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Ma L, Nail TJ, Hoz SS, Puccio AM, Lang MJ, Okonkwo DO, Gross BA. Traumatic Cerebral Venous Sinus Thrombosis: Management and Outcomes. World Neurosurg 2024; 187:e949-e962. [PMID: 38735561 DOI: 10.1016/j.wneu.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/03/2024] [Accepted: 05/04/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) with skull fractures parallel to or crossing venous sinuses is a recognized risk factor for traumatic cerebral venous sinus thrombosis (tCVST). Despite the recognition of this traumatic pathology in the literature, no consensus regarding management has been achieved. This study aimed to evaluate the impact of tCVST on TBI outcomes and related complications. METHODS Patients within a prospective registry at a level I trauma center from 2014 to 2023 were reviewed to identify tCVST cases. The impact of tCVST presence on Glasgow Outcome Scale scores at 6 months, 30-day mortality, and hospital length of stay were evaluated in multivariable-adjusted analyses. RESULTS Among 607 patients with TBI, 61 patients were identified with skull fractures extending to the vicinity of venous sinuses with dedicated venography. Twenty-eight of these 61 patients (44.3%) had tCVST. The majority (96.4%) of tCVST were located in a unilateral transverse or sigmoid sinus. Complete recanalization was observed in 28% of patients on follow-up imaging (7/25 with follow-up imaging). None of the 28 patients suffered attributable venous infarcts or thrombus propagation. In the adjusted analysis, there was no difference in the 30-day mortality or Glasgow Outcome Scale at 6 months between patients with and without tCVST. CONCLUSIONS Unilateral tCVST follows a benign clinical course without associated increased mortality or morbidity. The management of tCVST should be distinct as compared to spontaneous CVST, likely without the need for anticoagulation.
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Affiliation(s)
- Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tara Jayde Nail
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Isolated Increased Intracranial Pressure and Unilateral Papilledema in an Infant With Traumatic Brain Injury and Nondepressed Basilar Skull Fracture. Pediatr Emerg Care 2019; 35:e198-e200. [PMID: 31688803 DOI: 10.1097/pec.0000000000001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Traumatic brain injury is one of the most common pediatric injuries; totaling more than 500,000 emergency department visits per year. When the injury involves a skull fracture, sinus venous thrombosis and the risk of resultant increased intracranial pressure (ICP) are a concern. We describe a previously healthy 11-month-old female infant with nondepressed skull fracture who developed increased ICP in the absence of intracranial changes on imaging. Funduscopic examination revealed unilateral papilledema, and opening pressure on lumbar puncture was elevated at 35 cm of H2O. Computed tomography scan demonstrated a nondepressed occipital bone fracture. However, further imaging, including magnetic resonance imaging with angiogram/venogram, did not reveal any intracranial abnormalities. In particular, there was no evidence of sinus venous thrombosis. Given her presentation and signs of increased ICP, she was started on acetazolamide and improved dramatically. A thorough literature search was completed but yielded no information on infants with increased ICP after nondepressed skull fracture in the absence of radiographic findings to suggest a cause for the increase in pressure. Trauma alone can lead to increased ICP secondary to several processes, although this is expected in moderate to severe head trauma. Our case demonstrates that increased ICP can be present in infants with mild traumatic brain injury in the absence of intracranial pathology. This should be considered in patients who present with persistent vomiting that is refractory to antiemetics.
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Zabalo San Juan G, Vázquez Míguez A, Zazpe Cenoz I, Casajús Ortega A, García Campos M, de Frutos Marcos D, García Romero JC. Intracranial hypertension caused by superior sagittal sinus stenosis secondary to a depressed skull fracture: Case report and review of the literature. Neurocirugia (Astur) 2019; 30:243-249. [DOI: 10.1016/j.neucir.2018.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/07/2018] [Accepted: 10/09/2018] [Indexed: 10/27/2022]
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Pescatori L, Tropeano MP, Mancarella C, Prizio E, Santoro G, Domenicucci M. Post traumatic dural sinus thrombosis following epidural hematoma: Literature review and case report. World J Clin Cases 2017; 5:292-298. [PMID: 28798925 PMCID: PMC5535321 DOI: 10.12998/wjcc.v5.i7.292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/22/2016] [Accepted: 03/17/2017] [Indexed: 02/05/2023] Open
Abstract
Dural sinus thrombosis following a head trauma is a rare condition, described in literature along with the lack of consensus regarding diagnosis and management. We present a case of a fifty-year-old man with a head injury and combined supratentorial-subtentorial epidural hematoma who was treated conservatively through the administration of low molecular weight heparin. The diagnosis and management of this condition are discussed based on a literature review. The early diagnosis may prevent potentially treatable poor outcomes.
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Maruya J, Tamura S, Miyauchi T, Nishimaki K. Lateral sinus thrombosis following minor head injury in children. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2017. [DOI: 10.1016/j.inat.2016.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Araki T, Yokota H, Morita A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol Med Chir (Tokyo) 2017; 57:82-93. [PMID: 28111406 PMCID: PMC5341344 DOI: 10.2176/nmc.ra.2016-0191] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Pediatric TBI is associated with several distinctive characteristics that differ from adults and are attributable to age-related anatomical and physiological differences, pattern of injuries based on the physical ability of the child, and difficulty in neurological evaluation in children. Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. Here a review of recent studies relevant to important issues in pediatric TBI is presented, and recent specific topics are also discussed. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of pediatric TBI.
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Affiliation(s)
- Takashi Araki
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
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Yun JH, Ko JH, Lee MJ. Early Spontaneous Recanalization of Sigmoid Sinus Thrombosis Following a Closed Head Injury in a Pediatric Patient : A Case Report and Review of Literature. J Korean Neurosurg Soc 2015; 58:150-4. [PMID: 26361534 PMCID: PMC4564750 DOI: 10.3340/jkns.2015.58.2.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 02/03/2015] [Accepted: 03/02/2015] [Indexed: 12/28/2022] Open
Abstract
Cerebral venous sinus thrombosis (CVST) following a closed head injury in pediatric patients is a rare condition, and an early spontaneous recanalization of this condition is extremely rare. A 10-year-old boy was admitted with a mild, intermittent headache and nausea five days after a bicycle accident. The brain computed tomography showed an epidural hematoma at the right occipital area with pneumocephalus due to a fracture of the occipital skull bone. The brain magnetic resonance imaging and the magnetic resonance venography demonstrated a flow signal loss from the right sigmoid sinus to the right jugular vein. The diagnosis was sigmoid sinus thrombosis, so close observations were selected as a treatment for the patient because of his gradually improving symptoms; however, he complained of vomiting 14 days the after conservative treatment. The patient was readmitted for a further examination of his symptoms. The laboratory and the gastroenterological examinations were normal. Due to concern regarding the worsening of the sigmoid sinus thrombosis, the brain magnetic resonance venography was rechecked and it revealed the recanalization of the venous flow in the sigmoid sinus and in the jugular vein.
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Affiliation(s)
- Jung-Ho Yun
- Department of Neurological Surgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jung Ho Ko
- Department of Neurological Surgery, Dankook University College of Medicine, Cheonan, Korea
| | - Mee Jeong Lee
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
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Fahim DK, Luo L, Patel AJ, Robertson CS, Gopinath SP. Pulmonary embolus from acute superior sagittal sinus thrombosis secondary to skull fracture: case report. Neurosurgery 2011; 68:E1756-60; discussion E1760. [PMID: 21389895 DOI: 10.1227/neu.0b013e3182171439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Pulmonary embolus (PE) occurring concurrent with-and as a result of-traumatic superior sagittal sinus thrombosis (SSST) has never before been reported. We report the first case of a patient who presented with acute traumatic SSST and concomitant PE. CLINICAL PRESENTATION A 30-year-old man presented with altered mental status after a motorcycle collision, and subsequently developed respiratory distress. Computed tomography (CT) scanning of the head revealed multiple calvarial and skull base fractures, contusions, and hemorrhages. Air was noted within the superior sagittal sinus, indicating a fracture involving the sinus and suggesting thrombus formation. A chest CT scan obtained at the time of presentation revealed a PE in the right pulmonary artery. The patient had no personal or family history of hypercoagulability, and all coagulation study results were within normal limits. Work-up revealed no evidence of long bone fractures or deep venous thrombosis. Initial intervention involved placement of an external ventricular drain, brain tissue oxygen saturation probe, internal jugular venous oxygen saturation monitor, arterial line, and central venous line with extensive treatment of all abnormal values according to established standards. Ultimately, pentobarbital coma was initiated for persistently elevated intracranial pressure (ICP) refractory to conservative measures. Aggressive pulmonary resuscitation was required to maintain adequate oxygenation. Anticoagulation was begun 3 weeks after admission. CONCLUSION Our patient had good neurological recovery. This report highlights the possibility of acute PE in the setting of traumatic SSST.
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Affiliation(s)
- Daniel K Fahim
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA.
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Cerebral Venous Thrombosis: A Potential Mimic of Primary Traumatic Brain Injury in Infants. AJR Am J Roentgenol 2011; 197:W503-7. [DOI: 10.2214/ajr.10.5977] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Dlamini N, Billinghurst L, Kirkham FJ. Cerebral venous sinus (sinovenous) thrombosis in children. Neurosurg Clin N Am 2011; 21:511-27. [PMID: 20561500 PMCID: PMC2892748 DOI: 10.1016/j.nec.2010.03.006] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cerebral venous sinus (sinovenous) thrombosis (CSVT) in childhood is a rare, but underrecognized, disorder, typically of multifactorial etiology, with neurologic sequelae apparent in up to 40% of survivors and mortality approaching 10%. There is an expanding spectrum of perinatal brain injury associated with neonatal CSVT. Although there is considerable overlap in risk factors for CSVT in neonates and older infants and children, specific differences exist between the groups. Clinical symptoms are frequently nonspecific, which may obscure the diagnosis and delay treatment. While morbidity and mortality are significant, CSVT recurs less commonly than arterial ischemic stroke in children. Appropriate management may reduce the risk of recurrence and improve outcome, however there are no randomized controlled trials to support the use of anticoagulation in children. Although commonly employed in many centers, this practice remains controversial, highlighting the continued need for high-quality studies. This article reviews the literature pertaining to pediatric venous sinus thrombosis.
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Affiliation(s)
- Nomazulu Dlamini
- The Hospital For Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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Mathew JE, Sharma A. Bizarre depressed skull fracture by a tile fragment in a young child, causing superior sagittal sinus injury. Surg Neurol Int 2010; 1:52. [PMID: 20975970 PMCID: PMC2958324 DOI: 10.4103/2152-7806.69379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 08/10/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Head injuries following fall from height are not very uncommon in developing countries due to a lack of safety standards. We describe this bizarre injury by a tile fragment penetrating the superior sagittal sinus (SSS) and its successful surgical management. CASE DESCRIPTION A 7-year-old child presented with a tile fragment embedded in the skull, penetrating SSS. Urgent exploration and removal of the foreign body was done to prevent complications like infection and delayed development of intracranial hypertension. Although bleeding from the SSS was a problem, this was tackled by raising the head end and giving pressure with Surgicel and Gelatine sponge. This ensured a favorable outcome. CONCLUSION Although compound depressed fractures of the SSS are managed conservatively due to the risk of fatal venous hemorrhage, the unique nature of the injury in this case warranted surgical management. This case illustrates that even in such a scenario, adherence to neurosurgical principles can ensure a good outcome.
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Affiliation(s)
- Jacob Eapen Mathew
- Department of Neurosurgery, Christian Medical College, Ludhiana - 141 008, Punjab, India
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Abstract
OBJECTIVE The purpose of this manuscript is to review the various etiologies and to discuss the therapeutic issues in childhood stroke. METHODS A PubMed search of literature pertaining to childhood stroke was conducted from 1983 to 2008 using specific key search words pertinent to cerebrovascular disorders in childhood. RESULTS The analysis of the multiple causes of childhood stroke including arterial ischemic strokes and cerebral venous thrombosis was presented. Current therapy and outcome data in childhood stroke are also discussed throughout the length of the article. CONCLUSIONS With increasing vigilance among physicians and improved neuroimaging modalities, the diagnosis of childhood stroke is now made earlier, with increasing frequency and greater accuracy. However, larger and well-controlled studies regarding the optimal management of childhood stroke in terms of the use of both antithrombotic drugs and anticoagulation are still needed in addition to longitudinal follow-up studies of children with stroke.
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Affiliation(s)
- Rosario Maria S Riel-Romero
- Louisiana State University Health Sciences Center, School of Medicine in Shreveport, Shreveport, LA 71130, USA.
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Bishop FS, Finn MA, Samuelson M, Schmidt RH. Endovascular balloon angioplasty for treatment of posttraumatic venous sinus thrombosis. Case report. J Neurosurg 2009; 111:17-21. [PMID: 19326975 DOI: 10.3171/2009.2.jns08491] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In severe cases, posttraumatic cerebral sinus thrombosis can result in venous congestion and persistent intracranial hypertension refractory to both conventional medical therapy and surgical decompression. The authors report a unique case of a patient successfully treated with endovascular mechanical thrombolysis using balloon angioplasty for clinically significant posttraumatic venous sinus thrombosis and review the reported treatments for cerebral venous sinus occlusive disease. This 18-year-old man suffered severe closed head injury from a fall while skateboarding. A head CT scan demonstrated basilar skull fractures involving the left jugular foramen. A CT angiogram revealed thrombosis of the left transverse sinus and occlusion of the sigmoid sinus and internal jugular vein. Despite treatment with anticoagulation therapy and decompressive hemi- and suboccipital craniectomies, intracranial hypertension remained refractory. Serial angiography demonstrated progressive sinus occlusion. Endovascular balloon thrombolysis of the left transverse and sigmoid sinuses resulted in immediate reduction of intracranial pressures and improved sinus patency. Intracranial pressure measurements remained low after the procedure. The patient eventually improved neurologically, was able to follow commands and walk, and was discharged to a rehabilitation facility for further recovery. Anticoagulation therapy, surgical decompression, and endovascular thrombolysis have been reported as treatment modalities for clinically significant posttraumatic venous sinus thrombosis. In this case, endovascular mechanical thrombolysis with balloon angioplasty resulted in resolution of thrombus and successful immediate reduction of intracranial pressure. This treatment may be considered in patients with critically elevated intracranial pressure from posttraumatic venous sinus occlusion refractory to other treatment measures.
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Affiliation(s)
- Frank S Bishop
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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