Intracranial Hypertension Following Gunshot Wound to the Torcula: Case Report and Literature Review

BACKGROUND

Elevation of bone for the treatment of depressed skull fractures overlying venous sinuses is rarely required or performed. The neurosurgical literature only describes a handful of cases of surgical intervention in which the posterior two-thirds of the superior sagittal sinus was involved. Clinical course is variable, signs and symptoms suggest increased intracranial pressure, and all conservative measures should be exhausted before proceeding with the surgical route.

CASE DESCRIPTION

A 27-year-old man presented with a self-inflicted gunshot wound to posterior head. On presentation, there were no neurologic complaints. On imaging, the bullet fragment was associated with a comminuted anteriorly displaced fracture over the torcula. Vessel imaging showed tapering of the superior sagittal sinus and transverse sinuses near the torcula, suggesting narrowing due to mass effect. The patient did not respond to initial conservative management and developed worsening diplopia and papilledema concerning for increased intracranial pressure. Occipital/suboccipital craniectomy was performed with elevation of depressed skull fracture, decompression of dural venous sinus, removal of bullet, and mesh cranioplasty. Repeat ophthalmology examination postoperatively showed improvement in optic disc edema and diplopia.

CONSLUSIONS

This case confirms that the approach of surgical management of superior sagittal venous sinus injuries associated with skull fractures described in the literature also can be used successfully for injuries over the torcula if conservative management does not help alleviate the symptoms and results in good outcome. It was felt that delayed surgery also plays an important role, as it gives time for scar tissue to form, which may help to protect the sinus from injury during surgery.

Occipital Intraosseous Hemangioma over Torcula: Unusual Presentation with Raised Intracranial Pressure

BACKGROUND

Hemangiomas of the bone are benign, uncommon, slow-growing lesions accounting for <1.0% of all bony neoplasms. Intraosseous occipital hemangiomas are rare, and occipital hemangiomas presenting with features of raised intracranial tension are, with only 2 cases reported to date.

CASE DESCRIPTION

In this case report, we describe the unique case of a 30-year-old male patient presenting with raised intracranial pressure due to venous obstruction at the torcula. The patient underwent excision of the lesion and became symptom free.

CONCLUSIONS

Although these are benign lesions, they can have a varied clinical presentation. An understanding of the different clinical presentations and surgical nuances in excising such tumors can lead to early diagnosis and good patient outcome.