Key-words:
Head injury - penetrating head injury - penetrating sinus injury - penetrating superior
sagittal sinus injury - superior sagittal sinus injury
Introduction
Sinus injury is a very dangerous condition which occurs in 1.5%–5.5% of all head trauma
cases.[[1]] This type of injury constitutes 4%–12% of all head trauma cases. Despite making
a small proportion, the mortality rate of dural sinus injury reaches 41%.[[2]] Location of the injury affects the surgical approach and the consideration to salvage
or to preserve the related structure. Among all sinuses, the superior sagittal sinus
(SSS) is the most common injured site.[[1]],[[2]]
SSS injury that was caused by nail penetration is very rare.[[3]],[[4]] Complications of this condition include bleeding and thrombosis. Both can lead
to new neurologic deficits such as paresis or seizure and eventually increased intracranial
pressure when the extent of the bleeding or infarct is large enough. The surgical
procedure is necessary to extract the nail. Thus, imaging is very helpful for perioperative
planning.
The surgical procedure to extract the nail also acts as infection source control to
prevent further morbidities such as meningitis or encephalitis which can be devastating.
Therefore, comprehensive treatments and follow-ups are mandatory for the best possible
outcome.
Case Report
Authors reported a case of 3-year-old boy, attending to the emergency department at
National Brain Center, whose head was accidentally punctured with a corroded nail
using a rivet gun at the midline parietal 6 h before [[Figure 1]]. Complaint of pain was localized at the site of the injury. Bleeding was minimum
and the patient had no neurologic deficits at all. History of vaccination and immunization
was complete until he was 9-month-old, including for tetanus.
Figure 1: (a) Coronal, (b) Axial, and (c) Sagittal view of the brain computed tomography scan
The patient underwent the brain computed tomography (CT) scan and CT angiography to
achieve a better understanding of the exact site and position of the nail intracranially.
The nail did not injure the brain parenchyma at all; however, it completely penetrated
the middle portion of SSS [[Figure 2]]. There was no arteries appeared to be damaged [[Figure 3]]. The brain was looking edematous but from the clinical examination, the patient
did now show any signs of increased intracranial pressure.
Figure 2: (a) Axial view, (b) Sagittal view, and (c) Oblique view of computed tomography scan
three-dimensional reconstruction
Figure 3: Steps of dura repair. (a) Dura incision design (superior sagittal sinus). (b) The
suture was placed to the dura flaps. The nail was extracted and the hemostatic agent
was placed over the defect and also at the lateral walls of the sinus (not illustrated).
Immediately, the dura flaps were approximated. (c) The final result of the sinus repair
The patient received tetanus immunoglobulin 250 IU and underwent undergo surgery to
remove the nail and repair the dura. Cefazoline 400 mg intravenous was given as prophylaxis
treatment for this patient.
Management
The patient was positioned supine, with the neck slightly flexed. The aseptic and
antiseptic procedure was done at the parietal region. U-shaped incision was made at
the midparietal region and the skin was retracted downwardly. The nail was identified
on the surface of the bone, right on the sagittal suture. Craniotomy with a size of
4 cm × 4 cm was made at the midparietal. The bone was elevated, leaving the nail head
attached at the middle portion of SSS. From the injured sinus, there was no apparent
bleeding.
Two U-shaped incisions lateral to the nail, which will be the flaps to repair the
torn sinus, were made. The temporary clip was used to secure one of the draining veins.
The nail was quickly removed and gentle pressure with the finger was applied to control
the bleeding. The lateral sinus wall was packed with hemostatic agents until the bleeding
stopped while the surface of the sinus was closed with a hemostatic agent and the
dura flaps that were approximated and sutured at the midline [[Figure 4]]. There was no active bleeding after the sinus repair. The temporary clip was removed.
Synthetic dura was used to cover the exposed brain, the bone was put back, and the
skin was sutured. Total blood loss was 100cc.
Figure 4: Intraoperative findings. (a and b) The nail was being extracted. (c) Dural repair
with hemostat and flaps, with bleeding volume of 100 cc (d) 4.5 cm nail
The postoperative laboratory showed that hemoglobin level dropped from 12.5 g/dL to
7.7 g/dL. Packed red cell transfusion was given to the patient. He also received postoperative
antibiotics of ceftriaxone and metronidazole. During the hospital stay, the patient
showed no neurologic deficits neither signs of infection. The patient was discharged
after 1 week of treatments.
During 1-week, 1-month, 3-months, and 6-months clinic follow-up, the patient had no
complaints at all as well. The brain CT-scan, CT angiography, or magnetic resonance
venography (MRV) after the surgical procedure was not performed to the patient due
to the patients' stable clinical condition.
Discussion
Sinus injury composed a small portion of all head injury cases which can be very fatal
in some cases when not treated.[[1]] Intracranial nail injury constitutes a small portion of all head injury cases and
some of them involved the sinus.[[5]] When the injury does not injure the parenchyma or important blood vessels, the
neurologic status outcome is usually good.[[3]] In our case, since the nail was right at the midline, projecting anteriorly, the
brain was not damaged, explaining the good neurologic status.
Conditions resulted from sinus injury include bleeding that can manifest as epidural
hemorrhage or subdural hemorrhage. Other condition that has to be taken care of is
the probability of thrombosis at the injured site. The obstructed venous outflow of
a large draining vein may eventually cause severe brain edema which can be fatal.
The decision to treat SSS injury due to trauma depends on the site of the injury itself.
Out of all dural sinus injury, the most common is SSS, with the most common involving
the middle portion (48%), followed by the anterior (41%) and the posterior (10%).[[2]] Injury at the anterior portion of SSS can be treated by ligation, but this treatment
cannot be done to the middle and posterior portion of SSS in which repair is necessary.[[1]] Death rate was highest when the injury site involving the posterior portion, followed
by the middle, and finally anterior portion.[[2]] In our case, the sinus was repaired due to this reason.
Imaging studies for surgical planning is very crucial for trauma cases. Beside in
determining the approach and the size of craniotomy, it gives the operator information
of the extent of the injury and the possible route of extraction.[[6]] Blind extraction may be fatal when there is unknown vessel injury which may lead
to unexpected profuse bleeding. However, it is also important to remember that not
all vessels can be visualized clearly from imaging, especially if the diameter of
the blood vessel is very small. Ideally, imaging such as MRV after the surgical procedure
should be done to assess if there is thrombosis and will determine the need of anticoagulant
treatment. In some case series, venous thrombosis occurred and patients received short-term
anticoagulant treatment for better outcomes.[[1]] However, clinicians should decide if anticoagulant treatment would be safe enough
to be given to the patient considering the risk of bleeding. In our report, the patient
was a child who was clinically stable and therefore was not given any antiplatelets
nor anticoagulants.
During the surgery, the dural sinus can be repaired with direct pressure and various
kinds of hemostatic agents.[[5]] Depending on the needs, free duraplasty with or without muscle flap can also be
done, but in one case, the complication of total venous occlusion occurred after this
procedure.[[1]],[[2]] In our case, since the dural sinus defect was small, small flaps from the lateral
side of the sinus was considered sufficient for dura repair and stop the bleeding.
The patient's positioning during the surgery is also crucial since one of the risks
during the surgery is air embolism.
The risk of infection has to be kept in mind especially when trauma occurs in the
pediatric population since this population can be prone. Complications such as meningitis
and encephalitis are possible, which may lead to a prolonged hospital stay or even
disability. For this reason, the administration of antibiotics is generally recommended.[[3]] In a case, residual hemiparesis remained, related to the site of injury.[[7]]
The studies mentioned above are summarized in [[Table 1]].
Table 1: Reviews of Previous Articles on Sinus Injury
Conclusion
SSS injury is a rare case that can lead to morbidity and mortality if not treated
properly. Although surgical repair is necessary and done, clinicians should be aware
of the potential problems such as emboli, thrombosis, and infection during the recovery
period. Clinically stable patient during the hospital admission does not guarantee
that all of the complications mentioned will not occur. Comprehensive treatments and
thorough examination during the follow-ups are important to ensure patients' safety.
Informed consent
Informed consent from patient's guardian was collected.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form, the guardian has given his consent for images and other clinical information
to be reported in the journal. The guardian understands that names and initials will
not be published and due efforts will be made to conceal identity, but anonymity cannot
be guaranteed.
