Timing and Safety of Anticoagulation in Patients with a Traumatic Cerebral Venous Sinus Thrombosis and Intracranial Hemorrhage.

BACKGROUND: In traumatic cerebral venous sinus thrombosis (tCVST) with concurrent intracranial hemorrhage (tICH), clinicians must balance thrombus control against the risk of hemorrhagic expansion. Available evidence is heterogeneous, with variable outcomes and inconsistent recommendations. We aimed to synthesize the literature to clarify the timing and safety of therapeutic anticoagulation (AC). METHODS: We conducted a PRISMA guided systematic review of adults with tCVST and tICH from inception through October 2025. Eligible studies included adults with concurrent tCVST and tICH and at least one group receiving therapeutic AC; prophylactic-dose and untreated comparator groups were retained when reported. Extracted variables included AC type, timing of initiation after trauma, venous recanalization, mortality, and functional outcomes. Findings were summarized descriptively, with attention to AC timing and radiographic stability criteria. RESULTS: Seven studies including 410 patients met inclusion criteria. All were single center retrospective cohorts. The most commonly used agents were unfractionated heparin or low molecular weight heparin, often followed by warfarin. Direct oral anticoagulants were rarely reported. AC initiation ranged from 41 hours to 13.5 days after trauma. Radiographic stability criteria before AC were inconsistently defined. Hemorrhagic complications ranged from 0% in cohorts initiating AC only after stable repeat imaging to 21% in a cohort without such criteria. Recanalization was generally high, and recurrent CVST was rarely reported. Functional outcomes were usually stable or improved among survivors. CONCLUSIONS: Current retrospective evidence does not establish a clear benefit of therapeutic AC for recanalization or functional outcomes. Bleeding appeared uncommon when AC was started after a stable repeat head CT. Standardized definitions and prospective multicenter studies are needed.