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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 180-181

Distant cerebral venous sinus thrombosis in meningioma surgery: A rare complication


1 Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, India
2 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, India

Date of Submission06-Mar-2013
Date of Decision08-Mar-2013
Date of Acceptance17-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
T S Devaragudi
Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore - 560 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111145

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How to cite this article:
Redhu S, Mohd Abdul M, Pandey P, Devaragudi T S. Distant cerebral venous sinus thrombosis in meningioma surgery: A rare complication. Neurol India 2013;61:180-1

How to cite this URL:
Redhu S, Mohd Abdul M, Pandey P, Devaragudi T S. Distant cerebral venous sinus thrombosis in meningioma surgery: A rare complication. Neurol India [serial online] 2013 [cited 2020 Nov 29];61:180-1. Available from: https://www.neurologyindia.com/text.asp?2013/61/2/180/111145


Sir,

Cerebral venous sinus thrombosis (CVST) is common cause of stroke in young women. [1] CVST following meningioma surgery distant from any major venous sinus is extremely rare. We report one such rare case.

A 62-year-old female presented with progressive visual loss of 1 year duration and headache of 1 month. There was no history of seizures, loss of consciousness, or focal deficits. Cranial computed tomography (CT) scan revealed a suprasellar hyperdense lesion measuring 4 × 3 × 2.6 cm with contrast enhancement. The lesion was further defined with magnetic resonance imaging (MRI) as a tuberculum sella meningioma [Figure 1]a and b. Laboratory parameters, including the coagulation profile, were within normal ranges. The patient underwent a left pterional craniotomy and Simpson's Grade II excision of meningioma. The craniotomy did not extend till the midline, and no veins were coagulated during the procedure. The perioperative course was uneventful, and blood loss was 500 ml. The patient was reversed, but she remained unconscious with bilateral flexion response to painful stimuli and with sluggish reaction of pupils to light. Emergent cranial CT showed diffuse cerebral edema without any operative site hematoma [Figure 1]c. She was electively ventilated and was started on optimum anti-edema measures. However the patient's condition worsened over the next 12 hours and started to have spontaneous decerebration. An urgent MRI of the brain revealed severe diffuse cerebral edema, central herniation, and effacement of the basal cisterns [Figure 1]d along with complete non-filling of superior sagittal and straight sinuses on MR venography suggestive of superior sagittal sinus and straight sinus thrombosis [Figure 1]e and f. Workup for hypercoagulable state including protein C and S was negative. The patient was started on intravenous heparin; however, she rapidly deteriorated in sensorium, and died on the second postoperative day.
Figure 1: Preoperative T1W coronal (a) and sagittal (b) contrast images shows homogenously enhancing suprasellar lesion with epicenter over tuberculum sella, suggestive of tuberculum sella meningioma. Entire extent of superior sagittal sinus (SSS) seen patent in sagittal images (b). Post op CT head shows moderate diffuse cerebral edema (c). Post Contrast T1W coronal (d) and sagittal (e) images shows complete excision of tumor with thrombus at SSS, depicted by white arrows and features suggestive of central herniation. Entire extent of SSS not visualized in MRV images (f)

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Postoperative cerebral venous infarction has been described in many types of intracranial surgeries, particularly those associated with exposure of venous sinuses or with inadvertent injury of large cerebral veins. Postoperative CVST has been described mostly in surgeries for parasagittal meningiomas and in interhemispheric approaches for excision of intraventricular lesions. Raza et al., reported a series of 110 patients with parasagittal meningiomas, and the incidence of postoperative CVST was 7%. [2] Unusual cause of CVST in the perioperative period include venous thrombosis following spinal anesthesia. [3] However, superior sagittal sinus thrombosis following a surgery non-contiguous from the site of surgery has not been described. The etiology of the superior sagittal sinus thrombosis in this patient was unclear; however, hypercoagulable states associated with intracranial tumors, particularly meningiomas might be the cause. Brecknell et al. reported the development of disseminated intravascular coagulation during resection of a meningioma, and attributed it to the secretion of tissue factor from the meningioma. [4] Weinberg et al. also reported the development of hypercoagulability in a patient with intracranial tumor. [5] Probably the occurrence of CVST in this patient could be related to some of these abnormalities. In conclusion, this is a rare case of CVST following excision of a meningioma non-contiguous to the site of surgery. The probable cause for the thrombosis was hypercoagulable state secondary to the meningioma.

 
  References Top

1.De Brujin SF, Stam J, Kroopman MM, Vandenbroucke JP. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users who are cautious of hereditary prothrombotic conditions. BMJ 1998;316:589-92.  Back to cited text no. 1
    
2.Raza SM, Gallia GL, Brem H, Weingart JD, Long DM, Olivi A. Perioperative and long term outcomes from the management of parasagittal meningiomas invading the superior sagittal sinus. Neurosurgery 2010;67:885-93.  Back to cited text no. 2
    
3.Oz O, Akgun H, Yucel M, Battal B, Ipekdal HI, Ulas UH, et al. Cerebral venous thrombosis presenting with subarachnoid hemorrhage after spinal anesthesia. Acta Neurol Belg 2011;111:237-40.  Back to cited text no. 3
    
4.Brecknell JE, McLean CA, Hirano H, Malham GM. Disseminated intravascular coagulation complicating resection of a malignant meningioma. Br J Neurosurg 2006;20:239-41.  Back to cited text no. 4
    
5.Weinberg S, Phillips L, Twersky R, Cottrell JE, Braunstein KN. Hypercoagulability in a patient with a brain tumor. Anesthesiology 1984;61:200-2.  Back to cited text no. 5
    


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This article has been cited by
1 Geographically Remote Cerebral Venous Sinus Thrombosis in Patients with Intracranial Tumors
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[Pubmed] | [DOI]



 

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