Initial anticoagulation strategy for post-traumatic cerebral venous sinus thrombosis : insight from the two level-1 trauma centers of the Northern French Alps

Position du problème et objectif(s) de l’étude

Traumatic cerebral venous sinus thrombosis (tCVST) may complicate the course of traumatic brain injury (TBI). Therapeutic anticoagulation (AC) in the early phase of TBI carries the risk of intracranial hemorrhage (ICH). Contrary to medical CVST, the timing, type and duration of AC therapy remain largely understudied. In this context, we explored the current AC practices in TBI patients with concomitant tCVST and complications in our regional level-1 trauma centers.

Matériel et méthodes

A retrospective study over a 12-year period (2012-2023) in 3 intensive care units (ICU) from two level-1 trauma centers. Ethic approval was obtained (IRB 00010254‐2025-018). Patients admitted to ICU with mild-to-severe TBI and concomitant tCVST were included. Traumatic CVST was diagnosed by a CT-venography. Data were extracted from electronic patient health records. AC regimens were classified as prophylactic (enoxaparin 4000 IU/24h or unfractionated heparin 10000 IU/24h), intermediate-dose (enoxaparin 4000 IU/12h or unfractionated heparin 200 IU/kg/24h) or therapeutic (enoxaparin 100 UI/kg/12h or unfractionated heparin > 400 IU/kg/24h aiming for anti-Xa activity > 0.3 IU/mL or aPTT ratio >2). Patients were dichotomized into early (intermediate or therapeutic-dose < 7 days post-TBI) or late AC (intermediate or therapeutic-dose ≥ 7 days post-TBI).

Résultats & Discussion

We identified 94 patients during the study period (Figure 1). Overall, a progressive shift from no AC to therapeutic AC occurred during the first weeks after TBI, with a hinge between no or prophylactic and intermediate or therapeutic-dose AC regimen 7-day after TBI (Figure 2). Both ICU and hospital mortality were significantly higher in the late AC group, probably due to a greater initial TBI severity with a higher therapy intensity level during ICU stay as suggested by the trend toward more aggressive ICU therapies (Figure 1). A new (n=8) or worsening (n=2) ICH was observed in 10/94 (11%) patients under intermediate or therapeutic-dose AC, after a median of 12 [7-15] days after TBI and no significant difference between early vs. late AC subgroup (Figure 1). Among patients with ICH, death occurred in 3/10 patients in the ICU. A tCVST-related complication followed in 1 patient as hemorrhagic venous infarction, 3 days after TBI. Our study illustrated the heterogenous AC regimen used in tCVST after TBI. This heterogenicity reflects the lack of guidelines and the different patterns of TBI that may influence the perception of AC benefit-risk ratio for the physician. In accordance, the higher mortality observed in the late AC subgroup probably reflected the higher severity of these patients leading to a delayed AC strategy. The risk of severe tCVST related-complications seems low based on the presented data (1%). This finding, combined to the observed 10-fold greater risk (11%) of AC-associated ICH complications, argue in favor of a watchful and delayed initiation (≥ 7 days) of a stronger than prophylactic AC regimen in TBI patients with tCVST, albeit the small sample size of our cohort may contribute to the non-significant difference regarding this outcome among the early vs. late AC subgroup.

Conclusion

We suggest in favor of a late scaling-up of prophylactic AC regimen in tCVST patients with a close imaging monitoring of potential thrombosis progression during the early phase.

Auteurs

Jean Christophe GRONDIN HOAREAU (1) , Marc VINCLAIR (2), Clotilde SCHILTE (1), Serge HAUTEFEUILLE (2), Paul HENRY (1), Alexandre GODON (1), Gilles FRANCONY (1), Loic LEGRIS (1), Arnaud LAZARD (1), Olivier DETANTE (1), Alexandre KRAINIK (1), Pierre BOUZAT (1), Tobias GAUSS (1), Benoit CHAMPIGNEULLE (1) - (1)Université Grenoble Alpes, Grenoble, France, (2)CH annecy genevois, Annecy, France

Orateur(s)

Jean Christophe GRONDIN HOAREAU (Grenoble)