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Unusual penetrating injury of the superior sagittal sinus
Unusual Penetrating Injury of the Superior Sagittal Sinus Jionn-Jong Wu, M.D., and Chun-Jen Shih, M.D.
Two unusual cases of craniocerebral injury involving penetration of the superior sagittal sinus by a nail were encountered. After adequate surgical management and extraction of the retained nail, both patients recovered satisfactorily. The management of such cases is discussed. Wu J-J, Shih C-J: Unusualpenetratinginjuryof the superior sagittal sinus. SurgNeurol 17:43-46, 1982 Penetrating craniocerebral injuries are commonly seen on battle fields but are rarely seen in civil practice. In war high-velocity bullets frequently penetrate the head and often lodge inside the brain. Other objects have been reported to have penetrated the head, remaining there as foreign bodies [1, 4, 5, 11, 13-15, 17, 19]. At the Tri-service General Hospital during 1979 and 1980, we encountered 2 unusual cases of craniocerebral injury, both involving penetration of the superior sagittal sinus by a nail. After adequate surgical management and extraction of the retained nail, both patients recovered satisfactorily from their injuries. Because both patients exhibited rather unique clinical courses, we report briefly on their cases; in addition, we will discuss the management of such cases.
Case Reports Patient 1 A 27-year-old man was admitted on February 14, 1979, to the Tri-service General Hospital. Four days prior to admission, he had developed a transient violent emotional upset after quarreling with his boss and drinking two bottles of rice wine. He then secluded himself and attempted suicide by driving a stainless-steel nail into the middle of his head. Four days later he was found and sent to our emergency service. Throughout the entire course, he had no loss of consciousness, no fever, and no discomfort except pain from the wound. On examination, the patient was fully conscious and well
oriented. There was no neurological deficit. The nail was found penetrating at the midline, 16 cm posterior to the nasion (Fig. 1). The part of the nail outside the cranial cavity was 4 cm in length. No active bleeding from the wound was noticed. Roentgenograms (Fig. 2) showed that a great portion of the nail had been driven into the skull. Psychiatric examination revealed that the patient's behavior was generally passive, but he had no major psychiatric disorder. He had some guilt feeling about his suicide attempt and was anxious about his injury. The patient denied having illusions or hallucinations. Under general anesthesia, a craniectomy was performed around the nail. The nail was found to have penetrated the superior sagittal sinus. After removal of the bone surrounding the nail, the nail, together with a fragment of bone from the depressed fracture, was easily extracted. Massive hemorrhage from the lacerated sinus soon developed. The profuse bleeding was controlled with a piece of Gelfoam and external pressure. The extracted nail was 12 cm long and 0.5 cm thick. Culture of the nail tip showed Staphylococcus aureus; appropriate antibiotics were given. The patient's postoperative course was uneventful, and he was entirely well at the time of discharge (Fig. 3). In April, 1980, the patient was readmitted for follow-up studies. Neurological examination was normal. A right carotid angiogram demonstrated no occlusion of the superior sagittal sinus. A CT scan was also normal.
Patient 2 A 42-year-old workman was admitted to the Tri.service General Hospital on August 14, 1979. About thirty minutes prior to the admission, the patient had accidentally been struck by a stainless-steel nail, which had penetrated into his head in the left parietal region. He had been unconscious for about twenty minutes. On examination, the patient was stuporous, with a mild right hemiparesis, more marked in the leg. The point of entrance of the nail was in the left parietal region, 4 cm from the midline and 20 cm behind the nasion. The tip of the nail was located in the right parietal region, 2 cm from From the Section of Neurosurgery,Departmentof Surgery,National Defense MedicalCenter, and Tri-serviceGeneral Hospital, Taipei, Taiwan, the midline and 18 cm behind the nasion. There was no Republic of China. massive hemorrhage from either wound. Roentgenograms of his skull showed a curved metallic Address reprint requests to Dr. Jionn-JongWu, Departmentof Surgery, Tri-serviceGeneral Hospital, Taipei, Taiwan, Republicof China. foreign body lying underneath the vertex. It passed across Key words: penetrating craniocerebral injuries; superior sagittal sinus; the midline and emerged through the right parietal bone nailing. (Fig. 4). 0090-3019/82/010043-04501.25 © 1981 by Little, Brown and Company (Inc.)
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Fig. I. Patient 1. Photographs of the patient at initial examination.
Fig. 2. Patient I. Plain radiograms showing a nail that has been driven into the skull
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Wu and Shih: Penetrating Craniocerebral Injuries
45
Fig. 3. Patient 1. Photograph of the patient two weeks after the operation.
Under general anesthesia, a curved skin incision was made connecting the points of entrance and exit of the nail. Craniectomies of both parietal bones were performed. The nail and a small piece of the right parietal bone surrounding the nail tip were removed. Massive hemorrhage from a 1 cm laceration of the sinus developed immediately. The hemorrhage was controlled by covering the defect in the sinus with a piece of Gelfoam fastened to the surrounding dura mater with figure-eight sutures. The dura mater around the point of entrance of the nail was incised. Brain debris and a small intracerebral hematoma were evacuated. The extracted nail was 5 cm long and 0.4 cm thick. Culture of the nail tip revealed Staphylococcus epidermidis; appropriate antibiotics were prescribed. His postoperative course was smooth. At the time of discharge neurological function had nearly returned to normal except for a slight hemiparesis on the right side and sensory impairment of the right toes. At follow-up a year later, the motor and sensory function of the right limbs had returned almost to normal.
Fig. 4, Patient 2. Plain radiograms of the skull demonstrating the lo, cation of the nail.
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Surgical Neurology Vol 17 No 1 January 1982
Discussion It is a real challenge to manage penetrating craniocerebral injuries involving the superior sagittal sinus. In peacetime this type of injury is very rare; only a few cases have been described in the literature [13, 15, 19]. During World War I, Cushing proposed early definitive surgery. This principle has been proved sound in many later military surgical experiences [12, 16]. It is advisable first to clean the wound and remove the bone surrounding the foreign body in order to provide an adequate exposure. In this way, the surgeon is in a better position to extract the foreign body under direct vision and to control bleeding either by applying Gelfoam and pressure or by repairing the sinus. In a small laceration of the sinus, the application of Gelfoam and external pressure may effectively control bleeding, although the procedure may require considerable time. In Patient 1, two lacerations of the sinus were treated by this method. Another laceration on the lower portion of the sinus was not exposed, but the result in this patient was satisfactory, probably due to the fact that the lower laceration was small and was obliterated by the application of external pressure on the laceration of the upper wall. To manage such a penetrating injury of the sinus, it would sometimes seem unnecessary to expose the defect on the lower portion of the sinus, particularly when there is no further bleeding following the sealing of the upper tear. If the above procedure fails, repair of the lacerated sinus with or without graft is necessary [8, 10]. In Patient 2, the penetrating hole in the sinus was successfully treated by fastening a piece of Gelfoam over the defect using figureeight sutures. In the event of complete transection of the sinus, the management is more complicated. If the transection is located in the anterior third, it can then be ligated with little accompanying morbidity; however, bilateral hemorrhagic infarctions of the frontal lobes followed by death of the patient have been mentioned in the literature [2]. Ligation of either the middle or the posterior third of the sinus is extremely dangerous. Kalbag [6] proposed that the level of the coronal sutures is a determining factor in the management of transection injury of the sinus: reconstruction of the sinus should be carried out if the transection is caudal to the
coronal suture, that is, in the posterior two thirds of the sinus [3, 6, 8, 9, 16, 18]. Postoperatively, the patency of the sinus can be determined by angiograms and isotope sinograms [7].
We are grateful to ProfessorShih-Kwei Wang for his help in preparing this report.
References I. AskenasyHM, KosaryIZ, BrahamJ: Sewing needle in the brain with delayed neurological manifestations. J Neurosurg 18:554-556, 1961 2. Bonnal J, Brotchi J: Surgeryof the superior sagittal sinus in parasagittal meningiomas. J Neurosurg 48:935-945, 1978 3. DonaghyRMP, Wallman LJ, Flanagan MJ, Numoto M: Sagirtal sinus repair. Technical note. I Neurosurg 38:244-248, 1973 4. Goald HJ, Ronderos A: Traumatic perforation of the intracranial portion of the internal carotid artery with 11-daysurvival. Case report. J Neurosurg 18:401-404, 1961 5. Guthkelch AN: Apparently trivial wounds of the eyelids with intracranial damage. Br Med J 2:842-844, 1960 6. KalbagRM: Dural venous sinus thrombosis and head injury, in Vinken P], Bruyn GW (eds): Handbook of Clinical Neurology. Amster~ dam: North-Holland, 1976, Vol 24, pp 36%380 7. Kapp JP, Alfred HC, Jones T: Isotope sinograms. Technical note. J Neurosurg 44:393-394, 1976 8. Kapp JP, Gielchinsky I, Deardourff SL: Operative techniques for management of lesions involving the dural venous sinuses. Surg Neurol 7:339-342, 1977 9. Kapp JP, Gielchinsky 1, Petty C, McClure C: An internal shunt for use in the reconstruction of dural venous sinuses. Technical note. J Neurosurg 35:351-354, 1971 10. Kempe LG: Operative Neurosurgery. Berlin, Heidelberg: Springer, 1970, Vol 1, pp 142-144 11. Markham JW, McCleve DE, Lynge HN: Penetrating craniocerebral injuries. Report of two unusual cases. J Neurosurg 21:1095-1097, 1964 12. MeirowskyAM: Wounds of dural sinuses. J Neurosurg 10:496--514, 1953 13. Olumide AA, Adeloye A: Unusual cranio-cerebral injuries: report of two cases in Nigerians. Surg Neurol 6:306-308, 1976 14. Pilcher C: Penetrating wounds of the brain. An experimental study. Ann Surg 103:173-198, 1936 15. ReevesDL: Penetrating craniocerebral injuries. Report of two unusual cases. J Neurosurg 23:204-205, 1965 16. Rish BL: The repair of dural venous sinus wounds by autogenous venorrhaphy. I Neurosurg 35:392-395, 1971 17. Sherman IJ: Brass foreign body in the brain stem. A case report. J Neurosurg 17:483-485, 1960 18. Sindou M, MazoyerJF, Fischer G, PlaintJ, FourcadeC: Experimental bypass for sagittal sinus repair. J Neurosurg 44:325-330, 1976 19. Tiwari SM, Singh RG, Dharker SR, Chaurasia BD: Unusual craniocerebral injury by a key. Surg Neurol 9:267, 1978
Two unusual cases of craniocerebral injury involving penetration of the superior sagittal sinus by a nail were encountered. After adequate surgical management and extraction of the retained nail, both patients recovered satisfactorily. The management of such cases is discussed. Wu J-J, Shih C-J: Unusualpenetratinginjuryof the superior sagittal sinus. SurgNeurol 17:43-46, 1982 Penetrating craniocerebral injuries are commonly seen on battle fields but are rarely seen in civil practice. In war high-velocity bullets frequently penetrate the head and often lodge inside the brain. Other objects have been reported to have penetrated the head, remaining there as foreign bodies [1, 4, 5, 11, 13-15, 17, 19]. At the Tri-service General Hospital during 1979 and 1980, we encountered 2 unusual cases of craniocerebral injury, both involving penetration of the superior sagittal sinus by a nail. After adequate surgical management and extraction of the retained nail, both patients recovered satisfactorily from their injuries. Because both patients exhibited rather unique clinical courses, we report briefly on their cases; in addition, we will discuss the management of such cases.
Case Reports Patient 1 A 27-year-old man was admitted on February 14, 1979, to the Tri-service General Hospital. Four days prior to admission, he had developed a transient violent emotional upset after quarreling with his boss and drinking two bottles of rice wine. He then secluded himself and attempted suicide by driving a stainless-steel nail into the middle of his head. Four days later he was found and sent to our emergency service. Throughout the entire course, he had no loss of consciousness, no fever, and no discomfort except pain from the wound. On examination, the patient was fully conscious and well
oriented. There was no neurological deficit. The nail was found penetrating at the midline, 16 cm posterior to the nasion (Fig. 1). The part of the nail outside the cranial cavity was 4 cm in length. No active bleeding from the wound was noticed. Roentgenograms (Fig. 2) showed that a great portion of the nail had been driven into the skull. Psychiatric examination revealed that the patient's behavior was generally passive, but he had no major psychiatric disorder. He had some guilt feeling about his suicide attempt and was anxious about his injury. The patient denied having illusions or hallucinations. Under general anesthesia, a craniectomy was performed around the nail. The nail was found to have penetrated the superior sagittal sinus. After removal of the bone surrounding the nail, the nail, together with a fragment of bone from the depressed fracture, was easily extracted. Massive hemorrhage from the lacerated sinus soon developed. The profuse bleeding was controlled with a piece of Gelfoam and external pressure. The extracted nail was 12 cm long and 0.5 cm thick. Culture of the nail tip showed Staphylococcus aureus; appropriate antibiotics were given. The patient's postoperative course was uneventful, and he was entirely well at the time of discharge (Fig. 3). In April, 1980, the patient was readmitted for follow-up studies. Neurological examination was normal. A right carotid angiogram demonstrated no occlusion of the superior sagittal sinus. A CT scan was also normal.
Patient 2 A 42-year-old workman was admitted to the Tri.service General Hospital on August 14, 1979. About thirty minutes prior to the admission, the patient had accidentally been struck by a stainless-steel nail, which had penetrated into his head in the left parietal region. He had been unconscious for about twenty minutes. On examination, the patient was stuporous, with a mild right hemiparesis, more marked in the leg. The point of entrance of the nail was in the left parietal region, 4 cm from the midline and 20 cm behind the nasion. The tip of the nail was located in the right parietal region, 2 cm from From the Section of Neurosurgery,Departmentof Surgery,National Defense MedicalCenter, and Tri-serviceGeneral Hospital, Taipei, Taiwan, the midline and 18 cm behind the nasion. There was no Republic of China. massive hemorrhage from either wound. Roentgenograms of his skull showed a curved metallic Address reprint requests to Dr. Jionn-JongWu, Departmentof Surgery, Tri-serviceGeneral Hospital, Taipei, Taiwan, Republicof China. foreign body lying underneath the vertex. It passed across Key words: penetrating craniocerebral injuries; superior sagittal sinus; the midline and emerged through the right parietal bone nailing. (Fig. 4). 0090-3019/82/010043-04501.25 © 1981 by Little, Brown and Company (Inc.)
43
Fig. I. Patient 1. Photographs of the patient at initial examination.
Fig. 2. Patient I. Plain radiograms showing a nail that has been driven into the skull
44
Wu and Shih: Penetrating Craniocerebral Injuries
45
Fig. 3. Patient 1. Photograph of the patient two weeks after the operation.
Under general anesthesia, a curved skin incision was made connecting the points of entrance and exit of the nail. Craniectomies of both parietal bones were performed. The nail and a small piece of the right parietal bone surrounding the nail tip were removed. Massive hemorrhage from a 1 cm laceration of the sinus developed immediately. The hemorrhage was controlled by covering the defect in the sinus with a piece of Gelfoam fastened to the surrounding dura mater with figure-eight sutures. The dura mater around the point of entrance of the nail was incised. Brain debris and a small intracerebral hematoma were evacuated. The extracted nail was 5 cm long and 0.4 cm thick. Culture of the nail tip revealed Staphylococcus epidermidis; appropriate antibiotics were prescribed. His postoperative course was smooth. At the time of discharge neurological function had nearly returned to normal except for a slight hemiparesis on the right side and sensory impairment of the right toes. At follow-up a year later, the motor and sensory function of the right limbs had returned almost to normal.
Fig. 4, Patient 2. Plain radiograms of the skull demonstrating the lo, cation of the nail.
46
Surgical Neurology Vol 17 No 1 January 1982
Discussion It is a real challenge to manage penetrating craniocerebral injuries involving the superior sagittal sinus. In peacetime this type of injury is very rare; only a few cases have been described in the literature [13, 15, 19]. During World War I, Cushing proposed early definitive surgery. This principle has been proved sound in many later military surgical experiences [12, 16]. It is advisable first to clean the wound and remove the bone surrounding the foreign body in order to provide an adequate exposure. In this way, the surgeon is in a better position to extract the foreign body under direct vision and to control bleeding either by applying Gelfoam and pressure or by repairing the sinus. In a small laceration of the sinus, the application of Gelfoam and external pressure may effectively control bleeding, although the procedure may require considerable time. In Patient 1, two lacerations of the sinus were treated by this method. Another laceration on the lower portion of the sinus was not exposed, but the result in this patient was satisfactory, probably due to the fact that the lower laceration was small and was obliterated by the application of external pressure on the laceration of the upper wall. To manage such a penetrating injury of the sinus, it would sometimes seem unnecessary to expose the defect on the lower portion of the sinus, particularly when there is no further bleeding following the sealing of the upper tear. If the above procedure fails, repair of the lacerated sinus with or without graft is necessary [8, 10]. In Patient 2, the penetrating hole in the sinus was successfully treated by fastening a piece of Gelfoam over the defect using figureeight sutures. In the event of complete transection of the sinus, the management is more complicated. If the transection is located in the anterior third, it can then be ligated with little accompanying morbidity; however, bilateral hemorrhagic infarctions of the frontal lobes followed by death of the patient have been mentioned in the literature [2]. Ligation of either the middle or the posterior third of the sinus is extremely dangerous. Kalbag [6] proposed that the level of the coronal sutures is a determining factor in the management of transection injury of the sinus: reconstruction of the sinus should be carried out if the transection is caudal to the
coronal suture, that is, in the posterior two thirds of the sinus [3, 6, 8, 9, 16, 18]. Postoperatively, the patency of the sinus can be determined by angiograms and isotope sinograms [7].
We are grateful to ProfessorShih-Kwei Wang for his help in preparing this report.
References I. AskenasyHM, KosaryIZ, BrahamJ: Sewing needle in the brain with delayed neurological manifestations. J Neurosurg 18:554-556, 1961 2. Bonnal J, Brotchi J: Surgeryof the superior sagittal sinus in parasagittal meningiomas. J Neurosurg 48:935-945, 1978 3. DonaghyRMP, Wallman LJ, Flanagan MJ, Numoto M: Sagirtal sinus repair. Technical note. I Neurosurg 38:244-248, 1973 4. Goald HJ, Ronderos A: Traumatic perforation of the intracranial portion of the internal carotid artery with 11-daysurvival. Case report. J Neurosurg 18:401-404, 1961 5. Guthkelch AN: Apparently trivial wounds of the eyelids with intracranial damage. Br Med J 2:842-844, 1960 6. KalbagRM: Dural venous sinus thrombosis and head injury, in Vinken P], Bruyn GW (eds): Handbook of Clinical Neurology. Amster~ dam: North-Holland, 1976, Vol 24, pp 36%380 7. Kapp JP, Alfred HC, Jones T: Isotope sinograms. Technical note. J Neurosurg 44:393-394, 1976 8. Kapp JP, Gielchinsky I, Deardourff SL: Operative techniques for management of lesions involving the dural venous sinuses. Surg Neurol 7:339-342, 1977 9. Kapp JP, Gielchinsky 1, Petty C, McClure C: An internal shunt for use in the reconstruction of dural venous sinuses. Technical note. J Neurosurg 35:351-354, 1971 10. Kempe LG: Operative Neurosurgery. Berlin, Heidelberg: Springer, 1970, Vol 1, pp 142-144 11. Markham JW, McCleve DE, Lynge HN: Penetrating craniocerebral injuries. Report of two unusual cases. J Neurosurg 21:1095-1097, 1964 12. MeirowskyAM: Wounds of dural sinuses. J Neurosurg 10:496--514, 1953 13. Olumide AA, Adeloye A: Unusual cranio-cerebral injuries: report of two cases in Nigerians. Surg Neurol 6:306-308, 1976 14. Pilcher C: Penetrating wounds of the brain. An experimental study. Ann Surg 103:173-198, 1936 15. ReevesDL: Penetrating craniocerebral injuries. Report of two unusual cases. J Neurosurg 23:204-205, 1965 16. Rish BL: The repair of dural venous sinus wounds by autogenous venorrhaphy. I Neurosurg 35:392-395, 1971 17. Sherman IJ: Brass foreign body in the brain stem. A case report. J Neurosurg 17:483-485, 1960 18. Sindou M, MazoyerJF, Fischer G, PlaintJ, FourcadeC: Experimental bypass for sagittal sinus repair. J Neurosurg 44:325-330, 1976 19. Tiwari SM, Singh RG, Dharker SR, Chaurasia BD: Unusual craniocerebral injury by a key. Surg Neurol 9:267, 1978