Journal Club: Comparative Therapeutic Effectiveness of Anticoagulation and Conservative Management in Traumatic Cerebral Venous Sinus Thrombosis

Title and Citation

Comparative Therapeutic Effectiveness of Anticoagulation and Conservative Management in Traumatic Cerebral Venous Sinus Thrombosis

Neurosurgery 2022

Background and importance

Traumatic cerebral venous sinus thrombosis does not have a clear treatment and largely modeled off spontaneous cerebral venous sinus thrombosis

Trial design

Retrospective

Decision to initiate AC must have stable interval CT non contrast with no new or worsening bleeding at greater than or equal to 72 hours post injury and AC initiated at greater than or equal to 72 hours post injury after stability scan

AC held for greater than or equal to 72 hours after major neurosurgery (craniotomy or craniectomy) or surgery for extraneurological injury

Not held for EVD or intracranial pressure monitor

AC = IV heparin with PTT q6h

CT head when PTT 60-80 seconds on 2 consecutive draws (r/o new or worsening bleed)

Analysis based on two groups (Therapeutic AC vs conservative management)

Duration

2013-2020

Objectives

Investigate characteristics and outcomes of patients treated with anticoagulation compared with patients managed conservatively

Inclusion Criteria

18 years of age or greater

1 or more skull fracture after blunt head trauma

CT venogram or MR venogram available for review

Exclusion Criteria

Absence of venous imaging

No skull fracture

Unclear use of therapeutic anticoagulation

Severe intracranial pathology

Primary endpoint

Mortality

Secondary: degree of thrombus recanalization

Statistical Analysis

Chi square test or Fisher exact test

Results

N=137

82 treated with anticoagulation vs 55 conservative management

Variable	Treated with AC (n=82)	Conservative management (n=55)	P value
Mortality	1	8	0.009
No recanalization	12 (17%)	10 (32%)	0.116
Partial recanalization	20 (29%)	12 (38%)	0.392
Full recanalization	37 (54%)	10 (32%)	0.012

Limitations

Small sample size

“Patients who died were overall sicker than surviving patients”

36 patient loss to long term radiographic follow up

Greater radiographic follow up in AC group (may contribute to higher detection of recanalization)

AC treatment not uniform (LMWH, warfarin, apixaban, heparin)

Author’s Conclusion

Incidence of tCVST on venous imaging in patients with a pretest suspicion for sinus injury was 32.3%.

AC treatment led to higher rate of complete luminal recanalization compared to conservative management

Weaknesses

Possible bias (not randomized) such that treating physician may have elected to withhold AC for various reasons possibly co morbidities or other trauma affecting outcomes (however no statistically significant difference between AC treated and conservative management groups on injury severity score)

Only 84% of AC group and 58% completed follow up venous imaging

Applicability

Difficult to determine if can be applied to clinical practice since giving an anticoagulant to someone who may have an intracranial bleed is not the standard of care for some of these injuries. Also unsure of the clinical benefit of achieving complete recanalization vs partial in long term. Primary outcome was to detect difference in mortality and authors admitted those on conservative management who expired were sicker.