Intracranial Hypertension due to Cerebral Venous Sinus Thrombosis following Head Trauma: A Report of Two Cases
The patient was a 13-year-old female who was hit by a car while riding a horse. She was described as having a Glasgow coma scale score of 9 and intubated prior to transport to the neurosurgical department at Umeå University Hospital. During clinical examination with a low dose of propofol, the patient showed withdrawal to painful stimuli in all extremities and the pupils were of normal size and responsive to light. A CT scan showed unremarkable findings with only some minimal contusions and otherwise visible sulci on the convexities and open basal cisterns (fig. ). There was no visible skull fracture. The ICP, measured by an intraparenchymal pressure monitor (Codman MicroSensor; Johnson & Johnson), however, was 30 mm Hg. Despite sedation with phenobarbital and the placement of an external ventricular drainage for intermittent drainage of cerebrospinal fluid, the ICP was 30–35 mm Hg. To exclude venous thrombosis, an angiography was performed 2 days later that showed thrombosis in the right transverse sinus (TS) and contrast stagnation in cortical veins, including the vein of Labbé, as a sign of impaired venous drainage (fig. ). The right femoral vein was catheterized and a microcatheter (Renegade; Boston Scientific) was inserted into the right TS in an attempt to perform a mechanical thrombectomy. This maneuver, however, did not provide a lasting effect; 20 mg of tissue plasminogen activator was instead administered locally as a bolus. Angiographic imaging showed a partial resolution of the thrombus with flow in the TS (fig. ), whereas the ICP increased to 70 mm Hg. A CT scan showed newly formed subarachnoid haemorrhage, acute subdural haematomas bilaterally and progress of frontal contusions (fig. ). Evacuation of acute subdural haematomas and a bifrontal hemicraniectomy were performed immediately, and the postoperative ICP remained stable at <20 mm Hg (fig. ). The patient was then treated with dalteparin (2,500 U) daily during 5 additional days in the ICU until she could be extubated. The patient's recovery following a cranioplasty 2 months later was excellent, and there were no neurological deficits.