Li Lai-Fung, Pu Jenny Kan-Suen, Tsang Chun-Pong, Tsang Anderson Chun-On, Lui Wai-Man, Leung Gilberto Ka-Kit
Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.
Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.
World Neurosurg. 2017 Aug;104:1047.e13-1047.e17. doi: 10.1016/j.wneu.2017.05.041. Epub 2017 May 16.
Iatrogenic cerebral venous sinus injury and occlusion may occur during resection of parasagittal meningioma and lateral skull base surgery. The former involves the superior sagittal sinus, and direct surgical repair is associated with good results. Outcome of direct repair of transverse-sigmoid sinus injury is less clear. We present a patient with iatrogenic sigmoid sinus injury in whom direct repair was complicated by subsequent thrombosis that was successfully salvaged by combined endovascular mechanical and chemical thrombolysis.
A 60-year-old man with left tentorial atypical meningioma had disease recurrence after 3 excisions. Angiography revealed that the straight sinus and torcular and bilateral transverse sinuses were occluded. He underwent a fourth craniotomy with inadvertent occlusion of the transverse-sigmoid sinus junction. Direct surgical repair was done but was complicated by thrombosis. Mechanical endovenous thrombectomy was done followed by continuous urokinase infusion for 1 week. Digital subtraction angiography performed 7 days after endovascular treatment showed improved venous drainage through the left transverse-sigmoid sinus junction. The patient was ambulatory and fully independent, with no new neurologic deficit.
This case emphasizes the need to preserve every vein, especially when major venous sinuses have been obliterated. Detailed study of high-quality preoperative digital subtraction angiography is extremely important. Venous injury should be repaired immediately whenever possible. Postrepair venous sinus thrombosis may be effectively salvaged by endovascular thrombectomy for rapid recannulation, with or without combined use of continuous in situ thrombolytic therapy.
在矢状窦旁脑膜瘤切除术和侧颅底手术过程中可能发生医源性脑静脉窦损伤和闭塞。前者累及上矢状窦，直接手术修复效果良好。横窦-乙状窦损伤直接修复的结果尚不清楚。我们报告1例医源性乙状窦损伤患者，其直接修复术后并发血栓形成，通过血管内机械溶栓和化学溶栓联合治疗成功挽救。
一名60岁男性，患有左侧小脑幕非典型脑膜瘤，在3次切除术后疾病复发。血管造影显示直窦、窦汇和双侧横窦闭塞。他接受了第4次开颅手术，术中意外闭塞了横窦-乙状窦交界处。进行了直接手术修复，但术后并发血栓形成。进行了机械性静脉取栓术，随后持续输注尿激酶1周。血管内治疗7天后进行的数字减影血管造影显示，通过左侧横窦-乙状窦交界处的静脉引流有所改善。患者可独立行走，无新的神经功能缺损。
该病例强调了保护每一根静脉的必要性，尤其是在主要静脉窦已闭塞的情况下。详细研究高质量的术前数字减影血管造影极为重要。静脉损伤应尽可能立即修复。修复后静脉窦血栓形成可通过血管内取栓术有效挽救，以实现快速再通，可联合或不联合使用持续原位溶栓治疗。
