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Dural Venous Sinus Laceration Complicating Extradural Hematoma

  • Background:
    • Dural venous sinus tears secondary to head trauma can occur in up to 1–4% of the population.
    • This is associated with venous extradural hemorrhage and concurrent compression +/- thrombosis of the dural sinus, which can have significant mortality rates.
    • Linear skull fractures parallel to the dural sinus are at high risk for massive bleeding.
  • Clinical Presentation:
    • Patients will have a history of head trauma and possible loss of consciousness.
    • Mental status may initially be normal, although it will usually fluctuate and deteriorate.
    • Symptoms can include headache with external signs of trauma such as subgaleal hematoma or depressed skull fracture.
  • Key Diagnostic Features:
    • Skull fracture through a region where there is an underlying dural venous sinus
    • On noncontrast CT, focal hyperattenuation adjacent to the dural sinus should raise the suspicion of a dural tear.
    • Active extravasation from the dural sinus on venous phase contrast-enhanced imaging confirms the diagnosis.
    • Characteristic locations include the superior sagittal sinus at the vertex and torcular Herophili and transverse sinuses at the posterior cranial fossa.
    • Commonly associated with thrombosis or compression of the adjacent dural sinus
  • Differential Diagnoses:
    • Arterial extradural hematoma: Commonly due to injury of the middle meningeal artery; majority are supratentorial, lentiform shaped, sharply demarcated, hyperattenuating, and associated with a skull fracture
    • Dural venous sinus compression: Dural venous sinus tapering associated with surrounding extradural hematoma and apparent elevation of dural sinus from the underlying bone
    • Dural venous sinus thrombosis: Hyperdensity of the dural sinus on noncontrast imaging and relative enlargement of the sinus with engorged collateral veins; delta sign of intraluminal filling defect on CT venogram
  • Treatment:
    • Conservative or surgical management dependent on the location and progression of the injury
    • Linear skull fractures parallel to the dural sinus present the highest risk for dural sinus tear with massive bleeding.
June 2, 2022

A 15-year-old presents to the emergency department after being hit by a car while riding his bicycle. He has had increasing headaches and vomiting since the accident, with clinical evidence of head trauma with palpable hematoma in the left occipitoparietal region.

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