Management of a Persistent Oblique Occipital Sinus with Staged Ligation in a Case of Medulloblastoma: A Case Report

Abstract

<b><i>Introduction:</i></b> A patent persistent occipital sinus (OS) can be seen in 10% of adults. The presence of such a dominant draining OS can present as a challenge for posterior fossa surgeries. Occlusion or division of the sinus can cause venous hypertension, causing a cerebellar bulge or increased intra-op bleeding. <b><i>Case report:</i></b> A 3-and-a-half-year-old female child presented with a vermian medulloblastoma with hydrocephalus. MR venography (MRV) revealed a large patent OS draining from the torcula to the right sigmoid sinus. She underwent a left Frazier’s point VP shunt followed by a midline suboccipital craniotomy for the lesion. The OS was divided during a “Y”-shaped durotomy. Following the sinus ligation, there was a significant cerebellar bulge and excessive bleeding from the lesion. We released cisternal CSF and punctured the tumor cysts to allow the brain bulge to settle. Hemostasis was secured, and surgery was deferred, an augmented duroplasty was done, and bone flap was removed to allow for intracranial pressure decompression. The patient was electively ventilated for 24 h and weaned off gradually. A repeat MRV at 7 days showed the reorganization of the venous outflow at the torcula. Reexploration with tumor resection was done on post-op day 10. The patient recovered well from the surgery and was referred for adjuvant therapy. <b><i>Conclusion:</i></b> Surgeons should carefully analyze venous anatomy before posterior fossa surgeries. The persistent dominant OS, when present, should be taken care of while planning the durotomy. A hypoplastic but persistent transverse sinus allowed us to ligate and divide the OS. By doing a staged division of the sinus, reorganization of the venous outflow from the torcula can be allowed to occur, and the lesion can be resected.

The effect of the occipital sinus on the torcular Herophili and neighboring structures

“…OS injury should be avoided during open surgery and occipital screw fixation [ 6 ]. A hyperplastic oblique OS could present a hazardous surgical challenge for posterior fossa surgery, and craniotomy or dural opening can result in hazardous bleeding, air embolism, and intraoperative brain bulge due to venous hypertension [ 14 ]. Rarely, symptomatic intracranial hypertension can occur due to thrombosis of a persistent OS [ 15 ].…”