Gauze Packing and Removal: Two-staged Operations for Hemostasis of Traumatic Sinus Injury

Abstract

The importance of traumatic dural venous sinus injury lies in the probability of massive blood loss at the time of trauma or emergency operation resulting in a high mortality rate during the perioperative period. We present 2 case reports highlighting the successful outcome of patients with head trauma and cerebral venous sinus injury treated with gauze packing. Hemorrhage was successfully halted in 2 patients, and all survived their operations. Both of them were discharged from the hospital and had an improved Glasgow Coma Scale score at the time of the last follow-up. There were no postoperative intracranial or wound infections. Intracranial packing to tamponade severe intracranial hemorrhage can be a lifesaving neurosurgical maneuver.

Introduction

Traumatic brain injury (TBI) is the leading cause of mortality and long-term disability, with an estimated global annual incidence of 800 to 1300 per 100000 individuals.¹⁾ TBI frequently presents itself within the confines of the emergen²⁾ and the traumatic dural sinus injury is one of the most dangerous complications of TBI.^3-5) Nevertheless, it is noteworthy that traumatic dural sinus injury represents an infrequent manifestation of TBI, necessitating immediate regulation. Failure to promptly address this condition may lead to severe cerebral injury resulting from prolonged episodes of low blood pressure and oxygen deficiency, or even death from excessive bleeding.

Unfortunately, the existing literature provides scarce data concerning the specific management and outcomes related to trauma-induced venous sinus injuries.^4,5) This report describes a case series of two patients admitted for head injury complicated by sinus injury. The normally instinctual response to sinus injury entails suturing the affected region, utilizing bipolar coagulation, or employing materials such as oxidized cellulose, gelatin sponge, and autologous tissue. In the event that bleeding persists or becomes vigorous, it becomes imperative to pack any available material against and into the site. We use surgical gauze to control severe intracranial hemorrhage, and intentionally retain the gauze within a patient. As far back as 1909, Krause and Haubold⁶⁾ reported the efficacy of packing in tamponading otherwise uncontrollable intracranial bleeding, and several authors reported the usefulness of packing. Today, the use of gauze packing is prevalent, particularly in trauma surgery. Although the employment of intracranial packing to control severe hemorrhages likely surpasses what is reported in neurosurgical literature, the effectiveness of this intervention warrants further exploration.

Technique

If a preoperative imaging study reveals a fracture line crossing the venous sinus, the possibility of venous sinus injury should be considered for surgery. Once intraoperative bleeding is identified to be severe, one or more hemostasis-promoting materials such as gelatin sponge, oxidized cellulose, or Floseal (Baxter Healthcare Corporation, Deerfield, IL, USA), an absorbable local hemostatic agent that contains cross-linked gelatin particles and dried human thrombin are applied to the general region of hemorrhage via a wet cottonoid with continuous manual pressure of sufficient force to halt the bleeding. Following a continuous irrigation period of 5-10 mins, the packing material is carefully removed, allowing for the identification and control of the bleeding source through the utilization of electrocoagulation. If robust bleeding reoccurs within a short span of time, the packing technique may be repetitively employed. In cases where severe hemorrhage persists despite several attempts to remove the packing, the packing technique may be repetitively employed. If severe hemorrhage occurs after each of a few attempts to remove the packing, and particularly if associated with a significant fall in systemic blood pressure, or determined that hemostasis is difficult to achieve. The packing is left in place. In the absence of apparent bleeding, the dura is left exposed, while any exposed brain is diligently covered with DuraGen (Integra Life Sciences Corp., Princeton, NJ, USA), a collagen-based dural graft matrix. The galea is subsequently sutured, and the scalp edges are approximated with staples. This method is neither widely recognized nor generally accepted and is considered off-label. Consequently, the technique of gauze packing is not recommended and should be reserved solely for situations where no other options are available.

Case Review

Case 1

A 16-year-old male patient presented with a traffic accident. The assessment of the Glasgow Coma Scale (GCS) yielded a score of E1V1M1, accompanied by sluggish reactivity of the mid-dilated pupil on the left side. Computed tomography (CT) of the head revealed the presence of a supra and infratentorial hematoma exerting mass effect, along with fractures of temporal and occipital bones (Fig. 1A-C). Due to the patient's low GCS score and the presence of anisocoria, surgical decompression was scheduled as an urgent procedure. A suboccipital decompressive craniectomy was performed. We observed severe bleeding from the midline of the superior border of the craniotomy. We expanded the craniotomy superiorly by 3 cm to confirm the source of the bleeding. We identified the 2 cm disruption of the confluence of the left transverse sinus and superior sagittal sinus. The bleeding from this area was severe and could not be completely stopped by cauterization or surgical filling, or suturing. We did gauze packing. The patient experienced a blood loss of 2900 mL during the initial surgery and received multiple blood transfusions. Postoperative CT revealed the intentional retention of gauze within the patient (Fig. 1D, E). For perioperative antibiotics, first-generation cephem antibiotics were continued during the period of gauze retention. After the first operation, cerebral angiography was performed to confirm the absence of venous sinus obstruction or vascular leakage (Fig. 1F). The second operation was performed 8 days after the initial procedure. While slowly extracting the packing, we encountered some bleeding from the injured sinus, however, the hemorrhage was successfully controlled through manual pressure. The patient's GCS gradually improved to E4V4M6 with no apparent paresis and the Glasgow outcome scale score was determined to be 3. The patient was then transferred to a rehabilitation hospital.

Fig. 1

A: H-CT scan on admission showed an acute subdural hematoma and pneumoencephalopathy in the posterior cranial fossa.

B: H-CT showed a supratentorial acute subdural hematoma.

C: 3D reconstruction image of CT showed multiple fracture lines in the temporal, parietal, and occipital bones.

D: Postoperative H-CT showed the state of decompression of the posterior cranial fossa.

E: The high-intensity halo visible in this postoperative CT corresponds to the gauze implanted within the cranial cavity.

F: This image showed the venous phase of a cerebral angiogram performed from the left vertebral artery. The superior sagittal sinus, bilateral transverse, and sigmoidal sinuses are depicted.

3D: three-dimensional; CT: computed tomography; H-CT: head computed tomography

Case 2

A 71-year-old male patient presented with a traffic accident. The assessment of the patient's GCS was E1V1M1, accompanied by sluggish reactivity of the mid-dilated pupil on the left side. CT of the head revealed the presence of a left-sided temporoparietal-occipital hematoma exerting mass effect (Fig. 2A-C). Due to the patient's low GCS score and the presence of anisocoria, surgical decompression was scheduled as an urgent procedure. We observed a strong hemorrhagic tendency from the sphenoparietal sinus and sigmoid sinus. The severely depressed posterior half of the temporal bone, occipital bone, and bones around the mastoid process were removed after careful dissection of the dura mater. The bleeding from this area was severe and could not be completely stopped by cauterization or surgical filling. Gauze packing was utilized. The patient experienced a blood loss of 1500 mL during the initial surgery and required multiple blood transfusions. Subsequent postoperative CT revealed the intentional retention of the gauze within the patient (Fig. 2D, E). For perioperative antibiotics, first-generation cephem antibiotics were continued during the period of gauze retention. The second operation was performed 4 days after the initial procedure. The gauze was removed without encountering any difficulties. The patient's GCS gradually improved to E4VTM5 with no apparent paresis. The patient was then transferred to a rehabilitation hospital.

Fig. 2

A: H-CT on admission showed a left temporal acute subdural hematoma and air in the transverse and sigmoid sinus.

B: H-CT showed an extensive acute subdural hematoma and mild midline shift.

C: 3D reconstruction image of CT showed multiple fracture lines in the parietal and occipital bones.

D: Postoperative H-CT showed apparent brain contusions in the frontal and temporal lobes, and a high-intensity substance in the decompression area, which is gauze.

E: This image showed an improvement of the midline shift.

3D: three-dimensional; CT: computed tomography; H-CT: head computed tomography

Written, informed consent for publication of the patient's information and images was provided by their family.

Discussion

These 2 cases serve to demonstrate the efficacy of packing in managing severe traumatic intracranial hemorrhage. In cases of life-threatening intraoperative hemorrhage, particularly in the context of trauma, bleeding often arises from multiple vessels, both arterial and venous, with one source typically dominant. Notably, the main bleeding source in both our cases was venous sinus. Existing literature indicates that traumatic dural venous sinus injury occurs in approximately 4%-12% of cases during times of war and from 1% to 4% in civilian life. Furthermore, the associated mortality rate of sinus injury can reach up to 20% during the operative period and 41% overall.^7-9) However, our patients successfully underwent surgery and were subsequently transferred to a rehabilitation hospital. A literature review was conducted due to the infrequent occurrence of gauze packing in neurosurgery. Using the search terms "intracranial hemorrhage" and "packing" in the PubMed database, only 2 case series^10,11) detailing the use of gauze packing for intracranial hemorrhage were identified, encompassing a total of 15 cases (Table 1). Table 1 summarizes 15 cases of gauze packing for intracranial hemorrhage, detailing each patient's demographics, diagnosis, admission GCS score, the primary bleeding site, estimated blood loss during the initial surgery, and the interval in days between the initial operation and the removal of the packing. This table highlights the clinical contexts, outcomes, and procedural considerations pertinent to gauze packing in neurosurgical cases. Our review indicated that the patients were profoundly unconscious during transport, with the predominant cause of hemorrhage being trauma-induced injury to the venous sinuses, which was very similar to our cases. Gauze packing represents a straightforward concept that can be readily accomplished using materials and instruments universally available to neurosurgeons performing intracranial surgeries. The amount of manual force required against the packing to halt the bleeding can be subjectively described as that which is necessary to achieve and maintain hemostasis. When tamponade is successful, the force required to maintain hemostasis slowly diminishes as a consequence of clotting within the packing materials and the clotting within and around the damaged areas. Nonetheless, repeated unsuccessful attempts to control severe intracranial bleeding often become progressively more technically difficult, particularly in patients with extensive parenchymal injury from trauma, leading to the development of disseminated intravascular coagulation and heightened risks of further parenchymal injury, vessel disruption, and exacerbated hemorrhage. As in other anatomic sites, there have been many reports about packing as damage control surgery including thoracic hemorrhage,¹⁰⁾ pelvic fractures,¹¹⁾ high-grade liver lacerations,¹²⁾ and postpartum hemorrhage.¹³⁾ In the subsequent hrs and days, the clot matures within and around the injured vessels and contusions, initiating and progressing early healing processes, thus allowing the safe removal of packing without risk of reactivated bleeding. In cases of abdominal trauma, reoperation is generally recommended within 24-48 hrs after the first operation.^14-16) However, extending the timeline for reoperation beyond 48 hrs has recently been recommended for patients with high-grade liver injury requiring perihepatic packing to prevent re-bleeding.^17,18) Early reoperation was associated with re-bleeding requires repeat packing, and delaying the removal of packing did not increase the rate of infection.¹⁷⁾ The minimum number of days before the intracranial packings can be removed without risk of re-bleeding is not known. Freeman et al.¹⁹⁾ reported packing, which was used to halt intracranial bleeding, could be safely removed after 4 days to 61 days. In our cases, both packing gauzes were removed around 1 week after their initial surgery, with much less hemorrhage from the previous site of critical bleeding. And no obvious infectious complications were noted. In the case of very severe intraoperative hemorrhage which cannot be fairly quickly controlled, packing should not be delayed until after multiple severe hypotensive episodes or cardiac arrest. Traumatic dural sinus injuries cannot be diagnosed in all cases preoperatively. Therefore, when a linear skull fracture including a diastatic skull fracture overlying the sinus is parallel to the sinus, it is possible that a longitudinal laceration of the venous sinus and uncontrollable vigorous hemorrhage from the lacerated sinus wall can occur. No claim can be made that packing to tamponade severe intracranial bleeding can be successful in every case; however, in all patients in whom this technique was tried, there was survival.

Table 1

Summary of 15 cases of gauze packing for intracranial hemorrhage

Authors	Year	Age (year)	Sex	Diagnosis	Admission GCS	Dominant bleeding site	Blood loss (mL)		Days between operation
							During initial operation	During surgery to remove packing
F = female, M = male, SDH = subdural hematoma, ATV = all-terrain vehicle, GSW = gunshot wound, IPH = intraparenchymal hemorrhage, MVC = motor vehicle collision, SAH = subarachnoid hemorrhage, If a patient is intubated, they are assigned a verbal score of 1 and a ‘‘T’’ is added to their numerical score. SSS = Superior sagittal sinus
KR Winston	2014	2month	F	SDH, nonaccidental	3T	Multiple bridging veins along SSS	700	50	4
		4month	M	Medulloblastoma	14	Multiple sites over top of cerebellum	1600	120	4
		newborn	M	SDH, nonaccidental	3T	Multiple bridging veins along SSS	340	10	4
		6month	F	SDH, nonaccidental	3T	Multiple bridging veins along SSS	150	50	2
		4	M	SDH, nonaccidental	3T	Multiple bridging veins along SSS	900	175	7
		3	F	Gunshot	3T	Branches of both anterior cerebral arteries and cortical veins	350	50	2
		4	F	Compound depressed fracture; SDH	3T	Multiple vessels of both frontal lobes and right temporal lobe	4500	Large amount	3
		9month	M	Dog bite	11	Underneath right temporal lobe	3000	30	8
JL Freeman	2015	51	F	Seizure disorder	15	SSS: left anterior	1200	75	4
		28	M	Trauma (rollover ATV) brain contusion; SDH	6T	Cortical veins: multiple posterior frontal, SSS (uncertain)	500	400	6
		26	M	Trauma (GSWVorbit to occipital lobe) IPH/SDH/SAH	6T	Projectile tract	1700	50	5
		69	M	Trauma (fall from standing) SDH	14 but declined overnight to 8	Transverse sinus, sigmoid sinus junction	3500	57	5
		35	M	Trauma (assault with pipe) SDH	3	Veins: subdural	500	n.a.	n.a.
		30	F	Trauma (MVC) complex skull fractures, brain contusion	3T	SSS: parietal	10000	100	5
		39	M	Trauma (MVC) cerebral edema	4	SSS: parietal	1200	200	61

Conclusion

Gauze packing as damage control surgery is an effective maneuver that can often halt severe intracranial hemorrhage when more common techniques have failed. Neurosurgeons should be knowledgeable about their effectiveness.

Acknowledgments

Not applicable.

Sources of Funding

This publication was prepared without any external source of funding.

Conflicts of Interest Disclosure

All authors have no conflict of interest.

References

• 1)   Wada  T,  Yasunaga  H,  Doi  K, et al. Relationship between hospital volume and outcomes in patients with traumatic brain injury: a retrospective observational study using a national inpatient database in Japan. Injury. 2017;48 (7):1423-31. doi: 10.1016/j.injury.2017.05.003
• 2)   Dewan  MC,  Rattani  A,  Gupta  S, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg. 2018;130 (4):1080-97. doi: 10.3171/2017.10.JNS17352
• 3)   Hoffman  H,  Otite  FO,  Chin  LS. Venous injury in patients with blunt traumatic brain injury: retrospective analysis of a national cohort. Neurocrit Care. 2022;36 (1):116-22. doi: 10.1007/s12028-021-01265-6
• 4)   Mostafa Elkatatny  AAA,  Abd Elreheem  YA,  Hamdy  T. Traumatic dural venous sinuses injury. Open Access Maced J Med Sci. 2019;7 (19):3225-34. doi: 10.3889/oamjms.2019.535
• 5)   Kim  YS,  Jung  SH,  Lim  DH, et al. Traumatic dural venous sinus injury. Korean J Neurotrauma. 2015;11 (2):118-23. doi: 10.13004/kjnt.2015.11.2.118
• 6)   Krause  F,  Haubold  HA. Surgery of the brain and spinal cord, based on personal experiences. New York (NY): Medical Art Agency; 1909. Care of wounds of the brain: tamponade for bleeding; p. 1-282.
• 7)   Kapp  JP,  Gielchinsky  I. Management of combat wounds of the dural venous sinuses. Surgery. 1972;71 (6):913-7.
• 8)   Kapp  JP,  Gielchinsky  I,  Deardourff  SL. Operative techniques for management of lesions involving the dural venous sinuses. Surg Neurol. 1977;7 (6):339-42.
• 9)   Rish  BL. The repair of dural venous sinus wounds by autogenous venorrhaphy. J Neurosurg. 1971;35 (4):392-5. doi: 10.3171/jns.1971.35.4.0392
• 10)   Moriwaki  Y,  Toyoda  H,  Harunari  N, et al. Gauze packing as damage control for uncontrollable haemorrhage in severe thoracic trauma. Ann R Coll Surg Engl. 2013;95 (1):20-5. doi: 10.1308/rcsann.2013.95.1.20
• 11)   Abrassart  S,  Stern  R,  Peter  R. Unstable pelvic ring injury with hemodynamic instability: what seems the best procedure choice and sequence in the initial management? Orthop Traumatol Surg Res. 2013;99 (2):175-82. doi: 10.1016/j.otsr.2012.12.014
• 12)   Gao  J,  Du  D,  Zhao  X, et al. Liver trauma: experience in 348 cases. World J Surg. 2003;27 (6):703-8. doi: 10.1007/s00268-003-6573-z
• 13)   Hester  JD. Postpartum hemorrhage and reevaluation of uterine packing. Obstet Gynecol. 1975;45 (5):501-4.
• 14)   Coccolini  F,  Roberts  D,  Ansaloni  L, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7. doi: 10.1186/s13017-018-0167-4
• 15)   Karmali  S,  Evans  D,  Laupland  KB, et al. To close or not to close, that is one of the questions? Perceptions of Trauma Association of Canada surgical members on the management of the open abdomen. J Trauma. 2006;60 (2):287-93. doi: 10.1097/01.ta.0000203579.62446.75
• 16)   Kirkpatrick  AW,  Laupland  KB,  Karmali  S, et al. Spill your guts! Perceptions of Trauma Association of Canada member surgeons regarding the open abdomen and the abdominal compartment syndrome. J Trauma. 2006;60 (2):279-86. doi: 10.1097/01.ta.0000205638.26798.dc
• 17)   Nicol  AJ,  Hommes  M,  Primrose  R, et al. Packing for control of hemorrhage in major liver trauma. World J Surg. 2007;31 (3):569-74. doi: 10.1007/s00268-006-0070-0
• 18)   Kang  BH,  Jung  K,  Choi  D, et al. Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing. Surg Today. 2021;51 (6):891-6. doi: 10.1007/s00595-020-02178-1
• 19)   Freeman  JL,  Winston  KR,  Byers  JT, et al. Damage-control neurosurgery: packing to halt relentless intracranial bleeding. J Trauma Acute Care Surg. 2015;79 (5):865-9. doi: 10.1097/TA.0000000000000836