Cerebral venous sinus thrombosis: a case series including thrombolysis

Andrew A Mallick ¹, Peta M Sharples ¹, Sophie E Calvert ², Robert W A Jones ³, Mick Leary ¹, Andrew L Lux ¹, Finbar J O'Callaghan ¹, John P Osborne ⁴, Jayesh S Patel ¹, Anne T Prendiville ⁵, Shelley Renowden ⁶ and Philip E Jardine ^1*

¹ Bristol Royal Hospital for Children, Bristol, United Kingdom
² Royal Children’s Hospital, Brisbane, Australia
³ Derriford Hospital, Plymouth, United Kingdom
⁴ Royal United Hospital, Bath, United Kingdom
⁵ Royal Cornwall Hospital, Truro, United Kingdom
⁶ Frenchay Hospital, Bristol, United Kingdom

^* To whom correspondence should be addressed. E-mail: philip.jardine{at}bristol.ac.uk.

Accepted 15 June 2009

Abstract

Background: Cerebral venous sinus thrombosis (CVST) in children is associated with a high incidence of serious morbidity and mortality. The presenting features are variable. It can be diagnostically challenging and the optimal treatment is uncertain.

Aim: To describe the features of a series of children with CVST treated in a single paediatric neurology centre and to discuss the role of local thrombolysis.

Methods: Electronic databases were searched using diagnostic labels and ICD codes to identify children aged 1 month to under 17 years with CVST. Their records were reviewed.

Results: 21 children were identified over a period of 8.25 years with a median age of 7.1 years. The presenting symptoms included headache (15 children), vomiting (14 children) and visual disturbance (8 children). Signs found included papilloedema (16 children), fever (6 children), and 6th nerve palsy (6 children). The most common underlying condition was middle ear infection (13 children). All cases received unfractionated heparin and 4 severe cases received local pharmacological thrombolysis. 48% cases had an adverse outcome (death, chronic intracranial hypertension, residual hemiparesis or 6th nerve palsy).

Discussion: CVST has non-specific presenting features and a high risk of significant morbidity. CVST is typically found in association with a predisposing condition. Although heparin is the mainstay of treatment, thrombolysis may reverse deterioration as seen in three cases in this series. However, there is insufficient evidence to recommend the routine use of thrombolysis at present.