Effective management of traumatic venous sinus injuries in a resource-limited health system: a retrospective cohort study

OBJECTIVE: Traumatic venous sinus injury (VSI) is a rare but serious complication with high rates of morbidity and mortality. In resource-limited health systems, restricted access to advanced imaging and high trauma volumes further complicate care. The objectives of this study were to quantify the effectiveness of a resource-constrained imaging protocol, evaluate its impact on outcomes, and identify predictors of VSI. METHODS: The authors conducted a retrospective cohort study of adults with skull fractures overlying dural venous sinuses at Tygerberg Academic Hospital, a resource-limited public neurosurgical center in South Africa. Only assault-related isolated head injuries were included. All patients underwent noncontrast CT (NCCT), with contrast CT (CCT) used selectively on the basis of clinical or radiological suspicion of VSI. Intraoperative findings were the reference standard for VSI, allowing calculation of positive predictive value (PPV) and negative predictive value (NPV). Outcomes included Glasgow Outcome Scale-Extended (GOS-E) score at discharge, length of stay, septic complications, and mortality. Multivariable models identified predictors of VSI and GOS-E score. RESULTS: Of 104 patients, 90 underwent surgery, of whom 14 (15.6%) had traumatic VSI confirmed intraoperatively. NCCT indicated traumatic VSI in 27 (26%) patients, with a PPV of 20.8% and an NPV of 86.4%. CCT was selectively used in 32 patients, identifying 4 possible VSIs (12.5% diagnostic yield). Among the 27 patients who had both CCT and surgery, PPV was 75.0% and NPV 82.6%. VSI was independently associated with worse GOS-E (OR 0.15, 95% CI 0.04-0.54, p < 0.05) after analysis controlled for admission Glasgow Coma Scale score and other intracranial injuries. Radiological signs of raised intracranial pressure (ICP) were the strongest independent predictor of VSI (OR 3.88, 95% CI 1.1-16.8, p < 0.05). Outcomes did not differ significantly between the NCCT-only and CCT groups. Overall mortality was 3.8% (4/104), with a mortality rate among VSI patients of 14.3% (2/14). CONCLUSIONS: In resource-limited settings, a pragmatic pathway of universal NCCT screening with selective CCT can safely guide management of traumatic VSI without compromising outcomes. In the authors' setting, routine use of CCT is unlikely to improve outcomes significantly and may increase unnecessary radiation and costs. NCCT markers of raised ICP should heighten vigilance for VSI. Traumatic VSI is a critical determinant of outcome, underscoring the importance of clinical awareness of VSI and targeted imaging strategies in resource-limited environments.