Sinus pericranii. A case report

A review of extraaxial developmental venous anomalies of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, venous varices or aneurysmal malformations, and enlarged emissary veins

This paper is a narrative review of extraaxial developmental venous anomalies (eDVAs) of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, enlarged emissary veins, and venous varices or aneurysmal malformations. The article highlights the natural history, anatomy, embryology, imaging, clinical implications, and neurosurgical significance of these lesions, which the authors believe represent a continuum, with different entities characterized by distinct embryopathologic features. The indications and surgical management options are discussed for these individual intracranial pathologies with relevant illustrations, and a novel classification is proposed for persistent falcine sinus (PFS). The role of neurointervention and/or microsurgery in specific cases such as sinus pericranii and enlarged emissary veins of the skull is highlighted. A better understanding of the pathophysiology and developmental anatomy of these lesions can reduce treatment morbidity and mortality. Some patients, including those with vein of Galen malformations (VOGMs), can present with the added systemic morbidity of a high-output cardiac failure. Although VOGM is the most studied and classified of the above-mentioned eDVAs, the authors believe that grouping the former with the other venous anomalies/abnormalities listed above would enable the clinician to convey the exact morphophysiological configuration of these lesions, predict their natural history with respect to evolving venous hypertension or stroke, and extrapolate invaluable insights from VOGM treatment to the treatment of other eDVAs. In recent years, many of these symptomatic venous malformations have been treated with endovascular interventions, although these techniques are still being refined. The authors highlight the broad concept of eDVAs and hope that this work will serve as a basis for future studies investigating the role of evolving focal venous hypertension/global intracranial hypertension and possibilities of fetal surgical intervention in these cases.

Sinus pericranii: diagnosis and management in 21 pediatric patients

OBJECT

Sinus pericranii (SP) is a rare venous anomaly abnormally connecting the intracranial dural sinuses with the epicranial veins. In the present study the authors aimed to clarify this clinicoradiological entity, define the role of angiography in its preoperative assessment, and suggest a diagnostic-therapeutic flow chart for management purposes.

METHODS

The authors retrospectively reviewed the clinical charts and neuroimages of 21 patients with SP. All patients underwent brain MRI, MR venography, and craniocerebral CT. Diagnostic digital subtraction angiography was performed in 19 of 21 patients, and the SPs were categorized as dominant (draining the majority of the intracranial venous outflow) or accessory (draining only a minority of the intracranial venous outflow).

RESULTS

SP was median or paramedian in 20 patients and lateral in 1 patient. There were 5 dominant and 14 accessory SPs. The dominant SPs were not treated. Among the patients with accessory SP, 4 were not treated, 2 underwent surgical ligature, and 8 were treated endovascularly (with either transvenous or percutaneous embolization). No complications were observed, and symptoms disappeared after treatment in all cases.

CONCLUSIONS

Accepted guidelines or recommendations concerning the management, diagnosis, and treatment of SP are still lacking. The authors define here a diagnostic-therapeutic flow chart, in which angiography plays a crucial role in the classification of SP and choice of the optimal treatment. Only accessory SP is amenable to treatment, whereas dominant SP must be preserved. The endovascular approach is becoming increasingly relevant and has proven to be safe and effective.

Imaging of the calvarium

The skull vault consists of a multitude of flat bones held together by the cranial sutures. Radiologists encounter a vast array of calvarial pathologies that tend to cause abnormalities in thickness, abnormalities in density, focal defects, or an excess of soft tissue or bone tissue. Further anomalies related to the cranial sutures and fontanelles occur in the dynamic pediatric skull. The imaging features of the host of conditions resulting in these commonly detected calvarial abnormalities are reviewed and illustrated.

Sinus pericranii in the right frontal region and thrombosis

Sinus pericranii is a rare vascular anomaly in which an abnormal communication exists between the extracranial venous system and the underlying dural venous sinus via the diploe of the skull. We describe a case of a spontaneous thrombosis of the sinus pericranii which was located in the right frontal region and presented as a focal, leathery, and noncompressible mass distinguished in character from the typical manifestation of sinus pericranii. In this case, CT, DSA, MRI, MR venography (MRV), and pathologic examination were performed. The CT showed the bone depression in the skull and the MRI demonstrated the mass, but they were not sufficiently sensitive to detect the thrombus. Pathologic examination and MRV were helpful in depicting the thrombus. She underwent a surgical resection, and at the 5-month follow-up there was no evidence of recurrence.

Sinus pericranii: diagnostic and therapeutic considerations in 15 patients

INTRODUCTION

Sinus pericranii (SP) is a rare, usually asymptomatic condition characterized by a large communication between the intra- and the extracranial venous drainage pathways in which blood may circulate bidirectionally through dilated veins of the skull. We describe our diagnostic and therapeutic experience with SP, with a special focus on the vascular analysis of digital subtraction angiography (DSA).

METHODS

DSA images of 15 patients were evaluated with regard to the delay in opacification of the scalp vessels, the absence or distortion of the superficial cortical veins in the vicinity of the SP, the drainage patterns of the superior sagittal sinus, and the degree of maturation of the venous outlets of the brain. SP were classified either as "dominant", if the main stream of contrast flow used the SP to drain the brain bypassing usual venous outlets, or as "accessory", if only a small part of the venous outflow occurred through the extradiploic vessels.

RESULTS

All patients presented with a nonpulsatile, soft-tissue mass. The lesion was on the midline in 14 of 15 patients, frontal in 12 patients, and parietal in 2 patients. In 13 patients, associated intracranial venous anomalies were present, eight of which were developmental venous anomalies. Seven patients had a dominant SP, and eight an accessory SP.

CONCLUSION

SP can be considered the cutaneous sign of an underlying venous anomaly. If treatment is contemplated, analysis of the drainage pattern of the SP has to be performed. Treatment should be avoided in dominant SP or if its accessory role constitutes the only collateral pathway of an underlying venous anomaly.

Sinus pericranii: from gross and neuroimaging findings to different pathophysiological changes

CASE REPORTS

We report two girls with a typical presentation of sinus pericranii. Both patients received total excision of the subgaleal masses with complete obliteration of the communications to the intracranial portion. However, different gross appearances, neuroimaging findings and intraoperative findings were found. It took more time and attention to control the bleeding due to the large communication between the extracranial and intracranial components in the second case.

DISCUSSION

Sinus pericranii is composed of abnormal extracranial vascular tissues that communicate directly with intracranial dural sinuses or veins. A review of the literature showed that 13 out of 31 patients with sinus pericranii had a high-flow pattern. Detailed physical examination and imaging studies to detect dilated scalp veins and a large bony defect should remind surgeons of the presence of large venous communications. Meticulous treatment of the large communication during surgery can avoid massive bleeding.

Sinus pericranii: dermatologic considerations and literature review

Sinus pericranii is a rare disorder characterized by a congenital or acquired epicranial blood-filled nodule of the scalp that is in communication with an intracranial dural sinus through dilated diploic veins of the skull. We describe two patients with sinus pericranii: a 3-year-old boy with a congenital lesion and a 3-year-old girl whose lesion appeared after head trauma. We discuss the clinical presentation, dermatologic manifestations, differential diagnosis, and management as described in the available published literature. Patients with sinus pericranii may be brought to the attention of dermatologists and dermatopathologists because of skin changes in the scalp or forehead. The diagnosis is difficult to make clinically, because the skin manifestations are highly variable and may resemble other disorders of the scalp and cranium. The potentially lethal complications including hemorrhage, infection, and air embolism warrant a high index of suspicion for sinus pericranii.

Parietal sinus pericranii: case report and technical note

BACKGROUND

Sinus pericranii is a rare vascular anomaly that is defined as a group of abnormal communications between the extracranial and intracranial venous systems, usually involving the superior sagittal sinus. Different surgical techniques have been used to manage this anomaly. Surgical technique and radiologic findings are discussed.

CLINICAL PRESENTATION

A case of parietal sinus pericranii is presented that was developed spontaneously. This 33-year-old woman presented with a soft fluctuant mass in the right parietal region adjacent to the midline. She complained of headache and dizziness. The preoperative radiologic findings of simple skull X-ray, computed tomography, bone scan, and direct venogram are presented. The lesion was removed completely and then multiple small vascular channels through the underlying skull were obliterated by air-powered diamond drilling. The presence of vascular endothelium in the pathologic specimen suggested a congenital origin.

CONCLUSION

We think this method is very easy and useful for managing the multiple small fenestrations of the sinus pericranii without recurrence.

Subepicranial varix mimicking sinus pericranii: usefulness of three-dimensional computed tomography angiography and bone window computed tomography--case report

A 16-year-old female presented with a rare case of subepicranial varix in the left temporal area manifesting as a soft mass in the left temporal area when she laid down in the left lateral position. Bulging of the mass was observed when intracranial venous pressure was raised by the Valsalva maneuver, the left lateral position, or the prone position. Bone window computed tomography (CT) revealed a tiny hole, 1 mm in diameter, in the outer bone table. Three-dimensional CT (3D-CT) angiography clearly visualized a mass with a diameter of approximately 10 mm connected to the diploic vein. The mass was totally resected by operation. Venous bleeding was observed from the tiny hole. Histological examination revealed a venous lesion mimicking sinus pericranii and containing endothelial cells. No communication with the intracranial venous sinuses was identified, so the diagnosis was subepicranial varix. Radiological examination by direct injection of contrast medium is usually performed to identify subepicranial varix, but 3D-CT angiography is a non-invasive preoperative examination that can visualize this small venous lesion. Adjustment of the CT acquisition conditions may allow 3D-CT angiography to identify sinus pericranii in the future.

Sinus pericranii: radiological and etiopathological considerations. Case report

Sinus pericranii is a rare vascular anomaly involving an abnormal communication between the extracranial and intracranial circulations. A case of frontal sinus pericranii is presented which appeared to be a posttraumatic sinus because it developed 2 years after a cranial injury. However, the presence of vascular endothelium in the pathological examination and its association with a vascular anomaly (persistent trigeminal artery) suggested a congenital origin. The lesion, pericranial blood sinuses, and bone were totally removed. The computerized tomography, angiography, and magnetic resonance imaging findings are presented. The literature is reviewed and the pathogenesis of sinus pericranii is discussed.