technical note

Use of a contoured bioresorbable plate with a hemostatic
plug to control life-threatening bleeding from the superior
sagittal sinus during hemispherotomy: technical note
Gerald F. Tuite, MD,1,3 Carolyn M. Carey, MD,1,3 William W. Nelson, MD,4 Scott J. Raffa, MD,1,3 and
S. Parrish Winesett, MD2,3
Divisions of 1Pediatric Neurosurgery and 2Neurology, Neuroscience Institute, All Children’s Hospital/Johns Hopkins Medicine, St.
Petersburg; 3Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa;
and 4Division of Anesthesiology, Department of Surgery, All Children’s Hospital/Johns Hopkins Medicine, St. Petersburg, Florida

Profuse bleeding originating from an injured cerebral sinus can be a harrowing experience for any surgeon, particularly
during an operation on a young child. Common surgical remedies include sinus ligation, primary repair, placement of a
hemostatic plug, and patch or venous grafting that may require temporary stenting. In this paper the authors describe
the use of a contoured bioresorbable plate to hold a hemostatic plug in place along a tear in the inferomedial portion of a
relatively inaccessible part of the posterior segment of the superior sagittal sinus in an 11-kg infant undergoing hemispherotomy for epilepsy. This variation on previously described hemostatic techniques proved to be easy, effective, and
ultimately lifesaving. Surgeons may find this technique useful in similar dire circumstances when previously described
techniques are ineffective or impractical.
http://thejns.org/doi/abs/10.3171/2016.5.PEDS1633

Key Words superior sagittal sinus; cerebral sinus; injury; repair; hemispherotomy; hemorrhage; technique

U

profuse bleeding from the superior
sagittal sinus (SSS) during surgery can provoke
anxiety for even the most seasoned neurosurgeon.
Bleeding from far anterior sites can be definitively halted
with SSS ligation with minimal risk of cerebral ischemia
or hemorrhage. However, more posterior ligation of the
SSS is known to carry a significant risk of brain injury
due to stroke, hemorrhage, or raised intracranial pressure,
thereby necessitating repair when possible.28,29,31,34
Repairing a copiously bleeding cerebral sinus can be
trepidatious because temporary proximal and distal control of the vessel can be difficult to obtain. Surgeons are
burdened with controlling potentially life-threatening
hemorrhage while remaining acutely aware of the potential consequences of exsanguination or severe brain injury
if the repair is not successful.28,33,35
Primary suture is the optimal repair solution, but this is
sometimes not feasible.2,23,26,33,35 Packing the surface of the
nexpected

sinus with thrombogenic materials in combination with a
fibrin sealant will often suffice when the tear is small and
when direct pressure can be maintained on the hemostatic
plug.2,4,11–14 For large tears, repair with adjacent dura, a
separate autologous or allograft material, or even a vein
graft can be performed, with or without the assistance of a
temporary flow diversion stent.8,18,22,26,30,33 Emergency endovascular solutions may offer a viable alternative in some
select cases in the ideal setting, but this method has not
been widely reported.36
In this paper we report our solution to life-threatening
intraoperative bleeding originating from a hole in the inferomedial side of the SSS during hemispherotomy in an
11-kg infant. After considering and attempting many of
the typical options, we were able to successfully stop the
hemorrhage by fashioning a bioresorbable plate to hold
packing material firmly against the medial surface of the
SSS.

Abbreviations SSS = superior sagittal sinus.
SUBMITTED January 18, 2016. ACCEPTED May 4, 2016.
include when citing Published online July 8, 2016; DOI: 10.3171/2016.5.PEDS1633.
©AANS, 2016

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G. F. Tuite et al.

Case Report
Initial Operation

This 11-kg, 11-month-old boy was selected for left periinsular hemispherotomy3,6,7,17,19,27,38 due to medically refractory epilepsy related to a large, left hemisphere, perinatal
stroke (Fig. 1). The surgical approach proceeded without
incident through a left frontotemporoparietal craniotomy
that encompassed the insular area, with the medial margin
of the craniotomy approximately 4 cm from the midline. A
curvilinear dural opening was made, exposing an abnormal left hemisphere, consistent with imaging performed
prior to surgery. The brain was noted to be bulging through
the dural opening more than we would have expected in a
child with brain atrophy (Fig. 2).
While the operating microscope was being draped, before any resection of the brain, brisk venous bleeding was
noted to be originating from the subdural space. There
was no clear cause for the bleeding. The opening had been
uneventful, no brain resection had been performed, and
the patient was not undergoing hyperventilation. Dural elevation and subdural exploration to locate the source of
bleeding resulted in nearly uncontrollable bleeding and
massive blood loss, leading to severe hypotension and a
cardiac arrhythmia.
The resultant hypotension did reduce the bleeding
enough to allow direct visualization of the bleeding site,
which was determined to be an approximately 4-mm hole
in the inferomedial side of the SSS. It appeared that a large
cortical draining vein, possibly the vein of Trolard, had
avulsed directly from the SSS along the middle one-third
of the SSS.24
Repair of the Bleeding

Coagulation of the bleeding cortical vein and direct
compression of the hole in the SSS with Surgicel (Johnson & Johnson) followed by Floseal (Baxter), microfibrillar
collagen (Avitene, CR Bard), and cottonoid patties stopped
all bleeding, allowing the anesthesia team to transfuse
packed red blood cells and fresh frozen plasma. Over the
ensuing 30 minutes, direct pressure was maintained on the
SSS while the child was stabilized. Brisk bleeding resumed
every time the cotton patties were removed, regardless of
the thickness of the hemostatic plugs, despite multiple attempts over subsequent hours.
Because the bleeding could be controlled with direct
pressure, we chose to fashion a bioresorbable plate (Re­
sorbX Mesh, KLS Martin LP) to hold the packing material in place over the defect in the SSS. The bioresorbable
plate was contoured so it could be attached to the outer
portion of the skull, bent 90°, and then shaped to maintain
pressure on the packing material that was in place along
the medial surface of the SSS (Fig. 3). To more securely
hold the packing material in place, a long, thick, folded
piece of dural substitute (Durepair, Medtronic) was placed
between the hemostatic plug and the plate. We initially
tried to fashion a titanium plate to hold the packing in
place, but it fractured as it was bent excessively.
Temporal and occipital lobectomies were performed
while the hemostatic plug was manually held in place by
an assistant. All bleeding stopped after the bioresorbable
2

J Neurosurg Pediatr July 8, 2016

Fig. 1. Axial T2-weighted MR image of the infant prior to surgery, illustrating the extensive left hemispheric injury related to perinatal ischemia.

plate and packing material were in position. The dura was
closed around the plate and the bone was replaced. The
total operative time was 455 minutes exclusive of the anesthetic induction and preparation time. The total blood loss
was 1400 ml and the child received 1069 ml (3 adult units,
or 1.2 blood volumes) of packed red blood cells, 520 ml of
fresh frozen plasma, 40 ml of platelets, 40 ml of cryoprecipitate, as well as Factor VIIa (NovoSeven, Novo Nordisk) and vitamin K. He was taken to the intensive care unit
intubated, where he recovered.
Postoperative Course

The patient had an uneventful hospitalization for a child
who had undergone a life-threatening operation. He was
readmitted 4 weeks after surgery for Enterobacter cloacae meningitis, which required removal of the packing

Fig. 2. Photograph of hemisphere bulging through the dural opening
before any resection began, which may have led to the venous avulsion
from the SSS. Figure is available in color online only.

Resorbable plate with hemostatic plug to repair sinus injury

Fig. 3. Intraoperative photograph (left) taken just prior to closure, showing the bioresorbable plate contoured to hold packing
material firmly against the falx and SSS. Coronal contrast-enhanced CT scan (right) performed 1 day after surgery, showing the
bioresorbable plate holding Durepair and a hemostatic plug against a patent SSS. Figure is available in color online only.

material, the bioresorbable plate, and the bone flap. There
was no bleeding from the SSS when the plate and packing
material were removed. We realized there was a risk of
bleeding associated with removal of the plate and packing, but we chose to return to surgery and accept that risk,
without a lengthy trial of antibiotics, because the child
had a serious infection with definite signs of sepsis. We
believed that enough time had elapsed to allow sufficient
healing of the sinus injury to allow attempted removal of

the foreign body, which could have been contributing to
the severity of the infection.
CT venography performed the day after the initial surgery showed a patent SSS, but venous imaging 1 month after surgery showed a partially occluded SSS (Fig. 4). The
child was treated with enoxaparin (Lovenox, Sanofi) for
6 months. By 12 months, the posterior portion of the SSS
showed recanalization but the anterior portion remained
patent yet diminutive (Fig. 4).

Fig. 4. CT venography performed the day after surgery (A and B), and at 1 month (C and D) and 1 year (E and F) after surgery.
The anterior portion of the SSS is widely patent 1 day after surgery (A), occluded 1 month later (C), and partially recanalized at 1
year (E). Similarly, the posterior portion of the SSS is patent 1 day after surgery (B), mostly occluded at 1 month (D), and mostly
patent (F) 1 year after surgery.
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G. F. Tuite et al.

No injury occurred on the contralateral hemisphere,
and the boy’s neurological examination did not change
after surgery (Fig. 5). An extensive hematological evaluation also failed to show any evidence of coagulopathy. The
child has remained seizure free since surgery 1 year ago,
without any antiepileptic medications for 6 months.

Discussion

Hemispherectomy and its surgical variations have been
successfully used for the control of medically refractory
epilepsy since it was initially advocated by McKenzie
more than 75 years ago.3,7,19,32,38 Excellent seizure control
can be achieved in carefully selected patients, but early
enthusiasm for the procedure was tempered by high complication rates, particularly related to acute and chronic
bleeding.39 Refinements in surgical technique have reduced hemorrhagic complications, but recent reviews still
point to a 0.9%–2% overall mortality rate after hemispherectomy.17,21,37
Seizure control with hemispherectomy can be particularly dramatic and gratifying in infants with some of the
most severe forms of epilepsy,1,3,5,8,10,15–17,20,21,25,27,37 but the
risk of hemorrhage is greatest in babies with small total
blood volumes and “immature brain and blood vessels
that are fragile and vulnerable to bleeding.”10 While intraoperative death due to bleeding is exceedingly uncommon
with modern anesthetic and resuscitative techniques, coagulopathy is common and even cardiac arrest can occur
during hemispherectomy in the modern age of surgery.1,10
The current case illustrates the fragility of the blood
vessels in a young infant as well as the consequences of
sudden, profuse hemorrhage in a baby with a small blood
volume. Surgical trauma during the opening, brain manipulation, or the bulging of the brain through the dural opening (Fig. 2) may have led to the avulsion of a large draining vein from the SSS, which resulted in life-threatening
hemorrhage, cardiac arrhythmia, and coagulopathy within
a very short period of time. Based on this experience, we
recommend efforts to maintain the normal position of the
brain after dural opening. It is possible that a mild degree
of hyperventilation and/or modifications of patient positioning (neck less turned, head up slightly) might have
kept our patient’s brain from bulging through the dural
opening, which may have prevented a venous avulsion.

Fig. 5. Axial (left) and coronal (right) CT scans of the infant 1 year after
surgery, demonstrating typical postoperative changes after temporal
and occipital lobectomies with an unaffected contralateral hemisphere.
4

J Neurosurg Pediatr July 8, 2016

We chose to use a contoured bioresorbable plate to
maintain pressure on the hemostatic material that was
placed over the hole in the SSS only after the typical options to control bleeding were considered and many were
attempted. We do not believe the utilization of a bioresorbable plate to maintain pressure on the hemostatic plug
has been previously described, but the concept is a variation on techniques that have been described by other authors.2,4,11,12,14
Other authors have also reported excellent hemostatic
efficacy with long-term sinus patency utilizing a fibrin
sealant with a structural thrombogenic material. Most authors emphasize the importance of maintaining pressure
on the plug, often utilizing a dural tenting hitch stitch to
pull the dura firmly to the overlying bone.2,4,11,12,14 Dural
tenting was not technically feasible in our case because
the SSS injury occurred along the inferomedial aspect of
the SSS, in a location where a tenting dural stitch was not
possible. As a substitute for a tenting suture, the bioresorbable plate proved easy and effective.
Before utilizing the bioresorbable plate to hold the
packing material in place, other hemostatic techniques
were considered and many were attempted. Complete
ligation of the SSS was not considered prudent because
of the risk of bilateral ischemia that might have resulted
from ligation of the SSS so far posteriorly.28,29,31,34 Primary
suturing was not believed to be possible due to the width
of the opening and the inelasticity of the sinus. Medial
extension of the craniotomy with suturing of a dural leaflet over the hole in the SSS and falx was considered, but
they were believed to be too hazardous given the risk of
significant blood loss during such a maneuver in an 11-kg
infant. Direct placement of a temporary stent was not possible because the hole in the sinus was not large enough to
accommodate available stents.
It could be argued that the presence of the plate increased the risk of infection, leading to the child’s meningitis. However, we believe the long duration of the procedure,
the extraordinary blood loss with resultant transfusions,
and the prolonged hypotension likely played a pivotal role
in the child’s infection.15,17,37

Conclusions

Serious bleeding from an injury to the inferomedial
wall of the SSS during hemispherectomy was effectively
controlled with a thrombotic plug held in place with a bioresorbable plate. This plate was attached to the outer skull
layer and contoured into an S-shape to allow maintenance
of compression of a hemostatic plug on the injured inferomedial SSS. The use of the bioresorbable plate proved to
be an effective, efficient, and potentially lifesaving technique. This technique may be applicable to other surgical scenarios in which robust cerebral sinus bleeding from
poorly accessible locations is encountered, when standard
hemostatic techniques prove difficult.

Acknowledgments

We would like to thank Allyn DiVito for his assistance with
the figure annotations. William Nelson, MD, the anesthesiologist
caring for this child during surgery, deserves credit for his exem-

Resorbable plate with hemostatic plug to repair sinus injury

plary resuscitative efforts and for suggesting we use a resorbable
plate, which was much easier to contour than our attempts with a
metal plate.

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Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this
paper.

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J Neurosurg Pediatr July 8, 2016

Author Contributions

Conception and design: all authors. Acquisition of data: all
authors. Analysis and interpretation of data: all authors. Drafting the article: Tuite. Critically revising the article: all authors.
Reviewed submitted version of manuscript: all authors. Approved
the final version of the manuscript on behalf of all authors: Tuite.
Administrative/technical/material support: Tuite. Study supervision: Tuite.

Correspondence

Gerald Tuite, Division of Pediatric Neurosurgery, Neuroscience
Institute, All Children’s Hospital/Johns Hopkins Medicine, 601
5th St. S, Ste. 511, St. Petersburg, FL 33701. email: geraldtuite@
gmail.com.