Neurosurgery notes/Vascular/Occlusive disease/Cerebral venous sinus thrombosis/Post traumatic CSVT

Post traumatic CSVT

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Cerebral venous sinus thrombosis

General

  • CVST associated with traumatic brain injury (TBI) is a specific subtype CVST
  • The optimal management and follow-up of the condition in the setting of concurrent TBI remains undetermined, and specific guidelines are non-existent.

Numbers

  • CVST frequency
    • If skull fractures adjacent to a venous sinus: 26.2%
    • If skull fracture away from venous sinus: 4%

Mechanism

  • Due to
    • Direct mechanical disruption of the integrity of the vessel wall
      • Fractures overlying a dural venous sinus
      • Epidural hematomas overlying a dural venous sinus

Complication rates

  • Venous infarction:
    • Adults 7-18%
    • Paeds 38%
  • Intracerebral haemorrhage: 11%
  • Focal oedema 16
  • Generalized oedema 3%

Investigation

  • Venogram (most use CTV)
    • Indication
      • High risk factors for CVST
        • Fractures (OR 8.03) crossing a dural venous sinus
        • EDH (OR 3.06) crossing a dural venous sinus
    • Timing no evidence but should be done within 30 days
      • Some CVST develop after a delay
    • No data on when should f/u venography be started
  • Non-contrast CT
    • Poor (38%) sensitivity detection of CVST in the setting of TBI

Treatment

  • Anticoagulant
    • No data on
      • Type of anticoagulation, and what dose, should be used?
      • When should anticoagulation be started?
      • Duration of anticoagulants
    • Evidence (poor retrospective studies)
      • Kim et al 2022 (n137, adult pt).
        • Unfractionated heparin (UFH)
        • Initiation of treatment was withheld until interval CT scan showed stable traumatic haemorrhages ≥ 72 h after injury.
          • Mean time to initiation was 6.57 ± 1.08 days post injury
          • Mean UFH treatment duration was 118 ± 20.47 days.
            CVST
            Treated with UFH
            Not treated with UFH
            N
            82
            55
            New/worsening haemorrhage
            9%
            ㅤ
            Mortality
            1%
            15%
            Full thrombus recanalization
            54%
            32%
          • AC treated group had a more than 3-fold longer mean time to last follow-up venography, which may have confounded this result
        • Predictors for developing bleeding complications
          • Waiting longer to UFH tx reduced odds of developing bleeding complications (OR 0.63).
      • Xavier et al (n20 paeds)
        • Complication rates from anticoagulant treatment of 14/20 children with CVST and TBI
          • 13 had concurrent intracranial hemorrhage.
          • Anticoagulant of varying type was used (UFH/LMWH/warfarin)
          • Initiated median of 7 days (range 2–48 days) post-trauma after persistence (9/14) or propagation (5/14) of thrombus had been documented on venography.
            • 3 children were reported to have had minor bleeding complications (one epistaxis; two asymptomatic extension of hemorrhage) and further AC treatment was withheld.
          • No children were reported to have experienced significant worsening of intracranial hemorrhage.

Outcome

  • Recanalization post treatments
    • Rates
      • Adult
        • 41 and 80%
      • Paeds
        • 70-86%
    • With knowledge of recanalization we can stop anticoagulant tx
      • Can be performed at 1-2 week, 3 months
      • If complete recanalization is found then can stop anticoagulant
      • If not recanalized rescan in 6 months and try again
  • Propagation of thrombus
    • Adults 0-18%
    • Paeds none.
  • Mortality rates
    • 5 and 50% for all age groups
    • No mortality for paeds noted