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Traumatic vein of Labbe hemorrhagic infarction--clinical profile and outcome analysis.

Introduction

Dural venous sinus thrombosis (DVST) after blunt head trauma has been reported in a few case series. [1-6] Limited studies have been carried out on the outcomes that occur after traumatic vein of Labbe hemorrhagic infarction. [7] It is an important neurosurgical entity because of the eloquent territory it drains, higher affinity for causing early uncal herniation, and sometimes fatal outcome. [8-10] So, a strict observation of the patients and, if required, early surgical evacuation are the significant factors in the management of the same. This condition is identified by the differential diagnosis of the traumatic temporal artery damage where the damage to the medial temporal region including the insular territory is also observed. Another entity to be excluded is the transverse sinus thrombosis.

Materials and Methods

We included 26 cases admitted in the Department of Neurosurgery with the diagnosis of traumatic vein of Labbe hemorrhagic infarction from January 2013 to 2015. All patients with traumatic temporal lobe lesions were included in the study. The demographic data of patients, initial Glasgow coma scale (GCS) sore, associated findings, and other systemic injuries were also included. Patients presenting with low GCS and anisocoria and computed tomography (CT) image showing significant lesions with evidence of uncal herniation [Figure 1] were immediately taken up for surgical evacuation [Figure 2]. Patients with traumatic transverse sinus thrombosis were evaluated for possible evolution in the hemorrhagic infarction. Glasgow outcome score (GOS) of the patients at discharge were recorded. Magnetic resonance (MR) venography [Figure 3] was advised in all the cases, especially in those managed conservatively to confirm the diagnosis. Informed consent was taken in all the cases, and the clearance for the study was taken from the hospital ethical clearance committee. The analysis of the study was formulated using the SPSS software, version 20.

Result

The male:female ratio was 7.66:1 [Figure 4]. The age range of the patients was from 5 to 78 years.

* Laterality of injury

The left side was involved in 58% of the cases, while the right side was involved in 38% of the cases. Bilateral involvement was seen in one case. Associated injuries were seen in 77% of the cases.

* Severity of injury

Most of the patients presented with mild head injury (46%), whereas moderate and severe head injuries were seen in 23% and 31% of cases, respectively.

* Mode of management

Most of the patients were managed conservatively (57%). Craniotomy was performed in 34% of cases and Drake's craniactomy in 9% of them.

* Outcome of patients

About 42% of the patient revealed a GOS of four at 3 months [Figure 5] and 23% attained a GOS of five. The overall mortality in the series was 12%.

* Neurological deficits

About 65% of the patients attained full recovery. Hemiparesis was seen in 11% of the patients, and opercular syndrome was seen in 11% of them [Table 1].

Discussion

Eponymously named after the French surgeon Charles Labbe, the vein of Labbe (inferior anastomotic vein) crosses the temporal lobe between the Sylvian fissure and the transverse sinus and connects the superficial middle cerebral vein and the transverse sinus.

Because there is a higher affinity for early uncal herniation and rapid neurological deterioration, any traumatic temporal lobe lesion imposes an enigma to every neurosurgeon.

Impact injury and counterblow are the main reasons to the injury of Labbe vein, which consequently leads to serious traumatic cerebral infarction and bad prognosis. [7] Temporal bone fracture was associated in 15 of all the 16 cases in the study done by Long et al. [7] when compared with the results of 20 of 26 patients in our study.

In a study by Giannetti, [11] CT scan findings such as mediolateral diameter of the lesion, location of the hematoma, status of the ambient cisterns, and position of the midline structures were used as the criteria to decide which patients benefit from early surgery. The mean volume of the lesion in the patients undergoing operation was 25 mL. The mortality among the patients who were operated on was 50% and, among those who were managed conservatively, 22.7% compared with 12% in our study. In a study by Long et al., [7] five of 16 patients ended up in a vegetative state.

Multidetector CT venography of patients with blunt head trauma revealing skull fractures that stretch out to a dural venous sinus or jugular bulb identified DVST in 40.7% of cases, and of these, 55% were occlusive. [12] There is a high risk of evolution of the vein of Labbe hemorrhagic infarction in the subsets of patients with petrous bone fracture. So, proper monitoring is justified for any signs and symptoms of increased intracranial pressure.

Moreover, given the eloquent nature of the brain that vein of Labbe drains, there is a need for a long-term follow-up of these patients in determining the neurological sequel of these patients, especially in terms of memory. [13]

The strength of our study is the focus on one of the important aspects of neurotrauma, wherein critical management is upmost for a better management of the patients with traumatic head injury. The limitations include small volume of patients and the inability to perform MR venography in all the patients with severe traumatic brain injury in all trauma centers to correctly diagnose the entity.

Conclusion

A high index of suspicion needs to be taken in patients with petrous bone fracture for probable vein of Labbe hemorrhagic infarction following transverse sinus thrombosis. In those with traumatic venous infarction, stringent monitoring needs to be taken for evidence of early uncal herniation. In the case of lesions more than 25 mL, anisocoria, uncal herniation, and asymmetric ambient cisterns, early surgical evacuation is justified.

DOI: 10.5455/ijmsph.2016.2107201560

References

[1.] Stiefel D, Eich G, Sacher P. Posttraumatic dural sinus thrombosis in children. Eur J Pediatr Surg 2000; 10(1):41-4.

[2.] Miller JD, Jennett WB. Complications of depressed skull fracture. Lancet 1968; 2(7576):991-5.

[3.] Carlucci GA. Injury to the longitudinal sinus accompanying a depressed fracture of the skull. Am J Surg 1939; 45(1):120-4.

[4.] Kaplan A. Compound depressed fractures of the skull involving the superior longitudinal sinus. Am J Surg 1947; 74(1):80-5.

[5.] Reilly HP Jr, Erbengi A, Sachs E Jr, Dyke JR. Penetration of the sagittal sinus by a depressed skull fracture: roentgenographic diagnosis in an asymptomatic boy. JAMA 1967; 202(8):841-2.

[6.] Kinal ME. Traumatic thrombosis of dural venous sinuses in closed head injuries. J Neurosurg 1967; 27(2):142-5.

[7.] Long LS, Xin ZC, Wang WM, Zhao ZH, Zhang JZ, Li XL, et al. [Clinic analysis of 16 patients of craniocerebral trauma with Labbe vein injury]. Zhonghua Wai Ke Za Zhi 2011; 49(11):1022-5.

[8.] Heiskanen O, Vapalahti M. Temporal lobe contusion and haematoma. Acta Neurochir (Wien) 1972; 27(1):29-35.

[9.] Maurice-Williams RS. Temporal lobe swelling: a common treatable complication of head injury. Br J Surg 1976; 63(3):169-72.

[10.] McLaurin RL, Helmer F. The syndrome of temporal-lobe contusion. J Neurosurg 1965; 23(3):296-304.

[11.] Giannetti AV. Post-traumatic temporal lobe lesions: natural history and treatment. Arq Neuro-Psiquiatr 1998; 56(4):859.

[12.] Delgado Almandoz JE, Kelly HR, Schaefer PW, Lev MH, Gonzalez RG, Romero JM. Prevalence of traumatic dural venous sinus thrombosis in high-risk acute blunt head trauma patients evaluated with multidetector CT venography. Radiology 2010; 255(2):570-7.

[13.] Smith EE, Kosslyn SM. Cognitive Psychology: Mind and Brain. New Jersey: Prentice-Hall, 2007. pp. 21, 194-9, 349.

Source of Support: Nil, Conflict of Interest: None declared.

Sunil Munakomi

Department of Neurosurgery, International Society for Medical Education, College of Medical Sciences, Chitwan, Nepal.

Correspondence to: Sunil Munakomi, E-mail: sunilmunakomi@gmail.com

Received July 21, 2015. Accepted July 30, 2015

Table 1: Outcome analysis of the cases

Parameters               Frequency   %

GCS
  Mild                      12       46
  Moderate                   6       23
  Severe                     8       31
Sex
  Male                      23       88
  Female                     3       12
Site
  Left                      15       58
  Right                     10       38
  Bilateral                  1        4
Contracoup injury
  Yes                        8       31
  No                        18       69
Associated injury
  Yes                       20       77
  No                         6       23
Management
  Conservative              15       57
  Craniotomy                 9       34
  Drakes                     2        9
GOS
  5                          6       23
  4                         11       42
  3                          6       23
  1                          3       12
Neurological deficits
  Nil                       17       65
  Hemiparesis                3       11
  Opercular syndrome         3       11
Length of stay (days)
  Minimum                    2
  Maximum                   52
Age (years)
  Minimum                    5
  Maximum                   78

Figure 4: Male:female ratio (in %).

Male     88
Female   12

Note: Table made from pie chart.

Figure 5: GOS at three months (in %).

1   12
2   0
3   23
4   42
5   23

Note: Table made from bar graph.
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Article Details
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Title Annotation:Research Article
Author:Munakomi, Sunil
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Geographic Code:1USA
Date:Feb 1, 2016
Words:1424
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