Unilateral decompressive craniectomy in left transverse and sigmoid sinus thrombosis

Cerebral venous and dural sinus thrombosis is a rare cause of stroke. We explore the controversial issue of anticoagulation therapy and indication for decompressive craniectomy in association with severe sinus thrombosis. The 62-year-old female patient was admitted to hospital, because of first generalized seizure. A computed tomographic (CT) scan of the brain revealed a left occipital hemorrhage. Digital subtraction angiogram showing thrombosis of the left transverse and sigmoid sinus. An intravenously administered regimen of heparin was begun, because of a protein S deficiency. On the 6th day the patients level of consciousness deteriorated, necessitating intubation, hyperventilation, and mannitol. Repeat CT scan revealed increasing edema with midline shift and obliteration of the basal cisterns, although the hemorrhagic lesion was unchanged. The patient developed signs of diencephalic dysfunction. A large left temporoparietooccipital craniectomy was performed and the dura was opened. The multiloculated intraparenchymatous hemorrhage portion of the brain was not removed. In addition, the patient was treated postoperatively with heparin therapy for three months, than a regimen of phenprocoumon was begun. Twelve months later the hemianopsia had not improved and she had an incomplete Wernicke's dysphasia. When, despite adequate anticoagulation therapy and intensive care, neurological deterioration occurs in sigmoideus and/or transversus dural sinus thrombosis with unilateral edema, a decompressive craniectomy should be considered especially in young patients.