Department of Neurosurgery, Boston Medical Center, Boston, Massachusetts, USA.
Department of Neurosurgery, University of California Davis, Sacramento, California, USA.
World Neurosurg. 2020 May;137:94-97. doi: 10.1016/j.wneu.2020.01.170. Epub 2020 Jan 29.
Elevation of bone for the treatment of depressed skull fractures overlying venous sinuses is rarely required or performed. The neurosurgical literature only describes a handful of cases of surgical intervention in which the posterior two-thirds of the superior sagittal sinus was involved. Clinical course is variable, signs and symptoms suggest increased intracranial pressure, and all conservative measures should be exhausted before proceeding with the surgical route.
A 27-year-old man presented with a self-inflicted gunshot wound to posterior head. On presentation, there were no neurologic complaints. On imaging, the bullet fragment was associated with a comminuted anteriorly displaced fracture over the torcula. Vessel imaging showed tapering of the superior sagittal sinus and transverse sinuses near the torcula, suggesting narrowing due to mass effect. The patient did not respond to initial conservative management and developed worsening diplopia and papilledema concerning for increased intracranial pressure. Occipital/suboccipital craniectomy was performed with elevation of depressed skull fracture, decompression of dural venous sinus, removal of bullet, and mesh cranioplasty. Repeat ophthalmology examination postoperatively showed improvement in optic disc edema and diplopia.
This case confirms that the approach of surgical management of superior sagittal venous sinus injuries associated with skull fractures described in the literature also can be used successfully for injuries over the torcula if conservative management does not help alleviate the symptoms and results in good outcome. It was felt that delayed surgery also plays an important role, as it gives time for scar tissue to form, which may help to protect the sinus from injury during surgery.
为治疗覆盖静脉窦的凹陷性颅骨骨折而抬高骨瓣的情况很少需要或进行。神经外科学文献仅描述了少数几例手术干预的情况，其中涉及到上矢状窦的后三分之二。临床过程是多变的，症状和体征提示颅内压增高，所有保守措施都应在进行手术途径之前用尽。
一名 27 岁男子因头部后侧的自我枪击伤就诊。就诊时，没有神经学方面的抱怨。影像学检查显示，子弹碎片与 torcula 前方的粉碎性、向前移位的骨折有关。血管成像显示 torcula 附近的上矢状窦和横窦变细，提示由于肿块效应导致狭窄。患者对初始保守治疗没有反应，并出现复视和视乳头水肿，这表明颅内压增高。行枕骨/枕下入路颅骨切除术，抬高凹陷性颅骨骨折，减压硬脑膜静脉窦，取出子弹，并进行网片颅骨成形术。术后眼科检查显示视盘水肿和复视改善。
本病例证实，文献中描述的与颅骨骨折相关的上矢状窦静脉损伤的手术治疗方法，如果保守治疗不能缓解症状并取得良好效果，也可以成功用于 torcula 上方的损伤。人们认为，延迟手术也起着重要作用，因为它为疤痕组织的形成提供了时间，这可能有助于在手术过程中保护窦免受损伤。
