December 22, 2015
This video reviews the tenants for repair of injuries to the superior sagittal sinus during elevation of the bone flap. This is a 60 year-old female who presented with two parasagittal metastatic lesions on the sagittal contrast enhanced image. You can see the two parasagittal well-defined lesions on axial T2 images there is significant associated edema. Since the tumors in the rest of her body were under boot control, surgical resection deemed most appropriate to resolve the edema. The patient was placed in the lateral position. A lumbar drain was also installed to provide Cerebro decompression early, to access the interim as for its space for a section of these tumors. Based on your navigation. This is the location of anterior lesion, and this is the location of the posterior lesion. I planned a S incision to expose both tumors through a single incision. The next image demonstrates the position of the head of the patient. This is the craniotomy with tuber holes over the superior sagittal sinus upon elevation of the bone flap, the patient's blood pressure dropped acutely and a suspicion of venous air embolism was raised. Although there was not significant bleeding from the Douro. We suspected that the elevation of the head of the patient led to reverse suctioning of the air with unnecessarily bleeding through the laceration over the roof of their superior sagittal sinus. I immediately flood to the field with water irrigation fluid and lowered the head of the patient and covered the exposed duro with two large pieces of wet sponge. Here's the configuration of the opera field at the time of its coverage. I provided the anesthesiologist with a significant amount of time to assure complete stabilization of the vital signs. So the area of bleeding and potentially dural venous sinus injury can be explored. The patient vital signs were stabilized and the wet sponges were gently elevated. Bleeding was encounter now since the head of the patient is lowered and therefore air sanctioning is minimized but venous bleeding is more obvious. You can see my finger right over the area of the laceration. The roof of the sinus was injured. I maintained proximal and distal control over there. The sinus with gentle tamponade using the fingers of the assistance. A dural flap was elevated from the left side and the roof of the sinus was reconstructed. During this time, the head of the patient again was slightly lowered to prevent any entry of the air into the dura of inner sinus. A piece of, Surgicel fibrillar was used to cover also the area of the reconstruction. As you can see the ICG demonstrated relative pay to see of the supersaturate sinus in the area of the injury and anterior to it. The left sided more superficial tumor was removed. I also attempted to open the dura on the left side for the anterior lesion. However large venous lakes were encountered. I did not want to place the patient at risk of an additional venous air embolism. The operative plan was adjusted by opening the dura on the right side and using a trans fall scene approach to reach the left parasagittal tumor. The large veins or the right paracentral area were untethered and protected. The lumbar drain is significantly assisted with cerebral decompression. In this case, defaults was incised in a T fashion accord economy on the left medial poster frontal region was completed and the tumor was circumferential disconnected from the surrounding white matter areas. After removal of the tumor, the closure was completed in standard fashion. You can see the false in flaps that are being placed back to the original position. Post operative CT demonstrated patency of the superior sagittal sinus and this patient at walking from anesthesia without any new neurological deficits. This case has two specially important learning points. The first one is the importance of recognizing venous air embolism early, managing it appropriately, and also reconstructing the laceration over the roof of the superior sagittal sinus to maintain its patency. The second important point is to remain flexible and adjust operative plan. As you can see in this case, the opening of the dura on the left parasagittal area for the anterior lesion, risky since the patient had already suffered from an episode of venous air embolism. Therefore I adjusted the plan, and used the Trans force in approach despite his technical difficulty due to the position of the head of the patient. Both of these considerations minimize the risk of additional injury to the patient. Thank you.
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