There is insufficient evidence to support a strong, moderate strength or weak recommendation for operative repair of venous sinus injuries for the purposes of improving survivability and sinus patency.
Level IVSinus injuries should be repaired by open surgery when exsanguination or death from herniation would be more likely to occur in the absence of intervention to improve survivability.
No evidence or expert opinion supported distinct recommendations based on patient gender, age, wounding mechanism, or military vs. civilian context.
Venous sinus injuries fall within the spectrum of traumatic cerebrovascular injury suffered from foreign body penetration.
The prior head injury guidelines did not address this specific topic directly.
Three studies met inclusion criteria for formal inclusion as evidence for this topic. There was one large retrospective nonrandomized study identified in a primarily military population by Kapp et al with penetrating traumatic brain injury (pTBI) and dural venous sinus injuries in the Vietnam War that assessed management of venous sinus injuries and reported mortality outcomes.
Abdallah et al outlined surgical management of a traumatic SSS tangential injury that occurred in the Syrian Civil War.
An additional case report by Pricola et. al. outlined surgical management and venous sinus repair in a patient with a gunshot wound and retained fragment within the torcula.
Several additional studies (not meeting inclusion criteria) were identified that reported outcomes for patients with dural venous sinus injuries although none directly addressed the key question and results were typically reported in aggregate for patients with concomitant arterial injuries.
One study by Pylypenko et. al from Ukraine evaluated surgical management in 21 patients with dural venous sinus injury sustained in battle.
One study by Hammon et. al reported active exsanguination from venous sinus injury as an indication for immediate neurosurgical intervention.
One case series by Khan et al was identified which included three cases of surgically managed venous sinus injury.
These studies provide insufficient evidence to determine the benefits and harms of surgical or endovascular management of venous sinus injuries to prevent venous infarction. They do, however, provide very low strength evidence that operative repair of venous sinus injuries is feasible and may improve survivability (assuming exsanguination would be more likely to occur in the absence of surgery) and sinus patency.
Amongst the many goals of surgical intervention in the setting of penetrating brain injury, hemorrhage ranks among the highest. As with all literature in this area, high quality, prospective randomized studies in the management of penetrating sinus injury are not possible. The literature experience outlined above provides a useful guide in this area.
Many patients with penetrating cerebral venous injuries will die before they can be helped. Those who survive to hospital likely have characteristics that make them potentially salvageable. In some circumstances when there is not external hemorrhage these lesions can be managed non-operatively. In some circumstances endovascular treatment can be employed in conjunction with open surgery to help reduce blood loss. Open surgery for these lesions is extremely high risk and technically challenging. The entire operative team must be aware of and prepared for the risks of substantial blood loss and perioperative arrest. These can be desperate surgeries. Vascular neurosurgical expertise is very helpful when available. Good patient outcomes can be achieved in many of these patients, however, through a combination of luck and technical prowess.
In general, endovascular management of penetrating venous sinus injuries is not well described in the literature. There are no published case reports or described techniques (to the author's knowledge) advocating for endovascular intervention to preserve the venous sinus. It may be possible to help control active exsanguination with endovascular balloon assistance, but this would require combined endovascular operating rooms and acute multi-disciplinary management. Description of the rapid employment of this approach in practice would be beneficial. Current nitinol stent systems are, in general, designed for arterial deployment, are challenging to navigate in the cerebral venous sinus system, and require a period of dual antiplatelet therapy after deployment. Covered stent systems share the same characteristics with the added negative of covering and occluding draining cortical veins. Additional research and development of specific cerebral venous sinus stent systems that do not require dual antiplatelet therapy may provide some benefit in this and other areas. Here rigorously reported case reports and case series can make important contributions to the sparse literature.