Does Intracranial Venous Thrombosis Cause Subdural Hemorrhage in the Pediatric Population?

Abstract

SUMMARY: Unexplained SDH in infants and children is an accepted marker for AHT. It has been proposed that IVT may be the initiating event leading to the development of acute SDH, mimicking the appearance of traumatic SDH. Our study aims to investigate if nontraumatic IVT causes SDH in the pediatric population. We retrospectively identified 36 patients with IVT and reviewed neuroimaging studies for the concurrent presence of SDH. In our 36 patients with IVT, no associated SDH was observed. Even with extensive IVT, no SDH was present. Three false-positive diagnoses of IVT were identified in the setting of mastoiditis and traumatic SDH, demonstrating pitfalls in imaging. In conclusion, our findings do not support the previous AHT literature stating that IVT is associated with, or leads to, SDH in neonates, infants, or children.ABBREVIATIONS: AHT ϭ abusive head trauma; CECT ϭ contrast-enhanced CT; CI ϭ confidence interval; CVT ϭ cortical vein thrombosis; FOV ϭ field of view; GRE ϭ gradient recalled echo; ICV ϭ internal cerebral veins; IVT ϭ intracranial venous thrombosis; MIP ϭ maximum intensity projection; SDH ϭ subdural hematoma/hemorrhage; SPGR ϭ spoiled gradient-recalled; TOF ϭ time-of-flight I VT, which is defined as CVT and/or dural venous sinus thrombosis, is relatively rare in children and young adults. It is often associated with underlying disease states that predispose a patient to a thrombotic event. SDH is also rare in the neonate, infant, and young child, and is usually associated with trauma, infection, thrombogenic states, and less often with other causes.1 IVT occurs with an estimated prevalence of 0.67/100,000 among infants in the first year of life.2 Neonates account for a significant number of pediatric cases. Risk factors for neonatal IVT include polycythemia, other prothrombotic states, and perinatal complications such as head trauma, asphyxia, sepsis, and meningitis. Spontaneous IVT has been described in infants and children, and is frequently due to an underlying condition such as infection, shock, dehydration, hypercoagulable states, iron deficiency anemia, and tumors. 3 However, in a review of the literature, very few cases of IVT were associated with SDH.AHT in neonates, infants, and young children is a complex diagnosis, requiring the interaction of pediatrics, radiology, ophthalmology, and the child protection team. Commonly, young infants present for medical care with unexplained neurologic symptoms, and the diagnosis of a SDH is made based upon imaging. The diagnosis of AHT is then subsequently established through a process that ties medical opinions with history, assessment of other injuries, and investigative results. Patients with AHT may develop IVT as a consequence of intracranial injury. Most such patients also often have other indicators of abusive injury such as fractures, bruises, and retinal hemorrhages. Only recently has IVT been proposed as the initiating event for extra-axial hemorrhage, such as SDH and subarachnoid hemorrhage, in the pediatric population. The theory sugge...

Alternate theories of causation in abusive head trauma: What the science tells us

“…Clinical examples of welldocumented subdural hematoma in infants resulting from venous sinus thrombus (in the absence of trauma) have not been reported after the post-natal period. In fact, a recent study specifically examined imaging studies on infants who presented with primary venous sinus thrombosis and found that none of the infants who were not newborns had subdural hematoma [30].…”

Venous injury in abusive head trauma

“…Identification of cortical sinus and venous thrombosis can be a challenge because of the anatomical variations in venous anatomy and limitations of noninvasive neuroimaging techniques such as MR venography and CT venography. However, several previous studies have defined the clinical and neuroimaging findings in children with cortical sinus and venous thrombosis [4][5][6][7][8].…”

Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding

“…A single study evaluating nontraumatic intracranial venous thrombosis detected no subdural hematoma in the study population (n = 36). 139 Additionally, bleeding from intracranial thrombosis has a typical appearance on magnetic resonance imaging, including localized bleeding near the thrombus, typically in an intraparenchymal distribution. This appearance is in contrast to the typical presenting features of deceleration head trauma, including thin-film subdural hemorrhages involving the interhemispheric region and the cerebral convexities.…”