A systematic review of penetrating injuries to the superior sagittal sinus across two centuries.

OBJECTIVE

Penetrating injuries of the superior sagittal sinus (pSSSIs) are rare but catastrophic, often causing massive hemorrhage, intracranial hypertension, and neurological decline. Despite centuries of reported cases, management guidance remains fragmented. This study reports a systematic literature review that sought to characterize pSSSIs by mechanism, anatomical involvement, surgical management, and outcomes and trace the evolution of repair techniques over 2 centuries.

METHODS

PubMed, Embase, Scopus, and Cochrane databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria targeted original reports of pSSSIs, excluding iatrogenic or nonpenetrating trauma. Study quality was assessed using the Joanna Briggs Institute tools.

RESULTS

Thirty-nine articles describing 51 cases for the period 1826-2025 were included. Patients were predominantly male (49 of 51; 96%) with a mean (SD) age of 30.3 (15.1) years. Causes included military trauma (33%), accidents (29%), suicides (18%), and assaults (8%). The middle third of the sinus was most often affected (67%), followed by the anterior (24%) and posterior (18%) thirds. Nails (24%), bone fragments (16%), and bullets (16%) were frequent penetrating objects. Repair methods included hemostatic agents (25%), grafts (25%), ligation (14%), and sutures (14%). Mortality was 27% and was highest among individuals with injuries to the anterior third of the sinus and those with complex trauma.

CONCLUSION

pSSSIs are uncommon but life-threatening, with outcomes determined by the anatomical site, mechanism, and timely intervention. Although surgical management options have evolved, no standardized paradigm exists. Contemporary approaches emphasize tailored combinations of direct repair, reconstruction, and selective ligation. Further work is needed to establish consensus guidelines and optimize outcomes in these challenging cases.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251124767, identifier (CRD420251124767).