Progressive posttraumatic superior sagittal sinus thrombosis complicated by pulmonary embolism. Case report

Pulmonary embolus from acute superior sagittal sinus thrombosis secondary to skull fracture: case report

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.

A review of therapeutic strategies for the management of cerebral venous sinus thrombosis

OBJECT

Although initially described in the 19th century, cerebral venous sinus thrombosis (CVST) remains a diagnostic and therapeutic dilemma. It has an unpredictable course, and the propensity for hemorrhagic infarction produces significant consternation among clinicians when considering anticoagulation. It is the purpose of this review to analyze the evidence available on the management of CVST and to provide appropriate recommendations.

METHODS

A thorough literature search was conducted through MEDLINE and PubMed, with additional sources identified through cross-referencing. A classification and level of evidence assignment is provided for recommendations based on the American Heart Association methodologies for guideline composition.

RESULTS

Of the publications identified, the majority were isolated case reports or small case series. Few prospective trials have been conducted. Existing data support the use of systemic anticoagulation as an initial therapy in all patients even in the presence of intracranial hemorrhage. Chemical and/or mechanical thrombectomy, in conjunction with systemic anticoagulation, is an alternative strategy in patients with progressive deterioration on heparin therapy or in those who are moribund on presentation. Mechanical thrombectomy is probably preferred in patients with preexisting intracranial hemorrhage.

CONCLUSIONS

Effective treatments exist for the management of CVST, and overall outcomes are more favorable than those for arterial stroke. Further research is necessary to determine the role of individual therapies; however, the rarity of the condition poses a significant limitation.

Jugular bulb venous thrombosis caused by mild head injury: a case report

BACKGROUND

We present here the first report of a jugular bulb venous thrombosis after mild head injury, which lacked either a skull fracture or abnormal findings on CT scan.

CASE DESCRIPTION

An 8-year-old boy was hit on the back of the head and experienced headache and vomiting beginning the next morning. A CT scan and cranial x-ray examination failed to reveal any abnormal findings. The patient was treated conservatively; however, his headache and vomiting persisted. At 13 days after the injury, he began to show double vision due to left VIth nerve palsy and bilateral papilloedemas, suggesting an increased ICP. Although repeated CT scan failed to detect abnormal findings in both the supra- and infra-tentorial regions, MRI clearly visualized a thrombus which was situated within the right jugular bulb. Furthermore, MRV demonstrated disruption of venous flow at the jugular bulb. The patient was administered heparin continuously. His symptoms improved and the CSF pressure on lumbar puncture returned to a normal level at 20 days after admission. Magnetic resonance imaging showed resolution of the clot, and MRV appeared to demonstrate partial recanalization simultaneously. The patient was discharged without any neurologic deficits. The clot in the jugular bulb disappeared completely after 4 months, and he could be followed up for 1 year.

CONCLUSION

This case underscores the fact that MRI may represent the exclusive screening examination in cases of sinus thrombosis when it occurs within the jugular bulb, as CT scan fails to reveal any findings suggestive of venous thrombosis.

Persistent intracranial hypertension caused by superior sagittal sinus stenosis following depressed skull fracture. Case report and review of the literature

Intracranial hypertension caused by a compound depressed skull fracture on the posterior part of the superior sagittal sinus is a rare condition, and nonspecific symptoms and signs can delay appropriate diagnosis and treatment. The authors report on a case of intracranial hypertension that persisted despite conservative treatment, including anticoagulation therapy, which did not improve severe flow disturbance related to the venous sinus compression. Management of this rare condition is discussed and the literature is reviewed.

Sigmoid sinus thrombosis after mild closed head injury in an infant: diagnosis by magnetic resonance imaging in the acute phase--case report

Intracranial sinus thrombosis following a mild closed head injury without a skull fracture or intracranial hematoma is extremely rare. A 23-month-old girl presented with vomiting and gait ataxia 1 day after occipital trauma. Computed tomography revealed a slightly increased density area in the region of the left sigmoid sinus. T1-weighted magnetic resonance (MR) imaging demonstrated an isointense area in the left sigmoid sinus and T2-weighted imaging showed a hyperintense area reflecting the characteristics of oxyhemoglobin. MR angiography and cerebral angiography indicated occlusion of the left sigmoid sinus. After 4 days of conservative treatment, her symptoms subsided completely. Follow-up MR angiography and cerebral angiography showed recanalization of the sigmoid sinus. The MR images and MR angiograms were useful for both early diagnosis and follow-up. Treatment should reflect the severity of individual cases, and early diagnosis will help achieve a good outcome.

Reversibility of severe sagittal sinus thrombosis with open surgical thrombectomy combined with local infusion of tissue plasminogen activator: technical case report

OBJECTIVE

To explore the controversial issue of anticoagulant therapy and indications for surgery in association with severe sinus thrombosis.

METHODS

During the last 4 years, we have treated three patients with severe sinus thrombosis of the dural sinuses. All three patients received systemic anticoagulant therapy and, after experiencing neurological deterioration, underwent open thrombectomy and local thrombolysis. After the operation, aggressive intensive care was given and included cerebral perfusion monitoring, barbiturate administration, hyperventilation, and osmotherapy. The treatment was guided by repeated neuroradiological investigations.

RESULTS

All three patients returned to their normal lives.

CONCLUSION

Intracranial sinus thrombosis, even in the worst neurological state, should be treated aggressively. A cornerstone in treatment is systemic anticoagulant therapy and repeated neuroradiological studies. When, despite adequate anticoagulant therapy and intensive care, neurological deterioration occurs, a combination of open thrombectomy and local thrombolytic therapy should be considered.

Sagittal sinus thrombosis after closed head injury

Superior sagittal sinus thrombosis (SSST) is an unusual disorder, most often attributed to hematological abnormalities, oral contraceptive use, or association with the puerperium. Although SSST secondary to trauma has been reported, it still remains an extremely rare entity. Antemortem diagnosis of SSST is made by findings on computed tomographic scanning, cerebral angiography, or magnetic resonance imaging. Prognosis is variable and spontaneous resolution has been reported. Successful treatment options of spontaneous cases include systemic anticoagulation and thrombolytic therapy along with supportive measures. There are currently no guidelines for the management of SSST associated with traumatic brain injury. This report describes a case of SSST in a man who sustained a closed head injury.

Endovascular treatment of traumatic dural sinus thrombosis: case report

OBJECTIVE

Dural sinus thrombosis has rarely been associated with closed head injury. We present a unique case involving the use of endovascular thrombolysis in the treatment of traumatic dural sinus thrombosis, which has not been reported.

CLINICAL PRESENTATION

A 20-year-old male patient suffered a severe closed head injury while skiing. He developed refractory elevated intracranial pressure requiring barbiturate coma. Angiography demonstrated thrombosis of the dominant right transverse and sigmoid sinuses, with partial thrombosis of the superior sagittal sinus. Urokinase was administered via a microcatheter within the thrombus as a bolus of 250,000 units and then as a continuous infusion of 60,000 to 100,000 units per hour for 48 hours. The patient was maintained in a barbiturate coma and heparinized. Serial angiography was performed to assess the sinus patency and efficacy of thrombolysis.

RESULTS

After 48 hours of thrombolysis, angiography demonstrated normal patency of the superior sagittal, right transverse, and right sigmoid sinuses. The intracranial pressure decreased after thrombolysis and was manageable with conventional techniques. Within 48 hours of the completed thrombolysis, the barbiturates were withdrawn and the patient's neurological status rapidly improved until the time of discharge 2 weeks later.

DISCUSSION AND CONCLUSION

This case documents a rare instance of traumatic dural sinus thrombosis resulting from a closed head injury. In addition, endovascular thrombolysis resulted in subsequent opening of the dural sinuses and effective intracranial pressure management, despite the presence of a hemorrhagic contusion. Heparin was effective in maintaining sinus patency and was used safely in conjunction with urokinase in this setting of head injury.

Superior sagittal sinus thrombosis and pulmonary embolism: a syndrome rediscovered

Pulmonary emboli as a fatal complication of superior sagittal sinus thrombosis was once well recognized in the literature but appears to have been forgotten. The sagittal sinus appeared to be the source of pulmonary emboli in previously reported cases. Even in patients with no evidence of systemic thrombosis, but who have sagittal sinus thrombosis, the possibility of dislodging pulmonary emboli should be strongly considered. We report a case of nontraumatic sagittal sinus thrombosis complicated by multiple pulmonary emboli and a fatal saddle embolism, likely originating from the thrombosed sinus. Our review of the literature between 1942 and 1990 yielded 203 cases of intracranial venous thrombosis. The overall mortality rate was 49.3%. In 23 cases (11.3%), the venous sinus thrombosis was associated with pulmonary emboli and in these the overall mortality rate was 95.6%. In the 203 cases in our review, those patients who received anticoagulation therapy also had a statistically significant better outcome. Therefore, the presence of pulmonary emboli in association with sagittal sinus thrombosis mandates a sober assessment of the need of anticoagulation therapy in the absence of obvious contraindication.

Appearance and disappearance of empty delta sign in superior sagittal sinus thrombosis

The diagnostic value of the empty delta sign on post-infusion CT films was investigated in five patients with superior sagittal sinus thrombosis subsequently verified angiographically and/or pathologically. The empty delta sign, which has been considered to be unique and reliable in the diagnosis of cerebral venous sinus occlusion, was observed only on CT films taken one to four weeks after onset, and was not seen in the extremes of the acute or the chronic stage of the illness. These observations may explain why this sign has not been apparent in some reports concerning the CT findings of superior sagittal sinus thrombosis. Recanalization within the thrombus may be the reason why this sign was no longer apparent in the chronic stage of the patients with superior sagittal sinus thrombosis.