Cerebral Venous Sinus Thrombosis After Vestibular Schwannoma Surgery

A Call for Evidence-based Management Guidelines

Hussam Abou-Al-Shaar, MD; Yair M. Gozal, MD, PhD; Gmaan Alzhrani, MD; Michael Karsy, MD, PhD, MSc; Clough Shelton, MD; William T. Couldwell, MD, PhD


Neurosurg Focus. 2018;45(1):e4 

In This Article

Abstract and Introduction


Objective: Postoperative cerebral venous sinus thrombosis (CVST) is an uncommon complication of posterior fossa surgery. The true incidence of and optimal management strategy for this entity are largely unknown. Herein, the authors report their institutional incidence and management experience of postoperative CVST after vestibular schwannoma surgery.

Methods: The authors undertook a retrospective review of all vestibular schwannoma cases that had been treated with microsurgical resection at a single institution from December 2011 to September 2017. Patient and tumor characteristics, risk factors, length of stay, surgical approaches, sinus characteristics, CVST management, complications, and follow-up were analyzed.

Results: A total of 116 patients underwent resection of vestibular schwannoma. The incidence of postoperative CVST was 6.0% (7 patients). All 7 patients developed lateral CVST ipsilateral to the lesion. Four cases occurred after translabyrinthine approaches, 3 occurred after retrosigmoid approaches, and none occurred following middle cranial fossa approaches. Patients were managed with anticoagulation or antiplatelet therapy. Although patients were generally asymptomatic, one patient experienced intraparenchymal hemorrhage, epidural hemorrhage, and obstructive hydrocephalus, likely as a result of the anticoagulation therapy. However, all 7 patients had a modified Rankin scale score of 1 at the last follow-up.

Conclusions: Postoperative CVST is an infrequent complication, with an incidence of 6.0% among 116 patients who had undergone vestibular schwannoma surgery at one institution. Moreover, the management of postoperative CVST with anticoagulation therapy poses a serious dilemma to neurosurgeons. Given the paucity of reports in the literature and the low incidence of CVST, additional studies are needed to better understand the cause of thrombus formation and help to establish evidence-based guidelines for CVST management and prevention.


Cerebral venous sinus thrombosis (CVST) primarily occurs in the setting of trauma, infection, and congenital or acquired hypercoagulable states, but nearly 20%–25% of CVST cases occur without an identifiable cause.[16,19] It is estimated that 4.7%–11.6% of patients undergoing posterior fossa surgery for cerebellopontine angle tumors will develop postoperative lateral sinus thrombosis.[1,8,11] With the relatively low incidence of this serious complication, there is a paucity of reports in the literature regarding the diagnosis, management, and sequelae associated with postoperative CVST.

To date, the management strategy applied in the treatment of postoperative thrombosis has been elucidated from the better-studied approaches used to treat spontaneously occurring CVST.[3,15] However, because the primary strategy for treating spontaneous CVST is aggressive anticoagulation, its application in the immediate postoperative period poses a serious dilemma for otologists and neurosurgeons. Specifically, surgeons must balance the risk of postoperative hemorrhage caused by venous hypertension associated with sinus thrombosis with the risk of hemorrhage due to perioperative anticoagulation. In the absence of evidence-based guidelines for the management of this iatrogenic entity, we report herein our experience with CVST after the resection of vestibular schwannomas.