Dural Venous Sinus Thrombosis after Vestibular Schwannoma Surgery: The Anticoagulation Dilemma

Abstract

Introduction Dural venous sinus thrombosis (DVST) is a relatively understudied complication of vestibular schwannoma (VS) surgery. Several studies have examined this topic; however, there is limited data on the incidence, clinical progression, and proper management of this patient population. Methods A retrospective review was performed for patients undergoing surgery for VS at a single institution. All postoperative imaging was reviewed for incidence of DVST. Demographic data were collected including tumor and surgical characteristics along with postoperative course. Results A total of 63 patients underwent resection of their VS. The incidence of DVST was 34.9%. The operative time was greater in the dural venous sinus thrombosis (DSVT) group, at an average of 6.69 hours versus 4.87 in the no DSVT cohort (p = 0.04). Tumor size was correlationally significant (p = 0.051) at 2.75 versus 2.12 cm greatest diameter. The translabyrinthine approach was most prevalent (68.2%). The side of the thrombosis was ipsilateral to the tumor and surgery in all patients. The sigmoid sinus was most commonly involved (95.5%). Of them, 85% patients had a codominant or thrombus contralateral to the dominant sinus. All patients were asymptomatic. No patients were treated with anticoagulation. Resolution of thrombus was seen in five (22.7%) of the patients on last follow-up imaging. There were no hemorrhagic complications. Conclusion The overall incidence of DVST was (34.9%) of 63 patients who underwent VS surgery. All patients were asymptomatic and none were treated with anticoagulation. In our study, continuing to observe asymptomatic patients did not lead to any adverse events.

Translabyrinthine Craniotomy Is Associated with Higher Risk of Asymptomatic Dural Venous Sinus Thrombosis in Vestibular Schwannoma Resection

“…Our results are consistent with the more recent trend in CPA surgery of performing routine postoperative MRI, which has the highest sensitivity and specificity of diagnostic techniques for detection of cerebral venous thrombi (13). Concordant with other recent studies, dural venous thrombosis among our patients was rarely symptomatic (7,8). Only 1 (3.1%) of 32 patients with CVT was significantly symptomatic after surgery, suggesting that most patients with thrombi would remain undetected without imaging.…”

“…Thirty-one of our 32 patients with thrombi were followed postoperatively with repeat imaging; 80.6% of these patients experienced resolution of thrombi at a follow-up interval ranging from 5 to 39 months, a rate consistent to the rate noted by Guazzo et al (7), where 11 of 18 patients had resolution of thrombosis by one year. The lower rate of thrombosis resolution (22.7%) reported by Brahimaj et al (8) may be a result of their institutional practice of not routinely obtaining postoperative imaging for vestibular schwannomas, so there is limited ability to directly compare.…”

Post-operative segmental cerebral venous sinus thrombosis: risk factors, clinical implications and therapeutic considerations.

“…Similarly, Brahimaj et al reported a unusually higher incidence of CVST after vestibular schwannoma surgery compared with other similar series, but they did not observe any symptomatic patient despite none was treated with anticoagulation [4]. According to their evidence, they did not suggest a routinely use of dedicated vascular imaging such as CT or MR venograms with possible time-of-ight sequences to better delineate the presence of a sinus thrombosis.…”

“…However, other recent studies have shown that the rate of venous thrombosis after posterior fossa surgery is even greater when reviewed in a retrospective manner [22]. Brahimaj et al, in particular, reported about 35% of CVST incidence after vestibular schwannoma surgery [4]. It remains uncertain the reason why the majority of CVST are not identi ed on initial postoperative imaging.…”

Management of jugular bulb injury during retrosigmoid transmeatal resection of vestibular schwannoma

“…Finally, anticoagulation is not usually indicated, and few reports have shown safety in close monitoring of these cases. 4–6 …”