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Repair of Intraoperative Injuries to the Transverse-Sigmoid Junction

December 02, 2015


Intraoperative injuries to the dural venous sinuses can be quite catastrophic if they're not managed appropriately. The first step is to control their massive bleeding and importantly avoid the creation of the venous air embolism with a high suspicion of detecting venous air embolism by lowering the head and the communicating appropriately with the anesthesiologist. The next goal is obviously to reconstruct a lumen of the sinus to prevent its thrombosis, simply packing the lumen can be also problematic. In this video, I'm going to discuss the strategies for repair of a transverse-sigmoid junction injury, during a creation of the craniotomy. This was a patient who presented with a right sided occipital parietal high-grade glioma as you can see here, since this tumor had approach the tentorium, the Burr hole was planned to be placed just above the press for sinus, but low enough that an inferior trajectory can be planned to reach the inferior pole of the tumor. You can see the initial view of this MRI, which demonstrates a very dominant right-sided transfer sinus which obviously has to be protected during the surgery. Let's go ahead and see the findings here, This patient is placed in a lateral position with a relatively S sension just above the transfer sinus so we can go ahead and create an appropriate craniotomy to reach the entire extent of the lesion. When the craniotomy was elevated, a significant amount of venous splitting was encountered from the lower edge of the dura, which made us suspect that the transverse sigmoid sinus or their junction has been injured. First, the sponge was used to control the bleeding, we did not pack the air of the bleeding with a gel foam to prevent the chance of thrombosis of the dural sinus. Therefore, a large sponge was placed over there the body and to head was gently lowered in a trendelenburg position to avoid the risk of venous air embolism. Now that the bleeding is under control, that dura did not seem to be getting significantly more tense although it was slightly tense I am going ahead and bringing the microscope in and we're going to see the rest of the video here you can see now I'm trying to remove the bone over the roof of the area of the bleeding to be able to skeletonize where the injury occurred. Here you can see that the sinus has been injured just as it's joining the sigmoid sinus the whole lumen is avulsed where the initial craniotomy was performed with the foot plate. The suction is now within the lumen of this dominant sinus now we're going to go ahead and use a carotenoid and be able to have my assistant place gentle pressure with his suction until I'm able to completely skeletonized the dura and around the area of the injury. Let's go ahead and review the finding, here ,you can see that the initial bony opening was up to the level of here this is the transverse sinus, this is the sigmoid sinus, this is the junction that has been completely injured at the level of its roof and I used the M3 and removed the bone just around the area of the injury, so now I can plan my strategies regarding management and reconstruction of the roof of the sinus. Obviously just packing the area with a gel form or other hemostatic agents will lead to complete thrombosis and sacrifices sinus which in this case would not be desirable due to the very significant dominance of the dural venous sinus on this side. So now that I have been able to find the exact site, both proximally and distally, I have a carotenoid over that area I'm going to use the carotenoid to provide some hemostasis while I reflect the flap of the dura to reconstruct the floor. And here you can see that along the later stages, I had to remove the clots so as to have additional space to place the sutures, and I asked my assistant to place some gentle tamponade pressure over the proximal side of the sinus in order for me to have enough clear operating field to be able to complete the suturing process. You can see the vein over the brain that was joining the sinus that was currently protected during the reconstruction process and it looks very healthy. You can see on the ICG angiogram that the sinus is relatively patent, and we went ahead to proceed with a removal of the tumor without any complicating features and the post-operative MRI demonstrate the patency of the sinus or unchanged status of the sinus this area of the vault was present during the preoperative MRI and this patient did not have any on toward effect from a reconstructive sinus in this case. And the important point that I want to remind everyone is that it's best to keep calm, be able to achieve immediate hemostasis without packing the lumen of the sinus and be able to remain creative in terms of reconstructing the floor of the sinus and maintaining the patency of the sinus as much as possible. Thank you.

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