From the Guidelines
Management of traumatic dural sinus venous thrombosis (DSVT) from skull base fracture requires a multifaceted approach, with anticoagulation therapy as the cornerstone of treatment, typically with unfractionated heparin initially, transitioning to low molecular weight heparin or warfarin for 3-6 months, as recommended by the American Heart Association/American Stroke Association 1. Initial management includes stabilization of the patient with close neurological monitoring in an intensive care setting.
- Anticoagulation must be carefully considered in the context of traumatic brain injury, with the risk of hemorrhagic expansion weighed against the benefit of preventing clot propagation.
- In cases with significant mass effect or neurological deterioration despite anticoagulation, endovascular intervention with mechanical thrombectomy may be necessary.
- Supportive measures include:
- Adequate hydration
- Seizure prophylaxis with levetiracetam (500-1000 mg twice daily)
- Management of increased intracranial pressure with elevation of the head of bed to 30 degrees
- Osmotic therapy (mannitol 0.25-1 g/kg IV every 6 hours or hypertonic saline 3% at 0.5-1 mL/kg/hr)
- In severe cases, consideration of decompressive craniectomy The management approach is justified by the need to prevent clot propagation while minimizing the risk of hemorrhagic complications in the setting of trauma, with the ultimate goal of preserving cerebral blood flow and preventing venous infarction, as supported by the guidelines for the prevention of stroke in patients with stroke or transient ischemic attack 1. According to the proposed algorithm for the management of CVT, anticoagulation should be initiated if no major contraindications are present, and the patient's condition should be closely monitored for neurological improvement or deterioration 1. The American Heart Association/American Stroke Association also provides recommendations for the diagnosis, management, and prevention of recurrence of cerebral venous thrombosis, including considerations for the management of clinical complications and an algorithm for diagnosis and management of patients with cerebral venous sinus thrombosis 1.
From the Research
Management of Traumatic Dural Sinus Venous Thrombosis
The management of traumatic dural sinus venous thrombosis from skull base fracture is a complex issue, with various treatment options available.
- The use of anticoagulation is recommended as the initial treatment option 2.
- For patients with a poor prognosis, local thrombolysis with urokinase or recombinant tissue plasminogen activator may be considered 2.
- Rheolytic thrombectomy may be employed as a last resort for patients who are not suitable for local or systemic thrombolysis 2.
- The decision to anticoagulate patients with traumatic dural sinus thrombosis is controversial and requires careful consideration of the risks and benefits 3.
- Surgical intervention, such as craniotomy or craniectomy, may be necessary in some cases, particularly for patients with severe traumatic brain injury and associated skull fractures 4.
Risk Factors and Outcomes
Several risk factors have been identified as being associated with poor outcomes in patients with traumatic dural sinus venous thrombosis, including:
- Age > 60 years 4
- Presence of skull fractures, particularly those involving the temporal or parietal bone 5
- Cerebral contusions, intracranial haemorrhages, and traumatic subarachnoid haemorrhage 4
- Raised intracranial pressure 4
Diagnostic Imaging
Multidetector CT venography is a useful diagnostic tool for detecting traumatic dural sinus thrombosis, particularly in patients with high-risk acute blunt head trauma 6.
- CT venography can help identify patients with dural venous sinus abnormality and DVST, allowing for early intervention and management 5.