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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 94-96

Massive bifrontal infarction following massive depressed fracture overlying the superior sagittal sinus


1 Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Department of Emergency Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
3 Department of Radiology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India

Date of Web Publication10-Apr-2015

Correspondence Address:
Dr. Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1597-1112.154933

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  Abstract 

Injury to the superior sagittal sinus is the most common dural sinus injury which carries a high risk of morbidity and mortality. In this article, we report a case of 21-year male patient who sustained head injury while he was riding on a motorcycle, he lost balance, and his head struck against the road divider. The patient had massive injury to the superior sagittal sinus, underlying brain parenchyma, and probably laceration of draining venous channels surrounding the superior sagittal sinus. In spite of the elevation of the depressed fragments, injury to the superior sagittal sinus resulted in the bifrontal massive venous infarction and fatal outcome in the present case.

Keywords: Brain infarction, superior sagittal sinus laceration, superior sagittal sinus, skull fracture


How to cite this article:
Agrawal A, Kumar S S, Hegde KV, Reddy V U, Sundeep N. Massive bifrontal infarction following massive depressed fracture overlying the superior sagittal sinus. Afr J Trauma 2014;3:94-6

How to cite this URL:
Agrawal A, Kumar S S, Hegde KV, Reddy V U, Sundeep N. Massive bifrontal infarction following massive depressed fracture overlying the superior sagittal sinus. Afr J Trauma [serial online] 2014 [cited 2021 Nov 27];3:94-6. Available from: https://www.afrjtrauma.com/text.asp?2014/3/2/94/154933


  Introduction Top


Injury to the superior sagittal sinus is the most common dural sinus injury which carries a high risk of clinical deterioration and mortality rate. [1],[2] A number of etiological factors can cause superior sagittal sinus obstruction and clinical deterioration following head injury. [3],[4] In this article, we report an unusual case of extensive bifrontal infarction and its probable mechanism following massive bifrontal depressed fracture of the skull involving the superior sagittal sinus.


  Case Report Top


A 21-year male patient sustained head injury while he was riding on a motorcycle, lost balance, and his head struck against the road divider. He was unconscious since the time of injury, had nasal and oral bleeding and vomited many times. He had two episodes of generalized tonic-clonic seizures. At the time of examination in the emergency room, he had labored breathing for which the patient was intubated. His pulse was 88/min, and blood pressure was 140/80 mm/Hg.

His Glasgow Coma Scale-was E1V T M2 (total 3T). Pupils were mid-dilated and sluggishly reacting. He had bilateral black eyes and a large depression over the forehead with 4 cm laceration. There was active bleeding from a laceration. After hemodynamically stabilizing the patient, a computed tomography (CT) scan of the brain was performed. It showed a large comminuted, depressed fracture of the frontal bones crossing the midline with underlying extra-axial hematoma, patchy contusions, inter-hemispheric sub-arachnoid hemorrhage with cerebral edema and speck of pneumocephalus [Figure 1]a-d. In view of the large intracranial hematoma and significant compression of the superior sagittal sinus by bone fragments, the patient underwent elevation of the depressed fragments and evacuation of hematoma as an emergency procedure. After surgery, the patient was kept on elective ventilation in Intensive Care Unit. He received broad spectrum antibiotics, antiepileptics and antiedema measures in the postoperative period. The patient did not make significant improvement following surgery. A repeat CT scan showed extensive bifrontal infarctions, extending deep into the white matter [Figure 2]. The patient did not recover in his neurological status and succumb to his injuries on day 8.
Figure 1: Computed tomography scan brain plain with bone window (a-d) showing a large comminuted, depressed fracture of the frontal bones crossing the midline with underlying extra-axial hematoma, patchy contusions, inter-hemispheric sub-arachnoid hemorrhage with cerebral edema and specks of pneumocephalus

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Figure 2: A follow-up computed tomography scan showing extensive bifrontal infarctions, extending deep into the white matter

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  Discussion Top


Multiple factors are responsible for brain damage following injury to the superior sagittal sinus. Depressed fragments can cause raised intracranial pressure, can cause underlying parenchymal injury and cerebral edema and can compress the sinus leading to venous outflow obstruction [3],[5] Following dural sinus obstruction a vicious cycle of raised dural venous sinus and increasing intracranial pressure sets in leading to cerebral edema with venous infarction and hemorrhages. [6],[7] Injury to the superior sagittal sinus can result in increased intracranial pressure because of depressed fragments, underlying brain injury and cerebral edema or because of obstruction to the venous outflow and its consequences, progressive neurological deficit, and progressive deterioration in level consciousness, coma and death. [2],[8] CT scan with or without three-dimensional reconstruction is the investigation of choice to delineate the anatomical site, to assess the extent of depressed fragments and parenchymal injury in cases of traumatic dural sinus injuries. [2] A conservative approaches is recommended when there is not much depression of fractured segments and no neurological deficits. [9],[10] However, the surgical intervention is recommended when there is penetration by foreign bodies [9] or where the sharp bony spicules penetrate underlying major sinus resulting in major bleeding and parenchymal damage. [2],[10] The surgical management of traumatic dural sinus injuries is a highly challenging task to the neurosurgeons as elevating the depressed fragments carries a high risk of intra-operative bleeding. [2] The principles of the surgical management are head end elevation, wide exposure, elevation of the depressed fragments, evacuation of any hematoma, compression by Gelfoam and meticulous sinus repair. [2],[10] In addition stabilization of the patient in the acute stage, adequate hydration, anticonvulsants and broad spectrum antibiotics are needed. [11],[12] Anticoagulation therapy is suggested when there is clinical suspicion or a radiological diagnosis of superior sagittal sinus thrombosis or injury. [12],[13] As in the present case when the patients have a hemorrhagic lesion on imaging, anticoagulant therapy may not be an option as it can cause new hemorrhages. [2]


  Conclusion Top


In the present case, the patient had massive injury to the superior sagittal sinus injury, underlying brain parenchyma probably the laceration of draining venous channels surrounding the superior sagittal sinus. In spite of the elevation of the depressed fragments, this resulted in the bifrontal massive venous infarction and fatal outcome in the present case.

 
  References Top

1.
Fuentes S, Metellus P, Levrier O, Adetchessi T, Dufour H, Grisoli F. Depressed skull fracture overlying the superior sagittal sinus causing benign intracranial hypertension. Description of two cases and review of the literature. Br J Neurosurg 2005;19:438-42.  Back to cited text no. 1
    
2.
Mishra S, Panigrahi S, Das S, Behera S. Emergency surgical management of traumatic superior sagittal sinus injury: An unusual case. Indian J Neurosurg 2012;1:149.  Back to cited text no. 2
  Medknow Journal  
3.
Owler BK, Besser M. Extradural hematoma causing venous sinus obstruction and pseudotumor cerebri syndrome. Childs Nerv Syst 2005;21:262-4.  Back to cited text no. 3
    
4.
Meltzer H, LoSasso B, Sobo EJ. Depressed occipital skull fracture with associated sagittal sinus occlusion. J Trauma 2000;49:981.  Back to cited text no. 4
    
5.
Dalgiç A, Seçer M, Ergüngör F, Okay O, Akdag R, Ciliz D. Dural sinus thrombosis following head injury: Report of two cases and review of the literature. Turk Neurosurg 2008;18:70-7.  Back to cited text no. 5
    
6.
Poon CS, Chang JK, Swarnkar A, Johnson MH, Wasenko J. Radiologic diagnosis of cerebral venous thrombosis: Pictorial review. AJR Am J Roentgenol 2007;189:S64-75.  Back to cited text no. 6
    
7.
Usman U, Wasay M. Mechanism of neuronal injury in cerebral venous thrombosis. J Pak Med Assoc 2006;56:509-12.  Back to cited text no. 7
    
8.
Erdogan B, Caner H, Aydin MV, Yildirim T, Kahveci S, Sen O. Hemispheric cerebrovascular venous thrombosis due to closed head injury. Childs Nerv Syst 2004;20:239-42.  Back to cited text no. 8
    
9.
Balak N, Aslan B, Serefhan A, Elmaci I. Intracranial retained stone after depressed skull fracture: Problems in the initial diagnosis. Am J Forensic Med Pathol 2009;30:198-200.  Back to cited text no. 9
    
10.
Ozer FD, Yurt A, Sucu HK, Tektas S. Depressed fractures over cranial venous sinus. J Emerg Med 2005;29:137-9.  Back to cited text no. 10
    
11.
Stam J. The treatment of cerebral venous sinus thrombosis. Adv Neurol 2003;92:233-40.  Back to cited text no. 11
    
12.
Stiefel D, Eich G, Sacher P. Posttraumatic dural sinus thrombosis in children. Eur J Pediatr Surg 2000;10:41-4.  Back to cited text no. 12
    
13.
Ferrera PC, Pauze DR, Chan L. Sagittal sinus thrombosis after closed head injury. Am J Emerg Med 1998;16:382-5.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]



 

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