Surgery on Displaced Depressed Skull Fracture Overlying Sigmoid Sinus:

Rationale, Techniques and Risk Management

Tjokorda GB Mahadewa, Marleen

Department of Neurosurgery Faculty of Medicine, Udayana University, Sanglah General

Hospital

Bali, Indonesia

Corresponding author:

Marleen

Department of Neurosurgery Faculty of Medicine, Udayana University, Sanglah General

Hospital

E-mail: marleenlee1@gmail.com
 Abstract

Skull fracture may occur after direct trauma in all part of skull. Small part of skull

fracture may run overlying dural venous structure, which inherits risk of infection,

thrombosis and massive bleeding. Controversy arises among institution whether

surgical measure is superior rather than conservative option. The occurrence of

depressed skull fracture overlying sigmoid sinus seldom discussed in head trauma

literature, but some authors report the risk of infection and sepsis might occurred in

delayed fashion in these group of patient. Several report on radiological study in

depressed skull fracture overlying venous sinus found that fracture may predispose

this group of patient to have venous sinus thrombosis. The risk of massive bleeding

when attempt to elevate bone fragment, could place the patient into serious and

devastating condition, which need aggressive and effective bleeding control. We

report a middle-aged man who had a displaced depressed skull fracture overlying

right sigmoid sinus after fall from height. Surgery was held in attempt to decompress

right sigmoid sinus structure and repair the csf leakage in overlying duramater. The

patient was discharge from hospital with minimal conductive hearing disturbance and

no sequel of infection.

Keywords: Venous Sinus Thrombosis, Sepsis, CSF Leakage, Sigmoid Sinus,

Skullbase Fracture, Gelfoam

Introduction

Among all craniocerebral injuries, the incidence of dural venous sinus injury caused

by head trauma ranges from 4% to 12% at the time of war, and from 1% to 4% in

civilian life in the respective literature.1-3

Elevating depressed skull fractures overlying dural venous sinus is

considered hazardous. LeFeuvre et al.4 and Miller and Jennet5 reported that the

incidences of severe hemorrhagic complications in patients undergoing operative

treatment for depressed skull fractures over a venous sinus are 23% and 20%. In such

cases, conservative management is strongly emphasized because of the potential

mortality resulting from uncontrollable bleeding. An open depressed skull fracture is

usually repaired surgically and the dura is repaired as soon as possible to decrease

the incidence of infection. However, in a closed depressed skull fracture, many

author recommend surgery only for 1 of the following 3 reasons: evacuation of a

hematoma, repair of obviously lacerated dura (such as when large in-driven bone

fragments are seen on CT), or for correction of a severe cosmetic deformity.6

Multiple operative techniques have been used to control profuse bleeding

from the injured sinus wall. Digital pressure with Gelfoam, dura, pericranium,

temporal muscle or fascia is most frequently used simple method. Moreover, direct

repair of defects on the sinus wall using simple suturing, hitching up the dura to the

bone adjacent to the sinus, application of ligature around the rostral part, occlusion of

the rostral part by clips, transplantation of an autologous vein, artificial sinus

prosthesis, balloon catheter, and T-drainage have also been described. 1,2 There was a

recent report which suggested that application of tissue-glue-coated collagen sponge

(TachoSil, Nycomed UK, Oxford, Buckinghamshire, UK) is also an effective

surgical technique for repairing minor dural venous sinus laceration. 7 Although
various operative techniques are used in the treatment of sinus injury for stopping

massive bleeding loss, there is a report in which blood loss from a lacerated dural

venous sinus could be stopped with simple digital pressure in nearly all cases.8

Although a comparison of mortality rates associated with traumatic dural

sinus injuries in the literature is difficult because of insufficient data from the case

records and different time intervals between accident and operation, mortality rates

in patients with dural sinus injury reported in the literature range from 7% to

15%.2,9,10

Some authors reported that coagulopathy usually occurs due to massive

transfusion after significant blood loss in patients with dural venous sinus injury. In a

study by Behera et al.,11 thrombocytopenia occurred in 85% and defibrination

occurred in 69% of cases with dural sinus injury. Hence coagulations studies should

be performed during the perioperative period. Furthermore, preoperative

angiography can also be useful. Some authors have recommended that the venous

sinus should be visualized by angiographic investigation before surgery.8

Case Report

Male 60 years old present with open lacerated wound on right retroauricular region

after fall from 2-meter heights while attempted to fix his house ceiling roof. Vertigo

and dizziness also documented after the incidence. Since the wound was contaminated

with dirt and the skull fragment was exposed, we decide to perform immediate

surgery to explore and debride the open skull fracture and attempt to decompress and

elevate the bone fragment and repair the csf leakage if the dural layer is lacerated. The

NCCT (Non contrast CT) Scan confirmed an open displaced depressed skull fracture,

with bone fragment involving right mastoid air cell avulsed from their anatomical
position. Unfortunately, our emergency department setting was not equipped with

angiography, so that sigmoid sinus patency could not preoperatively analyzed.

We found that the bone fragment was filled by debris and we found small CSF

leakage from lacerated dural layer beneath the fracture fragment. Copious irrigation

by normal saline and foreign body removal was made to reduce risk of infection and

venous emboli, which might arise from sinus wall opening. Venous bleeding was

occurring while the bone fragment was elevated, and can be well controlled by

applying surgical combining gelfoam and soaked cottonoid pressure with dural tack-

up suture. We did not perform any kind of cranioplasty to achieve satisfactory

cosmetic result because we consider that applying any material in this case will

promote infection.

The patient was doing well after surgery, and discharge on day three with

persistent right conductive hearing disorder and no signs of infection.

Figure 1. (Left, arrow) Axial Bone Window NCCT of the patient shows depressed

skull fracture on right occipital bone which is anatomically adjacent with sigmoid

sinus. The bone fragment was displaced 1 cm from inner table. (Right, arrow) 3D

Reconstruction CT shows fracture line extending into the mastoid and skull base

region behind external auditory canal which might responsible for persistent

conductive hearing disturbance.

Figure 2. Brain window NCCT present intraparenchymal hemorrhage surrounding

fracture location. These hemorrhages occur as the sharp bone fragment penetrates

and violates underlying dural covering and brain tissue. Surgical measure permits

surgeon to eliminate all contused brain and controlled bleeding from pial vessels

injury. Furthermore, dural repair could be established directly in watertight fashion

to manage CSF leakage.

Discussion

Dural venous sinus thrombosis (DVST) is an recognized complication of traumatic

head injury.5, 12-14 The presence of skull fracture overlying a dural sinus on unenhanced

CT is associated with an increased risk of DVST: As many as 41% of patients with

this CT findings have DVST; conversely, fractures not overlying a sinus are unlikely

to lead to DVST.15 Importantly, the prompt diagnosis of DVST is essential because

DVST can be a cause of elevated intracranial pressure; venous hemorrhagic

infarction; and, ultimately, increased rates of morbidity or death.16-19 In blunt trauma,

the diagnosis of DVST on CTV can be confounded by the presence of extrinsic

compression, which may also cause luminal narrowing and may thus simulate

thrombosis. Extrinsic compression may be secondary to a depressed skull fracture,

extraaxial hematoma, or pneumocephalus.20,21 In particular, an epidural hematoma is

prone to causing extrinsic venous compression because it is often associated with a

skull fracture and leads to elevation of the dural leaflets, thereby displacing and even
causing detachment of the sinuses.22 Although posttraumatic dural sinus compression

has been described, its prevalence is not well established, and it is unclear to what

degree this phenomenon may affect the diagnosis of DVST. Therefore, it is

potentially critical to distinguish true DVST from isolated sinus compression because

there could be implications in prognosis or treatment decisions regarding

anticoagulation therapy.23-26

DVST is an important complication of blunt head injury because it has been

shown to predispose patients to poor clinical outcomes in the acute phase. Fractures

overlying the dural sinuses have a high risk of having DVST or extrinsic compression.

Only 31-33% of the affected dural sinuses were classified as normal, whereas the

remaining had some degree of sinus compromise. Both fractures through the

transverse sinus-sigmoid sinus complex of multiple dural sinuses were more likely to

predispose patients to DVST. In contrast, fractures through the SSS were more likely

predispose patients to sinus compression, and patients were unlikely to have DVST.27

The management of fractures overlying cranial venous sinuses remains a

major challenge to neurosurgeons. The difficulty posed by these fractures relates to

the potential morbidity associated with conservative treatment, and the risk associated

with surgery. An estimated 10% of skull fractures involve cerebral venous sinuses, 28

with 15% being compound depressed.29 The management of these fractures requires

both good judgment and experience because controversy exist regarding indications,

and there are no definite rules that apply due to the diversity in presentation.30

There are two popular strategies for management: surgical treatment, 4 where

the fracture can be carefully elevated, trying to gain control of the venous sinus as

soon as possible, preparing for significant transfusion requirements if needed, or ,

alternatively, conservative treatment if the fracture site is not contaminated grossly

with foreign materials, or will not lead to a major cosmetic or functional deformity, or

not causing intracranial hypertension secondary to sinus occlusion.31 Conservative

management includes scalp debridement alone with irrigation, followed by serial

follow-up CT scans for any signs of brain abscess. 30 However, a wide range of

complications have been reported with conservative management, for example:

venous sinus stenosis leading to venous hypertension and increased intracranial

pressure,20,32-37 sinus thrombosis leading to late deterioration, benign intracranial

hypertension,20,32,34,35,37 and even hemorrhagic infarction.38

We did fracture fragment elevation and meticulous debridement in this case.

Profuse bleeding were occurred during fracture elevation and was successfully

controlled by surgicel combining gelfoam and cottonoid pressure over venous

bleeding site. To avoid reopening source of bleeding, we also use reflecting dural flap

as proposed by Oh et al.39 to give additional pressure on bleeding site. Gazzeri et al.

report their experience using TachoSil, a tissue-glue-coated collagen sponge topical

hemostatic agent, to achieve effective hemostasis in persistent sinus bleeding. 7 Since

this hemostatic agent were not provided in our institution, we did not apply it during

this case. Dural defect then were sutured continuously in water-tight fashion, and we

avoid any cranioplasty measure to close bony defect in order to remove any foreign

materials in surgical site to promote better healing and reduce risk of infection.

Subcutaneous drain were applied and were removed in three days post operatively.

The patient did well after surgery, and there was no signs of infection symptom or

CSF leakage documented after surgery. The patient discharge from hospital on day

three with persistent right conductive hearing disorder and no signs of infection.

A critical argument may rise when a surgeon attempt to obliterate venous

sinus in order to control venous bleeding during surgery. Li et al. emphasize the need
to preserve every vein, especially when major venous sinuses have been obliterated.

Endovascular thrombectomy, with or without combined use of continuous in situ

thrombolytic therapy could be an option to facilitate rapid recannulation toward this

group of patient.40

Conclusion

Despite most depressed skull fracture overlying dural venous sinus was recommend to

be treated conservatively, condition such as venous sinus thrombosis, risk of infection

and progressive ongoin mass effect by contused brain might warrant surgery. Massive

bleeding and rapid threatening condition could occur while attempt was made to

elevate bony fragment overlying dural venous sinus. Surgery to elevate depressed

skull fracture overlying sigmoid sinus is safe if all preoperative measure was well-

prepared to overcome the risk of venous bleeding intraoperatively.

Acknowledgment

None

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