LETTER TO THE EDITOR
Reply to the Editor: Gauze Packing and Removal: Two-staged Operations for Hemostasis of Traumatic Sinus Injury
キーワード:
sinus injury,
traumatic brain injury
2026 年 13 巻 p. 331-332
詳細
2026 年 13 巻 p. 331-332
Dear Editor,
We sincerely thank Dr. Kim for his thorough reading of our manuscript, "Gauze Packing and Removal: Two-staged Operations for Hemostasis of Traumatic Sinus Injury," and for contributing his valuable clinical insights and case experience regarding the management of traumatic venous sinus injury (VSI).1) We welcome the opportunity to further discuss the critical nuances of managing this highly challenging condition. We would like to address the 2 primary considerations raised in the letter: the risk of infection related to the timing of gauze removal, and the surgical indications for case 1.
Regarding the first point on the risk of infection and the timing of gauze removal, we are in complete agreement with Dr. Kim. The risk of severe septic infection is unquestionably 1 of the most significant dangers associated with the retention of foreign materials, such as surgical gauze, within the intracranial space. In our practice, we prioritize strict aseptic techniques and the continuous administration of first-generation cephem antibiotics throughout the perioperative period, specifically while the gauze remains in place, to mitigate this severe risk. As noted in our report, the optimal timing for the safe removal of intracranial packing-balancing the risk of intractable rebleeding against the risk of infection-remains under-researched and lacks strict consensus in the current neurosurgical literature. Freeman et al. previously reported that packing used to halt intracranial bleeding could be safely removed anywhere from 4 to 61 days post placement. In our series, we successfully removed the packing on postoperative day 8 for case 1 and day 4 for case 2, without encountering any obvious infectious complications. However, we strongly concur with Dr. Kim's pragmatic recommendation that attempting removal within the first postoperative week is highly advisable. Doing so likely minimizes the window for infectious complications while still allowing sufficient time for clot maturation and early healing at the site of the venous sinus disruption.
Regarding the second point, Dr. Kim expressed concerns about the surgical indication for case 1, suggesting that the mass effect of the subdural hematoma on the initial computed tomography (CT) scans was not significant enough to warrant emergency surgery. He hypothesized that the patient's poor neurological state might have been primarily driven by diffuse axonal injury (DAI), and consequently proposed that conservative treatment would have been more appropriate. Although we respect this perspective, we must emphasize the critical clinical presentation that strictly dictated our surgical decision-making process.
The paramount factor necessitating urgent surgical decompression in case 1 was the patient's rapidly deteriorating and severe neurological status. The patient was in a deep coma with a Glasgow Coma Scale score of E1V1M1, coupled with a distinctly sluggish, mid-dilated left pupil indicating anisocoria. In the context of acute traumatic brain injury, the presence of anisocoria with such a depressed level of consciousness is a hallmark clinical sign of an impending or actively progressing uncal herniation. Although a single axial slice of a CT scan might not always dramatically convey the full extent of intracranial pressure, the 3-dimensional imaging revealed multiple fracture lines across the temporal, parietal, and occipital bones, alongside both supra- and infratentorial hematomas exerting a combined, critical mass effect on the brainstem.
Although it is highly probable that a component of DAI coexisted with the mass lesions-as is common in severe high-impact trauma-attributing the profound coma and focal pupillary abnormalities solely to DAI and electing for conservative management would have been an unacceptably high-risk strategy in the face of clinical herniation. Immediate decompressive craniectomy was a necessary, lifesaving intervention to alleviate the fatal pressure on the brainstem. It was during this essential and unavoidable decompression that we encountered massive, uncontrollable hemorrhage (causing 2,900 mL of blood loss) from a 2-cm disruption at the confluence of the left transverse and superior sagittal sinuses. When conventional hemostatic methods-including cauterization, suturing, and the application of various hemostatic agents-proved entirely ineffective, gauze packing was used as an emergency damage-control measure.
As highlighted in our literature review of 15 similar cases of gauze packing for intracranial hemorrhage, this technique is typically reserved for catastrophic situations in which patients present profoundly unconscious and experience massive intraoperative blood loss, most often from trauma-induced VSIs. The underlying concept of damage-control surgery-prioritizing physiological survival over anatomical repair during the initial operation-is well-established in general trauma surgery for managing severe thoracic, pelvic, and abdominal hemorrhages. Applying this principle to neurosurgery, particularly through the use of intentionally retained gauze packing, can similarly bridge the critical gap between lethal intraoperative exsanguination and successful physiological recovery.
Dr. Kim's conservatively managed case of an epidural hematoma with a sigmoid sinus injury is highly instructive and indicates an excellent clinical outcome. We fully agree that for VSIs associated with adjacent skull fractures-provided the patient does not exhibit clinical signs of brain herniation or life-threatening mass effect-conservative management, including careful control of intracranial pressure, is a very strong initial strategy. Our report does not advocate prophylactic surgery for VSI. Rather, it highlights that when emergency surgery is unequivocally mandated by impending herniation, and uncontrollable sinus bleeding is subsequently encountered, gauze packing remains a highly effective, last-resort maneuver to save the patient's life.
We are deeply grateful to Dr. Kim for initiating this vital discussion, which helps clarify the delicate balance between conservative management and damage-control surgery in the context of severe neurotrauma.
Sincerely,
Hidekazu Nakata, MD, et al.
All authors have no conflict of interest.
