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

Traumatic Cerebral Venous Sinus Thrombosis: Management and Outcomes

BACKGROUND

Traumatic brain injury (TBI) with skull fractures parallel to or crossing venous sinuses is a recognized risk factor for traumatic cerebral venous sinus thrombosis (tCVST). Despite the recognition of this traumatic pathology in the literature, no consensus regarding management has been achieved. This study aimed to evaluate the impact of tCVST on TBI outcomes and related complications.

METHODS

Patients within a prospective registry at a level I trauma center from 2014 to 2023 were reviewed to identify tCVST cases. The impact of tCVST presence on Glasgow Outcome Scale scores at 6 months, 30-day mortality, and hospital length of stay were evaluated in multivariable-adjusted analyses.

RESULTS

Among 607 patients with TBI, 61 patients were identified with skull fractures extending to the vicinity of venous sinuses with dedicated venography. Twenty-eight of these 61 patients (44.3%) had tCVST. The majority (96.4%) of tCVST were located in a unilateral transverse or sigmoid sinus. Complete recanalization was observed in 28% of patients on follow-up imaging (7/25 with follow-up imaging). None of the 28 patients suffered attributable venous infarcts or thrombus propagation. In the adjusted analysis, there was no difference in the 30-day mortality or Glasgow Outcome Scale at 6 months between patients with and without tCVST.

CONCLUSIONS

Unilateral tCVST follows a benign clinical course without associated increased mortality or morbidity. The management of tCVST should be distinct as compared to spontaneous CVST, likely without the need for anticoagulation.

Cerebral Venous Thrombosis in Patients With Traumatic Brain Injury: Epidemiology and Outcome

The natural history and epidemiological aspects of traumatic cerebral venous thrombosis (CVT) are not fully understood. Due to the concomitant occurrence with intracranial hemorrhages, guidelines for medical treatment have been highly controversial. In this study, our objective was to carry out an analysis description of the population and to conduct a literature review. A prospectively gathered radiology registry data of patients hospitalized at the tertiary hospital of Centro Hospitalar Universitário do São João, Porto, Portugal, between 2016 and 2021 was carried out. All patients with traumatic brain injury (TBI) and concomitant CVT were identified. CVT was confirmed by CT venogram. Demographic, clinical, and radiological data and their medical management were reported. In-hospital complications and treatment outcomes were compared between patients measured by the Glasgow Outcome Score Extended (GOSE) at discharge and GOSE at three months. There were 41 patients with traumatic CVT admitted to this study. The majority (45.2%) had a hyperdense signal near the lateral sinus at admission, and only 26.2% presented with skull fractures. Of this cohort, 95% had experienced lateral sinus thrombosis. Twenty-five patients (60%) had occlusive venous thrombosis. Venous infarct was the main complication following CVT. Thirty-two patients (78%) were anticoagulated after CVT and four developed complications. At the three-month follow-up after discharge, 28.2% had good recovery (GOSE > 6). This study revealed a higher incidence of CVT in severe TBI and a mild association with skull fractures. There is a higher incidence of CVT in the lateral sinus. Management was inconsistent, with no difference in outcome without or with anticoagulation. Larger, prospective cohort studies are required to better comprehend this condition and determine evidence-based guidelines.

Presentation and Management of Cerebral Venous Sinus Thrombosis After Supratentorial Craniotomy

BACKGROUND AND OBJECTIVES

Cerebral venous sinus thrombosis (CVST) after supratentorial craniotomy is a poorly studied complication, for which there are no management guidelines. This study assessed the incidence, associated risk factors, and management of postoperative CVST after awake craniotomy.

METHODS

This is an observational, retrospective, monocentric analysis of patients who underwent a supratentorial awake craniotomy. Postoperative CVST was defined as a flow defect on the postoperative contrast-enhanced 3D T1-weighted sequence and/or as a T2* hypointensity within the sinus.

RESULTS

In 401 supratentorial awake craniotomies (87.3% of diffuse glioma), the incidence of postoperative CVST was 4.0% (95% CI 2.5-6.4): 14/16 thromboses located in the superior sagittal sinus and 12/16 located in the transverse sinus. A venous sinus was exposed during craniotomy in 45.4% of cases, and no intraoperative injury to a cerebral venous sinus was reported. All thromboses were asymptomatic, and only two cases were diagnosed at the time of the first postoperative imaging (0.5%). Postoperative complications, early postoperative Karnofsky Performance Status score, and duration of hospital stay did not significantly differ between patients with and without postoperative CVST. Adjusted independent risk factors of postoperative CVST were female sex (adjusted Odds Ratio 4.00, 95% CI 1.24-12.91, P = .021) and a lesion ≤1 cm to a venous sinus (adjusted Odds Ratio 10.58, 95% CI 2.93-38.20, P < .001). All patients received standard prophylactic-dose anticoagulant therapy, and none received treatment-dose anticoagulant therapy. No thrombosis-related adverse event was reported. All thromboses presented spontaneous sinus recanalization radiologically at a mean of 89 ± 41 days (range, 7-171).

CONCLUSION

CVST after supratentorial awake craniotomy is a rare event with satisfactory clinical outcomes and spontaneous sinus recanalization under conservative management without treatment-dose anticoagulant therapy. These findings are comforting to neurosurgeons confronted with postoperative MRI reports suggesting CVST.

Cerebral venous sinus thrombosis in traumatic brain injury: A systematic review of its complications, effect on mortality, diagnostic and therapeutic management, and follow-up

Objective

Cerebral venous sinus thrombosis (CVST) is increasingly being recognized in the setting of traumatic brain injury (TBI), but its effect on TBI patients and its management remains uncertain. Here, we systematically review the currently available evidence on the complications, effect on mortality and the diagnostic and therapeutic management and follow-up of CVST in the setting of TBI.

Methods

Key clinical questions were posed and used to define the scope of the review within the following topics of complications; effect on mortality; diagnostics; therapeutics; recanalization and follow-up of CVST in TBI. We searched relevant databases using a structured search strategy. We screened identified records according to eligibility criteria and for information regarding the posed key clinical questions within the defined topics of the review.

Results

From 679 identified records, 21 studies met the eligibility criteria and were included, all of which were observational in nature. Data was deemed insufficiently homogenous to perform meta-analysis and was narratively synthesized. Reported rates of venous infarctions ranged between 7 and 38%. One large registry study reported increased in-hospital mortality in CVSP and TBI compared to a control group with TBI alone in adjusted analyses. Another two studies found midline CVST to be associated with increased risk of mortality in adjusted analyses. Direct data to inform the optimum diagnostic and therapeutic management of the condition was limited, but some data on the safety, and effect of anticoagulation treatment of CVST in TBI was identified. Systematic data on recanalization rates to guide follow-up was also limited, and reported complete recanalization rates ranged between 41 and 86%. In the context of the identified data, we discuss the diagnostic and therapeutic management and follow-up of the condition.

Conclusion

Currently, the available evidence is insufficient for evidence-based treatment of CVST in the setting of TBI. However, there are clear indications in the presently available literature that CVST in TBI is associated with complications and increased mortality, and this indicates that management options for the condition must be considered. Further studies are needed to confirm the effects of CVST on TBI patients and to provide evidence to support management decisions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO [CRD42021247833].

Case report: An illusive cortical venous infarction mimicking glioma hemorrhage

Cortical vein thrombosis (CVT) is a rare subtype of cerebral venous thrombosis. Because CVT is rare and its clinical and imaging findings are atypical, the misdiagnosis of CVT may be extremely high. We report a case of cortical venous infarction (CVI) secondary to CVT. Due to the atypical symptoms, we were perplexed about confirming the diagnosis between CVI and glioma hemorrhage. Eventually, CVT was confirmed by pathology combined with imaging.

The prevalence and risk factors of posttraumatic cerebral infarction in patients with traumatic brain injury: a systematic review and meta-analysis

Posttraumatic cerebral infarction (PTCI) is a serious complication of traumatic brain injury (TBI), and the prevalence and risk factors of PTCI in TBI patients are in dispute. We systematically searched the literature in the PubMed, Embase, and Cochrane library up to October 2021 to identify studies on the prevalence and risk factors of PTCI in patients with TBI. The quality of observational studies was assessed by the Newcastle-Ottawa scale tool. Random-effects model was conducted. The Higgins` I² statistic was used to measure heterogeneity between trials. Moreover, sensitive analyses were conducted to assess whether the pooled result was credible and robust. Eleven studies (3696 total TBI patients) were included. The pooled prevalence of PTCI in TBI patients was 14% (95% CI, 0.11-0.17; I² = 83.1%). Sensitive analyses showed that the pooled prevalence of PTCI was 13% (95% CI, 0.10-0.15; I² = 69.2%) by omitting Su et al. The prevalence of PTCI was associated with a lower Glasgow Coma Scale (GCS) score (OR, 0.33; 95% CI, 0.14-0.77; I² = 99.2%), pupillary dilation (OR, 4.73; 95% CI, 4.30-5.19; I² = 85.6%), abnormal PT (OR, 1.16; 95% CI,1.05-2.47; I² = 99.2%), hematoma location (OR, 1.16; 95% CI,1.05-2.47; I² = 99.2%) and hematoma volume (OR, 1.16; 95% CI,1.05-2.47; I² = 99.2%). Whereas hypotensive shock, duraplasty, cerebral herniation, and thrombocytopenia were not statistically associated with PTCI. Lower GCS, pupillary dilation, abnormal PT, hematoma location, and hematoma volume were risk factors for PTCI. Considering some limitations, the conclusion of our study should be interpreted with caution.