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Neurology Today Conference Reporter: CNS Annual Meeting

Tuesday, October 23, 2018

Anticoagulation Is Associated with Favorable Outcomes in Cerebral Sinovenous Thrombosis

BY THOMAS R. COLLINS

 CHICAGO—Anticoagulation in children with cerebral sinovenous thrombosis (CSVT) was associated with a favorable outcome in an analysis of data from an international study, according to a presentation here at the Child Neurology Society annual meeting.

The findings provide a rare look at the efficacy of anticoagulation in children with CSVT, a common practice supported by scant research in pediatrics.

"The [available] research doesn't have a whole lot of power behind it in terms of making treatment recommendations," said Ryan Felling, MD, PhD, director of the pediatric stroke program at Johns Hopkins Medicine, who presented the findings. "So often in children we end up extrapolating from adult data."

Researchers pulled data from the International Pediatric Stroke Study, a multicenter prospective study enrolling patients with arterial ischemic stroke and CSVT. They analyzed data for 410 patients with CSVT, excluding those with arterial ischemic stroke.

On multivariate analysis, anticoagulation was the only predictor of a favorable outcome, meaning there was no severe neurological impairment or death at discharge (HR=0.30; p=.032). Trauma or intracranial surgery was the only predictor of anticoagulant use — it was linked with less use — with a hazard ratio of 0.15 on multivariable analysis (p=.008).

Infarct was the only predictor of severe neurological impairment or death at discharge (HR = 3.47; p=0.018).

"The biggest upshot is that we saw an association between anticoagulation and better outcomes," Dr. Felling said.

Although a high percentage of the patients — 78 percent — receive anticoagulation, there is still hesitation about the treatment in certain children with CSVT, particularly those with head trauma. But Dr. Felling noted that, at least in this analysis, there was an association between anticoagulation and a good outcome even among those with head trauma.

"I think this adds a little bit of data just to say, 'Look, there is this association between anticoagulation and good outcomes," Dr. Felling said. "And that's supported by what we've seen in adults."

He acknowledged the data are retrospective, but said it's difficult to study the subject prospectively, given the rarity of the disorder.

He also noted that because the analysis was retrospective, it's unknown exactly why providers chose to use or not use anticoagulation.

"They may have not chosen to anticoagulate children who had very bad injuries and that might be the driver of poor outcome in that group but at least we're able to show the association there," he said. "And it still suggests that we need better studies to determine if anticoagulation is the driver of good outcomes."

Alexander Cohen, MD, PhD, instructor of neurology at Boston Children's Hospital who moderated the session, said the findings are the "first step to creating the clinical trials that we'll need to do down the line."

These retrospective data by themselves aren't sufficient to make any tweaks in how these children should be treated but the International Pediatric Stroke Study — now with more than 4,000 total patients enrolled — is building toward the numbers needed to begin moving into prospective trials, he said.

"Without the additional information about why the choices were made, or more categorization, I think it's going to be difficult" to modify treatment decisions, he said. "It's really going to need the prospective component. The International Pediatric Stroke Study gives us the grounds for proposing those experiments."

Drs. Felling and Cohen had no disclosures.

LINK UP FOR RELATED INFORMATION:

Ichord R. Cerebral sinovenous thrombosis. Front Pediatr 2017: 5:163.