1UConn School of Medicine, Farmington, Connecticut.
2Research Operations and Development, Divisions of.
Neurosurg Focus. 2023 Oct;55(4):E8. doi: 10.3171/2023.7.FOCUS23374.
Septic cerebral venous sinus thrombosis (CVST) is a recognized complication of pediatric sinogenic and otogenic intracranial infections. The optimal treatment paradigm remains controversial. Proponents of anticoagulation highlight its role in preventing thrombus propagation and promoting recanalization, while others cite the risk of hemorrhagic complications, especially after a neurosurgical procedure for an epidural abscess or subdural empyema. Here, the authors investigated the diagnosis, management, and outcomes of pediatric patients with sinogenic or otogenic intracranial infections and a septic CVST.
All patients 21 years of age or younger, who presented with an intracranial infection in the setting of sinusitis or otitis media and who underwent neurosurgical treatment at Connecticut Children's, Rady Children's Hospital-San Diego, or Ann and Robert H. Lurie Children's Hospital of Chicago from March 2015 to March 2023, were retrospectively reviewed. Demographic, clinical, and radiological data were systematically collated.
Ninety-six patients were treated for sinusitis-related and/or otitis media-related intracranial infections during the study period, 15 (15.6%) of whom were diagnosed with a CVST. Of the 60 patients who presented prior to the COVID-19 pandemic, 6 (10.0%) were diagnosed with a septic CVST, whereas of the 36 who presented during the COVID-19 pandemic, 9 (25.0%) had a septic CVST (p = 0.050). The superior sagittal sinus was involved in 12 (80.0%) patients and the transverse and/or sigmoid sinuses in 4 (26.7%). Only 1 (6.7%) patient had a fully occlusive thrombus. Of the 15 patients with a septic CVST, 11 (73.3%) were initiated on anticoagulation at a median interval of 4 (IQR 3-5) days from the most recent neurosurgical procedure. Five (45.5%) patients who underwent anticoagulation demonstrated complete recanalization on follow-up imaging, and 4 (36.4%) had partial recanalization. Three (75.0%) patients who did not undergo anticoagulation demonstrated complete recanalization, and 1 (25.0%) had partial recanalization. None of the patients treated with anticoagulation experienced hemorrhagic complications.
Septic CVST is frequently identified among pediatric patients undergoing neurosurgical intervention for sinogenic and/or otogenic intracranial infections and may have become more prevalent during the COVID-19 pandemic. Anticoagulation can be used safely in the acute postoperative period if administered cautiously, in a monitored setting, and with interval cross-sectional imaging. However, some patients exhibit excellent outcomes without anticoagulation, and further studies are needed to identify those who may benefit the most from anticoagulation.
化脓性和耳源性颅内感染可引起小儿化脓性颅内静脉窦血栓（CVST），这是一种公认的并发症。最佳治疗方案仍存在争议。抗凝支持者强调其在预防血栓传播和促进再通方面的作用，而其他人则指出出血并发症的风险，尤其是在硬膜外脓肿或硬膜下积脓的神经外科手术后。在此，作者研究了患有化脓性或耳源性颅内感染并伴有化脓性 CVST 的小儿患者的诊断、治疗和结局。
回顾性分析 2015 年 3 月至 2023 年 3 月期间在康涅狄格儿童医疗中心、圣地亚哥 Rady 儿童医院或芝加哥安和罗伯特·H·卢里儿童医院接受神经外科治疗的 21 岁或以下因鼻窦炎或中耳炎引起颅内感染并接受神经外科治疗的所有患者。系统收集人口统计学、临床和影像学数据。
在研究期间，有 96 例患者因与鼻窦炎相关和/或与中耳炎相关的颅内感染接受治疗，其中 15 例（15.6%）被诊断为 CVST。在 COVID-19 大流行之前就诊的 60 例患者中，有 6 例（10.0%）被诊断为化脓性 CVST，而在 COVID-19 大流行期间就诊的 36 例患者中，有 9 例（25.0%）为化脓性 CVST（p=0.050）。12 例（80.0%）患者累及上矢状窦，4 例（26.7%）累及横窦和/或乙状窦。只有 1 例（6.7%）患者存在完全闭塞性血栓。在 15 例化脓性 CVST 患者中，11 例（73.3%）在最近一次神经外科手术后中位数 4（IQR 3-5）天开始抗凝治疗。5 例（45.5%）接受抗凝治疗的患者在随访影像学上显示完全再通，4 例（36.4%）显示部分再通。3 例（75.0%）未接受抗凝治疗的患者显示完全再通，1 例（25.0%）显示部分再通。接受抗凝治疗的患者无一例发生出血并发症。
化脓性 CVST 常在接受神经外科治疗化脓性和/或耳源性颅内感染的小儿患者中发现，且在 COVID-19 大流行期间可能更为普遍。如果在密切监测的情况下，谨慎使用抗凝剂，并在间隔进行横断面影像学检查，那么在急性术后期间使用抗凝剂是安全的。然而，一些患者即使不接受抗凝治疗也能获得良好的预后，需要进一步研究以确定哪些患者最受益于抗凝治疗。
