Classification System For Intracranial Hemorrhage Secondary To Neonatal Cerebral Venous Sinus Thrombosis

Background: Neonatal cerebral venous sinus thrombosis (CVST) is commonly associated with intracranial hemorrhage (ICH) and brain injury at diagnosis. Presence of “severe” ICH poses a challenge for anti-coagulation therapy. There is currently no classification system to characterize ICH severity in neonatal CVST.

Objective: To develop a classification system to characterize the location and severity of ICH in neonatal CVST.

Methods: A retrospective chart review was conducted of term neonates with radiologically confirmed CVST (MRI/MRV or CT/CTV) from 2000-2023. Neonates were excluded if they were preterm and if CVST was diagnosed with cranial ultrasound. Scans were reviewed to confirm thrombus location and ICH.

Results: ICH secondary to CVST was categorized (Figure 1) based on location (extra-axial, parenchymal, intraventricular, supratentorial, infratentorial) and severity (minor, major). Extra-axial hemorrhage was classified as minor for thin hemorrhage < 3mm and major for thick hemorrhage > 3mm or mass effect. Parenchymal hemorrhage was classified as minor for petechial hemorrhage and major for hematomas or mass effect. Intraventricular hemorrhage was classified as minor for grades 1-2, and major for grade 3 with or without periventricular hemorrhagic infarct, mass effect or hydrocephalus. Imaging characteristic of each type of hemorrhage are presented in Figure 2. Validation of this classification system is in progress.

Conclusions: The development of a neonatal CVST ICH classification system permits a comprehensive and standardized description of hemorrhage in neonates with CVST. The utility of a classification system for CVST associated hemorrhage includes stratification of at-risk neonates, identification of neonates eligible for anticoagulation therapy and neuroprognostication.