Pulmonary Embolism and Sigmoid Sinus Thrombosis After Translabyrinthine Vestibular Schwannoma Resection: A Retrospective Case Series

Abstract

Objective: To describe the presentation and treatment of patients developing pulmonary embolism following translabyrinthine approach for vestibular schwannoma resection. Methods: This was a retrospective case series of patients at 2 academic tertiary medical centers who developed symptomatic pulmonary embolism post-operatively following translabyrinthine approach for vestibular schwannoma resection and were found to have evidence of sigmoid sinus thrombosis. Results: Three patients were identified to have post-operative pulmonary emboli after translabyrinthine approach for vestibular schwannoma resection with sigmoid sinus or internal jugular vein clots in the absence of lower extremity deep vein thrombosis. Caprini scores for these patients were 5 or lower. All patients underwent CT pulmonary angiography and were confirmed to have pulmonary emboli. Two were promptly anticoagulated with heparin drips and transitioned to long-term oral anticoagulation therapy and 1 had delayed anticoagulation. None of these patients suffered from intracranial hemorrhage post-operatively. Conclusions: Patients undergoing translabyrinthine approach for vestibular schwannoma can develop pulmonary embolism from sigmoid sinus entry or thrombosis. No clear guidelines exist for the management of this complication in the setting of recent craniotomy and the risk of intracranial hemorrhage must be considered prior to initiating anticoagulation.

Deskeletonizing the Sigmoid Sinus Is Noncompulsory in Skull Base Surgery: 3D Modeling of the Translabyrinthine Approach

“…In the TL approach, both prolonged sinus retraction during surgery as well as pressure caused by fat-grafts in the resection cavity after closure, can cause compression of the sigmoid sinus (SS), which might increase post-operative morbidity (e.g. CFS leakage, headache, intracranial hypertension, cerebellar infarct) (19)(20)(21)(22)(23). Furthermore, SS injury (e.g., during routine deskeletonization) can lead to SS embolization and even pulmonary embolism (20).…”

“…CFS leakage, headache, intracranial hypertension, cerebellar infarct) (19)(20)(21)(22)(23). Furthermore, SS injury (e.g., during routine deskeletonization) can lead to SS embolization and even pulmonary embolism (20). If this is the case, an increase in SS related morbidity is hypothesized when compared to retrosigmoid resection of CPA tumors, throughout which neither the sinus is retracted, nor are compressive fatgrafts used during closure.…”