What is the management of traumatic dural venous sinus thrombus?

Management of Traumatic Dural Venous Sinus Thrombosis

Anticoagulation is the mainstay of treatment for traumatic dural venous sinus thrombosis, even in the presence of intracranial hemorrhage, and should be initiated as soon as bleeding has been controlled. 1

Diagnostic Approach

Before initiating treatment, confirmation of diagnosis is essential:

• MRI with MRV is the preferred diagnostic modality

  • Look for absence of flow void with altered signal intensity in the dural sinus
  • T2 hypointensity suggesting thrombus in acute phase (first week)
  • T1 and T2 hyperintensity in second week due to methemoglobin
  • Contrast-enhanced MRI may show the "empty delta sign"

• CT/CTV if MRI is not readily available

  • Initial non-contrast CT may show hyperdense sinus (direct sign of thrombosis)
  • Gas in the dural venous sinus after trauma increases likelihood of DVST 2
  • Increasing density (>65 Hounsfield units) in follow-up scans is highly suggestive 2

Treatment Algorithm

Step 1: Initial Management

• Confirm diagnosis with appropriate imaging
• Assess for contraindications to anticoagulation
• Evaluate for mass effect, ICH, and neurological status

Step 2: Anticoagulation Therapy

• Initiate anticoagulation once bleeding is controlled 1
  • Use IV heparin or subcutaneous LMWH initially
  • Important: Intracranial hemorrhage resulting from DVST is NOT a contraindication for anticoagulation 1
  • Delay anticoagulation by 24 hours in cases of active bleeding, coagulopathy, hemodynamic instability 1
  • In traumatic brain injury, hold until CT shows no progression of hemorrhage 1

Step 3: Monitoring and Escalation of Care

• Monitor neurological status closely
• If stable or improving: Continue anticoagulation
• If deteriorating:
  • Assess for severe mass effect or expanding ICH
  • Consider endovascular therapy if:
    • Patient has contraindications to anticoagulation
    • Failure of initial anticoagulation therapy 1
    • Mechanical thrombectomy with or without thrombolysis may be considered 3
  • Consider decompressive hemicraniectomy for life-threatening mass effect 1

Step 4: Long-term Management

• Transition to oral anticoagulation
• Continue for 3-12 months depending on underlying etiology 1
  • 3 months for transient reversible factors
  • Longer duration for thrombophilia
• Consider follow-up imaging at 3-6 months to assess recanalization 1

Special Considerations

Skull Fractures and Sinus Injury

• Linear skull fractures crossing the dural venous sinus can often be controlled with simple digital pressure using Gelfoam 4
• Linear skull fractures parallel to the sinus or depressed fractures penetrating the sinus may cause massive bleeding that is difficult to control 4

Endovascular Treatment

• Reserved for cases refractory to anticoagulation or with contraindications to anticoagulation
• Options include:
  • Mechanical thrombectomy
  • Intrasinus thrombolysis (though limited evidence in traumatic cases) 5

Monitoring and Follow-up

• Serial imaging to assess thrombus progression and recanalization
• Monitor for clinical deterioration suggesting thrombus propagation
• Follow-up imaging at 3-6 months to assess recanalization 1
• Be vigilant for development of dural arteriovenous fistula as a delayed complication 1

Common Pitfalls to Avoid

1. Withholding anticoagulation due to presence of intracranial hemorrhage - This is not a contraindication when the hemorrhage is a consequence of DVST 1

2. Delaying diagnosis - Early recognition is vital; look for gas and increasing density in the dural venous sinus on non-enhanced CT 2

3. Inadequate monitoring - Regular neurological assessments and follow-up imaging are essential

4. Overlooking underlying skull fractures - Especially those parallel to or penetrating the sinus, which may cause massive bleeding 4