Fracture-related pediatric traumatic cerebral venous sinus thrombosis: A neurosurgical perspective on mechanism and management

Background: Traumatic cerebral venous sinus thrombosis (CVST) is an uncommon but increasingly recognized complication of pediatric head injury. It is frequently associated with skull fractures involving or closely abutting the dural venous sinuses and presents unique diagnostic and therapeutic challenges, particularly regarding anticoagulation in the presence of associated intracranial hemorrhage. Current evidence is limited to small retrospective series, case reports, and heterogeneous cohorts, resulting in considerable variability in diagnostic and therapeutic strategies. Methods: We conducted a retrospective single-center study including consecutive pediatric patients (<18 years) diagnosed with traumatic CVST between January 2010 and December 2025. Clinical presentation, injury mechanism, radiological findings, venous sinus involvement, management strategy, radiological evolution, and clinical outcomes were analyzed. Anticoagulation was individualized according to neurological status, associated intracranial injuries, hemorrhagic risk, and serial radiological assessment. Results: Twenty-nine children met the inclusion criteria. The mean age was 7.5 ± 4.0 years, and road traffic accidents represented the most common mechanism of injury (55.2%). The sigmoid sinus, either alone or in combination with the transverse sinus, was the most frequently involved venous structure. Nineteen patients (65.5%) received low-molecular-weight heparin (LMWH), whereas seven (24.1%) were managed without anticoagulation because of associated hemorrhagic lesions or other individualized considerations. Four patients (13.8%) died in the context of severe primary traumatic brain injury. Among the 24 patients with available follow-up venous imaging, complete recanalization occurred in 18 (75.0%) and partial recanalization in 6 (25.0%), with no persistent occlusion. No recurrent CVST was documented among the 25 surviving patients during the available follow-up. Conclusion: Traumatic pediatric CVST is frequently associated with skull fractures involving or closely abutting the dural venous sinuses, particularly the transverse-sigmoid complex. Management should be individualized according to neurological status, associated intracranial injuries, hemorrhagic risk, and serial radiological assessment. The proposed management algorithm represents an institutional experience rather than an evidence-based guideline. Until higher-level evidence becomes available, individualized multidisciplinary management and targeted venous imaging remain essential.