Compound depressed skull fractures overlying dural venous sinuses

ABSTRACT

The purpose of this study was to characterize the patients with compound depressed skull fractures overIying dural venous sinuses clinically and radiologically and to discuss the patients' circumstances that favour conservative or surgical treatment, in addition to the outcome. Of 192 patients with depressed skull fractures admitted to our Neurosurgical Department, Assiut University Hospital between January 2004 to December 2005, 30 patients [15.6%] with compound depressed skull fractures over a dural venous sinus were prospectively studied. There were 27 [90%] males and 3 [10%] females. Eighteen patients [60%] were paediatrics [3- 18 yrs] while 12 [40%] were adults [20-60 yrs]. Twenty-four patients had a Glasgow Coma Scale [GCS] of 14- 15/15, 3 patients had a GCS of 9- 13 and 3 patients had a GCS of <8. Aetiological falls and motor vehicle accident were predominant in the paediatric group while among adults assault and motor vehide accident were predominant. The superior sagittal sinus was the most commonly involved sinus [28 out of 30 patients = 93.3%] with anterior injuries more common than posterior ones [26 out of 28 patients = 92.9%]. Thirteen patients [43.3%] were treated conservatively and 17 [56.7%] patients were treated surgically; either initially in 15 cases due to the presence of neurological deficit, underlying haematoma, egress or escape of intracranial contents and/or deep contamination, or later on in the other 2 cases due to development of intracranial hypertension. lntraoperative difficulty was experienced in 8 [47.1%] patients. Of those treated non-operatively, 3 [23.1%] patients developed wound infection while wound infection among those treated operatively was seen in 2 [11.8%] patients. There was no mortality and the neurological deficit was reversed with the aid of physiotherapy by time and the patients returned to their daily activities. Our opinion favours conservative approach to fractures involving a dural sinus, if the wound is not contaminated, as the risk of infection is low. Surgery exposes the patient to the very real risk of massive haemorrhage. In instances where there is a clear need for surgery adequate precautions should be taken. Computed tomographic venography is a reliable tool for demonstrating early sinus compression and/or occlusion that facilitates surgical decision. However, delayed intracranial hypertension is a possible complication and should always be considered in patients with the appropriate clinical findings in the follow-up period