Case1
Clinical condition: A 35-year-old male was brought after a two-wheeler accident, with an open wound in the midline anterior to the vertex. There was profuse bleeding. He was in shock with systolic blood pressure of 80 mm of Hg and was unconscious. Glasgow Coma Scale (GCS) was E1M1V1 (eye opening, motor response, verbal response) and pupils were 2 mm and not reacting to light. He was intubated and ventilation was started. Fluid resuscitation was started. The wound was padded.
Imaging: Computerized tomography (CT) scan of brain was done and it showed multiple comminuted fractures in midline with interhemispheric bleed and subarachnoid hemorrhage over the underlying parenchyma (Fig. 2a). Bone fragments were seen piercing down in the midline and into the parenchyma (Fig. 2b). Anterior third of superior sagittal sinus (SSS) was injured and it was the cause of profuse bleeding.
Surgery: He was shifted to operation theater. Wound was opened and the fragments were removed rapidly. Gelfoam (absorbable gelatin sponge) pieces were placed. Wound was closed in two layers with non-suction drain. Six packed red blood cell units (PRBC) were given and dopamine infusion also was started. Blood pressure got normalized on the second day.
Outcome: On the third day he began to respond. His G.C.S became E2M5VET. CT brain was repeated and showed bifrontal hypodensities suggestive of venous infarcts. He was weaned from ventilator slowly. He improved to a state of consciousness.
Follow-up: He had impairment of short-term memory, behavioral changes and emotional disturbances such as increased rage. Magnetic resonance imaging (MRI) revealed bifrontal gliosis (Fig. 2c). Magnetic resonance venogram (MRV) showed narrowing of anterior SSS (Fig. 2d). He is on follow-up for 12 years. He did not develop any symptoms of raised intracranial pressure in this period.
Case 2
Clinical condition: A 24-year-old male was brought in unconscious state after a high-velocity two-wheeler accident. He had facial injuries and profuse oral bleed. He had only flexion response to pain and pupils were 2.5 mm and not reacting to light. G.C.S. was E1M3V1. He was intubated and ventilated.
Imaging: CT head showed multiple facial bone fractures, fracture in right parietal bone extending through coronal suture to bilateral frontal bones and bilateral extra-axial hematoma extending from midline (Fig. 3a, b). The hematoma was mainly on right side with small component on left side. Pneumocephalus was seen inside, from midline and laterally from the fracture site. Diffuse brain edema was seen.
Surgery: Right frontotemporoparietal decompressive craniectomy and evacuation of extradural hematoma was done. Active bleeding was seen from fracture in the midline and from the anterior and middle third of superior sagittal sinus (SSS). The duramater was hitched to periosteum with Gelfoam, to reduce bleeding. Subdural hematoma was evacuated after opening the duramater. Duraplasty was done with artificial substitute (G patch), to reduce the brain edema. Two PRBCs were given. He was ventilated. Pupil size reduced bilaterally. Postoperative CT showed near total evacuation of extra-axial hematoma, except on left side (Fig. 3c). On third day left pupil dilated, suggestive of intracranial hypertension. CT brain was repeated and it showed left frontotemporal hemorrhagic contusions with edema (Fig. 3d). Left decompressive craniectomy and removal of hemorrhage was done. He was ventilated continuously till he slowly improved.
Outcome: By 2 weeks, he was weaned from ventilator. And he had cognitive improvement by 2 months. Bilateral cranioplasty was done after 6 months, with Titanium mesh.
Follow-up: There are no significant posttraumatic sequelae on follow-up after 2 years.
Case 3
Clinical condition: A 30-year-old male had a high-velocity two-wheeler accident. He had multiple long bone fractures—bilateral femur fractures and left tibia and radius fractures. Scalp contusions were there. He was drowsy, but responsive to call. G.C.S. was E3M6V5.
Imaging: CT head showed diastasis of coronal suture and underlying extradural hematoma (EDH) from midline to left (Fig. 4a, b). Initial orthopedic stabilization was done. Follow-up CT brain after 4 h showed enlargement of EDH with ‘swirl sign’ near midline suggestive of active bleeding. Coronal reformat of CT showed hematoma crossing midline to right (Fig. 4c).
Surgery: Left frontoparietal decompressive craniectomy was done under general anesthesia. EDH was evacuated. There was active bleeding from draining veins and the middle third of superior sagittal sinus (SSS). Bleeding could be stopped only after digital compression for one hour, with Gelfoam soaked in thrombin–gelatin hemostatic matrix (Surgiflo) (Fig. 4d). Bone was not kept back in the wound, to aid decompression. Four units of PRBC were given. Postoperative CT brain showed minimal residual bleed in midline and in right.
Outcome: Fixation of long bone fractures were done and he improved without any neurological deficits.
Follow-up: He recovered. Cranioplasty was done after 1 month.
Case 4
Clinical condition: A 59-year-old male was brought with bleeding from large open wound of scalp and right pinna laceration following a three-wheeler accident. He was drowsy, responsive to call. His G.C.S. was E3M6V5. The wound of scalp was large, from right temporal region to left parietal region, with bleeding and clots. Large skull defect was seen (Fig. 5a). The comminuted skull pieces were seen at the site of accident.
Imaging: CT head showed large skull defect in middle and bilateral parietal regions, and extradural bleeding from midline to left side (Fig. 5b). 3D CT showed the large defect (Fig. 5c).
Surgery: Wound exploration was done under general anesthesia. Lavage was done with saline and hydrogen peroxide. Clots were removed. Active bleeding was seen from the middle third of superior sagittal sinus (SSS). Thrombin–gelatin hemostatic matrix (Surgiflo) was applied and compression was done with Gelfoam. Wound was closed with drain. Ear repair was done.
Outcome: He improved without any deficit. He had right renal injury, which was managed conservatively.
Follow-up: After 6 weeks, cranioplasty was done with contoured Titanium mesh (Fig. 5d).
Case 5
Clinical condition: A 6-year-old girl was admitted with headache and vomiting after fall at school hostel, from a height of around 8 feet. Her G.C.S. was E4M6V5 on admission.
Imaging: CT brain showed right occipital bone fracture and extradural hematoma (EDH) extending down to posterior fossa. Initial conservative management was done. But she had continuous headache, drowsiness and vomiting, suggestive of intracranial hypertension. G.C.S. became E3M6V4 on next day. MRI was done on next day. EDH had increased and was compressing right transverse sinus lower end of superior sagittal sinus (Fig. 6a, b). MR Venogram (MRV) showed nonvisualization of right transverse sinus (Fig. 6c).
Surgery: Induction of anesthesia was done. Craniotomy was done, both supratentorial and infratentorial, preserving bone in the region of torcula (Fig. 6d). EDH was evacuated. Oozing from the region of transverse sinus was controlled with Gelfoam.
Outcome: She improved without any deficits.
Follow-up: She did not have any symptoms on follow-up upto 6 months.
Peculiarities of the cases: Among the five cases described, four were having injury to SSS and one injury to transverse sinus. Three patients had continuous bleeding and two had intracranial hypertension. Decompressive craniectomy was done in three, only wound hemostasis and closure in one, and craniotomy and evacuation of hematoma in one. Among the hemostatic methods in literature, compression with gelatin sponge was the main method for hemostasis and thrombin–gelatin hemostatic matrix had to be applied in two, with continued pressure for one hour. Hitching of the duramater to the periosteum was done in one patient. The methods used are similar to those described in the literature [1, 3, 4, 6, 21, 23]. The patient who had open fractures with profuse bleeding and hypotension had bifrontal infarction and behavioral changes. Wide decompressive craniectomy had to be done for involvement of the middle third of SSS. The final outcome was good in all patients in the background of the literature.