Superior sagittal sinus occlusion caused by a compound depressed skull fracture: a case treated by emergency surgery

Depressed skull fractures compressing major venous sinuses are rare, and the treatment is a matter of controversy. The majority of depressed fractures are treated conservatively for fear of bleeding from venous sinuses, but surgical intervention was conducted in a few cases. We report a case of a 59-year-old man with a compound depressed fracture occluding the superior sagittal sinus (SSS). The patient was struck on the head by a heavy iron bar and admitted to our emergency center because of deterioration of consciousness. A computed tomographic scan showed depressed skull fracture overlying the SSS with hemorrhagic lesions in the bilateral parietal lobes and an acute epidural hematoma at the right temporoparietal convexity. Digital subtraction angiography (DSA) showed an occlusion of the SSS and compensatory venous drainage associated with poor capillary filling in the left parietal lobe. On an emergency basis, bone fragments compressing the SSS were surgically removed piece-by-piece to resolve severe venous congestion and to avoid infection. A small tear in the SSS was treated by head elevation and compressing the SSS with Gelfoam. Postoperative DSA confirmed the patency of the SSS and normal blood flow in the left parietal lobe. The patient exhibited slight disorientation and was transferred to another hospital for further rehabilitation. Because of symptomatic severe venous congestion, we had to perform emergency surgical decompression and removal of bone fragments. Treatment strategy for depressed skull fracture with SSS involvement was discussed with review of the literature.