Lumbo Peritoneal Shunt in Management of Cases of Depressed Skull Fractures with Superior Sagittal Sinus Occlusion

Abstract
Background: Patients with depressed skull fractures overlying the superior sagittal sinus (SSS) present an ongoing challenge. Many surgeons would opt for a conservative man-agement of these cases if there was no associated deficit to avoid risky sinus surgery. A variable percentage of patients presenting with such fractures suffer from SSS occlusion resulting in Benign Intracranial Hypertension (BIH).
Aim of Study: We aim to evaluate SSS patency, evaluate intracranial tension and evaluate options for management in patients with simple depressed skull fractures overlying posterior 2/3 of SSS and not surgically indicated.
Patient and Methods: Prospective study of cases which admitted to Cairo University Hospitals, and Bani sueif Uni-versity Hospital, Department of Neurosurgery, Accidents and Emergency between Jan. 2014 and December 2015.
Patients with simple and compound depressed skull frac-tures overlying the SSS and not indicated for surgery, with no other intracranial abnormality, with a Glasgow Coma Scores (GCS) of 12 or better were admitted to the study. Patients underwent Magnetic Resonance Venography (MRV) to determine SSS patency on admission, they were clinically followed up using Computerized Tomography (CT) and repeat MRV when needed. Patients underwent serial lumbar manom-etry, and were given medical treatment in the form of aceta-zolamide, furosemide plus low molecular weight heparin and anti platelets. Patients were then assessed and evaluated to be admitted for LP shunt surgery and followed-up.
Results: A total of 12 cases were included in the study, 7 patients had complete SSS occlusion and 5 cases has nar-rowing with patent SSS. The 5 cases with incomplete SSS occlusion had a stable course with only one case (20%) developing elevated intracranial pressure (ICP) not responding to medications and requiring LP shunt. Of the 7 patients with complete occlusion, 100% developed elevated ICP not re-sponding to medical treatment, and all required LP Shunt insertion, 5 patients developed multiple contusions due to anticoagulant therapy on top of SSS occlusion, with discon-tinuation of anticoagulants and deterioration of conscious level, 8 patients had LP surgery and showed a stable improving post operative course, 2 patients had restored SSS patency on repeat MRV.
Conclusion: Management of depressed skull fractures overlying the SSS remains controversial, patients with partial occlusion have a better prognosis, patients with complete occlusion can improve with best medical treatment. LP shunt is recommended for all cases of SSS occlusion.