Recognizing cerebral clots in children with brain infections - Children's National

The big picture

Acute bacterial intracranial infections place children at risk for serious neurologic complications. In addition to inflammation and direct brain injury, these infections create conditions that promote clot formation through dehydration, venous stasis, endothelial injury and hypercoagulability. Cerebral sinovenous thrombosis, or CSVT, has historically been underrecognized in this population.

As highlighted in a recent Neurology editorial, new evidence shows that CSVT is far more common than previously appreciated. In a retrospective observational study of children hospitalized for acute bacterial intracranial infections, nearly one-third developed CSVT. This finding reframes how clinicians should think about risk, screening and management in these high-risk patients.

The hold-up in the field

Despite clear risk factors for CSVT, there are no standardized guidelines for screening children with intracranial bacterial infections. Prior studies have often focused on CSVT as the starting point rather than asking how frequently it complicates infection.

"As clinicians, we see this as a common clinical presentation," said Dana Harrar, MD, PhD, director of the Pediatric Stroke Program at Children's National Hospital and one of the editorial authors. "This study confirms just how common CSVT is as a complication of intracranial bacterial infection."

Diagnosis is further complicated by variability in neuroimaging. In the study discussed in the editorial, 63% of CSVT cases were not detected on initial imaging. Not all children underwent MRI, and no single imaging sequence consistently identified CSVT.

Uncertainty around treatment has also slowed progress. While the study was not designed to definitively assess safety or effectiveness, no patients experienced symptomatic bleeding related to anticoagulation. "This suggests that anticoagulation may be a safe treatment option in this population," Dr. Harrar noted.

Children's National Hospital leads the way

At Children's National, this work serves as a foundation for advancing care. Multidisciplinary teams from Neurology, Neurosurgery, Hematology and Critical Care Medicine are collaborating to develop a standardized clinical pathway for diagnosing and managing infectious CSVT.

"Future efforts should focus on establishing clearer approaches to identifying CSVT in children with intracranial bacterial infections, while also evaluating when and how anticoagulation should be used," said Dr. Harrar. "Further study is also needed to understand how newer anticoagulants may fit into care."

Read the full editorial, "Cerebral Sinovenous Thrombosis in Children With Bacterial Intracranial Infections ", in Neurology.