Diagnosis and Management of Dural Sinus Thrombosis following Resection of Cerebellopontine Angle Tumors

Abstract

Objective Lateral sinus thrombosis is a potentially devastating but seldom studied complication of cerebellopontine angle (CPA) tumor surgery. Systemic anticoagulation in the early postoperative period has often been avoided due to the potential risks of intracranial hemorrhage.

Design Retrospective review.

Setting Tertiary referral center.

Main Outcome Measures The goal of this study was to identify the frequency, treatment, and outcomes in patients who develop postoperative venous sinus thrombosis following CPA tumor surgery and receive early systemic anticoagulation.

Results Of 43 patients with CPA tumors, we report five patients (11.6%) with transverse and/or sigmoid sinus thrombosis following resection of the tumor, four of which were detected on routine early postoperative noncontrast computed tomography (CT) scan. The thrombosis was confirmed in all cases with CT venography or magnetic resonance venography. Affected patients had significantly larger tumors than controls and tended to undergo longer operations. These patients were treated with immediate anticoagulation (intravenous heparin, followed by Coumadin for 6 months) without complication.

Conclusion Venous sinus thrombosis is an underrecognized complication of CPA surgery, but it can be diagnosed in the early postoperative period by noncontrast CT imaging. Early postoperative initiation of systemic anticoagulation appears safe and effective to prevent the progression of thrombosis and its consequences.

Keywords

venous sinus thrombosis - cerebellopontine angle tumor - acoustic schwannoma - complications - anticoagulation

• References

• 1 Crocker M, Nesbitt A, Rich P, Bell B. Symptomatic venous sinus thrombosis following bone wax application to emissary veins. Br J Neurosurg 2008; 22 (6) 798-800
• 2 Ohata K, Haque M, Morino M , et al. Occlusion of the sigmoid sinus after surgery via the presigmoidal-transpetrosal approach. J Neurosurg 1998; 89 (4) 575-584
• 3 Coutinho JM, de Bruijn SF, deVeber G, Stam J. Anticoagulation for cerebral venous sinus thrombosis. Stroke 2012; 43 (4) e41-e42
• 4 Ropposch T, Nemetz U, Braun EM, Lackner A, Walch C. Low molecular weight heparin therapy in pediatric otogenic sigmoid sinus thrombosis: a safe treatment option?. Int J Pediatr Otorhinolaryngol 2012; 76 (7) 1023-1026
• 5 Delgado Almandoz JE, Kelly HR, Schaefer PW, Lev MH, Gonzalez RG, Romero JM. Prevalence of traumatic dural venous sinus thrombosis in high-risk acute blunt head trauma patients evaluated with multidetector CT venography. Radiology 2010; 255 (2) 570-577
• 6 Medel R, Monteith SJ, Crowley RW, Dumont AS. A review of therapeutic strategies for the management of cerebral venous sinus thrombosis. Neurosurg Focus 2009; 27 (5) E6
• 7 Nimjee SM, Powers CJ, Kolls BJ, Smith T, Britz GW, Zomorodi AR. Endovascular treatment of venous sinus thrombosis: a case report and review of the literature. J Neurointerv Surg 2011; 3 (1) 30-33
• 8 Einhäupl KM, Villringer A, Meister W , et al. Heparin treatment in sinus venous thrombosis. Lancet 1991; 338 (8767) 597-600
• 9 Keiper Jr GL, Sherman JD, Tomsick TA, Tew Jr JM. Dural sinus thrombosis and pseudotumor cerebri: unexpected complications of suboccipital craniotomy and translabyrinthine craniectomy. J Neurosurg 1999; 91 (2) 192-197
• 10 Wasay M, Kojan S, Dai AI, Bobustuc G, Sheikh Z. Headache in cerebral venous thrombosis: incidence, pattern and location in 200 consecutive patients. J Headache Pain 2010; 11 (2) 137-139
• 11 Nonaka Y, Fukushima T, Watanabe K , et al. Contemporary surgical management of vestibular schwannomas: analysis of complications and lessons learned over the past decade. Neurosurgery 2013; 72 (2) , Suppl Operative ): ons103 –ons115; discussion ons115
• 12 Ginat DT, Meyers SP. Intracranial lesions with high signal intensity on T1-weighted MR images: differential diagnosis. Radiographics 2012; 32 (2) 499-516
• 13 Goldberg AL, Rosenbaum AE, Wang H, Kim WS, Lewis VL, Hanley DF. Computed tomography of dural sinus thrombosis. J Comput Assist Tomogr 1986; 10 (1) 16-20
• 14 Buonanno FS, Moody DM, Ball MR, Laster DW. Computed cranial tomographic findings in cerebral sinovenous occlusion. J Comput Assist Tomogr 1978; 2 (3) 281-290
• 15 Virapongse C, Cazenave C, Quisling R, Sarwar M, Hunter S. The empty delta sign: frequency and significance in 76 cases of dural sinus thrombosis. Radiology 1987; 162 (3) 779-785
• 16 Ginat DT, Martuza RL. Postoperative imaging of vestibular schwannomas. Neurosurg Focus 2012; 33 (3) E18
• 17 Christensen N. Lateral sinus thrombosis: a review of seven cases and proposal of management algorithm. Int J Pediatr Otorhinolaryngol 2010; 74 (4) 435
• 18 Lee JH, Choi SJ, Park K, Choung YH. Managements for lateral sinus thrombosis: does it need the ligation of internal jugular vein or anticoagulants?. Eur Arch Otorhinolaryngol 2009; 266 (1) 51-58
• 19 Manolidis S, Kutz Jr JW. Diagnosis and management of lateral sinus thrombosis. Otol Neurotol 2005; 26 (5) 1045-1051
• 20 Shima T, Okita S, Okada Y . Anatomical dominance of venous sinuses and jugular vein examined by intravenous digital subtraction angiography. In: Hakuba A, ed. Surgery of the Intracranial Venous System. Tokyo, Japan: Springer-Verlag; 1996. :58–62
• 21 Zouaoui A, Hidden G. Cerebral venous sinuses: anatomical variants or thrombosis?. Acta Anat (Basel) 1988; 133 (4) 318-324
• 22 Ichijo H, Hosokawa M, Shinkawa H. Differences in size and shape between the right and left sigmoid sinuses. Eur Arch Otorhinolaryngol 1993; 250 (5) 297-299
• 23 Soleau SW, Schmidt R, Stevens S, Osborn A, MacDonald JD. Extensive experience with dural sinus thrombosis. Neurosurgery 2003; 52 (3) 534-544 ; discussion 542–544