Focal epidural hematoma occluding the sigmoid sinus evacuated through a single burr hole in a pediatric patient: Illustrative case and review of the literature

Background: Venous sinus occlusion is a rare complication of head trauma, carrying increased morbidity and mortality. Sinus occlusion is usually a result of intraluminal thrombosis, with rare cases attributed to external pressure from depressed fractures and extensive hematomas. Case Description: We present a 13-year-old female who developed intractable life-threatening intracranial hypertension with signs of impending uncal herniation 48 h after pediatric intensive care unit admission due to head trauma. This was attributed to occlusion of the right dominant sigmoid sinus, caused by a focal traumatic epidural hematoma (EDH) contained entirely within the sigmoid sinus-transverse sinus groove and causing no mass effect otherwise. The extraluminal location of the EDH was ascertained in magnetic resonance imaging. Emergency burr-hole placement over the point of the sigmoid sinus occlusion achieved immediate intracranial pressure (ICP) normalization and reconstitution of sigmoid sinus flow, evidenced by intraoperative Doppler ultrasonography. The patient was reoperated on 24 h later due to re-elevation of ICP for cranial extension of the burr hole to evacuate EDH remnants over the transverse sinus. Afterward, anticoagulation was instituted due to a small thrombus inside the sigmoid sinus, attributable to the preceding sinus occlusion. The patient made a full neurologic recovery. A systematic review of the relevant literature is also presented. Conclusion: Dominant sigmoid sinus occlusion can cause life-threatening intracranial hypertension due to venous stasis. A focal epidural hematoma over the sinus can be safely evacuated with a burr hole over the point of maximal compression, allowing for enough reconstitution of flow within the sinus to alleviate intracranial hypertension.