A Rare Case of Extradural Hematoma Traversing Over the Transverse Sinus

Traumatic brain injury (TBI) is one of the most commonly encountered emergencies in the emergency department (ED).[1] Out of all the TBIs encountered, the incidence of extradural hematoma (EDH) is around 10%. The common cause of EDH is trauma. Patients can also present as spontaneous EDH due to coagulopathy, arteriovenous fistulas, etc.[2] As per the location, EDH is most commonly present on convexity like temporal or parietal-temporal (85%); however, midline and posterior fossa are also described to be present. The incidence of EDH due to venous sinus injury is around 4 to 5%. However, the morbidity and mortality associated with the disease is around 40%.[3] The middle 1/3rd sagittal sinus injury or vertex EDH is more common followed by the transverse sinus and the sigmoid sinus injury. The transverse sinus injury is most commonly due to trauma with the calvarium fracture line crossing over the transverse sinus. These sinuses are placed inside a triangular area of dural attachment. To these dural sinuses, multiple cortical veins drain along with arachnoid granulations, which drain the cerebrospinal fluid (CSF) into the sinus. Traumatic injury to the sinus can result in massive blood losses as they do not collapse following the trauma. This is also followed by sinus thrombosis or stenosis. This results in venous infarcts and increased intracranial pressure (ICP). Blockage to the arachnoid granulations can result in hydrocephalous, features of raised ICP and bradycardia.[4]

We present to you a 40-year-old gentleman who presented to our ED with a history of road traffic accident 8 hours back followed by altered sensorium. His Glasgow Coma Scale (GCS) at presentation was found to be GCS-7/15. The ATLS (Advanced Trauma Life Support) protocol was followed. Cervical spine was stabilized. FAST (Focused Assessment with Sonography for Trauma) was found to be negative. He was evaluated with noncontrast computed tomography (CT) brain, which was suggestive of a large EDH involving the left occipital parietal region, traversing to the posterior fossa compressing the cerebellar hemispheres and pons. The EDH traverses the left transverse sinus with suspected injury to the sinus. There was an associated left frontal contusion present ([Fig. 1A] and [B]). He was planned for emergency decompression and evacuation. The patient was first positioned prone. A horse shoe incision was made on the left side. Separate craniotomies were made for the supratentorial and posterior fossa EDH ([Fig. 2A] and [B]). The separate craniotomy appears like a book, which was one while leaving a strip of bone over the left transverse sinus. Intraoperatively, there was suspected sinus injury, which was appreciated due to the sudden massive loss from the sinus wall after craniotomy. Gel foams were placed over the sinus and pressure was given, the dura was hitched along the side of the bone strip to achieve adequate pressure over the sinus to achieve hemostasis. The frontal contusion was evacuated with a separate frontoparietal craniotomy. Postop CT brain was suggestive of complete evacuation of EDH ([Fig. 3A] and [B]). Blood loss was around 250 mL intraoperatively. Due to intraoperative edema of the brain parenchyma, cranioplasty was done in a second sitting after weeks. Postop period recovery was progressive but slow.

Fig. 1 Noncontrast computed tomography (NCCT) brain which was suggestive of a large extradural hematoma (EDH) involving the left occipital parietal region, traversing to the posterior fossa compressing the cerebellar hemispheres and pons (A, B).

Fig. 2 Separate craniotomies were made for the supratentorial and posterior fossa extradural hematoma (A, B).

Fig. 3 Postop computed tomography (CT) brain was suggestive of complete evacuation of extradural hematoma (EDH) (A, B).

The incidence of venous sinus injury of the brain is around 4 to 5%. It has a high incidence of morbidity and mortality with a range of up to 40 to 50%.[3] The cause of sinus injury can be blunt due to trauma with the most common cause being road traffic accidents. The other cause can be penetrating injury, which can result in sinus injury. A high degree of suspicion is a must as it can lead to massive intraoperative blood losses followed by shock. Magnetic resonance venography is an option to identify venous injury.[5] Most EDHs present as acute emergencies and need to be operated as early as possible. Venous injury can result in thrombosis, which can result in venous infarcts and intraparenchymal hemorrhages. Disruption of the arachnoid villa can lead to CSF pathways blockade, which can lead to hydrocephalous, raised ICP, and bradycardia. Identifying the intraoperative sinus injury and managing it is difficult and it can lead to massive blood losses in a short span of time. There are multiple options to repair the sinus like pressure with gel foam with saline irrigation. Multiple dural hitches plus gel foam coating. Primary repair of the sinus with fascia lata is done; however, care must be taken not to compromise the diameter of the sinus. Bypassing the sinus is another option. Veno-venous channel can be another alternative.[6] In our case, we have managed the case with separate craniotomy on either side of the transverse sinus followed by multiple dural hitches on either side of the transverse sinus with gel foam packing to achieve hemostasis. As per the study conducted prospectively by the Neurosurgery Department, Trauma Casualty Unit, Cairo University between August 2013 and March 2014 on patients suffering from TBIs with associated dural venous sinus injury, they concluded that traumatic dural venous sinus injury is one of the most dangerous complications of TBI, either due to fatal intracranial compressing venous bleeding, or disturbing the ICP, which could be caused by injury to the superior sagittal sinus.[1] [7]

On the other hand, posttraumatic dural sinus thrombosis is considered a rare complication that may lead to hemorrhagic infarction with serious consequences including epilepsy, neurological deficits, or death.

 

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Conflict of Interest

None declared.

• References

• 1 Elkatatny AAAM, Elreheem YAA, Hamdy T. Traumatic dural venous sinuses injury. Open Access Maced J Med Sci 2019; 7 (19) 3225-3234
• 2 Acharya A, Mahapatra AK, Tripathy S. R et al. Postoperative contralateral spontaneous epidural hematoma. Indian J Neurosurg 2024;
• 3 Forbes JA, Reig AS, Tomycz LD, Tulipan N. Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion. J Neurosurg Pediatr 2010; 6 (01) 23-28
• 4 Yilmazlar S, Kocaeli H, Dogan S. et al. Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases. Acta Neurochir (Wien) 2005; 147 (12) 1241-1248 , discussion 1248
• 5 Uppar A, Kadregula S, Sadashiva N. et al. Surgical outcomes of Supra- Infra Tentorial Extradural Hematoma (SIEDH): a retrospective study from a single institution. Clin Neurol Neurosurg 2021; 200: 106369
• 6 Yoon SY, Seok J, Kim Y. et al. Surgical management of supratentorial and infratentorial epidural hematoma in Korea: three case reports. J Trauma Inj 2023; 36 (04) 399-403
• 7 Parker SL, Kabani AA, Conner CR. et al. Management of venous sinus-related epidural hematomas. World Neurosurg 2020; 138: e241-e250

Publication History

Article published online:
25 August 2025