Hrev_master [Emergency Care Journal 2016; 12:5441] [page 11] Emergency Care Journal 2016; volume 12: Cerebral sinus venous throm- bosis in traumatic brain injury Christina Mueller-Hoecker, Urs Pietsch Klinik für Anästhesiologie, Intensiv-, Rettungs- und Schmerzmedizin, St. Gallen, Switzerland Abstract A 36-year-old, healthy man was admitted to the emergency department with a traumatic brain injury with an injury severity score of 25 points. The head computed tomography revea- led a subarachnoidal, epidural hemorrhage as well as a fracture of the occipital calotte. Intracranial pressure (ICP) management was installed according to the LUND concept. In the following scan an angiography revealed a thrombosis of the sinus sigmoideus and trans- versus. Located next to the fractured skull, the thrombosis was highly likely traumatic, caused by the head trauma. As there was only a little congestion of the blood flow, no lysis or throm- bectomy was performed. To lower ICP, a cra- niectomy was performed. After seven days, mechanical ventilation was terminated. Four days later the patient was already stable enough to be discharged from the surgical itensive care unit. Introduction Cerebral sinus venous thrombosis is a rare phenomenon and a complication of traumatic head injury. The sufficiency of the collateral blood drainage will determine the symptoms. The cerebral venous drainage and related ana- tomical structures can be affected. The symp- toms may appear in relation to increased intra- cranial pressure (ICP). When collaterals are insufficient the venous congestion causes ischemia and infarctions. The spectrum can range from venous congestion detectable or not on neuroimaging, to the parenchymal cor- tical or subcortical ischemic injury. So far, there is no consensus on the treatment of trau- matic cerebral venous sinus thrombosis. It is a clinical challenge to balance the appropriate timing for anticoagulant with risk of increased cerebral hemorrhage in a traumatic patient.1-5 Here we present a patient with traumatic subarachnoidal, epidural haemorrhage as well as a cerebral sinus venous with a good clinical recovery. Case Report A 36-year-old, healthy man was admitted to the emergency department with a traumatic brain injury (TBI) with an injury severity score of 25 points. Prior to admission he got into a fight with a stranger and fell onto his occiput. With a Glasgow coma scale of 5 points he was intubated on scene and transported to our hos- pital. The head computed tomography (CT) revealed a TBI with a subarachnoidal, epidural haemorrhage as well as a fracture of the occip- ital calotte (Figure 1). No further injuries were found. The patient was directly transferred to the OR to evacuate the hematomas. An ICP- probe was installed for further ICP-monitoring. The patient was consistently in a hemodynam- ic stable state and was admitted to the surgical itensive care unit, where ICP management according to the LUND concept, as commonly used in our hospital, was installed. Already after some hours the brain pressure began to rise despite deep sedation with a bispectral index monitor (BIS) under 40 and consistently normothermia normoventilated. Another brain CT was performed, which showed a swelling of the brain with an axis shift of 7 mm. This time additionally an angio- CT was performed as the radiologist had already suspected a dissection of the Arteria vertebralis in the first scan. No dissection was found, but a thrombosis of the sinus sig- moideus and transversus was depicted. Located next to the fractured skull (Figure 2) the thrombosis was highly likely traumatic, caused by the head trauma. As there was only little congestion of the venous flow and the contralateral sinus showed a sufficient blood drainage no lyse or thrombectomy was per- formed. After a multidispliciplinary conference the decision was made to lower the intracra- nial pressure by perfoming a craniectomy. In the following therapeutic heparin therapy was induced. After seven days, mechanical ventilation was terminated. Four days later the patient was already stable enough to be dis- charged from the surgical ICU. Even though, a small ischaemic areal appeared in the follow up scan (Figure 3) the patient did not show any further neurological deficiency besides a neurocognitive deficit. To date he is in a reha- bilitation clinic. Conclusions Summarizing, despite the fact that traumatic sinus venous thrombosis is rare, it is treated the same way as non-traumatic thrombosis. Standard therapy is anticoagulation, as early as possible, even if an intracranial bleeding is Emergency Care Journal 2016; volume 12:5441 Correspondence: Christina Mueller-Hoecker, Klinik für Anästhesiologie, Intensiv-, Rettungs- und Schmerzmedizin, Rorschacherstrasse 95, 9000 St.Gallen, Switzerland. E-mail: christina.muellerhoecker@googlemail.com Acknowledgements: special thanks go to Dr. Jürgen den Hollander (Kantonspital, St. Gallen, Switzerland), who contributed to the making of images. Contributions: CMH was responsible for the con- cept, drafting of the manuscript and for analysis of the radiologic data and revision of the manu- script. UP was responsible for revision and final approval of the manuscript. Conflict of interest: the authors declare no poten- tial conflict of interest. Note: the data was collected during clinical work. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written con- sent is available for review by the Editor-in-Chief of this journal. Received for publication: 14 July 2015. Revision received: 7 November 2015. Accepted for publication: 9 November 2015. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright C. Mueller-Hoecker and U. Pietsch, 2016 Licensee PAGEPress, Italy Emergency Care Journal 2016; 12:5441 doi:10.4081/ecj.2016.5441 Figure 1. Partial thrombogenic occlusion of the transvers sinus (arrows). Non co mmerc ial us e o nly [page 12] [Emergency Care Journal 2016; 12:5441] apparent.3,5 To date intracranial lysis or thrombectomy is only chosen in single cases, especially when there is congestion of the blood flow.5 Ambulant warfarin therapy can range from 3-12 months or longer depending on the etiology and must be chosen individually. References 1. Kaplan MOM, Topsakal C, Erol FS, Akdemir I. Asymptomatic interval in delayed trau- matic intracerebral hemorrhage: report of two cases. Clin Neurol Neurosurg 2003; 105:153-5. 2. Bishop FS, Finn MA, Samuelson M, Schmidt RH. Endovascular balloon angio- plasty for treatment of posttraumatic venous sinus thrombosis. Case report. J Neurosurg 2009;111:17-21. 3. Ghandehari K, Riasi HR, Noureddine A, et al. Safety assessment of anticoagulation therapy in patients with hemorrhagic cerebral venous thrombosis. Iran J Neurol 2013;12:87-91. 4. Glassner S, Srivastava K, Cofnas P, et al. Prevention of venous thrombotic events in brain injury: review of current practices. Rambam Maimonides Med J 2013;4:e0001. 5. Weimar MF, Masuhr F, Hajjar K. Diagnosis and treatment of cerebral venous thrombo- sis. Expert Rev Cardiovasc Ther 2012;10:1 545-53. Case Report Figure 2. Fracture of the skullcap. Figure 3. Ischaemic area (arrows) due to the thrombogenic occlusion of the trans- vers sinus. Non co mmerc ial us e o nly