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Bleeding from Bridging Veins and Superior Petrosal Sinus

December 11, 2015

Transcript

Control of the bleeding within the cerebellopontine angle can be quite important in avoiding resulting complications. There are two scenarios where the bleeding can be quite problematic. The first scenario is where the superior petrosal sinus is avulsed during dissection around the sinus and the second scenario is when the swollen cerebellar hemisphere is mobilized and the bridging vein between the tentorial surface of the cerebellum and the tentorium is avulsed leading to excessive bleeding within the blind spot of the surgeon. This is a right sided, retromastoid craniotomy. The retractor was mobilized and as you can see, the superior petrosal sinus was avulsed in this situation. There are two ends or pedicles to the evolved sinus. The one on the cerebellum, this torn end can be readily controlled with bipolar coagulation and can be collapsed. However, the other bleeding end of the superior petrosal sinus is at the level of Petro-tentral junction and most often within the tentorium, the stiff tentorium avoids collapse of the lumen of the vein via bipolar coagulation. And therefore, I use a piece of thrombin soaked gel foam at the back end of a small piece of cottonoid to seal the defect or the opening within the bore of the sinus with gel foam. In this situation, most of the bleeding was occurring at the level of the tentorium. The cottonoid with a piece of gel foam is being prepared. The other torn end at the level of the cerebellum does not seem to be as active. Here's that piece of the cotton with some thrombin soaked gel foam at the end of it, which is pushing the gel form into the lumen of the torn superior petrosal sinus. In this second scenario, this is a left sided, retromastoid craniotomy. This is the sagittal sinus transfer sinus, the cerebellum was noted to be quite swollen. The operator mobilized the cerebellum medially and excessive bleeding was encountered within the CP angle. Initially, the source of bleeding is not very clear. However, the arachnoid bands around the superior petrosal sinus are not even manipulated yet. Therefore, the most common source of bleeding is from a bridging vein from the tentorial surface of the cerebellum joining the tentorium. Additional suction is used to keep the operative field clear. I follow the flow of the blood until I can clearly identify the source of bleeding. Packing blindly with gel foam is avoided as this will block adequate visualization of the source of bleeding and will prevent definitive treatment and addressing of the source of bleeding. Here you can see the bridging vein that is quite evident. I move my bipolar forceps toward the vein where the bleeding is occurring at the midsection of the bridging vein. In this situation, the pedicle of the vein at the level of tentorium is left intact. And by just coagulating the exact site of the bleeding at the midsection of the vein, I can keep the bleeding under good control. Subsequently, the vein is transected so the tension on the pedicle at the level of the tentorium is minimized. This maneuver will lead to control the any bleeding most often minor in this situation from the level of the tentorium by relieving the tension on the wall of the vein so the vein can collapse. The vein is completely coagulated. There is an end to the piece of the vein at the level of the tentorium therefore sealing the opening with gel foam is not necessary as compared to the first video. Next, the blood can be cleared and the operation can proceed. Again the most important learning point is to remain patient follow the flow of the blood and avoid blind packing of the area of the bleeding without definitively addressing the source of bleeding. Thank you for your attention.

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