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Cerebral Sinovenous Thrombosis in Children With Acute Bacterial Intracranial Infection
Nehali Mehta1,2,3, Nakul Sheth4,5, Mark Halverson4,5
1Division of Neurology, Children's Hospital of Philadelphia, PA.
Insights
Cerebral sinovenous thrombosis (CSVT) affects 31% of children with acute bacterial intracranial infections. Risk factors include mastoiditis and cerebritis, with anticoagulation proving safe and effective for treatment.
Area of Science:
- Pediatric Neurology
- Infectious Diseases
- Vascular Neurology
Background:
- Cerebral sinovenous thrombosis (CSVT) epidemiology and optimal treatment in children with acute bacterial intracranial infections remain poorly understood.
- This study addresses the knowledge gap regarding CSVT prevalence, risk factors, and management in pediatric patients.
Purpose of the Study:
- To determine the prevalence of CSVT in children hospitalized with acute bacterial intracranial infections.
- To identify independent risk factors associated with CSVT development in this pediatric population.
- To describe the utilization and outcomes of anticoagulation therapy for CSVT in children.
Main Methods:
- Retrospective observational cohort study of children aged 1-18 years.
- Inclusion criteria: hospitalization for acute bacterial intracranial infection with head imaging.
- Multivariable logistic regression with LASSO technique to identify risk factors for CSVT.
Main Results:
- 31% (33/108) of children developed CSVT; prevalence did not vary by year.
- Independent risk factors for CSVT included mastoiditis, cerebritis, extra-axial focal suppurative infection, and dehydration.
- 73% of CSVT patients received anticoagulation without major bleeding; all showed thrombus resolution.
Conclusions:
- CSVT is prevalent in children with acute bacterial intracranial infections and challenging to diagnose clinically.
- High suspicion for CSVT is warranted, especially in children with mastoiditis, cerebritis, extra-axial focal suppurative infection, or dehydration.
- Anticoagulation appears safe and effective, but further research is needed on optimal use for infection-related CSVT.
Background And Objectives:
The epidemiology and optimal treatment strategy of cerebral sinovenous thrombosis (CSVT) in children with acute bacterial intracranial infection is largely unknown. We aimed to define the prevalence of CSVT among children with acute bacterial intracranial infection at a tertiary care pediatric hospital, to identify risk factors associated with the development of CSVT in this population, and to describe the use of anticoagulation in these children at our institution.
Methods:
This was a retrospective observational cohort study of children aged 1-18 years hospitalized at a tertiary care children's hospital for acute bacterial intracranial infection between January 1, 2015, and March 31, 2023. Children with bacterial meningitis/meningoencephalitis, cerebritis, intraparenchymal abscess, subdural empyema, and/or epidural abscess who had at least 1 head imaging study were included. Cases were identified using ICD codes; medical charts were manually screened to confirm diagnoses. A multivariable logistic regression model was built to identify independent risk factors for the primary outcome of CSVT using the least absolute shrinkage and selection operator technique.
Results:
Of 108 patients included (median age 10 years, 41% female), 33 (31%) developed CSVT. The prevalence of CSVT did not vary by year, but the absolute number of hospitalizations for acute bacterial intracranial infection rose during the study period, particularly after 2020. Presenting neurologic signs/symptoms did not differ between those who did and did not develop CSVT. Mastoiditis (adjusted odds ratio [aOR] 12.2, 95% CI 3.1-48.5), cerebritis (aOR 4.6, 95% CI 1.5-14.5), extra-axial focal suppurative infection (aOR 10.2, 95% CI 1.7-61.6), and dehydration (aOR 3.9, 95% CI 1.0-15.1) were each independently associated with CSVT. Seventy-three percent of children with CSVT (24/33) received anticoagulation (median duration 91 days) with no major bleeding events. All children with CSVT had at least partial thrombus resolution; 60% (20/33) had complete resolution.
Discussion:
CSVT is common in children with acute bacterial intracranial infection but difficult to clinically identify. Clinicians should maintain a high index of suspicion for CSVT in this population and consider appropriate screening imaging studies, particularly in children with mastoiditis, cerebritis, extra-axial focal suppurative infection, and/or dehydration. Anticoagulation was well-tolerated in this cohort; further studies should focus on determining its safety, benefit, and ideal duration in infection-related CSVT.
