Improvement in venous outflow following superior sagittal sinus decompression after a gunshot wound to the head: case report

Abstract

The most commonly described indications for surgical management of closed depressed skull fractures are hematoma evacuation and repair of extensive cosmetic deformity. Venous sinus injury, which occurs in a subset of depressed skull fractures is not typically listed as an indication for surgical treatment due to the potential for major venous hemorrhage associated with operation near these structures. However, if patients exhibit signs and symptoms of intracranial hypertension and radiographic findings demonstrate sinus compromise, surgical elevation of the depressed skull fragments is indicated. The authors present the case of a 25-year-old woman with a depressed skull fracture secondary to a gunshot wound with symptomatic compromise in venous outflow of the posterior one-third of the superior sagittal sinus. The patient was treated with surgical decompression via bilateral craniectomy along with intracranial pressure lowering medical therapy and had almost full resolution of her presenting symptoms with documented improvement in flow through the superior sagittal sinus. While the use of surgical treatment for these types of injuries is highly debated we demonstrate here that safe, effective surgical management of these patients is possible and that surgical decompression should always be considered in the case of symptomatic venous sinus flow obstruction.

Delayed Neurological Deterioration after Depressed Fracture over Superior Sagittal Sinus: Our Experience with 13 Patients

“…The use of a thecoperitoneal shunt to relieve the It is better to restore the normal functional anatomy via surgical elevation of the depressed segment and allow sinus flow, especially if the sinus is partially or completely occluded. 16 Failure of surgery to restore the flow warrants insertion of a thecoperitoneal shunt. Fuentes et al described successful treatment of increased intracranial pressure in two patients after surgical elevation of depressed skull fractures over the SSS.…”

Traumatic open depressed cranial fracture causing occlusion of posterior superior sagittal sinus

“…[ 1 , 14 , 15 ] For example, the bone fragment could be left in place and drilled to an eggshell thickness when there was a high risk of venous sinus bleeding. [ 7 ] Angiographic imaging like CTA and MRV are highly recommend in all patients presenting with symptoms of increased intracranial pressure after DCFs for early diagnosis of SSS occlusion and appropriate surgical planning. [ 2 , 15 ]…”

“…Therefore, more aggressive management of the lacerated sinus like SSS reconstitution was not performed as these procedures would carry additional risks of iatrogenic injuries. [ 1 , 7 ] Instead, meticulous intracerebral bone fragments removal and duraplasty with periosteum were performed to reduce the risk of complications like infection and CSF leak.…”

“…[ 4 – 6 ] Moreover, surgical intervention involving major sinus are suggested to be postponed until there is evidence of active bleeding or development of intracranial hypertension (ICH). [ 7 , 8 ] Nevertheless, in cases with compound/open DCFs or when the posterior third of the SSS is affected, surgical intervention is warranted with the aims of the closure of the dura tear and prevention of the occurrence of fatal ICH. [ 9 ] The authors present here a 22-year-old male with an open DCF in the left parietooccipital bone and the fracture extended across the posterior third of the SSS to the right parietal bone.…”

Compound Depressed Fracture Over Dural Venous Sinuses: Experience of 22 Surgically Treated Cases

“…So cases with major sinus injury, conservative treatment are advised unless there is active bleeding or development of idiopathic intracranial hypertension (ICH) [8,9] .…”