Objective:

We aimed to determine the incidence of intracranial thrombotic complications and to assess imaging sensitivity in children with sinusitis (SIE) or otomastoiditis (OIE) with intracranial extension.

Background:

SIE and OIE carry significant morbidity in pediatric patients, including cerebral sinus venous thrombosis (CSVT), reported to occur in 6-47% of cases. Few published cohorts include MRI for all patients, which may underestimate rates of thrombotic complications, leading to delayed use of antithrombotic therapy.

Design/Methods:

Retrospective data were collected from patients ≤18 years admitted from 2018-2023 with diagnosis codes confirming SIE or OIE. Imaging findings were classified as no thrombosis, possible thrombosis, or definitive thrombosis based on radiologist interpretation. McNemar’s test compared CT versus MRI for thrombus detection.

Results:

Our cohort (n=40) was 59% male, with an average age of 9.9 years. Among SIE patients (n=29), 62% developed epidural abscess, 45% subdural empyema, 10% intraparenchymal abscess and 17% cerebritis. Ninety percent (90%) of SIE patients developed CSVT. Among OIE patients (n=11), 64% developed epidural abscess, 27% subdural empyema, 9% intraparenchymal abscess and none cerebritis. Ninety-one percent (91%) of OIE patients developed CSVT.

Contrast-enhanced MRI was obtained in 39/40 patients during admission. CT comprised the first brain imaging studies at presentation in 78% (n=31) of patients (52% [16/31] with contrast), while MRI was the first study in 22% (n=9) of patients (89% [8/9] with contrast). Seventy-five percent (75%) underwent repeat imaging within 48 hours. Of 15 patients with paired CT and MRI, non-contrast CTH definitively identified 0/9 thrombi found on MRI. Contrast CTH identified thrombi in 4/5 patients. Non-contrast CTH was significantly less sensitive than MRI/MRV (p=0.008).

Conclusions:

CSVT occurred in 90% of patients—far more than previously reported. Given the high incidence of CSVT and poor sensitivity of non-contrast CTH, early contrast CTH or MRI/MRV should be prioritized with potential SIE/OIE, leading to earlier initiation of antithrombotic therapy.