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

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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.

ABBREVIATIONS AHA = American Heart Association; ASA = American Stroke Association; CTV = CT venography; CVST = cerebral venous sinus thrombosis; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICH = intracranial hemorrhage; ICP = intracranial pressure; IQR = interquartile range; MRV = MR venography; MVC = motor vehicle collision.

Article Information

Correspondence Edward S. Ahn, Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N Wolfe St., Phipps Ste. 560, Baltimore, MD 21287. email: eahn4@jhmi.edu.

INCLUDE WHEN CITING Published online December 15, 2017; DOI: 10.3171/2017.9.PEDS17311.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Axial head CT scan without contrast obtained in a 5-year-old boy who was struck by a bus, showing a depressed right occipital fracture (arrow) adjacent to the transverse sinus. B and C: Diffusion-weighted MR image (B) and matching apparent diffusion coefficient map (C) of the brain, showing a venous infarct (dashed circle) involving the right temporal and occipital lobes. D: MRV showing an intrinsic sinus thrombosis resulting in near-complete occlusion of the right transverse sinus (arrowheads). The patient was monitored closely and not treated with anticoagulation. E: MRV obtained 4 months later, showing partial recanalization of the right transverse sinus (arrowheads).

  • View in gallery

    A and B: Three-dimensional surface-shaded CT reconstruction (A) and an axial bone algorithm CT image (B) obtained in a 6-year-old girl who had an unwitnessed fall and developed a nondepressed right parietal fracture (arrow). C: Soft-tissue algorithm, non–contrast-enhanced CT image showing an associated right-sided epidural hematoma. D: After craniotomy for evacuation of the hematoma, an additional head CT showed an asymmetrical hyperdensity of the right transverse sinus (arrowheads). E: MRV showing the complete lack of flow-related enhancement, consistent with an occlusive thrombus of the right transverse and sigmoid sinuses and ipsilateral internal jugular vein (arrowheads). F and G: Diffusion-weighted MR image (F) and matching apparent diffusion coefficient map (G) showing a venous infarct (dashed circle). H: Interval head CT scan showing stability after the patient was initiated on a low-dose unfractionated heparin drip. Figure is available in color online only.

  • View in gallery

    A: Axial bone algorithm CT image obtained in a 5-month-old boy who fell from a couch, showing a nondepressed right occipital fracture (arrow). B: Axial, soft-tissue algorithm, non–contrast-enhanced CT image showing that the fracture was associated with an adjacent subdural hematoma (not shown) and subarachnoid hemorrhage. A large extracranial hematoma was noted overlying the fracture. C: Diffusion-weighted MR image showing diffusion restriction involving the posterior temporal, occipital, and inferior parietal lobes (dashed circle). D: MRV showing an occlusive thrombus involving the distal superior sagittal sinus (arrowheads), torcula, and right transverse and sigmoid sinuses. E: Follow-up MRV showing recanalization of the sagittal sinus (arrowheads) after 6 months of anticoagulation therapy.

  • View in gallery

    Three-dimensional surface-shaded CT reconstruction (A), sagittal multiplanar projection reconstruction CT image (B), and sagittal 3D reconstructions of CTV (C) showing the comminuted, depressed frontoparietal fractures in an 8-year-old boy involved in an MVC. The superior sagittal sinus was severely compressed by the depressed calvarial fragments. The 3D (D) and sagittal (E) reconstructions of a postoperative CTV after craniotomy for elevation of the depressed skull fracture fragments show reperfusion of the superior sagittal sinus. Figure is available in color online only.

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