Depressed skull fracture overlying the superior sagittal sinus as a cause of benign intracranial hypertension. Case report

Airgun Wound with Superior Sagittal Sinus Involvement in a Child: Case Report and Review of the Literature

INTRODUCTION

Although still considered quite harmless, nonpowder guns (NPG) may cause severe head injuries in children. We present the case of a depressed skull fracture with superior sagittal sinus involvement following NPG injury. Decision-making and surgical management are discussed, and the current literature concerning NPG-related pediatric head injuries is reviewed.

CASE PRESENTATION

A 4-year-old boy hit by a compressed-air rifle came to our center. CT scan showed a depressed skull fracture of the occipital bone on the midline and intracranial penetration of some fragments of the pellet. CT angiography documented a compression of the superior sagittal sinus without thrombosis. Soon after hospital admission, the patient showed deterioration of the neurological status suggesting intracranial hypertension. Surgery was performed with fracture elevation, removal of metal fragments, and wound debridement. The patient had a full recovery without subsequent neurological deficits.

DISCUSSION/CONCLUSION

Modern airguns may produce severe penetrating head injuries in children. Parents and physicians should be aware of the danger of NPG. Depressed skull fracture and dural venous sinus involvement can occur, and even a stable neurological condition may worsen. In such instances, a thorough preoperative assessment including vascular imaging is mandatory. The surgical risk is not negligible due to the possible injury of the sinus wall and subsequent intraoperative bleeding. This has to be weighted against potential complications of the penetrating injury, such as infection, sinus thrombosis, and intracranial hypertension. Our case suggests that prompt surgical treatment can be a safe and effective option.

Pediatric cerebral venous sinus thrombosis or compression in the setting of skull fractures from blunt head trauma

OBJECTIVE Pediatric cerebral venous sinus thrombosis has been previously described in the setting of blunt head trauma; however, the population demographics, risk factors for thrombosis, and the risks and benefits of detection and treatment in this patient population are poorly defined. Furthermore, few reports differentiate between different forms of sinus pathology. A series of pediatric patients with skull fractures who underwent venous imaging and were diagnosed with intrinsic cerebral venous sinus thrombosis or extrinsic sinus compression is presented. METHODS The medical records of patients at 2 pediatric trauma centers were retrospectively reviewed. Patients who were evaluated for blunt head trauma from January 2003 to December 2013, diagnosed with a skull fracture, and underwent venous imaging were included. RESULTS Of 2224 pediatric patients with skull fractures following blunt trauma, 41 patients (2%) underwent venous imaging. Of these, 8 patients (20%) had intrinsic sinus thrombosis and 14 patients (34%) displayed extrinsic compression of a venous sinus. Three patients with intrinsic sinus thrombosis developed venous infarcts, and 2 of these patients were treated with anticoagulation. One patient with extrinsic sinus compression by a depressed skull fracture underwent surgical elevation of the fracture. All patients with sinus pathology were discharged to home or inpatient rehabilitation. Among patients who underwent follow-up imaging, the sinus pathology had resolved by 6 months postinjury in 80% of patients with intrinsic thrombosis as well as 80% of patients with extrinsic compression. All patients with intrinsic thrombosis or extrinsic compression had a Glasgow Outcome Scale score of 4 or 5 at their last follow-up. CONCLUSIONS In this series of pediatric trauma patients who underwent venous imaging for suspected thrombosis, the yield of detecting intrinsic thrombosis and/or extrinsic compression of a venous sinus was high. However, few patients developed venous hypertension or infarction and were subsequently treated with anticoagulation or surgical decompression of the sinus. Most had spontaneous resolution and good neurological outcomes without treatment. Therefore, in the setting of pediatric skull fractures after blunt injury, venous imaging is recommended when venous hypertension or infarction is suspected and anticoagulation is being considered. However, there is little indication for pervasive venous imaging after pediatric skull fractures, especially in light of the potential risks of CT venography or MR venography in the pediatric population and the unclear benefits of anticoagulation.

Impact of depressed skull fracture surgery on outcome of head injury patients

Objective:

To assess outcomes in surgically managed patients with depressed skull fractures and associated moderate to severe head injury.

Methods:

The study was conducted in the Department of Neurosurgery Jinnah Postgraduate Medical Centre, Karachi, from January 2016 to December 2017. We analyzed 90 patients with depressed skull fracture managed surgically from January 2015 to December 2016. The patients selected for this study belonged to all age groups with clinically palpable depressed skull fracture confirmed by CT brain with bone window. Outcome was assessed by Glasgow outcome score.

Results:

Total 90 patients were included in the study. Sixty (66.7%) were male and 30 (33.3%) were female with mean age of years 27.58+11.329. Among 90 patients, 38.8% were aged between 21 and 30 years. Road traffic accident was seen in 72 (80%) patients. The commonest site of fracture was frontal region in 50 patients (55.6%). GCS improved post operatively on comparison to preoperative. Five patients expired.

Conclusion:

Depressed skull fracture is common neuro surgical issue. Timely surgical management gives excellent results by decreasing morbidity and mortality.

Post traumatic dural sinus thrombosis following epidural hematoma: Literature review and case report

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.

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

RATIONALE

The superior sagittal sinus (SSS) is the major dural sinuses that receive a considerable amount of venous drainage. Interruption of its posterior third has been suggested to cause intracranial hypertension and lead to potentially fatal consequences.

PATIENT CONCERNS

We presented a 22-year-old man with a severe headache and scalp bleeding after a head chop wound. Physical examination identified a 20-cm straight laceration in his parietooccipital scalp. Computed tomography (CT) demonstrated a depressed cranial fracture (DCF) in the left parietooccipital bone, a fracture line across the midline to the right side, and penetrations of bone fragments into the brain parenchyma.

DIAGNOSES

Traumatic open DCF in left parietooccipital bone.

INTERVENTIONS

An emergent left parietooccipital craniotomy, followed by cranioplasty to restore the depressed bone flap, was delivered to the patient. Postoperative CT confirmed successful elevation of the DCF and removal of intracerebral bone fragments. However, postoperative CT angiography (CTA) demonstrated an absence of venous flow distal to the fracture, suggesting occlusion of the posterior third of SSS. MRV revealed a persistent absence of venous flow in the posterior third of SSS with dilated cortical venous drainage. Anticoagulation treatment was initiated 3 days after surgery, and follow-up CTA and digital subtraction angiography showed gradually improved patency in the anterior and middle two-thirds of SSS.

OUTCOMES

Despite occlusion of the posterior third of SSS, patient's symptoms resolved after the operation and he was discharged without complications.

LESSONS

The favorable clinical outcome after complete occlusion of the posterior third of the SSS has rarely been reported and it might be explained by our timely surgical intervention and development of compensatory cerebral collateral circulation.

Traumatic elevated vertex fracture with delayed increase in intracranial pressure: a rare case

INTRODUCTION

Skull fractures are traditionally classified into linear, comminuted or depressed which can either be simple or compound. A skull fracture where the bone fragment is elevated above the intact skull known as elevated skull fracture has been reported infrequently in literature.

CASE PRESENTATION

We report a unique case of simple elevated vertex fracture in a 3-month-old child where the vertex had separated from the calvarium and was elevated above the level of outer table in a patient with delayed neurological deterioration. Cerebrospinal fluid leak into tight subgaleal space and gradual thrombosis of superior sagittal sinus could have led to late clinical deterioration.

CONCLUSION

Prolonged monitoring, probably early repair of dural tear and aggressive management of raised ICP, is required. Reduction of fracture with careful manipulation of SSS should weigh the risk of exsanguination. No such case of an elevated vertex fracture has been reported so far in the literature.

Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure

For 200 years, the 'closed box' analogy of intracranial pressure (ICP) has underpinned neurosurgery and neuro-critical care. Cushing conceptualised the Monro-Kellie doctrine stating that a change in blood, brain or CSF volume resulted in reciprocal changes in one or both of the other two. When not possible, attempts to increase a volume further increase ICP. On this doctrine's "truth or relative untruth" depends many of the critical procedures in the surgery of the central nervous system. However, each volume component may not deserve the equal weighting this static concept implies. The slow production of CSF (0.35 ml/min) is dwarfed by the dynamic blood in and outflow (∼700 ml/min). Neuro-critical care practice focusing on arterial and ICP regulation has been questioned. Failure of venous efferent flow to precisely match arterial afferent flow will yield immediate and dramatic changes in intracranial blood volume and pressure. Interpreting ICP without interrogating its core drivers may be misleading. Multiple clinical conditions and the cerebral effects of altitude and microgravity relate to imbalances in this dynamic rather than ICP per se. This article reviews the Monro-Kellie doctrine, categorises venous outflow limitation conditions, relates physiological mechanisms to clinical conditions and suggests specific management options.

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

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 surgery 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, the authors 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.

Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion

OBJECT

Intracranial hypertension resulting from compression of the superior sagittal sinus (SSS) by an overlying depressed calvarial fracture is a rare condition. Primary surgical treatment for the symptomatic patient in this setting traditionally involves elevation of the fracture, which often carries significant associated morbidity.

METHODS

The authors report a case involving a 6-year-old boy who suffered a closed, depressed, parietooccipital fracture as the result of an unhelmeted all-terrain vehicle accident. This fracture caused compression and subsequent thrombosis of the SSS, which resulted in CSF malabsorption and progressive intracranial hypertension. Initially headache free following the injury, he had developed severe and unremitting headaches by postinjury Day 7. A CT angiography study of the head obtained at this time exhibited thrombosis of the SSS underlying the depressed calvarial fracture. Subsequent lumbar puncture demonstrated markedly elevated intrathecal pressures. Large volumes of CSF were removed, with temporary improvement in symptoms. After medical management with anticoagulation failed, the decision was made to proceed with image-guided ventriculoperitoneal shunt insertion.

RESULTS

The patient's headaches resolved immediately following the procedure, and anticoagulation therapy was reinstituted. Follow-up images obtained 4 months after the injury demonstrated evidence of resolution of the depressed fracture, with recanalization of the SSS. The anticoagulation therapy was then discontinued. To the authors' knowledge, this report is the first description of ventriculoperitoneal shunt insertion as the primary treatment of this infrequent condition.

CONCLUSIONS

This report demonstrates that select patients with this presentation can undergo CSF diversion in lieu of elevation of the depressed skull fracture-a surgical procedure shown to be associated with increased risks when the depressed fracture overlies the posterior SSS. The literature on this topic is reviewed and management of this condition is discussed.

Intracranial retained stone after depressed skull fracture: problems in the initial diagnosis

In this article, a 9-year-old male patient with a compound depressed skull fracture overlying the superior sagittal sinus and an intracranial stone foreign body is presented. A cerebral penetrating injury caused by a stone is rare. The computed tomography images obtained at standard window widths and window density levels may not reveal a retained stone, which has a chemical structure similar to bone and may not show any artifacts in the computed tomography scans.

Isolated intracranial hypertension as a late manifestation of sinus venous compression secondary to a depressed skull fracture

Cerebral venous sinus compression can mimic idiopathic intracranial hypertension. The authors report the case of a 12-year-old girl who presented with diplopia and papilledema 3 weeks after a head injury. Lumbar puncture confirmed raised intracranial pressure, and neuroimaging subsequently identified a skull fracture compressing the right transverse sinus. Papilledema and diplopia resolved following surgical elevation of the bone fragment. Computer tomography or magnetic resonance venography are indicated in children presenting with isolated intracranial hypertension following head injury to exclude cerebral venous sinus compression secondary to skull fracture.

Depressed skull fracture overlying the superior sagittal sinus causing benign intracranial hypertension. Description of two cases and review of the literature

The purpose of this report is to describe successful surgical treatment of benign intracranial hypertension (BIH) in two patients presenting with depressed skull fractures over the superior sagittal sinus (SSS). The first case involved a 22-year-old patient who presented with depressed skull fracture overlying the posterior third of the SSS. Symptoms of BIH developed within 48 h. The second case involved a 33-year-old patient who presented with depressed skull fracture overlying the junction between the middle and posterior thirds of the SSS. Symptoms of BIH developed 1 month after. Although this patient presented with bilateral papilloedema, the less straightforward nature of his BIH symptoms prompted us to undertake further neuroradiological assessment by angiography with retrograde venous catheterization. A high-pressure gradient was found between venous flow upstream and downstream from the compressed zone. Both patients underwent surgical decompression in the lateral decubital position. Continuous monitoring of intracranial pressure was begun upon induction of general anaesthesia. High preoperative pressure declined immediately after elevation of the depressed zone. Bleeding was not a problem at any time during the procedure. Follow-up MRI and angio-MRI demonstrated total restoration of SSS patency. Benign intracranial hypertension is an uncommon complication of depressed skull fracture. Retrograde venous catheterization with pressure measurement can be a useful diagnostic adjunct. Surgical treatment is indicated in symptomatic patients. Based on the two cases reported, we now propose MRI venography in all patients presenting with symptoms of BIH and arteriography with retrograde venous catheterization when venous sinus stenosis exists.

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.

Capillary Hemangioma in the Superior Sagittal Sinus as a Rare Cause of Intracranial Hypertension in a Child: Case Report

OBJECTIVE AND IMPORTANCE

The etiological factors involved in idiopathic intracranial hypertension are not easy to identify. This case of idiopathic intracranial hypertension was associated with a capillary hemangioma growing in the lumen of the superior sagittal sinus.

CLINICAL PRESENTATION

A 10-year-old girl had experienced progressive headaches and abdominal pain. Fundoscopic examination disclosed bilateral papilledema and high intrathecal pressure, suggesting idiopathic intracranial hypertension. Magnetic resonance imaging, including magnetic resonance angiography as well as digital angiography, revealed a 3-cm mass protruding into the superior sagittal sinus lumen above the torcular.

INTERVENTION

A capillary hemangioma attached to the internal dural wall of the sagittal sinus lumen was microsurgically removed. The symptoms resolved in several days and no additional treatment was required.

CONCLUSION

A tumor growing into a venous sinus is a rare cause of venous outflow impairment and may generate the clinical signs of idiopathic intracranial hypertension. This case emphasizes the importance of multiple complementary imaging modalities and the efficacy of a direct surgical approach, which allowed resolution of symptoms.

Superior sagittal sinus thrombosis associated with raised intracranial pressure in closed head injury with depressed skull fracture

A case of delayed signs of intracranial hypertension following closed head injury with a depressed cranial fracture and superior sagittal sinus thrombosis is reported. Conservative treatment of intracranial hypertension, including just repeated lumbar puncture and oral acetazolamide, was performed. Spontaneous recanalization of the superior sagittal sinus was observed. Pathogenesis and different modalities of treatment are discussed.

Simple depressed skull fracture causing sagittal sinus stenosis and increased intracranial pressure: case report and review of the literature

The surgical management of depressed skull fractures is determined in part by whether a fracture is open or closed. Open fractures are usually elevated surgically, but closed fractures are most often treated nonoperatively, and the only 2 indications commonly described for operative treatment of closed fractures are hematoma evacuation and correction of cosmetic deformity. There is another indication, however, that is occasionally encountered when a depressed skull fracture injures a venous sinus. This injury can result in venous sinus stenosis, leading to venous hypertension and elevated intracranial pressure (ICP). A case is presented of closed depressed fracture of the midline skull, causing compressive stenosis of the superior sagittal sinus (SSS), venous hypertension, and encephalopathy. The fracture was surgically elevated to relieve the compression of the SSS and the encephalopathy resolved. The clinical identification, the imaging, and the risks and benefits of operative repair of this condition are reviewed. Increased ICP secondary to venous sinus injury is not commonly described in association with closed depressed skull fractures, but should always be considered in patients with the appropriate clinical findings when a fracture overlies a venous sinus, even in the absence of a hematoma.

Resolution of Intracranial Hypertension after Elevation of Depressed Cranial Fracture over the Superior Sagittal Sinus:Case Report

OBJECTIVE AND IMPORTANCE:

It is common neurosurgical wisdom that depressed cranial fractures (DCFs) over the superior sagittal sinus (SSS) should not be elevated because of the risk of fatal venous hemorrhage.

CLINICAL PRESENTATION:

A 34-year-old man presented with severe headache and diplopia after a motor vehicle accident. Clinical examination demonstrated severe papilledema and bilateral abducens palsy. Imaging findings demonstrated a DCF over the posterior third of the SSS and absent flow distal to the fracture with dilated cortical venous drainage.

INTERVENTION:

Conservative treatment with acetazolamide only partially alleviated the patient's headache and diplopia. Definitive surgical treatment via elevation of the DCF was discussed and decided upon. Twelve days after injury, the patient underwent midline parieto-occipital craniotomy with successful elevation of the DCF off the posterior third of the SSS. Postoperative magnetic resonance venograms revealed restoration of patency in the SSS with reduced tortuosity of cortical veins. The patient's headache resolved, and his papilledema and diplopia resolved gradually.

CONCLUSION:

Elevation of DCF over the SSS can be attempted in cases in which favorable bone anatomy and the patient's clinical condition warrant. This may result in rapid and dramatic resolution of signs and symptoms of secondary intracranial hypertension.

Compound depressed skull fractures involving a venous sinus

BACKGROUND

Neurosurgeons have always been wary about operating on compound depressed skull fractures overlying a venous sinus. Conservative treatment of such lesions, however, must be weighed against the benefits of surgery reducing sepsis, mass effect, and improving cosmetic appearance. There has been little published on this surgical problem and with this in mind, we undertook a review of the clinical features, management and outcome of patients presenting to our unit with a depressed fracture over a venous sinus.

METHODS

A retrospective review of all patients presenting with a compound depressed skull fracture over a venous sinus from 1997 to 2000. Computer tomography scans and patient records were used.

RESULTS

Of the 146 patients with depressed skull fractures, 27 (18%) were eligible. Of the 27 patients, 14 were treated conservatively and 13 were treated with surgery. Intra-operative difficulty was experienced in 6 (46%) of those taken to the operating room. Of those treated conservatively 14% developed sepsis.

CONCLUSION

We feel that a more conservative approach to fractures involving a sinus is warranted. If the wound is not contaminated, the risk of infection is low. Surgery exposes the patient to the very real risk of massive hemorrhage. In instances where there is a clear need for surgery, such as the presence of mass effect or deep contamination, adequate precautions should be taken.

Re-occlusion of the superior sagittal sinus after surgical recanalisation

A 24-year-old woman was struck on the head by a hammer. Because of early signs and symptoms of intercranial hypertension, she underwent surgery for elevation of the depressed fragments which was compressing the superior sagittal sinus (SSS). After operation, the intracranial pressure (ICP) once decreased, but it gradually increased again. After hypothermia and barbiturate therapy, she recovered fully except for partial visual field defect due to brain contusion. A carotid angiogram 28 days after injury revealed complete occlusion of the whole SSS with good collateral circulation. After brain edema had subsided, a follow-up angiogram revealed normal blood flow through the SSS. Elevation of depressed bony fragments is required for a case presenting with early signs and symptoms of intracranial hypertension due to sinus compression. In a case with severe destruction of the SSS, one needs to know that re-occlusion of the dural sinus may occur after surgical recanalisation.