Visual failure and sinus thrombosis following depressed skull fracture: management with single session...

Elevation of a depressed skull fracture (DSF) overlying a venous sinus is generally avoided due to risk of sinus injury. Rarely, the sinus may be compressed by the fractured segment, causing intracranial hypertension (IH) or encephalopathy and can only be diagnosed with cerebral angiography or MR imaging techniques. The posterior third of the superior sagittal sinus (SSS) was found involved in all the reported cases. There is no consensus on its management, but most patients did not have any sinus thrombosis and improved after elevation of the compressing DSF alone. There are isolated reports of improvement with serial lumbar punctures or ventriculoperitoneal shunt.We report for the first time, a single session lumboperitoneal shunt and DSF elevation for a patient with thrombosis of the posterior part of SSS due to an overlying DSF, causing florid papilledema and impending blindness. Elevation of the DSF alone would not have achieved patency of the thrombosed sinus immediately to save his vision. Hence a lumboperitoneal shunt was done for immediate relief of IH. This CSF diversion alone was insufficient to achieve patency of the thrombosed sinus in the presence of significant external compression by the DSF; even if anticoagulants were used. Hence we elevated the DSF after craniotomy using a technical modification; by making a wide gutter circumferentially around the DSF with a high speed drill, to avoid sinus injury; prior to its elevation. The patient's vision improved in 48 hours and anticoagulants were used till 2 months when sinuses were found normal on MRI. Serial CT &MR images showing progression to thrombosis and recovery after decompression are presented. Both CSF diversion and DSF elevation are necessary when vision is threatened by IH due to sinus thrombosis with an overlying DSF.