- University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85004, USA
- Department of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ 85004, USA
Department of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ 85004, USA
DOI:10.4103/2152-7806.130908Copyright: © 2014 Awad A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Awad A, Bhardwaj R. Acute posttraumatic pediatric cerebral venous thrombosis: Case report and review of literature. Surg Neurol Int 16-Apr-2014;5:53
How to cite this URL: Awad A, Bhardwaj R. Acute posttraumatic pediatric cerebral venous thrombosis: Case report and review of literature. Surg Neurol Int 16-Apr-2014;5:53. Available from: http://sni.wpengine.com/surgicalint_articles/acute-posttraumatic-pediatric-cerebral-venous-thrombosis-case-report-and-review-of-literature/
Background:Pediatric cerebral venous thrombosis (CVT) is a common sequelae of infection, coagulopathies, and dehydration in the pediatric population. Acute posttraumatic CVT is an uncommon etiology of pediatric CVT that presents a unique management challenge. There are no established guidelines outlining the treatment of this small subset of patients.
Case Description:We present a case of a 12-year-old boy with posttraumatic CVT who was safely treated with anticoagulation therapy, and had resolution of his symptoms and radiographic improvement within 3 days of therapy. The relevant literature is reviewed.
Conclusion:Anticoagulation therapy may be safely used in the treatment of acute posttraumatic CVT in pediatric patients, and may reduce the incidence of clot propagation, hospitalization time, and cost of treatment.
Keywords: Anticoagulation, cerebral venous thrombosis, head trauma, pediatric, sigmoid sinus thrombosis, trauma
Pediatric cerebral venous thrombosis (CVT) is a potential life-threatening condition that requires a high index of suspicion to diagnose. The etiologies of pediatric CVT are multifocal and include underlying infection, coagulopathies, and trauma.[
We used the following search terms to find reported cases of pediatric CVT in Google Scholar Search: “Cerebral venous thrombosis in childhood”, “post trauma cerebral venous thrombosis”, “anticoagulation pediatric cerebral venous thrombosis”, and “sigmoid sinus thrombosis after closed head injury in children”. Reported articles were reviewed for cases of posttraumatic CVT in pediatric patients, treatment methods and outcomes were evaluated and reported in
History of present illness
We report a case of a 12-year-old boy with no significant past medical history who presented at Phoenix Children's Hospital Emergency Room following a motor vehicle accident (MVA). The patient was sharing a seatbelt with one other sibling in the back seat of a 4-door sedan. The vehicle was involved in a “T-bone” collision, which resulted in a temporal head injury against the side door. At the time of presentation, the patient complained of neck tenderness, pain at the right skull base, and nausea. The patient did have poor recollection of the accident; however, there was no indication of loss of consciousness. The patient denied any neck or head pain prior to the accident, and denied any fever, chills, emesis, or seizures. Prior to his presentation, the patient was otherwise healthy, performed well in school, has no family history of coagulopathies, was not taking any medications, and had a negative review of systems except what was discussed earlier. On physical examination, the patient was alert and oriented and appeared well nourished and well hydrated. His pupils were equal and reactive to light, extraocular movements were intact, his smile was symmetric and his hearing present in both ears. He had no otorrhea or rhinorrhea, but some ecchymosis was noted around the right ear. There was some neck tenderness at the level of C3, a neck brace was applied as a precautionary measure pending imaging results. He had full power and normal tone in his upper and lower extremities. His pulses were equal bilaterally to palpation. Overall, the patient was clinically stable but remained somewhat confused with a Glasgow coma scale (GCS) of 14. The patient was admitted to the pediatric intensive care unit pending imaging studies.
Initial imaging studies
A computed tomography (CT) of the head [
The patient's coagulation profile was within normal limits, he was admitted and started on IV heparin and monitored with serial exam for changes in neurologic function. The patient remained stable and on the third day of admission, a repeat MRV [
The incidence of CVT is 0.67 per 100,000 children per year, neonates make up to 43% of reported cases.[
It is important to consider the age of the patient when using diagnostic imaging in suspected cases of pediatric CVT. Although in the setting of head trauma, CT is commonly used to evaluate for possible intracranial hemorrhage and fractures, suspected thrombosis requires further studies to confirm the diagnosis if time permits. CT is only 84% accurate in diagnosing CVT in children,[
Per published CTV guidelines,[
Although others have decided to opt for the use of conservative therapy in the treatment of posttraumatic pediatric CVT,[
After 3 days of AC therapy, our patient's symptoms of nausea and headache had completely resolved. On the third day of treatment, a repeat MRV [
Acute posttraumatic CVT is an uncommon etiology of pediatric CVT, as such its management is not clearly established. We report a case of posttraumatic CVT in a 12-year-old boy who was safely treated with AC therapy, and had symptomatic and radiographic improvement within 3 days of therapy. This readily reversible medical therapy may help reduce mortality and morbidity associated with conservative management. In addition, the simplicity of drug management may hasten recovery and thereby reduce hospitalization time. Further randomized controlled trials are necessary to fully assess the efficiency of such therapy in this specialized patient population.
1. Barron TF, Gusnard DA, Zimmerman RA, Clancy RR. Cerebral venous thrombosis in neonates and children. Pediatr Neurol. 1992. 8: 112-6
2. Belman AL, Roque CT, Ancona R, Anand AK, Davis RP. Cerebral venous thrombosis in a child with iron deficiency anemia and thrombocytosis. Stroke J Cereb Circ. 1990. 21: 488-93
3. Carvalho KS, Bodensteiner JB, Connolly PJ, Garg BP. Cerebral venous thrombosis in children. J Child Neurol. 2001. 16: 574-80
4. deVeber G, Andrew M, Adams C, Bjornson B, Booth F, Buckley DJ. Cerebral Sinovenous Thrombosis in Children. N Engl J Med. 2001. 345: 417-23
5. deVeber G, Chan A, Monagle P, Marzinotto V, Armstrong D, Massicotte P. Anticoagulation therapy in pediatric patients with sinovenous thrombosis: A cohort study. Arch Neurol. 1998. 55: 1533-7
6. Georgoulis G, Alexiou G, Prodromou N. Sigmoid sinus thrombosis as a sequel of head injury in children and its management. World Neurosurg [Epub ahead of print]. p.
7. Huisman TA, Holzmann D, Martin E, Willi UV. Cerebral venous thrombosis in childhood. Eur Radiol. 2001. 11: 1760-5
8. Keane S, Gallagher A, Ackroyd S, McShane MA, Edge JA. Cerebral venous thrombosis during diabetic ketoacidosis. Arch Dis Child. 2002. 86: 204-5
9. Kenet G, Kirkham F, Niederstadt T, Heinecke A, Saunders D, Stoll M. Risk factors for recurrent venous thromboembolism in the European collaborative paediatric database on cerebral venous thrombosis: A multicentre cohort study. Lancet Neurol. 2007. 6: 595-603
10. Medlock MD, Olivero WC, Hanigan WC, Wright RM, Winek SJ. Children with cerebral venous thrombosis diagnosed with magnetic resonance imaging and magnetic resonance angiography. Neurosurgery. 1992. 31: 870-6
11. Moharir MD, Shroff M, Stephens D, Pontigon AM, Chan A, MacGregor D. Anticoagulants in pediatric cerebral sinovenous thrombosis: A safety and outcome study. Ann Neurol. 2010. 67: 590-9
12. Muthukumar N. Uncommon cause of sinus thrombosis following closed mild head injury in a child. Childs Nerv Syst. 2005. 21: 86-8
13. Philips MF, Bagley LJ, Sinson GP, Raps EC, Galetta SL, Zager EL. Endovascular thrombolysis for symptomatic cerebral venous thrombosis. J Neurosurg. 1999. 90: 65-71
14. Rich C, Gill JC, Wernick S, Konkol RJ. An unusual cause of cerebral venous thrombosis in a four-year-old child. Stroke. 1993. 24: 603-5
15. Saposnik G, Barinagarrementeria F, Brown RD, Bushnell CD, Cucchiara B, Cushman M. American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cerebral venous thrombosis a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011. 42: 1158-92
16. Sébire G, Tabarki B, Saunders DE, Leroy I, Liesner R, Saint-Martin C. Cerebral venous sinus thrombosis in children: Risk factors, presentation, diagnosis and outcome. Brain. 2005. 128: 477-89
17. Sousa J, O’Brien D, Bartlett R, Vaz J. Sigmoid sinus thrombosis in a child after closed head injury. Br J Neurosurg. 2004. 18: 187-8
18. Soysal DD, Citak A, Aydin K, Karaböcüoglu M, Uçsel R, Uzel N. Cerebral venous thrombosis in childhood. Eur J Emerg Med. 2008. 15: 120-2
19. Stiefel D, Eich G, Sacher P. Posttraumatic dural sinus thrombosis in children. Eur J Pediatr Surg. 2000. 10: 41-4
20. Taha JM, Crone KR, Berger TS, Becket WW, Prenger EC. Sigmoid sinus thrombosis after closed head injury in children. Neurosurgery. 1993. 32: 541-6
21. Vielhaber H, Ehrenforth S, Koch HG, Scharrer I, Van der Werf N, Nowak-Göttl U. Cerebral venous sinus thrombosis in infancy and childhood: Role of genetic and acquired risk factors of thrombophilia. Eur J Pediatr. 1998. 157: 555-60
22. Wasay M, Dai AI, Ansari M, Shaikh Z, Roach ES. Cerebral venous sinus thrombosis in children: A multicenter cohort from the United States. J Child Neurol. 2008. 23: 26-31