Are Isolated Linear Fractures over Major Dural Venous Sinuses a Risk Factor for Sinus Thrombosis in Mild TBI?

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Segev Gabay, Guy Dunetz, Lottem Bergman, Dana Niry, Jonathan Roth This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6231145/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Jun, 2025 Read the published version in Neuroradiology → Version 1 posted You are reading this latest preprint version Abstract Objective : Cerebral venous sinus thrombosis (CVST) can increase intracranial pressure and cause secondary brain injury. There is uncertainty in the literature regarding the risk of traumatic CVST (tCVST) following fractures over a major sinus, the need and timing for venous imaging, and treatment. The current study aims to review our experience with tCVST when treating patients with isolated linear fractures over the major sinuses. Methods : This is a retrospective study of 95 adult patients, treated between January 2017 and March 2023, with mild, blunt, isolated traumatic head injury (GCS 13-15) and cranial fracture traversing the major dural venous sinus. Data regarding presentation, radiological features, hospitalization, and follow-up course of CVST were collected and analyzed. Images suspected to show a CVST were retrospectively reviewed by two teams blinded to the radiological interpretation. Results : Of 95 patients, 31 (32%) were identified as having or suspected to have CVST as interpreted by the radiologists. Among them, 14 were treated with anticoagulation, and 1 was treated with anti-aggregates for concomitant arterial dissection. There were no long-term symptoms or newly diagnosed CVST amongst the entire cohort. No major morbidity or mortality occurred. Upon analyzing the images retrospectively, the inter-rater reliability varied. The agreement was fair for definite cases of CVST, slight for uncertain cases that showed epidural hematoma compression and narrowing of the sinus, or arachnoid granulations, and almost perfect for patients without thrombosis. Conclusions : Amongst patients with mild, isolated, blunt traumatic head injury, with fractures traversing major dural venous sinus, true CVST may be over-diagnosed, with some of the lesions being local epidural hematomas mimicking CVST. The outcome of CVST was excellent, whether or not they were treated with anticoagulants. Figures Figure 1 Introduction Cerebral venous sinus thrombosis (CVST) refers to the formation of a blood clot in one of the dural venous sinuses. CVST may lead to increased intracranial pressure and venous infarction, leading to morbidity and mortality 1 , 2 . Head trauma is one of the risk factors for the formation of CVST 1 , 3 . In contrast to spontaneous CVST, which is typically associated with prothrombotic states such as pregnancy, puerperium, and oral contraceptive usage, traumatic CVST (tCVST) is typically caused by a direct traumatic disruption of the dural sinus wall caused by overlying fractures, or from local external compression of the dural sinus wall by epidural hematoma 1 , 3 . These risk factors go in accordance with Virchow's triad, defining the cornerstones for thrombosis formation, which are vascular wall injury, blood flow stasis, or changes in blood composition 1 , 4 . Traumatic CVST is known to be associated with an increased risk of hospitalization length, morbidity, and mortality 5 , 6 . Recently, Netteland, et al showed in a systematic review that the available data is insufficiently homogenous to provide answers to many key clinical questions, leaving many aspects unsolved 3 . Specifically, the current literature regarding indications for venous imaging and timing for diagnosis of tCVST in patients with mild TBI is insufficient 3 . Our current study aims to review the available literature and share our experience from a large tertiary center regarding the occurrence of tCVST following mild, isolated, and blunt traumatic head injury, with a linear fracture traversing major sinuses. Methods Following institutional review board approval (IRB 0550-23-TLV), we retrospectively collected data on all patients at our department hospitalized due to TBI between January 2017 and March 2023. Patient data was collected from our electronic database system. Overall, 1035 trauma patients were identified during this period. Patients were included if they sustained a mild and isolated traumatic brain injury (defined as Glasgow Coma Scale (GCS) 13–15) and had a cranial linear fracture traversing over a major dural venous sinus (superior sagittal sinus (SSS), transverse sinus (TS), sigmoid sinus (SS), jugular bulb (JB), or Torcular Herophili (TH)). Patients excluded from this study included patients on anticoagulation or anti-aggregant medications at the time of injury, age < 18 years old, known coagulation disorder, additional severe extracranial injury, and surgery (of any kind) at admission. Collected data included: Demographics Patient presentation (mechanism of trauma, GCS at arrival) Radiology features (time from trauma, findings on initial computed tomography (CT) scan (including bleedings and fractures), vascular imaging in the form of computed tomography angiography (CTA), computed tomography venography (CTV), or Magnetic Resonance Venography (MRV), name of sinus involved, dominance of the sinus, and the presence of major sinus thrombosis) Treatment related to CVST Hospitalization course (hospitalization duration, imaging during hospitalization, funduscopic eye exams, management, immediate complications) Most recent follow-up data (date, long-term complications, imaging) Based on the internal guidelines of our department, in the majority of cases (at the discretion of the attending physician), whenever a skull fracture crosses a major dural venous sinus, venous imaging (CTV) is usually done at some point during the hospitalization, with the majority of cases done immediately after the initial CT scan, or at repeated imaging approximately 6 hours after the first scan if bleeding was noted on the initial CT scan. In cases when sinus thrombosis is diagnosed, repeated venous imaging depends on the discretion of the attending neurosurgeon, based on the severity and location of the thrombosis, and the patient's clinical condition. All scans with a suspected CSVT (per radiological interpretation) were retrospectively evaluated by JR. In addition, all scans were retrospectively rereviewed by an experienced senior neuroradiologist (DN) blinded to the radiological interpretation. Statistics As the cohort of patients, namely those with CVST, is relatively small, no statistical analysis was done in this study. Interrater agreement was calculated using Fleiss' kappa and Cohens' kappa coefficients (κ) 7 . Results Patient demographics, including age, sex, mechanism of injury, and Glasgow coma scale (GCS) on arrival, are shown in Table 1. A total of 95 patients were included in this study (Figure 1). 60 patients were male (63%) and 35 were female (37%). The average age was 46.5 years (± standard deviation (SD) 19 years, median 43 years). The first vascular imaging following injury was performed within 6 hours in 25 patients, after 6-12 hours in 35 patients, after 12-24 hours in 14 patients, and after more than 24 hours in 11 patients. In 4 patients the time of vascular imaging from the trauma was unknown, and in 6 patients no vascular imaging was done. 25 patients had subsequent vascular imaging during their hospitalization; 19 had 1 additional imaging study, 4 had 2 additional imaging studies, and 2 had 3 additional imaging studies. We divided our cohort into the following divisions and groups: 1. The first division was based on the presence or absence of a thrombus on vascular imaging (CTA or CTV), as interpreted by the formal radiology report at the time of the trauma , divided as follows: a. Group 1: 31 patients (33%) were identified as either having or suspected to have CVST. Of these: A. 12 patients ( 13 %) were identified with definite CVST. B. 19 patients (20%) were identified with suspected CVST; as it could not be definitely diagnosed or definitely ruled out (either due to concomitant external compression by epidural hematoma or because the CSVT could not be fully differentiated, in the context of trauma, from arachnoid granulations). b. Group 2: 58 patients (61%) had no thrombosis. c. Group 3: 6 patients (6%) did not have vascular imaging, therefore the presence or absence of thrombosis could not be determined. Furthermore, none of these patients exhibited any clinical symptoms that would raise suspicion for CVST. Additionally, none of them received anticoagulation or anti-aggregant treatment. 2. The second division was based on a retrospective review and reanalysis of the vascular imaging by the senior neurosurgeon author (JR). This division included only the 89 patients who originally had vascular imaging. In this division, of the 31 patients (35%) who were originally identified as having or suspected to have CVST, a review of the images led to the following re-classifications: a. 6 patients (7%) were identified with CVST, and kept in Group 1A. b. 4 patients (4%) were identified with suspected CVST - it could not be definitely diagnosed or definitely ruled out - and moved to Group 1B. c. 21 patients (24%) definitely had no thrombosis, and moved to Group 2. Following the neurosurgeon’s review and reanalysis of these 89 images, he found a total of 79 patients (83%) with no thrombosis (Group 2). 3. The third division was based on a retrospective review and reanalysis of the vascular imaging by the senior neuroradiologist author (DN). This division also included only the 89 patients who originally had vascular imaging. In this division, of the 31 patients (35%) who were originally identified as having or suspected to have CVST: a. 8 patients (9%) were identified with CVST, and kept in Group 1A. b. 8 patients (9%) were identified with suspected CVST - it could not be definitely diagnosed or definitely ruled out - and kept/moved to Group 1B. c. 15 patients (17%) definitely had no thrombosis, and moved to Group 2. Following the neuroradiologist’s review and reanalysis of these 89 images, she found a total of 73 patients (76%) with no thrombosis (Group 2). The validity of these three divisions was tested, and the presence or absence of CVST for patients was evaluated using Fleiss’ kappa and Cohens’ kappa statistics (Table 2). The Fleiss’ kappa coefficient, calculated between three raters for the 12 patients in the first division, who were identified with CVST from the formal radiological report, yielded a value of 0.21, suggesting fair agreement. Similarly, the Cohen kappa coefficient, computed between two raters (JR and DN) for the same patients, indicated a fair level of agreement with a value of 0.25. In contrast, when examining the patients identified with CVST from the senior authors’ reports, the Fleiss’ kappa coefficients were 0.67 and 0.44, indicating improved inter-rater reliability. The Fleiss’ kappa coefficient for the 19 patients in the first division, in which the presence of CVST could not be definitively excluded from the initial radiological report, was 0.03, indicating a slight degree of agreement. The Cohen kappa coefficient between two raters (JR and DN) for the same patients was 0.37, suggesting fair agreement. The Fleiss’ kappa coefficient for the 58 patients in the first division, who did not have a thrombosis from the initial radiological report, was 0.91, indicating almost perfect agreement. The Cohen kappa coefficient between two raters (JR and DN) for the same patients was 0.87, indicating also almost perfect agreement. Based on these results, several important observations can be made. First, among those individuals who were definitively diagnosed with thrombosis by the senior authors, the same findings were corroborated in the formal radiological report. Conversely, 40% of those who were definitively diagnosed with thrombosis in the formal report were reported by the senior authors as having no thrombus. Furthermore, in 55-85% of the patients (depending on the rater) in the first division where the formal radiological report indicated that CVST could not be definitively excluded, the senior authors noted that CSVT could certainly be definitively excluded. Location of fractures and sinus dominance Radiological characteristics are shown in Table 3. All fractures in this study were linear and non-displaced fractures, crossing major dural sinuses. Some patients sustained multiple fractures, or fractures traversing more than 1 cranial bone. 4 frontal fractures, 15 parietal, 20 temporal, and 70 occipital fractures were observed. Most of the 31 patients in Group 1 Group 1, with presumed CSVT had fractures in the occipital bone, followed by the temporal bone as the most common location. This may partially explain the bias in the radiological interpretation, as fractures in the occipital bone most of the time cross one of the major dural sinuses (torcula, TS, or SS), and may lead to an adjacent epidural hematoma, thereby causing the radiologist to incorrectly suspect the presence CSVT. Regarding sinus dominance, in 62 patients the right transverse/sigmoid sinuses were dominant, in 13 patients the left sinuses were the dominant, 14 patients had no dominance, and in 6 patients the dominance could not be evaluated because of lack of venous imaging. The fractures overrode dominant sinuses in 41 patients; of these, 19 had a radiological interpretation of CVST. Likewise, the fractures overrode non-dominant sinuses in 48 patients, with 12 having a radiological interpretation of CVST (p=0.035). Treatment Among the 31 patients originally diagnosed with thrombosis, 14 were treated with anticoagulation, 1 was treated with anti-aggregants for concomitant arterial dissection, and 16 were treated conservatively with fluids and close observation. Among the 6 patients diagnosed with thrombosis by the neurosurgeon in the second division of the cohort, 5 had been treated with anticoagulation and 1 was treated conservatively. Follow-up Of the 95 patients included in this study, 67 had clinical follow-up (average 3.3 months ± SD 9.1 months, median 2 months) and 28 patients were lost to clinical follow-up. Among those with follow-up, 50 were symptom-free, and 17 patients had only mild symptoms, including fatigue, headaches, dizziness, or imbalance. These symptoms were attributed to the trauma itself (post-concussion syndrome). No major morbidity or mortality was observed from the entire cohort. 11 out of 31 patients from the first division with thrombosis diagnosed had vascular radiological follow-up (average 2.35 months ± SD 2.01 months, median 1.75 months), with either CTV or MRV. This imaging demonstrated full thrombus resolution. Among these 11 patients, 5 received anticoagulation, while 6 did not. 10 of the 58 patients from the first division with no thrombosis diagnosed had vascular radiological follow-up (average 3.1 months ± SD 3.1 months, median 1.75 months). This imaging did not demonstrate any newly diagnosed CVSTs. Among the entire cohort of 95 patients, only 1 patient treated with anticoagulation for a non-dominant, right sigmoid sinus thrombosis was re-hospitalized 2 weeks after his discharge because of unremitting headaches and dizziness. His original head CT demonstrated a right temporo-occipital linear fracture traversing the right TS and SS, and a non-surgical epidural hematoma, compressing the TS and SS. Because of the proximity to the previous hospitalizations, and the continuation of the complaints, he was re-hospitalized for evaluation. A new head CT and CTV were done that demonstrated resolution of the compressing epidural hematoma and no sinus thrombosis. He was discharged after a few days of observation. Discussion In the present study, we present a cohort of patients focusing on the incidence of tCVST, complications, and long-term outcomes amongst patients with mild TBI and linear fractures traversing the major venous sinuses. The incidence of CVST among TBI patients with skull fractures adjacent to a cerebral venous sinus is relatively high in the literature, ranging between 26%-32% 8,9 . The presence of temporal bone fracture was associated with even higher rates, approaching 40% 8 . This is consistent with our initial findings, where 32% of our patients with linear fractures traversing the major venous sinuses were diagnosed with CVST. Recent systematic reviews evaluated indications for venous imaging in the setting of TBIs 3 , 8 . In most studies, the presence of a skull fracture in the vicinity of a dural sinus was followed by venous imaging. However, there is limited data to apprise the appropriate indications for venous imaging 3 , 8 . Furthermore, there is a lack of consensus regarding the optimal timing for venous imaging 3 . A contributing factor to this uncertainty is the fact that CVST is probably formed in a delayed fashion post-TBI, and not during the first few hours following the injury 3 , 10 . In our cohort, we could not find a specific indication for the optimal timing for venous imaging, as in both groups, with and without thrombosis, the initial timing of venous imaging varied. Cerebral venous drainage dominance is of great importance and should be actively evaluated, as it can have significant clinical implications. Thrombosis of the SSS or the dominant SS/TS sinus can lead to venous hypertension, leading to cerebral edema and venous strokes 11 . In most of our cohort, the right transverse/sigmoid sinuses were more often dominant over the left side, consistent with the literature 12 . The implication of fracture over the dominant sinus, in the setting of traumatic brain injury, is not known. In our cohort of mild brain injury, among 31 patients with a radiological interpretation of CVST, 19 patients had fractures overriding the dominant sinuses, and 12 patients with fractures overriding non-dominant sinuses. In both groups, the prognosis was excellent. The inter-rater reliability for the identification of CVST varied across different patient groups. For patients originally diagnosed with CVST (12 patients), the kappa coefficients indicated only fair agreement between the raters. In cases where the presence of CVST could not be definitively excluded (19 patients), the kappa coefficients dropped, suggesting just a slight degree of agreement. However, for patients without thrombosis (58 patients), the kappa coefficients demonstrated almost perfect agreement between raters. These findings underscore that while there is fairly reasonable inter-rater reliability agreement in detecting CVST, and much improved inter-rater reliability in the absence of thrombosis, the inter-rater reliability agreement is much more variable when dealing with ambiguous or uncertain cases. Limitations This is a retrospective series. Although our initial cohort was relatively large, the group with radiological interpretation of CVST, and especially the group that was deemed to actually have a CVST, is small. In addition, due to the retrospective nature of this study, there is considerable heterogenicity in several important parameters, including the time of initial venous imaging relative to the trauma. Furthermore, about a third of the study population did not have clinical or radiological follow-up, and the remaining had only limited follow-up, making long-term conclusions unclear. Moreover, the radiological distinction between compressing epidural hematoma or arachnoid granulations to actual CVST, among the patients who were deemed to have a CVST by the senior authors, is not proven, leaving room for error. Lastly, our study, as with other retrospective studies, involves retrospectively re-analyzing previous radiological images that have the unavoidable interpretation bias. Conclusion In a cohort of TBI patients with mild, isolated, blunt traumatic brain injury, with a linear non-displaced fracture traversing major dural venous sinus and an underlying CVST, the prognosis was excellent regardless of treatment with anticoagulants. CVST may be over-diagnosed, as an epidural hematoma or arachnoid granulations may mimic CVST. Declarations Informed consent Since the study was retrospective, informed consent was not applicable. Competing interests There is no conflict of interest. Ethical approval Institutional Review Board approval was obtained from Tel-Aviv Medical Center, Clinical Research Ethics Committee (IRB 0550-23-TLV). Funding No funding was received. References Ulivi L, Squitieri M, Cohen H, Cowley P, Werring DJ. Cerebral venous thrombosis: a practical guide. Pract Neurol . 2020;20(5):356-367. doi:10.1136/practneurol-2019-002415 Ropper AH, Klein JP. Cerebral Venous Thrombosis. New England Journal of Medicine . 2021;385(1):59-64. doi:10.1056/NEJMra2106545 Netteland DF, Sandset EC, Mejlænder-Evjensvold M, et al. Cerebral venous sinus thrombosis in traumatic brain injury: A systematic review of its complications, effect on mortality, diagnostic and therapeutic management, and follow-up. Front Neurol . 2023;13. doi:10.3389/fneur.2022.1079579 Bourrienne M, Gay J, Mazighi M, Ajzenberg N. State of the art in cerebral venous sinus thrombosis animal models. Journal of Thrombosis and Haemostasis . 2022;20(10):2187-2196. doi:10.1111/jth.15816 Netteland DF, Mejlænder-Evjensvold M, Skaga NO, Sandset EC, Aarhus M, Helseth E. Cerebral venous thrombosis in traumatic brain injury: a cause of secondary insults and added mortality. J Neurosurg . 2020;134(6):1912-1920. doi:10.3171/2020.4.JNS20511 Hoffman H, Otite FO, Chin LS. Venous Injury in Patients with Blunt Traumatic Brain Injury: Retrospective Analysis of a National Cohort. Neurocrit Care . 2022;36(1):116-122. doi:10.1007/S12028-021-01265-6 Landis JR, Koch GG. The Measurement of Observer Agreement for Categorical Data. Biometrics . 1977;33(1):159. doi:10.2307/2529310 Bokhari R, You E, Bakhaidar M, et al. Dural Venous Sinus Thrombosis in Patients Presenting with Blunt Traumatic Brain Injuries and Skull Fractures: A Systematic Review and Meta-Analysis. World Neurosurg . 2020;142:495-505.e3. doi:10.1016/j.wneu.2020.06.117 Kim KT, Wessell AP, Oliver J, et al. Comparative Therapeutic Effectiveness of Anticoagulation and Conservative Management in Traumatic Cerebral Venous Sinus Thrombosis. Neurosurgery . 2022;90(6):708-716. doi:10.1227/neu.0000000000001892 Rischall MA, Boegel KH, Palmer CS, Knoll B, McKinney AM. MDCT Venographic Patterns of Dural Venous Sinus Compromise After Acute Skull Fracture. AJR Am J Roentgenol . 2016;207(4):852-858. doi:10.2214/AJR.15.15972 Rodallec MH, Krainik A, Feydy A, et al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. Radiographics . 2006;26 Suppl 1(SPEC. ISS.). doi:10.1148/RG.26SI065505 Durgun B, Ilgit E, Çizmeli M, Atasever A. Evaluation by angiography of the lateral dominance of the drainage of the dural venous sinuses. Surgical and Radiologic Anatomy . 1993;15(2):125-130. doi:10.1007/BF01628311 Tables Table 1: Patient characteristics and injury information Variable Group 1 (CVST positive 1 ) N = 31 Group 2 (CVST negative) N = 58 Group 3 ( CVST unknown) N = 6 Age (years) 44 (± 18.5) 45.9 (± 18.4) 63.8 (± 21.8) Sex (Male / Female) 21 (68%) / 10 (32%) 36 (62%) / 22 (38%) 3 (50%) / 3 (50%) Glasgow coma scale on arrival (average) 14.3 14.7 14.6 Mechanism of injury Fall 13 (42%) 20 (34%) 3 (50%) Motor vehicle accident related 9 (29%) 10 (17%) 2 (33%) eScooter/eBike related 6 (19%) 20 (34%) 0 Assault 1 (3%) 4 (7%) 1 (17%) Other / Not available 1 (3%) / 1 (3%) 1 (2%) / 3 (5%) 0 1 CVST = Cerebral venous sinus thrombosis, based on formal radiological report Table 2: Interrater variability using Fleiss’ kappa and Cohens’ kappa statistics Number of patients Fleiss’ kappa coefficient (between three raters) Cohen kappa coefficient (between senior authors) CVST identified 1 12 0.21 0.25 CVST could not be definitively excluded 19 0.03 0.37 CVST excluded 58 0.91 0.87 1 CVST = Cerebral venous sinus thrombosis, based on formal radiological report Table 3: Radiological characteristics Variable Group 1 (CVST positive) N = 31 Group 2 (CVST negative) N = 58 Group 3 ( CVST unknown) N = 6 Fracture location (multiple fractures possible) Frontal 1 3 0 Parietal 3 10 2 Temporal 8 11 1 Occipital 23 41 6 Fracture over dominant sinus 19 22 N/A 1 Time of vascular imaging from trauma 1 N/A 2 N/A N/A 24 hours 2 9 1 N/A = Not available Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6231145","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435930995,"identity":"9f826ef4-47a9-4331-af82-864390fa2fb0","order_by":0,"name":"Segev Gabay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYPACCWZ+EJVQQLwWC3bJBpAWA+K1VPAbHADRxGiRb2+/+Jjnl4S08fnViR8eGDDI84sdwK/F4MyZYmPePgljsxtvN0sAHWY4c3YCAS0SOWmSM3skks1unN0A0pJgcJuAFvn5b9J/ArXUb55xdvMPorQw3GA/xvDhhwSzAX/vNuJsMTiTwyzxsUGCWeIG7zaLBAMJwn6Rbz/+8EPCnzpm/v6zm2/+qLCR55cm5DAGHgMGxjYgLQFWKUFIOQiwP2Bg+AOk+Q8Qo3oUjIJRMApGIgAA1/dFyiT4MhEAAAAASUVORK5CYII=","orcid":"","institution":"Tel Aviv Sourasky Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Segev","middleName":"","lastName":"Gabay","suffix":""},{"id":435930996,"identity":"da09c268-c630-404b-b93e-2fbc6cc6472b","order_by":1,"name":"Guy Dunetz","email":"","orcid":"","institution":"Tel Aviv Sourasky Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Guy","middleName":"","lastName":"Dunetz","suffix":""},{"id":435930997,"identity":"1a380914-78b2-456a-99dc-d58fcf5edfa6","order_by":2,"name":"Lottem Bergman","email":"","orcid":"","institution":"Tel Aviv Sourasky Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Lottem","middleName":"","lastName":"Bergman","suffix":""},{"id":435930998,"identity":"6a2ebb51-bce9-4ff3-9e37-868faa2498f5","order_by":3,"name":"Dana Niry","email":"","orcid":"","institution":"Tel Aviv Sourasky Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Dana","middleName":"","lastName":"Niry","suffix":""},{"id":435930999,"identity":"781e68b9-5d32-4b34-b542-0fb23211fd56","order_by":4,"name":"Jonathan Roth","email":"","orcid":"","institution":"Tel Aviv Sourasky Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Roth","suffix":""}],"badges":[],"createdAt":"2025-03-15 07:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6231145/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6231145/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00234-025-03670-6","type":"published","date":"2025-06-23T15:57:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79648552,"identity":"33c7505c-be30-480d-9b26-6e1f1455c69d","added_by":"auto","created_at":"2025-04-01 07:26:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":632712,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart detailing inclusion of patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf 1035 with TBI and CT scans, 95 patients met the inclusion criteria. Of these 95, 89 patients had some form of vascular imaging (CTA or CTV), leaving 6 patients with no vascular imaging (Group 3).\u003c/p\u003e\n\u003cp\u003eThe first division of the cohort, was based on the formal radiology report. It included 31 patients with CVST (Groups 1A [definite] and 1B [presumed]), and 58 patients with no CVST (Group 2).\u003c/p\u003e\n\u003cp\u003eIn the second division of the cohort, as interpreted by the senior author (JR), only 6 patients were deemed to have CVST (Group 1A). In 4 patients, the presence or absence of CVST was unclear (Group 1B). 21 patients had no CVST, with instead either compressing epidural hematoma or arachnoid granulation, yielding a total of 79 patients that had no thrombosis (Group 2).\u003c/p\u003e\n\u003cp\u003eIn the third division of the cohort, as interpreted by the senior author (DN), only 8 patients were deemed to have CVST (Group 1A). In 8 patients, the presence or absence of CVST was unclear (Group 1B). 15 patients had no CVST, with instead either compressing epidural hematoma or arachnoid granulation, yielding a total of 73 patients that had no thrombosis (Group 2).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6231145/v1/dc51a268f84721cb80a0765c.png"},{"id":85686167,"identity":"6b2ffff0-0632-42ad-be93-702c9e81608e","added_by":"auto","created_at":"2025-06-30 16:04:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1336064,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6231145/v1/789d0a0c-e26b-4771-91d0-53ec613604e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Are Isolated Linear Fractures over Major Dural Venous Sinuses a Risk Factor for Sinus Thrombosis in Mild TBI?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCerebral venous sinus thrombosis (CVST) refers to the formation of a blood clot in one of the dural venous sinuses. CVST may lead to increased intracranial pressure and venous infarction, leading to morbidity and mortality\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Head trauma is one of the risk factors for the formation of CVST\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In contrast to spontaneous CVST, which is typically associated with prothrombotic states such as pregnancy, puerperium, and oral contraceptive usage, traumatic CVST (tCVST) is typically caused by a direct traumatic disruption of the dural sinus wall caused by overlying fractures, or from local external compression of the dural sinus wall by epidural hematoma\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. These risk factors go in accordance with Virchow's triad, defining the cornerstones for thrombosis formation, which are vascular wall injury, blood flow stasis, or changes in blood composition\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Traumatic CVST is known to be associated with an increased risk of hospitalization length, morbidity, and mortality\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Recently, Netteland, et al showed in a systematic review that the available data is insufficiently homogenous to provide answers to many key clinical questions, leaving many aspects unsolved\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Specifically, the current literature regarding indications for venous imaging and timing for diagnosis of tCVST in patients with mild TBI is insufficient\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur current study aims to review the available literature and share our experience from a large tertiary center regarding the occurrence of tCVST following mild, isolated, and blunt traumatic head injury, with a linear fracture traversing major sinuses.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFollowing institutional review board approval (IRB 0550-23-TLV), we retrospectively collected data on all patients at our department hospitalized due to TBI between January 2017 and March 2023. Patient data was collected from our electronic database system. Overall, 1035 trauma patients were identified during this period. Patients were included if they sustained a mild and isolated traumatic brain injury (defined as Glasgow Coma Scale (GCS) 13\u0026ndash;15) and had a cranial linear fracture traversing over a major dural venous sinus (superior sagittal sinus (SSS), transverse sinus (TS), sigmoid sinus (SS), jugular bulb (JB), or Torcular Herophili (TH)). Patients excluded from this study included patients on anticoagulation or anti-aggregant medications at the time of injury, age\u0026thinsp;\u0026lt;\u0026thinsp;18 years old, known coagulation disorder, additional severe extracranial injury, and surgery (of any kind) at admission.\u003c/p\u003e \u003cp\u003eCollected data included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatient presentation (mechanism of trauma, GCS at arrival)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRadiology features (time from trauma, findings on initial computed tomography (CT) scan (including bleedings and fractures), vascular imaging in the form of computed tomography angiography (CTA), computed tomography venography (CTV), or Magnetic Resonance Venography (MRV), name of sinus involved, dominance of the sinus, and the presence of major sinus thrombosis)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTreatment related to CVST\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHospitalization course (hospitalization duration, imaging during hospitalization, funduscopic eye exams, management, immediate complications)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMost recent follow-up data (date, long-term complications, imaging)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e Based on the internal guidelines of our department, in the majority of cases (at the discretion of the attending physician), whenever a skull fracture crosses a major dural venous sinus, venous imaging (CTV) is usually done at some point during the hospitalization, with the majority of cases done immediately after the initial CT scan, or at repeated imaging approximately 6 hours after the first scan if bleeding was noted on the initial CT scan. In cases when sinus thrombosis is diagnosed, repeated venous imaging depends on the discretion of the attending neurosurgeon, based on the severity and location of the thrombosis, and the patient's clinical condition. All scans with a suspected CSVT (per radiological interpretation) were retrospectively evaluated by JR. In addition, all scans were retrospectively rereviewed by an experienced senior neuroradiologist (DN) blinded to the radiological interpretation.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eAs the cohort of patients, namely those with CVST, is relatively small, no statistical analysis was done in this study. Interrater agreement was calculated using Fleiss' kappa and Cohens' kappa coefficients (κ)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePatient demographics, including age, sex, mechanism of injury, and Glasgow coma scale (GCS) on arrival, are shown in Table 1.\u003c/p\u003e\n\u003cp\u003eA total of 95 patients were included in this study (Figure 1). 60 patients were male (63%) and 35 were female (37%). The average age was 46.5 years (\u0026plusmn; standard deviation (SD) 19 years, median 43 years). The first vascular imaging following injury was performed within 6 hours in 25 patients, after 6-12 hours in 35 patients, after 12-24 hours in 14 patients, and after more than 24 hours in 11 patients. In 4 patients the time of vascular imaging from the trauma was unknown, and in 6 patients no vascular imaging was done. 25 patients had subsequent vascular imaging during their hospitalization; 19 had 1 additional imaging study, 4 had 2 additional imaging studies, and 2 had 3 additional imaging studies.\u003c/p\u003e\n\u003cp\u003eWe divided our cohort into the following divisions and groups:\u003c/p\u003e\n\u003cp\u003e1. The first division was based on the presence or absence of a thrombus on vascular imaging (CTA or CTV), as interpreted by the formal radiology report \u003cem\u003eat the time of the trauma\u003c/em\u003e, divided as follows:\u003c/p\u003e\n\u003cp\u003ea. Group 1: 31 patients (33%) were identified as either having or suspected to have CVST. Of these:\u003c/p\u003e\n\u003cp\u003eA. 12 patients (\u003cspan dir=\"RTL\"\u003e13\u003c/span\u003e%) were identified with definite CVST.\u003c/p\u003e\n\u003cp\u003eB. 19 patients (20%) were identified with suspected CVST; as it could not be definitely diagnosed or definitely ruled out (either due to concomitant external compression by epidural hematoma or because the CSVT could not be fully differentiated, in the context of trauma, from arachnoid granulations).\u003c/p\u003e\n\u003cp\u003eb. Group 2: 58 patients (61%) had no thrombosis.\u003c/p\u003e\n\u003cp\u003ec. Group 3: 6 patients (6%) did not have vascular imaging, therefore the presence or absence of thrombosis could not be determined. Furthermore, none of these patients exhibited any clinical symptoms that would raise suspicion for CVST. Additionally, none of them received anticoagulation or anti-aggregant treatment.\u003c/p\u003e\n\u003cp\u003e2. The second division was based on a \u003cem\u003eretrospective\u003c/em\u003e review and reanalysis of the vascular imaging by the senior\u003cem\u003e neurosurgeon \u003c/em\u003eauthor (JR). This division included only the 89 patients who originally had vascular imaging. In this division, of the 31 patients (35%) who were originally identified as having or suspected to have CVST, a review of the images led to the following re-classifications:\u003c/p\u003e\n\u003cp\u003ea. 6 patients (7%) were identified with CVST, and kept in Group 1A.\u003c/p\u003e\n\u003cp\u003eb. 4 patients (4%) were identified with suspected CVST - it could not be definitely diagnosed or definitely ruled out - and moved to Group 1B.\u003c/p\u003e\n\u003cp\u003ec. 21 patients (24%) definitely had no thrombosis, and moved to Group 2.\u003c/p\u003e\n\u003cp\u003eFollowing the neurosurgeon\u0026rsquo;s review and reanalysis of these 89 images, he found a total of 79 patients (83%) with no thrombosis (Group 2).\u003c/p\u003e\n\u003cp\u003e3. The third division was based on a \u003cem\u003eretrospective\u003c/em\u003e review and reanalysis of the vascular imaging by the senior \u003cem\u003eneuroradiologist\u003c/em\u003e author (DN). This division also included only the 89 patients who originally had vascular imaging. In this division, of the 31 patients (35%) who were originally identified as having or suspected to have CVST:\u003c/p\u003e\n\u003cp\u003ea. 8 patients (9%) were identified with CVST, and kept in Group 1A.\u003c/p\u003e\n\u003cp\u003eb. 8 patients (9%) were identified with suspected CVST - it could not be definitely diagnosed or definitely ruled out - and kept/moved to Group 1B.\u003c/p\u003e\n\u003cp\u003ec. 15 patients (17%) definitely had no thrombosis, and moved to Group 2.\u003c/p\u003e\n\u003cp\u003eFollowing the neuroradiologist\u0026rsquo;s review and reanalysis of these 89 images, she found a total of 73 patients (76%) with no thrombosis (Group 2).\u003c/p\u003e\n\u003cp\u003eThe validity of these three divisions was tested, and the presence or absence of CVST for patients was evaluated using Fleiss\u0026rsquo; kappa and Cohens\u0026rsquo; kappa statistics (Table 2).\u003c/p\u003e\n\u003cp\u003eThe Fleiss\u0026rsquo; kappa coefficient, calculated between three raters for the 12 patients in the first division, who were identified with CVST from the formal radiological report, yielded a value of 0.21, suggesting fair agreement. Similarly, the Cohen kappa coefficient, computed between two raters (JR and DN) for the same patients, indicated a fair level of agreement with a value of 0.25. In contrast, when examining the patients identified with CVST from the senior authors\u0026rsquo; reports, the Fleiss\u0026rsquo; kappa coefficients were 0.67 and 0.44, indicating improved inter-rater reliability.\u003c/p\u003e\n\u003cp\u003eThe Fleiss\u0026rsquo; kappa coefficient for the 19 patients in the first division, in which the presence of CVST could not be definitively excluded from the initial radiological report, was 0.03, indicating a slight degree of agreement. The Cohen kappa coefficient between two raters (JR and DN) for the same patients was 0.37, suggesting fair agreement.\u003c/p\u003e\n\u003cp\u003eThe Fleiss\u0026rsquo; kappa coefficient for the 58 patients in the first division, who did not have a thrombosis from the initial radiological report, was 0.91, indicating almost perfect agreement. The Cohen kappa coefficient between two raters (JR and DN) for the same patients was 0.87, indicating also almost perfect agreement.\u003c/p\u003e\n\u003cp\u003eBased on these results, several important observations can be made. First, among those individuals who were definitively diagnosed with thrombosis by the senior authors, the same findings were corroborated in the formal radiological report. Conversely, 40% of those who were definitively diagnosed with thrombosis in the formal report were reported by the senior authors as having no thrombus. Furthermore, in 55-85% of the patients (depending on the rater) in the first division where the formal radiological report indicated that CVST could \u003cem\u003enot \u003c/em\u003ebe definitively excluded, the senior authors noted that CSVT could \u003cem\u003ecertainly \u003c/em\u003ebe definitively excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eLocation of fractures and sinus dominance\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRadiological characteristics are shown in Table 3. All fractures in this study were linear and non-displaced fractures, crossing major dural sinuses. Some patients sustained multiple fractures, or fractures traversing more than 1 cranial bone. 4 frontal fractures, 15 parietal, 20 temporal, and 70 occipital fractures were observed. Most of the 31 patients in Group 1 \u003cs\u003eGroup 1,\u003c/s\u003e with presumed CSVT had fractures in the occipital bone, followed by the temporal bone as the most common location. This may partially explain the bias in the radiological interpretation, as fractures in the occipital bone most of the time cross one of the major dural sinuses (torcula, TS, or SS), and may lead to an adjacent epidural hematoma, thereby causing the radiologist to incorrectly suspect the presence CSVT.\u003c/p\u003e\n\u003cp\u003eRegarding sinus dominance, in 62 patients the right transverse/sigmoid sinuses were dominant, in 13 patients the left sinuses were the dominant, 14 patients had no dominance, and in 6 patients the dominance could not be evaluated because of lack of venous imaging. The fractures overrode dominant sinuses in 41 patients; of these, 19 had a radiological interpretation of CVST. Likewise, the fractures overrode non-dominant sinuses in 48 patients, with 12 having a radiological interpretation of CVST (p=0.035).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTreatment\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 31 patients originally diagnosed with thrombosis, 14 were treated with anticoagulation, 1 was treated with anti-aggregants for concomitant arterial dissection, and 16 were treated conservatively with fluids and close observation. Among the 6 patients diagnosed with thrombosis by the neurosurgeon in the second division of the cohort, 5 had been treated with anticoagulation and 1 was treated conservatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFollow-up\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 95 patients included in this study, 67 had clinical follow-up (average 3.3 months \u0026plusmn; SD 9.1 months, median 2 months) and 28 patients were lost to clinical follow-up. Among those with follow-up, 50 were symptom-free, and 17 patients had only mild symptoms, including fatigue, headaches, dizziness, or imbalance. These symptoms were attributed to the trauma itself (post-concussion syndrome). No major morbidity or mortality was observed from the entire cohort. 11 out of 31 patients from the first division with thrombosis diagnosed had vascular radiological follow-up (average 2.35 months \u0026plusmn; SD 2.01 months, median 1.75 months), with either CTV or MRV. This imaging demonstrated full thrombus resolution. Among these 11 patients, 5 received anticoagulation, while 6 did not. 10 of the 58 patients from the first division with no thrombosis diagnosed had vascular radiological follow-up (average 3.1 months \u0026plusmn; SD 3.1 months, median 1.75 months). This imaging did not demonstrate any newly diagnosed CVSTs.\u003c/p\u003e\n\u003cp\u003eAmong the entire cohort of 95 patients, only 1 patient treated with anticoagulation for a non-dominant, right sigmoid sinus thrombosis was re-hospitalized 2 weeks after his discharge because of unremitting headaches and dizziness. His original head CT demonstrated a right temporo-occipital linear fracture traversing the right TS and SS, and a non-surgical epidural hematoma, compressing the TS and SS. Because of the proximity to the previous hospitalizations, and the continuation of the complaints, he was re-hospitalized for evaluation. A new head CT and CTV were done that demonstrated resolution of the compressing epidural hematoma and no sinus thrombosis. He was discharged after a few days of observation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we present a cohort of patients focusing on the incidence of tCVST, complications, and long-term outcomes amongst patients with mild TBI and linear fractures traversing the major venous sinuses. The incidence of CVST among TBI patients with skull fractures adjacent to a cerebral venous sinus is relatively high in the literature, ranging between 26%-32%\u003csup\u003e8,9\u003c/sup\u003e. The presence of temporal bone fracture was associated with even higher rates, approaching 40%\u003csup\u003e8\u003c/sup\u003e. This is consistent with our initial findings, where 32% of our patients with linear fractures traversing the major venous sinuses were diagnosed with CVST.\u003c/p\u003e \u003cp\u003eRecent systematic reviews evaluated indications for venous imaging in the setting of TBIs\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. In most studies, the presence of a skull fracture in the vicinity of a dural sinus was followed by venous imaging. However, there is limited data to apprise the appropriate indications for venous imaging\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Furthermore, there is a lack of consensus regarding the optimal timing for venous imaging\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. A contributing factor to this uncertainty is the fact that CVST is probably formed in a delayed fashion post-TBI, and not during the first few hours following the injury\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. In our cohort, we could not find a specific indication for the optimal timing for venous imaging, as in both groups, with and without thrombosis, the initial timing of venous imaging varied.\u003c/p\u003e \u003cp\u003eCerebral venous drainage dominance is of great importance and should be actively evaluated, as it can have significant clinical implications. Thrombosis of the SSS or the dominant SS/TS sinus can lead to venous hypertension, leading to cerebral edema and venous strokes\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In most of our cohort, the right transverse/sigmoid sinuses were more often dominant over the left side, consistent with the literature\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The implication of fracture over the dominant sinus, in the setting of traumatic brain injury, is not known. In our cohort of mild brain injury, among 31 patients with a radiological interpretation of CVST, 19 patients had fractures overriding the dominant sinuses, and 12 patients with fractures overriding non-dominant sinuses. In both groups, the prognosis was excellent.\u003c/p\u003e \u003cp\u003eThe inter-rater reliability for the identification of CVST varied across different patient groups. For patients originally diagnosed with CVST (12 patients), the kappa coefficients indicated only fair agreement between the raters. In cases where the presence of CVST could not be definitively excluded (19 patients), the kappa coefficients dropped, suggesting just a slight degree of agreement. However, for patients without thrombosis (58 patients), the kappa coefficients demonstrated almost perfect agreement between raters. These findings underscore that while there is fairly reasonable inter-rater reliability agreement in \u003cem\u003edetecting\u003c/em\u003e CVST, and much improved inter-rater reliability in the \u003cem\u003eabsence\u003c/em\u003e of thrombosis, the inter-rater reliability agreement is much more variable when dealing with ambiguous or uncertain cases.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis is a retrospective series. Although our initial cohort was relatively large, the group with radiological interpretation of CVST, and especially the group that was deemed to actually have a CVST, is small. In addition, due to the retrospective nature of this study, there is considerable heterogenicity in several important parameters, including the time of initial venous imaging relative to the trauma. Furthermore, about a third of the study population did not have clinical or radiological follow-up, and the remaining had only limited follow-up, making long-term conclusions unclear. Moreover, the radiological distinction between compressing epidural hematoma or arachnoid granulations to actual CVST, among the patients who were deemed to have a CVST by the senior authors, is not proven, leaving room for error. Lastly, our study, as with other retrospective studies, involves retrospectively re-analyzing previous radiological images that have the unavoidable interpretation bias.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn a cohort of TBI patients with mild, isolated, blunt traumatic brain injury, with a linear non-displaced fracture traversing major dural venous sinus and an underlying CVST, the prognosis was excellent regardless of treatment with anticoagulants. CVST may be over-diagnosed, as an epidural hematoma or arachnoid granulations may mimic CVST.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eInformed consent\u003c/h3\u003e\n\u003cp\u003eSince the study was retrospective, informed consent was not applicable.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThere is no conflict of interest.\u003c/p\u003e\n\u003ch3\u003eEthical approval\u003c/h3\u003e\n\u003cp\u003eInstitutional Review Board approval was obtained from Tel-Aviv Medical Center, Clinical Research Ethics Committee\u0026nbsp;(IRB 0550-23-TLV).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUlivi L, Squitieri M, Cohen H, Cowley P, Werring DJ. Cerebral venous thrombosis: a practical guide. \u003cem\u003ePract Neurol\u003c/em\u003e. 2020;20(5):356-367. doi:10.1136/practneurol-2019-002415\u003c/li\u003e\n\u003cli\u003eRopper AH, Klein JP. Cerebral Venous Thrombosis. \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e. 2021;385(1):59-64. doi:10.1056/NEJMra2106545\u003c/li\u003e\n\u003cli\u003eNetteland DF, Sandset EC, Mejl\u0026aelig;nder-Evjensvold M, et al. Cerebral venous sinus thrombosis in traumatic brain injury: A systematic review of its complications, effect on mortality, diagnostic and therapeutic management, and follow-up. \u003cem\u003eFront Neurol\u003c/em\u003e. 2023;13. doi:10.3389/fneur.2022.1079579\u003c/li\u003e\n\u003cli\u003eBourrienne M, Gay J, Mazighi M, Ajzenberg N. State of the art in cerebral venous sinus thrombosis animal models. \u003cem\u003eJournal of Thrombosis and Haemostasis\u003c/em\u003e. 2022;20(10):2187-2196. doi:10.1111/jth.15816\u003c/li\u003e\n\u003cli\u003eNetteland DF, Mejl\u0026aelig;nder-Evjensvold M, Skaga NO, Sandset EC, Aarhus M, Helseth E. Cerebral venous thrombosis in traumatic brain injury: a cause of secondary insults and added mortality. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 2020;134(6):1912-1920. doi:10.3171/2020.4.JNS20511\u003c/li\u003e\n\u003cli\u003eHoffman H, Otite FO, Chin LS. Venous Injury in Patients with Blunt Traumatic Brain Injury: Retrospective Analysis of a National Cohort. \u003cem\u003eNeurocrit Care\u003c/em\u003e. 2022;36(1):116-122. doi:10.1007/S12028-021-01265-6\u003c/li\u003e\n\u003cli\u003eLandis JR, Koch GG. The Measurement of Observer Agreement for Categorical Data. \u003cem\u003eBiometrics\u003c/em\u003e. 1977;33(1):159. doi:10.2307/2529310\u003c/li\u003e\n\u003cli\u003eBokhari R, You E, Bakhaidar M, et al. Dural Venous Sinus Thrombosis in Patients Presenting with Blunt Traumatic Brain Injuries and Skull Fractures: A Systematic Review and Meta-Analysis. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2020;142:495-505.e3. doi:10.1016/j.wneu.2020.06.117\u003c/li\u003e\n\u003cli\u003eKim KT, Wessell AP, Oliver J, et al. Comparative Therapeutic Effectiveness of Anticoagulation and Conservative Management in Traumatic Cerebral Venous Sinus Thrombosis. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2022;90(6):708-716. doi:10.1227/neu.0000000000001892\u003c/li\u003e\n\u003cli\u003eRischall MA, Boegel KH, Palmer CS, Knoll B, McKinney AM. MDCT Venographic Patterns of Dural Venous Sinus Compromise After Acute Skull Fracture. \u003cem\u003eAJR Am J Roentgenol\u003c/em\u003e. 2016;207(4):852-858. doi:10.2214/AJR.15.15972\u003c/li\u003e\n\u003cli\u003eRodallec MH, Krainik A, Feydy A, et al. Cerebral venous thrombosis and multidetector CT angiography: tips and tricks. \u003cem\u003eRadiographics\u003c/em\u003e. 2006;26 Suppl 1(SPEC. ISS.). doi:10.1148/RG.26SI065505\u003c/li\u003e\n\u003cli\u003eDurgun B, Ilgit E, \u0026Ccedil;izmeli M, Atasever A. Evaluation by angiography of the lateral dominance of the drainage of the dural venous sinuses. \u003cem\u003eSurgical and Radiologic Anatomy\u003c/em\u003e. 1993;15(2):125-130. doi:10.1007/BF01628311\u003cspan dir=\"RTL\"\u003e\u003cbr\u003e\u003c/span\u003e\u003cbr\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 1: Patient characteristics and injury information\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u0026nbsp;\u003cbr\u003e (CVST positive\u003csup\u003e1\u003c/sup\u003e\u003ca href=\"#_ftn1\" name=\"_ftnref1\" title=\"\"\u003e\u003c/a\u003e)\u003cbr\u003e\u0026nbsp;N = 31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2\u0026nbsp;\u003cbr\u003e\u0026nbsp;(CVST negative)\u003cbr\u003e\u0026nbsp;N = 58\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 3\u0026nbsp;\u003cbr\u003e\u0026nbsp;(\u003c/strong\u003e\u003cstrong\u003eCVST unknown)\u003cbr\u003e\u0026nbsp;N = 6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e44 (\u0026plusmn; 18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e45.9 (\u0026plusmn; 18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e63.8 (\u0026plusmn; 21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSex (Male / Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e21 (68%) / 10 (32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e36 (62%) / 22 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3 (50%) / 3 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eGlasgow coma scale on arrival (average)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMechanism of injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 468px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e13 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e20 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMotor vehicle accident related\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e9 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e10 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eeScooter/eBike related\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e6 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e20 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eAssault\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e4 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eOther / Not available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e1 (3%) / 1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e1 (2%) / 3 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e CVST = Cerebral venous sinus thrombosis, based on formal radiological report\u003c/p\u003e\n\u003ch3\u003e\u003cu\u003eTable 2:\u0026nbsp;\u003c/u\u003e\u003cu\u003eInterrater variability using Fleiss\u0026rsquo; kappa and Cohens\u0026rsquo; kappa statistics\u003c/u\u003e\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFleiss\u0026rsquo; kappa coefficient (between three raters)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohen kappa coefficient (between senior authors)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCVST identified\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCVST could not be definitively excluded\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCVST excluded\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e CVST = Cerebral venous sinus thrombosis, based on formal radiological report\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cu\u003eTable 3: Radiological characteristics\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u0026nbsp;\u003cbr\u003e\u0026nbsp;(CVST positive)\u003cbr\u003e\u0026nbsp;N = 31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2\u0026nbsp;\u003cbr\u003e\u0026nbsp;(CVST negative)\u003cbr\u003e\u0026nbsp;N = 58\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 3\u0026nbsp;\u003cbr\u003e\u0026nbsp;(\u003c/strong\u003e\u003cstrong\u003eCVST unknown)\u003cbr\u003e\u0026nbsp;N = 6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFracture location\u0026nbsp;\u003cbr\u003e\u0026nbsp;(multiple fractures possible)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFrontal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eParietal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eTemporal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eOccipital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFracture over dominant sinus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eTime of vascular imaging from trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1 N/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2 N/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u0026lt; 6 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e6 \u0026ndash; 12 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e12 \u0026ndash; 24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u0026gt; 24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e N/A = Not available\u003c/p\u003e\n\u003c/div\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6231145/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6231145/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: Cerebral venous sinus thrombosis (CVST) can increase intracranial pressure and cause secondary brain injury. There is uncertainty in the literature regarding the risk of traumatic CVST (tCVST) following fractures over a major sinus, the need and timing for venous imaging, and treatment. The current study aims to review our experience with tCVST when treating patients with isolated linear fractures over the major sinuses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This is a retrospective study of 95 adult patients, treated between January 2017 and March 2023, with mild, blunt, isolated traumatic head injury (GCS 13-15) and cranial fracture traversing the major dural venous sinus. Data regarding presentation, radiological features, hospitalization, and follow-up course of CVST were collected and analyzed. Images suspected to show a CVST were retrospectively reviewed by two teams blinded to the radiological interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Of 95 patients, 31 (32%) were identified as having or suspected to have CVST as interpreted by the radiologists. Among them, 14 were treated with anticoagulation, and 1 was treated with anti-aggregates for concomitant arterial dissection. There were no long-term symptoms or newly diagnosed CVST amongst the entire cohort. No major morbidity or mortality occurred. Upon analyzing the images retrospectively, the inter-rater reliability varied. The agreement was fair for definite cases of CVST, slight for uncertain cases that showed epidural hematoma compression and narrowing of the sinus, or arachnoid granulations, and almost perfect for patients without thrombosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Amongst patients with mild, isolated, blunt traumatic head injury, with fractures traversing major dural venous sinus, true CVST may be over-diagnosed, with some of the lesions being local epidural hematomas mimicking CVST. The outcome of CVST was excellent, whether or not they were treated with anticoagulants.\u003c/p\u003e","manuscriptTitle":"Are Isolated Linear Fractures over Major Dural Venous Sinuses a Risk Factor for Sinus Thrombosis in Mild TBI?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 07:25:57","doi":"10.21203/rs.3.rs-6231145/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2fdbf3d7-0832-4c44-b874-1ed653c20551","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-30T16:00:27+00:00","versionOfRecord":{"articleIdentity":"rs-6231145","link":"https://doi.org/10.1007/s00234-025-03670-6","journal":{"identity":"neuroradiology","isVorOnly":false,"title":"Neuroradiology"},"publishedOn":"2025-06-23 15:57:32","publishedOnDateReadable":"June 23rd, 2025"},"versionCreatedAt":"2025-04-01 07:25:57","video":"","vorDoi":"10.1007/s00234-025-03670-6","vorDoiUrl":"https://doi.org/10.1007/s00234-025-03670-6","workflowStages":[]},"version":"v1","identity":"rs-6231145","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6231145","identity":"rs-6231145","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}