Abstract:Objective Lateral sinus thrombosis is a potentially devastating but seldom studied complication of cerebellopontine angle (CPA) tumor surgery. Systemic anticoagulation in the early postoperative period has often been avoided due to the potential risks of intracranial hemorrhage. Design Retrospective review. Setting Tertiary referral center. Main Outcome Measures The goal of this study was to identify the frequency, treatment, and outcomes in patients who develop postoperative venous sinus thrombosis following … Show more
“…First-line management of cerebral venous sinus thrombosis involves careful anticoagulation. 76 , 77 We have also previously reported on the potential role of optic nerve sheath fenestration in post VS-resection cerebral venous sinus thrombosis with threatened vision. 5 Figure 4 Magnetic resonance venogram following resection of a left vestibular schwannoma showing absence of filling of the left transverse venous sinus (arrows) due to a transverse venous sinus thrombosis.…”
Section: Papilledemamentioning
confidence: 90%
“…First-line management of cerebral venous sinus thrombosis involves careful anticoagulation. 76,77 We have also previously reported on the potential role of optic nerve sheath fenestration in post VS-resection cerebral venous sinus thrombosis with threatened vision. 5…”
Section: Papilledemamentioning
confidence: 90%
“…Cerebral venous sinus thrombosis is a recognized complication of skull-based surgery with reported rates following VS surgery varying between 5% and 30%. 70 , 75 , 76 Figure 4 shows a post-VS-resection venogram for a patient who developed transverse venous sinus thrombosis with associated papilledema and central visual disturbance post-operatively. First-line management of cerebral venous sinus thrombosis involves careful anticoagulation.…”
Vestibular schwannomas (VSs), also called acoustic neuromas, are benign intracranial neoplasms of the vestibulocochlear (VIII) cranial nerve. Management options include “wait-and-scan,” stereotactic radiosurgery and surgical resection. Due to the proximity of the VIII nerve to the facial (VII) nerve in the cerebello-pontine angle, the VII nerve is particularly vulnerable to the effects of surgical resection. This can result in poor eye closure, lagophthalmos and resultant corneal exposure post VS resection. Additionally, compression from the tumor or resection can cause trigeminal (V) nerve damage and a desensate cornea. The combination of an exposed and desensate cornea puts the eye at risk of serious ocular complications including persistent epithelial defects, corneal ulceration, corneal vascularization, corneal melting and potential perforation. The abducens (VI) nerve can be affected by a large intracranial VS causing raised intracranial pressure (a false localizing sign) or as a result of damage to the VI nerve at the time of resection. Other types of neurogenic strabismus are rare and typically transient. Contralaterally beating nystagmus as a consequence of vestibular dysfunction is common post-operatively. This generally settles to pre-operative levels as central compensation occurs. Ipsilaterally beating nystagmus post-operatively should prompt investigation for post-operative cerebrovascular complications. Papilledema (and subsequent optic atrophy) can occur as a result of a large VS causing raised intracranial pressure. Where papilledema follows surgical resection of a VS, it can indicate that cerebral venous sinus thrombosis has occurred. Poor visual function following VS resection can result as a combination of all these potential complications and is more likely with larger tumors.
“…First-line management of cerebral venous sinus thrombosis involves careful anticoagulation. 76 , 77 We have also previously reported on the potential role of optic nerve sheath fenestration in post VS-resection cerebral venous sinus thrombosis with threatened vision. 5 Figure 4 Magnetic resonance venogram following resection of a left vestibular schwannoma showing absence of filling of the left transverse venous sinus (arrows) due to a transverse venous sinus thrombosis.…”
Section: Papilledemamentioning
confidence: 90%
“…First-line management of cerebral venous sinus thrombosis involves careful anticoagulation. 76,77 We have also previously reported on the potential role of optic nerve sheath fenestration in post VS-resection cerebral venous sinus thrombosis with threatened vision. 5…”
Section: Papilledemamentioning
confidence: 90%
“…Cerebral venous sinus thrombosis is a recognized complication of skull-based surgery with reported rates following VS surgery varying between 5% and 30%. 70 , 75 , 76 Figure 4 shows a post-VS-resection venogram for a patient who developed transverse venous sinus thrombosis with associated papilledema and central visual disturbance post-operatively. First-line management of cerebral venous sinus thrombosis involves careful anticoagulation.…”
Vestibular schwannomas (VSs), also called acoustic neuromas, are benign intracranial neoplasms of the vestibulocochlear (VIII) cranial nerve. Management options include “wait-and-scan,” stereotactic radiosurgery and surgical resection. Due to the proximity of the VIII nerve to the facial (VII) nerve in the cerebello-pontine angle, the VII nerve is particularly vulnerable to the effects of surgical resection. This can result in poor eye closure, lagophthalmos and resultant corneal exposure post VS resection. Additionally, compression from the tumor or resection can cause trigeminal (V) nerve damage and a desensate cornea. The combination of an exposed and desensate cornea puts the eye at risk of serious ocular complications including persistent epithelial defects, corneal ulceration, corneal vascularization, corneal melting and potential perforation. The abducens (VI) nerve can be affected by a large intracranial VS causing raised intracranial pressure (a false localizing sign) or as a result of damage to the VI nerve at the time of resection. Other types of neurogenic strabismus are rare and typically transient. Contralaterally beating nystagmus as a consequence of vestibular dysfunction is common post-operatively. This generally settles to pre-operative levels as central compensation occurs. Ipsilaterally beating nystagmus post-operatively should prompt investigation for post-operative cerebrovascular complications. Papilledema (and subsequent optic atrophy) can occur as a result of a large VS causing raised intracranial pressure. Where papilledema follows surgical resection of a VS, it can indicate that cerebral venous sinus thrombosis has occurred. Poor visual function following VS resection can result as a combination of all these potential complications and is more likely with larger tumors.
“…[ 3 , 13 ] Early retrospective studies reported pCVST incidence between 5.2% and 11.6% with more recent prospective studies revealing much higher rates between 32.4% and 38.9%. [ 1 , 4 , 7 , 12 ] This discrepancy is, in part, a result of the overwhelmingly asymptomatic nature of pCVST where capturing the diagnosis is largely dependent on the standardization of postoperative imaging.…”
Section: Discussionmentioning
confidence: 99%
“…Some advocate diagnostic vigilance and therapeutic anticoagulation or antiplatelet therapy regardless of clinical symptoms as supported by trials involving sCVST. [ 5 , 6 , 12 ] However, others choose to treat only if it is symptomatic noting that therapeutic anticoagulation in the immediate postoperative period is not without risk of significant intracranial hemorrhage and that available evidence point toward pCVST being a largely benign and asymptomatic process with up to 61% rate of recanalization at 1 year follow-up without any intervention. [ 2 , 3 , 7 ] Indeed, in two large prospective studies, Benjamin et al .…”
Background:
Postoperative cerebral venous sinus thrombosis (pCVST) after resection of cerebellopontine angle and posterior fossa tumor resections occur almost exclusively in the lateral venous sinuses and are generally asymptomatic. Thrombus extension and involvement of the superior sagittal sinus (SSS) – a serious and potentially devastating complication – are rarely described and, as such, successful treatment for which is still poorly understood. We report a case of pCVST involving the SSS after translabyrinthine approach for resection of a metastatic neuroendocrine tumor (NET), and the first that was successfully treated with anticoagulation therapy.
Case Description:
A 40-year-old man presented with headaches, diminished right-sided hearing, and ataxia was found to have a large right-sided cerebellopontine angle (CPA) lesion with extra-axial and possible intraparenchymal invasion. A retrosigmoid craniotomy for debulking and diagnosis was undertaken. Postoperative imaging revealed patent venous sinuses. Pathology confirmed NET. Further imaging revealed a likely pancreatic primary lesion. The patient then underwent subsequent translabyrinthine approach for definitive surgical resection. Postoperative imaging again revealed patent venous sinuses. The patient subsequently developed headaches on postoperative day 10 and was found to have pCVST involving the ipsilateral internal jugular to the SSS. The patient was started on therapeutic heparin with significant improvement in pCVST and symptoms.
Conclusion:
Extensive pCVST involving the SSS after CPA and posterior fossa tumor resections is extremely rare. Initial management with anticoagulation can yield promising results and should be initiated early in the clinical course unless otherwise contraindicated.
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