Trans-sinus fracture as the gatekeeper: a two-step clinical strategy to guide venous imaging in mild-to-moderate traumatic brain injury
Year: 2026
Type: article
Study design: Observational Study
Abstract: Background: Traumatic cerebral venous sinus thrombosis (tCVST) is an underrecognized complication of traumatic brain injury (TBI). Despite its potential for serious neurological sequelae, no consensus exists regarding indications for CT venography (CTV) or MR venography (MRV) in patients with mild-to-moderate TBI. Trans-sinus fracture has been identified as a risk factor for tCVST, yet its predictive value alone remains insufficient to guide clinical decision-making. Objective: To propose a two-step clinical decision strategy for guiding venous imaging selection in mild-to-moderate TBI, using trans-sinus fracture as a gatekeeper followed by D-dimer and headache visual analog scale (VAS) score stratification. Methods: This single-center retrospective cohort study included 528 patients with mild-to-moderate TBI (Glasgow Coma Scale score > 8) who underwent CTV, MRV, or digital subtraction angiography between January 2024 and January 2026. Firth penalized logistic regression was employed to identify tCVST predictors. A two-step strategy was derived: Step 1 screened for trans-sinus fracture; Step 2 applied D-dimer threshold ≥ 3.95 mg/L or headache VAS score ≥ 3 in trans-sinus fracture-positive patients. Results: < 0.0001). As a standalone gatekeeper, trans-sinus fracture yielded sensitivity 58.5%, specificity 89.1%, negative predictive value 96.3%, and positive likelihood ratio 3.96. Among trans-sinus fracture-positive patients, the high-risk subgroup (D-dimer ≥ 3.95 mg/L or VAS ≥ 3) exhibited a tCVST rate of 31.2%, compared with 4.3% in the low-risk subgroup. The two-step strategy achieved a number needed to image of 3, avoiding 85% of unnecessary venous examinations compared with universal screening, and reduced the number needed to image from 13 (universal approach) to 3 (two-step approach). Conclusions: This two-step strategy represents a simple, bedside-ready exploratory tool that may help optimize CTV/MRV selection in mild-to-moderate TBI by identifying a high-yield subgroup for targeted imaging. These findings are hypothesis-generating and require prospective external validation before clinical implementation.
Source: Frontiers in Neurology
Language: English
Subfield: Clinical Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,801
OpenAlex ID: W7223180838