J Clin Neurol.  2013 Oct;9(4):259-268. 10.3988/jcn.2013.9.4.259.

Early Diagnosis and Management of Cerebral Venous Flow Obstruction Secondary to Transsinus Fracture after Traumatic Brain Injury

• Wang WH
• Lin JM
• Luo F
• Hu LS
• Li J
• Huang W

• KMID: 1980546
• DOI: http://doi.org/10.3988/jcn.2013.9.4.259

Abstract

BACKGROUND AND PURPOSE
Cerebral venous flow obstruction (CVFO) is a fatal complication of traumatic brain injury. To compare the outcomes of patients with CVFO secondary to traumatic-brain-injury-induced transsinus fracture who were diagnosed early versus those diagnosed late in the therapeutic course.
METHODS
In total, 403 patients with transsinus fracture were reviewed retrospectively. The patients were divided into an early-diagnosis group (n=338) and a delayed-diagnosis group (n=65). The patients submitted to 2D time-of-flight magnetic resonance venography (2D-TOF MRV) and/or CT venography (CTV), depending upon the findings of intracranial pressure monitoring, in order to identify potentially complicated CVFO. These examinations took place within 3 days of the onset of malignant intracranial hypertension symptoms in the early-diagnosis group, and after an average of 7 days in the delayed-diagnosis group. Once diagnosed, patients received intravenous thrombolytic therapy with low-dose urokinase. Patients with massive transsinus epidural hematoma, depressed fracture, or cerebral hernia were treated surgically to relieve the compression and repair any damage to the venous sinuses.
RESULTS
Cerebral venous flow obstruction was much more severe in the delayed-diagnosis group than in the early-diagnosis group (p<0.001), and hence patients in the former group were given a higher dose of urokinase (p<0.001) for thrombolytic therapy. They were also significantly more likely to need surgery (48.1% vs. 20.6%, p=0.003) and had a higher mortality rate (37.0% vs. 4.1%, p<0.001). However, patients in both groups experienced a similarly favorable prognosis, not only with regard to functional outcome but also with respect to neuroradiological improvement, as evaluated by 2D-TOF MRV/CTV at the final follow-up (p=0.218).
CONCLUSIONS
Delayed diagnosis can result in increased risk of surgery and death in the acute phase. Thrombolytic therapy with low-dose urokinase resulted in promising improvements in both functional and neuroradiological outcomes in all of the patients in this study, regardless of the time to diagnosis.

Keyword

traumatic brain injury; transsinus fracture; transsinus epidural hematoma; cerebral venous flow obstruction; urokinase; two-dimensional time-of-flight magnetic resonance venography

MeSH Terms

Brain Injuries*
Delayed Diagnosis
Early Diagnosis*
Encephalocele
Follow-Up Studies
Hematoma
Humans
Intracranial Hypertension
Intracranial Pressure
Magnetics
Magnets
Phlebography
Prognosis
Retrospective Studies
Thrombolytic Therapy
Urokinase-Type Plasminogen Activator
Urokinase-Type Plasminogen Activator

Figure

• 

  Fig. 1 Diagnostic and therapeutic flow chart for patients in the early-diagnosis and delayed-diagnosis groups. CVFO: cerebral venous flow obstruction, ICP: intracranial pressure, LP: lumbar puncture, MRV: magnetic resonance venography, UK: urokinase.

• 

  Fig. 2 Urokinase treatment for thrombosis of the left transverse sinus and sigmoid sinus in a traumatic-brain-injury patient. The CT images in the top row show multiple linear fractures in the occipital bone (yellow arrows). The MRI images in the middle row show thrombosis of the left transverse sinus and sigmoid sinus before urokinase treatment (red arrows). The MRV image does not allow visualization of the left transverse sinus, sigmoid sinus, or internal jugular vein; however, a considerable collateral circulation is evident. The MRI images in the bottom row show the disappearance of CVST (red arrows). The MRV image shows satisfactory recanalization of the left transverse sinus, sigmoid sinus, and internal jugular vein, and disappearance of the collateral circulation (blue arrow). CVST: cerebral venous sinus thrombosis, MRV: magnetic resonance venography.

• 

  Fig. 3 Urokinase treatment for thrombosis of the superior sagittal sinus in a traumatic-brain-injury patient. The CT images in the upper row show a depressed fracture in the middle of parietal bone before surgical treatment (yellow arrows). MRI images show the compression of a depressed fracture on the superior sagittal sinus before urokinase treatment (red arrows). The MRV image shows nonvisualization of the superior sagittal sinus. The CT images in the lower row show the repositioning of the fracture after surgery. The MRI images show that compression has been relieved (red arrows). The MRV image shows satisfactory recanalization of the superior sagittal sinus after surgery and urokinase treatment (blue arrow). MRV: magnetic resonance venography, UK: urokinase.

• 

  Fig. 4 Recanalization of the right transverse sinus and sigmoid sinus in a patient with transsinus epidural hematoma after urokinase thrombolysis. Images were obtained from a female patient who had suffered a traumatic brain injury 3 hours before admission. Plain CT scans revealed an epidural hematoma crossing the right transverse sinus and sigmoid sinus (A). She received emergent twist-drill drainage for evacuation of an epidural hematoma on admission. Thereafter, the hematoma was gradually evacuated to relieve the mechanical compression (B). However, she still complained of persistent headache and occasional vomiting. A lumbar puncture was performed, which revealed a pathologically high ICP (300 mmH2O) and suggested the presence of CVFO. Subsequent CTV and MRV examinations revealed nonvisualization of the right transverse sinus and sigmoid sinus (C, E). This patient was given thrombolytic therapy with urokinase at a dosage of 100000 U/day. After 3 days of this medication her clinical symptoms were totally alleviated and her ICP had decreased to 115 mmH2O. Subsequent reexamination with CTV and MRV suggested that the involved venous sinuses had recanalized (D, F). CVFO: cerebral venous flow obstruction, CTV: CT venography, ICP: intracranial pressure, MRV: magnetic resonance venography, UK: urokinase.

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