Successful Management of Open Depressed Skull Fracture with Superior Sagittal Sinus Injury and Refractory Intracranial Hypertension

Traumatic dural venous sinus injury is uncommon but potentially fatal because of massive hemorrhage at presentation or during surgery, and intracranial hypertension caused by impaired venous outflow. We report a case of a young woman with an open depressed skull fracture over the vertex caused by repeated blunt assault. Computed tomography revealed a large midline depressed fracture with bony fragments penetrating the superior sagittal sinus. On arrival, the patient was in hemorrhagic shock, with a semicoma status and right hemiparesis. Emergency surgery was performed for hemostasis and wound debridement. Because the wound was contaminated, irregular, and associated with a crushed sinus wall, direct sinus suturing was considered unsuitable for this patient. After temporary hemostasis with head elevation and Gelfoam compression, the injured superior sagittal sinus was reconstructed using an autologous fascia lata patch reinforced with fibrin glue. A postoperative epidural hematoma at the fracture site required immediate evacuation. On day 2, severe intracranial hypertension developed despite the initial surgery, and multimodal neurocritical care was instituted, including intracranial pressure monitoring, external ventricular drainage, deep sedation and analgesia, neuromuscular blockade, hypertonic saline, targeted temperature management, and pentobarbital infusion. The intracranial pressure gradually stabilized, and the patient was extubated on postoperative day 14. She was transferred for rehabilitation and ultimately achieved an excellent functional outcome, with a modified Rankin Scale score of 1. This case highlights the importance of preserving superior sagittal sinus patency using autologous patch repair in contaminated open injuries and promptly escalating intracranial pressure-directed intensive care when delayed venous outflow impairment is suspected.