Treatment of pediatric cerebral venous sinus thromboses: the role of anticoagulation



Cerebral venous sinus thromboses (CVST) occur in children with a variety of etiologies. However, no standard treatment paradigm is established. We sought to identify what treatments have been applied, their outcomes, and the role of anticoagulation in pediatric patients with CVST.


A systematic review was conducted exploring all treatments of pediatric CVSTs using PubMed, Embase, Scopus, and Cochrane Library and Cochrane Central Register of Controlled Trials. Studies meeting inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes.


Of 2946 resultant articles, 51 full-text articles were included. Management of infectious CVST included broad-spectrum antibiotics, surgery, and anticoagulation. Neoplastic and traumatic CVST treatment included anticoagulation. Treatment of CVSTs associated with metabolic abnormalities centered on correction of metabolic derangements, or supplementation where appropriate, and anticoagulation. Autoimmune, congenital, and thrombotic pathway CVSTs were treated with anticoagulation and treatment of the underlying disorder. Unfractionated heparin and low molecular weight heparin were most commonly used and seen to be effective and safe. Uncommonly, endovascular interventions including venous thrombectomy and intravenous injection of thrombolytic therapy were used with varying success.


While conservative, medical, thombolytic, endovascular, and surgical treatment all have a role in in the treatment of pediatric CVSTs, anticoagulation is commonly applied and found to be safe and effective in pediatrics. Risks and benefits of anticoagulation must be considered on an individual basis as no randomized trials have established a standard of care. Based on our findings, we propose an approach to CVST treatment and look to future study aimed at more clearly delineating treatment dose, duration, and timing of re-evaluation in these patients.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

Data availability

All references are cited and included studies are in table.


  1. 1.

    deVeber G, Andrew M, Adams C, Bjornson B, Booth F, Buckley DJ, Camfield CS, David M, Humphreys P, Langevin P (2001) Cerebral sinovenous thrombosis in children. N Engl J Med 345:417–423

    PubMed  CAS  Google Scholar 

  2. 2.

    Carvalho KS, Bodensteiner JB, Connolly PJ, Garg BP (2001) Cerebral venous thrombosis in children. J Child Neurol 16:574–580

    PubMed  CAS  Google Scholar 

  3. 3.

    Sébire G, Tabarki B, Saunders D, Leroy I, Liesner R, Saint-Martin C, Husson B, Williams A, Wade A, Kirkham F (2005) Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome. Brain 128:477–489

    PubMed  Google Scholar 

  4. 4.

    Wasay M, Dai AI, Ansari M, Shaikh Z, Roach E (2008) Cerebral venous sinus thrombosis in children: a multicenter cohort from the United States. J Child Neurol 23:26–31

    PubMed  Google Scholar 

  5. 5.

    Heller C, Heinecke A, Junker R, Knöfler R, Kosch A, Kurnik K, Schobess R, von Eckardstein A, Sträter R, Zieger B (2003) Cerebral venous thrombosis in children: a multifactorial origin. Circulation 108:1362–1367

    PubMed  Google Scholar 

  6. 6.

    deVeber G, Chan A, Monagle P, Marzinotto V, Armstrong D, Massicotte P, Leaker M, Andrew M (1998) Anticoagulation therapy in pediatric patients with sinovenous thrombosis: a cohort study. Arch Neurol 55:1533–1537

    PubMed  CAS  Google Scholar 

  7. 7.

    Hashmi M, Wasay M (2011) Caring for cerebral venous sinus thrombosis in children. J Emerg Trauma Shock 4:389

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Filippidis A, Kapsalaki E, Patramani G, Fountas KN (2009) Cerebral venous sinus thrombosis: review of the demographics, pathophysiology, current diagnosis, and treatment. Neurosurg Focus 27:E3

    PubMed  Google Scholar 

  9. 9.

    Wong B, Hickman S, Richards M, Jassar P, Wilson T (2015) Management of paediatric otogenic cerebral venous sinus thrombosis: a systematic review. Clin Otolaryngol 40:704–714

    PubMed  CAS  Google Scholar 

  10. 10.

    Moharir MD, Shroff M, Stephens D, Pontigon AM, Chan A, MacGregor D, Mikulis D, Adams M, deVeber G (2010) Anticoagulants in pediatric cerebral sinovenous thrombosis: a safety and outcome study. Ann Neurol 67:590–599

    PubMed  CAS  Google Scholar 

  11. 11.

    Afshari D, Moradian N, Nasiri F, Razazian N, Bostani A, Sariaslani P (2015) The efficacy and safety of low-molecular-weight heparin and unfractionated heparin in the treatment of cerebral venous sinus thrombosis. Neurosciences 20:357

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Bertini G, Perugi S, Dani C, Prisco D, Fonda C (2009) Cerebral venous thrombosis treated with enoxaparin in an IUGR neonate with DIC. Childs Nerv Syst 25:899–902

    PubMed  CAS  Google Scholar 

  13. 13.

    Bishop FS, Finn MA, Samuelson M, Schmidt RH (2009) Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis: case report. J Neurosurg 111:17–21

    PubMed  Google Scholar 

  14. 14.

    Coutinho G, Júlio S, Matos R, Santos M, Spratley J (2018) Otogenic cerebral venous thrombosis in children: a review of 16 consecutive cases. Int J Pediatr Otorhinolaryngol 113:177–181

    PubMed  Google Scholar 

  15. 15.

    Funamura JL, Nguyen AT, Diaz RC (2014) Otogenic lateral sinus thrombosis: case series and controversies. Int J Pediatr Otorhinolaryngol 78:866–870

    PubMed  Google Scholar 

  16. 16.

    Kersbergen KJ, de Vries LS, Van Straaten H, Benders MJ, Nievelstein RA, Groenendaal F (2009) Anticoagulation therapy and imaging in neonates with a unilateral thalamic hemorrhage due to cerebral sinovenous thrombosis. Stroke 40:2754–2760

    PubMed  CAS  Google Scholar 

  17. 17.

    Mallick AA, Sharples PM, Calvert SE, Jones RW, Leary M, Lux AL, O’Callaghan FJ, Osborne JP, Patel JS, Prendiville AT (2009) Cerebral venous sinus thrombosis: a case series including thrombolysis. Arch Dis Child 94:790–794

    PubMed  CAS  Google Scholar 

  18. 18.

    Moharir MD, Shroff M, Pontigon A-M, Askalan R, Yau I, MacGregor D, deVeber GA (2011) A prospective outcome study of neonatal cerebral sinovenous thrombosis. J Child Neurol 26:1137–1144

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Novoa E, Podvinec M, Angst R, Gürtler N (2013) Paediatric otogenic lateral sinus thrombosis: therapeutic management, outcome and thrombophilic evaluation. Int J Pediatr Otorhinolaryngol 77:996–1001

    PubMed  Google Scholar 

  20. 20.

    Pergami P, Abraham L (2011) Impact of anticoagulation on the short-term outcome in a population of neonates with cerebral sinovenous thrombosis: a retrospective study. J Child Neurol 26:844–850

    PubMed  Google Scholar 

  21. 21.

    Ranta S, Tuckuviene R, Mäkipernaa A, Albertsen BK, Frisk T, Tedgård U, Jónsson OG, Pruunsild K, Gretenkort Andersson N, Winther Gunnes M (2015) Cerebral sinus venous thromboses in children with acute lymphoblastic leukaemia–a multicentre study from the Nordic Society of Paediatric Haematology and Oncology. Br J Haematol 168:547–552

    PubMed  Google Scholar 

  22. 22.

    Rosenberg JD, Parikh SR (2011) Anticoagulation therapy as a supplement to recanalization for the treatment of sigmoid sinus thrombosis: a case report. Ear Nose Throat J 90:418–422

    PubMed  Google Scholar 

  23. 23.

    Rossor T, Arichi T, Bhate S, Hart AR, Raman Singh R (2018) Anticoagulation in the management of neonatal cerebral sinovenous thrombosis: a systematic review and meta-analysis. Dev Med Child Neurol 60:884–891

    PubMed  Google Scholar 

  24. 24.

    Schobess R, During C, Bidlingmaier C, Heinecke A, Merkel N, Nowak-Gottl U (2006) Long-term safety and efficacy data on childhood venous thrombosis treated with a low molecular weight heparin: an open-label pilot study of once-daily versus twice-daily enoxaparin administration. Haematologica 91:1701–1704

    PubMed  CAS  Google Scholar 

  25. 25.

    Stam J, Majoie CB, van Delden OM, van Lienden KP, Reekers JA (2008) Endovascular thrombectomy and thrombolysis for severe cerebral sinus thrombosis: a prospective study. Stroke 39:1487–1490

    PubMed  Google Scholar 

  26. 26.

    Ulanovski D, Yacobovich J, Kornreich L, Shkalim V, Raveh E (2014) Pediatric otogenic sigmoid sinus thrombosis: 12-year experience. Int J Pediatr Otorhinolaryngol 78:930–933

    PubMed  Google Scholar 

  27. 27.

    Wasay M, Bakshi R, Dai A, Roach S (2006) Local thrombolytic treatment of cerebral venous thrombosis in three paediatric patients

  28. 28.

    Friese S, Müller-Hansen I, Schöning M, Nowak-Göttl U, Küker W (2003) Isolated internal cerebral venous thrombosis in a neonate with increased lipoprotein (a) level: diagnostic and therapeutic considerations. Neuropediatrics 34:36–39

    PubMed  CAS  Google Scholar 

  29. 29.

    Keller E, Pangalu A, Fandino J, Könü D, Yonekawa Y (2005) Decompressive craniectomy in severe cerebral venous and dural sinus thrombosis. In: New Trends of Surgery for Stroke and its Perioperative Management. Springer, pp 177–183

  30. 30.

    Kuczkowski J, Mikaszewski B (2001) Intracranial complications of acute and chronic mastoiditis: report of two cases in children. Int J Pediatr Otorhinolaryngol 60:227–237

    PubMed  CAS  Google Scholar 

  31. 31.

    Mortimer AM, Bradley MD, O'Leary S, Renowden SA (2013) Endovascular treatment of children with cerebral venous sinus thrombosis: a case series. Pediatr Neurol 49:305–312

    PubMed  Google Scholar 

  32. 32.

    Johnson MC, Parkerson N, Ward S, de Alarcon PA (2003) Pediatric sinovenous thrombosis. J Pediatr Hematol Oncol 25:312–315

    PubMed  Google Scholar 

  33. 33.

    Khan IS, Ladner TR, Satti KF, Ehtesham M, Jordan LC, Singer RJ (2014) Endovascular thrombolysis for pediatric cerebral sinus venous thrombosis with tissue plasminogen activator and abciximab: case report. J Neurosurg Pediatr 13:68–71

    PubMed  Google Scholar 

  34. 34.

    Scardapane A, Del Torto M, Nozzi M, Elio C, Breda L, Chiarelli F (2010) Gradenigo’s syndrome with lateral venous sinus thrombosis: successful conservative treatment. Eur J Pediatr 169:437–440

    PubMed  Google Scholar 

  35. 35.

    Au JK, Adam SI, Michaelides EM (2013) Contemporary management of pediatric lateral sinus thrombosis: a twenty year review. Am J Otolaryngol 34:145–150

    PubMed  Google Scholar 

  36. 36.

    Bertamino M, Severino M, Parodi A, Andreato C, Malova M, Svahn J, Tortora D, Moretti P, Molinari AC, Ramenghi LA (2020) Bivalirudin anticoagulation to overcome heparin resistance in a neonate with cerebral sinovenus thrombosis. Blood Coagul Fibrinolysis 31:97–100

    PubMed  Google Scholar 

  37. 37.

    Ghosh PS, Ghosh D, Goldfarb J, Sabella C (2011) Lateral sinus thrombosis associated with mastoiditis and otitis media in children: a retrospective chart review and review of the literature. J Child Neurol 26:1000–1004

    PubMed  Google Scholar 

  38. 38.

    Kenet G, Kirkham F, Niederstadt T, Heinecke A, Saunders D, Stoll M, Brenner B, Bidlingmaier C, Heller C, Knöfler R (2007) Risk factors for recurrent venous thromboembolism in the European collaborative paediatric database on cerebral venous thrombosis: a multicentre cohort study. Lancet Neurol 6:595–603

    PubMed  PubMed Central  Google Scholar 

  39. 39.

    Sitton MS, Chun R (2012) Pediatric otogenic lateral sinus thrombosis: role of anticoagulation and surgery. Int J Pediatr Otorhinolaryngol 76:428–432

    PubMed  Google Scholar 

  40. 40.

    Bielecki I, Cofala M, Mierzwinski J (2011) Otogenic lateral sinus thrombosis in children. Otol Neurotol 32:1111–1115

    PubMed  Google Scholar 

  41. 41.

    Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Bmj 355:i4919

    PubMed  PubMed Central  Google Scholar 

  42. 42.

    Csákányi Z, Rosdy B, Kollár K, Móser J, Kovács É, Katona G (2013) Timely recanalization of lateral sinus thrombosis in children: should we consider hypoplasia of contralateral sinuses in treatment planning? Eur Arch Otorhinolaryngol 270:1991–1998

    PubMed  Google Scholar 

  43. 43.

    Holzmann D, Huisman TA, Linder TE (1999) Lateral dural sinus thrombosis in childhood. Laryngoscope 109:645–651

    PubMed  CAS  Google Scholar 

  44. 44.

    Kao A, Dlugos D, Hunter JV, Mamula P, Thorarensen O (2002) Anticoagulation therapy in cerebral sinovenous thrombosis and ulcerative colitis in children. J Child Neurol 17:479–482

    PubMed  Google Scholar 

  45. 45.

    Khatri V, Chan AK, Stein N, Paes B, Bhatt M (2018) Conservative management of neonatal cerebral sinovenous thrombosis with coexisting thrombophilia. Blood Coagul Fibrinolysis 29:399–403

    PubMed  Google Scholar 

  46. 46.

    Kulcsár Z, Marosfői M, Berentei Z, Szikora I (2010) Continuous thrombolysis and repeated thrombectomy with the Penumbra System™ in a child with hemorrhagic sinus thrombosis. Acta Neurochir 152:911–916

    PubMed  Google Scholar 

  47. 47.

    Li G, Zeng X, Hussain M, Meng R, Liu Y, Yuan K, Sikharam C, Ding Y, Ling F, Ji X (2013) Safety and validity of mechanical thrombectomy and thrombolysis on severe cerebral venous sinus thrombosis. Neurosurgery 72:730–738

    PubMed  Google Scholar 

  48. 48.

    Lancon J, Killough K, Tibbs R, Lewis A, Parent A (1999) Spontaneous dural sinus thrombosis in children. Pediatr Neurosurg 30:23–29

    PubMed  CAS  Google Scholar 

  49. 49.

    Malhotra P, Jain S, Kapoor G (2018) Symptomatic cerebral sinovenous thrombosis associated with L-asparaginase in children with acute lymphoblastic leukemia: a single institution experience over 17 years. J Pediatr Hematol Oncol 40:e450–e453

    PubMed  CAS  Google Scholar 

  50. 50.

    Misra U, Kalita J, Chandra S, Kumar B, Bansal V (2012) Low molecular weight heparin versus unfractionated heparin in cerebral venous sinus thrombosis: a randomized controlled trial. Eur J Neurol 19:1030–1036

    PubMed  CAS  Google Scholar 

  51. 51.

    Rammos SK, Phillips J, Lin J, Moresco K, Meagher S (2013) Successful rheolytic mechanical thrombectomy of cerebral venous thrombosis in a pediatric patient: case report. J Neurosurg Pediatr 11:140–143

    PubMed  Google Scholar 

  52. 52.

    Shaikh H, Pukenas BA, McIntosh A, Licht D, Hurst RW (2014) Combined use of Solitaire FR and Penumbra devices for endovascular treatment of cerebral venous sinus thrombosis in a child. Case Rep 2014:bcr2013011088

    Google Scholar 

  53. 53.

    Siddiqui FM, Banerjee C, Zuurbier SM, Hao Q, Ahn C, Pride GL, Wasay M, Majoie CB, Liebeskind D, Johnson M (2014) Mechanical thrombectomy versus intrasinus thrombolysis for cerebral venous sinus thrombosis: a non-randomized comparison. Interv Neuroradiol 20:336–344

    PubMed  PubMed Central  Google Scholar 

  54. 54.

    Cannon ML, Antonio BL, McCloskey JJ, Hines MH, Tobin JR, Shetty AK (2004) Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med 5:86–88

    PubMed  Google Scholar 

  55. 55.

    Rahimi A, Yarandi KK, Aryan H (2017) Role of optic nerve fenestration as an effective salvage therapy in cerebral venous thrombosis: a case report and review of literature. Galen Med J 6:160–165

    Google Scholar 

  56. 56.

    Ropposch T, Nemetz U, Braun EM, Lackner A, Walch C (2012) Low molecular weight heparin therapy in pediatric otogenic sigmoid sinus thrombosis: a safe treatment option? Int J Pediatr Otorhinolaryngol 76:1023–1026

    PubMed  Google Scholar 

  57. 57.

    Scorpecci A, Massoud M, Giannantonio S, Zangari P, Lucidi D, Martines F, Foligno S, Di Felice G, Minozzi A, Luciani M (2018) Otogenic lateral sinus thrombosis in children: proposal of an experience-based treatment flowchart. Eur Arch Otorhinolaryngol 275:1971–1977

    PubMed  Google Scholar 

  58. 58.

    Shah UK, Jubelirer TF, Fish JD, Elden LM (2007) A caution regarding the use of low-molecular weight heparin in pediatric otogenic lateral sinus thrombosis. Int J Pediatr Otorhinolaryngol 71:347–351

    PubMed  Google Scholar 

  59. 59.

    Younis RT, Lazar RH (1993) Cavernous sinus thrombosis: successful treatment using functional endonasal sinus surgery. Arch Otolaryngol Head Neck Surg 119:1368–1372

    PubMed  CAS  Google Scholar 

  60. 60.

    Zanoletti E, Cazzador D, Faccioli C, Sari M, Bovo R, Martini A (2015) Intracranial venous sinus thrombosis as a complication of otitis media in children: critical review of diagnosis and management. Int J Pediatr Otorhinolaryngol 79:2398–2403

    PubMed  Google Scholar 

  61. 61.

    Ghanem KM, Dhayni RM, Al-Aridi C, Tarek N, Tamim H, Chan AK, Saab R, Abboud MR, El-Solh H, Muwakkit SA (2017) Cerebral sinus venous thrombosis during childhood acute lymphoblastic leukemia therapy: risk factors and management. Pediatr Blood Cancer 64:e26694

    Google Scholar 

  62. 62.

    Gowda VK, Nanjundappa RC, Pendharkar H, Benakappa N (2017) Homocystinuria with cerebral venous sinus thrombosis: excellent recovery with intravenous recombinant tissue plasminogen activator. Iran J Child Neurol 11:48

    PubMed  PubMed Central  Google Scholar 

  63. 63.

    Westwick HJ, Obaid S, Bordeleau-Roy F, Truffer E, Weil AG (2019) Surgical superior sagittal sinus thrombectomy in refractory thrombosis: a technical note. Pediatr Neurosurg 54:212–217

    PubMed  Google Scholar 

  64. 64.

    Xavier F, Komvilaisak P, Williams S, Kulkarni AV, deVeber G, Moharir MD (2014) Anticoagulant therapy in head injury-associated cerebral sinovenous thrombosis in children. Pediatr Blood Cancer 61:2037–2042

    PubMed  CAS  Google Scholar 

  65. 65.

    Jordan LC, Rafay MF, Smith SE, Askalan R, Zamel KM, deVeber G, Ashwal S, Group IPSS (2010) Antithrombotic treatment in neonatal cerebral sinovenous thrombosis: results of the International Pediatric Stroke Study. J Pediatr 156:704–710 e702

    PubMed  PubMed Central  CAS  Google Scholar 

  66. 66.

    Waugh J, Plumb P, Rollins N, Dowling MM (2012) Prolonged direct catheter thrombolysis of cerebral venous sinus thrombosis in children: a case series. J Child Neurol 27:337–345

    PubMed  Google Scholar 

  67. 67.

    Zerah M, Patterson R, Hansen I, Briones M, Dion J, Renfroe B (2007) Resolution of severe sinus vein thrombosis with super selective thrombolysis in a pre-adolescent with diabetic ketoacidosis and a prothrombin gene mutation. J Pediatr Endocrinol Metab 20:725–731

    PubMed  Google Scholar 

  68. 68.

    Coutinho JM, Ferro JM, Canhao P, Barinagarrementeria F, Bousser M-G, Stam J (2010) Unfractionated or low–molecular weight heparin for the treatment of cerebral venous thrombosis. Stroke 41:2575–2580

    PubMed  CAS  Google Scholar 

  69. 69.

    Gonda DD, Fridley J, Ryan SL, Briceño V, Lam SK, Luerssen TG, Jea A (2015) The safety and efficacy of use of low-molecular-weight heparin in pediatric neurosurgical patients. J Neurosurg Pediatr 16:329–334

    PubMed  Google Scholar 

  70. 70.

    Ross CS, Brown TM, Kotagal S, Rodriguez V (2013) Cerebral venous sinus thrombosis in pediatric cancer patients: long-term neurological outcomes. J Pediatr Hematol Oncol 35:299–302

    PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Sandi Lam.

Ethics declarations

Conflicts of interest/competing interests


Consent for publication

All authors have approved the final version of this manuscript.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.



Table 3 Search terms

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Shlobin, N.A., LoPresti, M.A., Beestrum, M. et al. Treatment of pediatric cerebral venous sinus thromboses: the role of anticoagulation. Childs Nerv Syst (2020).

Download citation


  • Pediatric neurosurgery
  • Cerebral venous sinus thrombosis
  • Deep venous thrombosis
  • Sinus thrombus
  • Anticoagulation
  • Endovascular intervention