Anticoagulants in pediatric cerebral sinovenous thrombosis: A safety and outcome study
Article first published online: 7 DEC 2009
Copyright © 2010 American Neurological Association
Annals of Neurology
Volume 67, Issue 5, pages 590–599, May 2010
How to Cite
Moharir, M. D., Shroff, M., Stephens, D., Pontigon, A.-M., Chan, A., MacGregor, D., Mikulis, D., Adams, M. and deVeber, G. (2010), Anticoagulants in pediatric cerebral sinovenous thrombosis: A safety and outcome study. Ann Neurol., 67: 590–599. doi: 10.1002/ana.21936
- Issue published online: 26 APR 2010
- Article first published online: 7 DEC 2009
- Manuscript Accepted: 20 NOV 2009
- Manuscript Revised: 4 NOV 2009
- Manuscript Received: 27 APR 2009
- Hospital for Sick Children Foundation
- NINDS. Grant Number: 1 RO1 NS062820-01
- Auxilium Foundation
Clinical trials are lacking in pediatric cerebral sinovenous thrombosis (CSVT). Neonates and children increasingly receive anticoagulant therapy (ACT) based on adult studies. Safety data for ACT in pediatric CSVT are scant and urgently needed. The objective was to assess the safety and outcome of ACT in pediatric CSVT.
In a single-center prospective study, neonates and children with CSVT received ACT (standard/low molecular weight heparin, warfarin) by standardized protocol. A study neuroradiologist (M.S.) assessed all initial and follow-up neuroimaging for intracranial hemorrhage (ICH), thrombus propagation, and recanalization. Clinical outcome was assessed with the Pediatric Stroke Outcome Measure.
Among 162 pediatric patients, 85 received ACT at diagnosis, including 29/83 (35%) neonates and 56/79 (71%) children. Major hemorrhage occurred in 6% (6/99) of treated patients, including 14% (3/21 neonates, 2/15 children) with and 2% (0/17 neonates, 1/46 children) without pretreatment ICH. ACT-associated bleeds were all nonfatal, and clinical outcome was favorable in 50%, similar to the remaining patients (53%). Early follow-up imaging demonstrated thrombus propagation in 11/57 neonates (10/35 [28%] without and 1/22 [4%] with ACT [p = 0.037]) and 10/63 children (7/19 [37%] without and 3/44 [7%] with ACT [p = 0.006]). Propagation was associated with new venous infarcts in 10% neonates and 40% children and worse clinical outcome in children (p = 0.053). Recanalization occurred earlier and more completely in neonates (p = 0.002). Clinical outcome was unfavorable in 47%.
In pediatric CSVT, ACT appears safe. Nontreatment with ACT is associated with thrombus propagation, observed in ¼ of untreated neonates and over ⅓ of children. Anticoagulants merit strong consideration in pediatric CSVT. ANN NEUROL 2010;67:590–599