-year-old boy after a minor head injury

Posttraumatic cerebral sinus thrombosis is an uncommon disease in children that is rarely seen in the setting of a closed head injury. We report a 6-year-old boy who developed cerebral sinus thrombosis after an apparent minor head injury. The clinical presentation, neuroimaging findings, and treatment strategies are discussed. Serial neurological evaluation and close observation are important, and the decision for anticoagulation should be carefully considered with hematological consultants.

Dural sinus and internal jugular vein thrombosis complicating a blunt head injury in a pediatric patient

INTRODUCTION

Cerebral venous sinus thrombosis (CVST) following a blunt head trauma is a rare condition, described in the literature along with the lack of consensus regarding diagnosis and management. We present a case of a pediatric patient with a blunt head injury and epidural hematoma, who developed dural sinus and internal jugular vein thrombosis with fatal outcome.

DISCUSSION

Most of reports show good outcome and recovery, but CVST might be related to poor recovery and even lead to death. The diagnosis and management of this condition are discussed based on a literature review.

CONCLUSION

It is important to keep a high degree of suspicion of CVST since early diagnosis may prevent potentially treatable catastrophic outcomes.

Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis. Case report

In severe cases, posttraumatic cerebral sinus thrombosis can result in venous congestion and persistent intracranial hypertension refractory to both conventional medical therapy and surgical decompression. The authors report a unique case of a patient successfully treated with endovascular mechanical thrombolysis using balloon angioplasty for clinically significant posttraumatic venous sinus thrombosis and review the reported treatments for cerebral venous sinus occlusive disease. This 18-year-old man suffered severe closed head injury from a fall while skateboarding. A head CT scan demonstrated basilar skull fractures involving the left jugular foramen. A CT angiogram revealed thrombosis of the left transverse sinus and occlusion of the sigmoid sinus and internal jugular vein. Despite treatment with anticoagulation therapy and decompressive hemi- and suboccipital craniectomies, intracranial hypertension remained refractory. Serial angiography demonstrated progressive sinus occlusion. Endovascular balloon thrombolysis of the left transverse and sigmoid sinuses resulted in immediate reduction of intracranial pressures and improved sinus patency. Intracranial pressure measurements remained low after the procedure. The patient eventually improved neurologically, was able to follow commands and walk, and was discharged to a rehabilitation facility for further recovery. Anticoagulation therapy, surgical decompression, and endovascular thrombolysis have been reported as treatment modalities for clinically significant posttraumatic venous sinus thrombosis. In this case, endovascular mechanical thrombolysis with balloon angioplasty resulted in resolution of thrombus and successful immediate reduction of intracranial pressure. This treatment may be considered in patients with critically elevated intracranial pressure from posttraumatic venous sinus occlusion refractory to other treatment measures.

Cerebral venous sinus thrombosis risk factors

Cerebral venous sinus thrombosis is an uncommon disease marked by clotting of blood in cerebral venous, or dural sinuses, and, in rare cases, cortical veins. It is a rare but potentially fatal cause of acute neurological deterioration previously related to otomastoid, orbit, and central face cutaneous infections. After the advent of antibiotics, it is more often related to neoplasm, pregnancy, puerperium, systemic diseases, dehydration, intracranial tumors, oral contraceptives, and coagulopathies are the most common causes, but in 30% of cases no underlying etiology can be identified. It has been found in association with fibrous thyroiditis, jugular thrombosis after catheterization, or idiopathic jugular vein stenosis. Other factors include surgery, head trauma, arterio-venous malformations, infection, paraneoplastic, and autoimmune disease. This article presents a comprehensive review of cerebral venous sinus thrombosis etiologies.

Evaluation of posttraumatic venous sinus occlusion with CT venography

BACKGROUND

Although cerebral venous sinus occlusion (CVSO) is reported to be associated with intracranial hypertension, its incidence or significance in head trauma is not clear. This study investigated with CT venography the incidence of posttraumatic CVSO, its clinical course, and relation to intracranial hypertension.

PATIENTS

This study comprised 97 consecutive patients admitted to our Trauma Center from 2002 through 2008 with skull fracture of the petrous portion of the temporal bone or that crossed the dural sinus. Patients with CVSO were examined with CT venography and followed up with CT venography or magnetic resonance imaging. The relation of CVSO to patient outcome and incidence of "talk and deteriorate" was also investigated.

RESULTS

CVSO was observed in 22 of 97 patients (22.4%). Mortality was significantly higher in the CVSO group versus no-CVSO group (50.0% vs. 9.3%, p < 0.001). Incidence of lethal intracranial hypertension was higher in the CVSO versus no-CVSO group (40.9% vs. 5.3%, p < 0.001), although there was no difference in Glasgow Coma Scale score at admission between the two groups (CVSO group, 8 +/- 5 vs. no-CVSO group, 10 +/- 4). Recanalization without treatment for CVSO occurred by 6 months in 9 of the 11 survivors (81.8%) who could be followed up.

CONCLUSION

CVSO incidence after head injury was much higher than ever thought. It was associated with mortality and lethal intracranial hypertension, indicating that CVSO may induce acute increase in intracranial pressure in some cases. Early recognition of CVSO may be important to predict deterioration after admission and for starting immediate treatment.

What is new about idiopathic intracranial hypertension? An updated review of mechanism and treatment

Idiopathic intracranial hypertension (IIH) is the syndrome of raised intracranial pressure without clinical, laboratory or radiological evidence of intracranial pathology. IIH is a relatively rare disease but rapidly increasing incidence is reported due to a global increasing incidence of obesity. Disease course is generally said to be self-limiting within a few months. However, some patients experience a disabling condition of chronic severe headache and visual disturbances for years that limit their capacity to work. Permanent visual defects are serious and not infrequent complications. The pathophysiology of IIH is still not fully understood. Advances in neuroimaging techniques have facilitated the exclusion of associated conditions that may mimic IIH. No causal treatment is yet known for IIH and existing treatment is symptomatic and rarely sufficient. The aim of this review is to provide an updated overview of this potentially disabling disease which may show a future escalating incidence due to obesity. Theories of pathogenesis, diagnostic criteria and treatment strategies are discussed.

Uncommon cause of sinus thrombosis following closed mild head injury in a child

OBJECT

Sinus thrombosis following a closed mild head injury is rare. A case of dural sinus thrombosis following a mild closed head injury due to an uncommon cause is reported.

METHODS

A 7-year-old child presented with GCS 15 after a road traffic accident. CT revealed an occipital fracture. Ten days later the child developed signs of increased intracranial pressure. An MR venogram at this time revealed thrombosis of the transverse sinus with hypoplasia of the contralateral transverse and sigmoid sinuses. The patient's anitiphospholipid antibody titres were elevated. The patient was treated with anticoagulants and improved.

CONCLUSIONS

The role of inherited and acquired procoagulant factors in the aetiology of sinus thrombosis is increasingly being recognized. When a patient presents with sinus thrombosis after a closed mild head injury, it is necessary to investigate for the presence of risk factors for thrombophilia as it has implications for the long-term management of the patient.

Endovascular treatment of traumatic dural sinus thrombosis: case report

OBJECTIVE

Dural sinus thrombosis has rarely been associated with closed head injury. We present a unique case involving the use of endovascular thrombolysis in the treatment of traumatic dural sinus thrombosis, which has not been reported.

CLINICAL PRESENTATION

A 20-year-old male patient suffered a severe closed head injury while skiing. He developed refractory elevated intracranial pressure requiring barbiturate coma. Angiography demonstrated thrombosis of the dominant right transverse and sigmoid sinuses, with partial thrombosis of the superior sagittal sinus. Urokinase was administered via a microcatheter within the thrombus as a bolus of 250,000 units and then as a continuous infusion of 60,000 to 100,000 units per hour for 48 hours. The patient was maintained in a barbiturate coma and heparinized. Serial angiography was performed to assess the sinus patency and efficacy of thrombolysis.

RESULTS

After 48 hours of thrombolysis, angiography demonstrated normal patency of the superior sagittal, right transverse, and right sigmoid sinuses. The intracranial pressure decreased after thrombolysis and was manageable with conventional techniques. Within 48 hours of the completed thrombolysis, the barbiturates were withdrawn and the patient's neurological status rapidly improved until the time of discharge 2 weeks later.

DISCUSSION AND CONCLUSION

This case documents a rare instance of traumatic dural sinus thrombosis resulting from a closed head injury. In addition, endovascular thrombolysis resulted in subsequent opening of the dural sinuses and effective intracranial pressure management, despite the presence of a hemorrhagic contusion. Heparin was effective in maintaining sinus patency and was used safely in conjunction with urokinase in this setting of head injury.