Evaluating the Safety of Ligating the Anterior Superior Sagittal Sinus

Background: It is a common belief within neurosurgery that ligation of the anterior third of the superior sagittal sinus (SSS) is safe. This principle can be traced back to Cushing’s meningiomas text, wherein he states that ligation of the sinus anterior to the Rolandic vein has little comorbidity and allows for aggressive resection of tumors involving the sinus. There are few publications in modern literature examining the outcomes following ligation of the sinus. The goal of this study is to outline the complications seen following SSS ligation.

Methods: A retrospective review was performed utilizing our institution’s electronic medical records system. Patients who underwent bifrontal craniotomy between 2010 and 2019 were screened to identify those with operative ligation of the sinus. A total of 38 patient records were reviewed for the presence of postoperative infarct, edema, or new neurological deficit.

Results: Of the 40 bifrontal craniotomies performed among 38 patients, 15 included ligation of the SSS. This group comprised 11 parafalcine meningiomas, 3 olfactory groove meningiomas, and 2 other anterior skull base lesions. Ten of these patients had imaging demonstrating preoperative occlusion of the sinus. After ligation, 2 patients developed worsening of preoperative deficits and 4 developed new deficits. Four patients had new anterior cerebral artery infarcts and 5 demonstrated worsening edema on postoperative MRI. Tumor recurrence occurred in one patient.

Conclusion: Our evaluation identified patients with poor neurological outcomes following ligation of the anterior superior sagittal sinus, particularly venous infarct and edema. While this has typically been regarded as a safe surgical technique, this does not hold true in all cases. Review of the literature shows morbidity relating to venous edema ranging from 0 to 54% and mortality ranging from 0 to 22% for bifrontal craniotomy with sinus ligation. The incidence of venous infarct following SSS ligation may be related to disruption of collateral veins associated with the tumor in an already-compromised venous system. Recent anatomical studies suggest that there are varying degrees of vascularity in the frontal lobes ranging from minimal to dominant drainage into the SSS, making certain individuals more sensitive to disruption of the sinus. Anterior SSS ligation is not a universally safe maneuver and should be considered carefully before it is performed.

No conflict of interest has been declared by the author(s).