Association of intra- and extradural developmental venous anomalies, so-called venous angioma and sinus pericranii

Sinus Pericranii (Parietal and Occipital) With Epicranial Varicosities in a Case of Craniosynostosis

Sinus pericranii is a type of slow flow venous malformation with communication between intracranial venous system and epicranial veins through transosseous emissary veins. They can be isolated or may be seen with malformations like craniosynostosis. It has been postulated that transient intracranial venous hypertension in the late embryonic period could lead to the development of venous anomalies, including sinus pericranii. We present a case of oxycephaly with concurrent presence of sinus pericranii in parietal and occipital regions with epicranial varicosities with other imaging findings of raised intracranial pressure. Other findings suggestive of raised intracranial pressure were cerebellar tonsillar herniation/prominent optic nerve dural sleeves. The paucity of literature warrants future studies to establish role of intracranial hypertension in etiopathogenesis of sinus pericranii.

Conventional and advanced MRI evaluation of brain vascular malformations

Vascular malformations (VMs) of the central nervous system (CNS) include a wide range of pathological conditions related to intra and extracranial vessel abnormalities. Although some VMs show typical neuroimaging features, other VMs share and overlap pathological and neuroimaging features that hinder an accurate differentiation between them. Hence, it is not uncommon to misclassify different types of VMs under the general heading of arteriovenous malformations. Thorough knowledge of the imaging findings of each type of VM is mandatory to avoid these inaccuracies. Conventional MRI sequences, including MR angiography, have allowed the evaluation of CNS VMs without using ionizing radiation. Newer MRI techniques, such as susceptibility-weighted imaging, black blood sequences, arterial spin labeling, and 4D flow imaging, have an added value of providing physiopathological data in real time regarding the hemodynamics of VMs. Beyond MR images, new insights using 3D printed models are being incorporated as part of the armamentarium for a noninvasive evaluation of VMs. In this paper, we briefly review the pathophysiology of CNS VMs, focusing on the MRI findings that may be helpful to differentiate them. We discuss the role of each conventional and advanced MRI sequence for VMs assessment and provide some insights about the value of structured reports of 3D printing to evaluate VMs.

Intracranial venous malformations: Incidence and characterization in a large pediatric cohort

BACKGROUND

Significant advances have been reported recently in the genetic and mechanistic characterization of extracranial venous malformations. However, intracranial purely venous malformations (icVM) analogous to those outside the CNS have not been systematically described.

PURPOSE

We sought to ascertain whether such an entity as icVM could in fact be identified, distinct from previously described CNS venous anomalies and analogous to extracranial venous malformations.

METHODS

Our prospectively collected pediatric cerebrovascular database was reviewed to identify patients with icVM; 1458 consecutive angiograms and/or angiographic interventions performed on 706 children at our institution from October, 2006 through May, 2019 were evaluated, in addition to outside imaging studies on 192 additional patients sent to our Vascular Anomalies Center for cerebrovascular review during the same time period. Thus, the cohort consisted of 898 children.

RESULTS

Nineteen of 898 patients (2.1%) were found to harbor icVM, including 9 (47.3%) with sinus pericranii, 15 (78.9%) with associated large, complex extracranial venous malformations, and 3 (15.7%) with neurocognitive delay. There was no intracranial hemorrhage or venous hypertension seen in the cohort. Asymptomatic venous thrombosis in the superior sagittal sinus was seen in three patients.

CONCLUSION

Venous malformations, both extracranial and icVM, share many characteristics that are distinct from developmental venous anomalies. icVM were not associated with venous hypertension. The underlying genetic mutations involved in the development of icVM, germ-line or somatic, remain to be elucidated, but may very well involve shared mechanisms and pathways with extracranial venous malformations.

Sinus Pericranii Complicated by Hydrocephalus: Case Report and Literature Review

BACKGROUND

Sinus pericranii (SP) is a rare vascular condition that results when abnormal communication between the intracranial and extracranial venous systems is present. Here we report a rare case of hydrocephalus revealed through a SP scalp mass with a review of literature.

CASE DESCRIPTION

A 13-year-old girl presented with a history of bulging left eye, bilateral gradual deterioration of vision, nausea, and progressive headaches. The family reported the sudden appearance of a scalp mass prior to these symptoms. Brain imaging showed supra- and infratentorial communicating hydrocephalus and subcutaneous vascular collaterals from the midportion of the superior sagittal sinus. After ventriculoperitoneal shunt insertion, interval reduction of the ventricular size and disappearance of extracranial veins without associated intra- or extracranial vascular anomalies was observed.

CONCLUSIONS

SP is divided into two main types: (1) Spontaneous type, in which lesions are formed due to acquired causes without a syndromic association or other vascular anomalies or stenosis. The most commonly reported cause is trauma in which SP may develop at the trauma site rather than the midline. (2) Congenital type, in which case the most commonly reported association is craniosynostosis. It can also be seen with vein of Galen hypoplasia, vein of Galen malformations, dural sinus malformations, solitary developmental venous anomalies, and intraosseous arteriovenous malformations. We are reporting the first case of idiopathic SP with hydrocephalus without a congenital association or acquired cause, including trauma. The sudden change in SP size can indicate a change in intracranial pressure and the development of hydrocephalus.

Venous pathologies in paediatric neuroradiology: from foetal to adolescent life

The interpretation of cerebral venous pathologies in paediatric practice is challenging as there are several normal anatomical variants, and the pathologies are diverse, involving the venous system through direct and indirect mechanisms. This paper aims to provide a comprehensive review of these entities, as their awareness can avoid potential diagnostic pitfalls. We also propose a practical classification system of paediatric cerebral venous pathologies, which will enable more accurate reporting of the neuroimaging findings, as relevant to the underlying pathogenesis of these conditions. The proposed classification system comprises of the following main groups: arterio-venous shunting-related disorders, primary venous malformations and veno-occlusive disorders. A multimodal imaging approach has been included in the relevant subsections, with a brief overview of the modality-specific pitfalls that can also limit interpretation of the neuroimaging. The article also summarises the current literature and international practices in terms of management options and outcomes in specific disease entities.

Symptomatic Sinus Pericranii with Adult Onset Headache: A Case Report with Pathologic Perspective

Sinus pericranii (SP) is a rare vascular anomaly of the scalp that consists of an abnormal pericranial venous channel connected to adjacent dural venous sinuses. Most SP are asymptomatic and are found in the pediatric age group. We aim to report a case of symptomatic SP in adult and describe the clinical, radiological, and pathohistological findings to help understand and differentiate this lesion from other scalp lesions. A 40-year-old man with a scalp mass was admitted to our hospital complaining of headache. The lesion enlarged when the patient was in a recumbent position or during Valsalva maneuver. The radiologic imaging suggested its diagnosis as an accessory type of SP with bone erosion. Surgical resection and cranioplasty were successfully performed, and the related headache also gradually subsided. At the 3-year follow-up, there was no recurrence on magnetic resonance imaging.

Sinus Pericranii with Dominant Venous Outflow in the Superior Eyelid

Sinus pericranii (SP) located in the superior eyelid is an unusual clinical presentation. Here, we report a case of 72-year-old woman with an unruptured cerebral aneurysm presented with an SP located in the left superior eyelid. The SP was found to have a dominant venous outflow from the bilateral frontal region with an arterialized blood flow pattern on color Doppler ultrasonography (CDUS). During the aneurysmal surgery, intraoperative monitoring of the dominant venous outflow with CDUS was useful for the prevention of venous outflow obstruction. Physicians should carefully consider intracranial vascular anomalies in the differential diagnosis of vascular lesions of the superior eyelid.

Acquired Sinus Pericranii Due To Parasagittal Meningiomatous Invasion of the Superior Sagittal Sinus and Bilateral Transverse Sinuses

BACKGROUND

Sinus pericranii is a rare vascular anomaly characterized by abnormal connections between the extra- and intracranial venous systems. Although the etiology still remains unclear, sinus pericranii is usually congenital in nature, or less likely may be secondary to spontaneous or traumatic causes.

CASE DESCRIPTION

We present a unique case of spontaneous sinus pericranii secondary to a parasagittal meningioma invading and occluding the superior sagittal sinus, torcula herophilii, and bilateral transverse sinuses. The resultant venous outlet obstruction and venous hypertension may have been the inciting factors for the development of the collateral channel connecting the intra- and extracranial venous systems.

CONCLUSIONS

This case highlights the effect of the reversal of normal venous outflow secondary to meningiomatous occlusion of intracranial dural sinuses. Sinus pericranii may, on rare occasions, represent the sole means for intracranial venous drainage in cases of intracranial venous thrombosis or incomplete development of the cerebral venous system. Therefore, this case also highlights the importance of pretreatment evaluation of the venous drainage system in patients with sinus pericranii and those with meningiomas.

A rare case of diploic venous anomaly: asymptomatic venous sac expanding in the diploe

BACKGROUND

Vascular anomalies accompanied with the diploic veins are rare. Among them, sinus pericranii, which is characterized by abnormal connections between intra- and extracranial venous systems, is relatively common. Besides sinus pericranii, a few cases of subepicranial varix with connections to diploic veins have been reported, but these varices had no connections to intracranial venous sinuses. Herein, we present a rare case of an expanding venous sac in the diploe which communicated with the intracranial sinus but not with the extracranial venous systems.

CASE PRESENTATION

An adult woman presented to us with a minor transient headache. Although no abnormal appearances were found on her scalp, imaging studies showed a club-shaped venous sac in the left parietal diploe that communicated with the superior sagittal sinus and diploic veins on the medial and lateral sides, respectively. It was revealed that the lesion had expanded as compared with a previous computed tomography image. Surgery was performed to intercept venous supply from the diploic veins, and the lesion was filled with thrombi. In a follow-up of 15 months, there was no recurrence of abnormal venous flow. Histological examination showed the endothelial lining in the membranous wall of the sac, which is typically observed in sinus pericranii. However, no communication with the pericranial veins of the scalp was identified on the imaging studies and intraoperative observation. Accordingly, it was diagnosed as another entity "intradiploic varix".

CONCLUSIONS

The abnormal connection between the intracranial and the diploic venous systems via the large venous sac was surgically treated. It was pathologically similar to sinus pericranii, but anatomically considered to be another form of venous anomaly. In cases of expanding lesions, surgical treatment is recommended.

The Management of Symptomatic Cerebral Developmental Venous Anomalies: A Clinical Experience of 43 Cases

Background

Developmental venous anomalies (DVAs) are rare vascular diseases becoming more frequently diagnosed. Most patients with DVAs have no clinical symptoms with the exception of a few patients with epilepsy, intracranial hemorrhage, or neuro-function deficit. There is still controversy with respect to treatment strategies for symptomatic DVAs.

Material/Methods

Forty-three cases of symptomatic DVAs from January 2006 to October 2015 were retrospectively reviewed and the imaging characteristics of DVAs by CT, MRI, and DSA and the treatment modalities for DVAs were studied.

Results

Typical imaging characteristics of symptomatic DVAs were wedge or umbrella-shaped collections of dilated medullary veins converging in an enlarged subependymal or transcortical collecting vein, draining to the superficial or deep vein system. Based on location and draining vein features, symptomatic DVAs were tentatively classified into six different subtypes. Of the 43 cases, 19 were treated by surgical methods and 24 were treated conservatively.

Conclusions

We concluded that the rate of accompanying abnormalities in cases of symptomatic DVAs was high. Intracerebral hemorrhage was usually attributed to associated CMs or AVMs. The associated lesions and the branches responsible for bleeding could be resected while preserving the collecting vein as far as possible.

The scalp hair collar and tuft signs: A retrospective multicenter study of 78 patients with a systematic review of the literature

BACKGROUND

Hair collar sign (HCS) and hair tuft of the scalp (HTS) are cutaneous signs of an underlying neuroectodermal defect, but most available data are based on case reports.

OBJECTIVE

We sought to define the clinical spectrum of HCS and HTS, clarify the risk for underlying neurovascular anomalies, and provide imaging recommendations.

METHODS

A 10-year multicenter retrospective and prospective analysis of clinical, radiologic, and histopathologic features of HCS and HTS in pediatric patients was performed.

RESULTS

Of the 78 patients included in the study, 56 underwent cranial and brain imaging. Twenty-three of the 56 patients (41%) had abnormal findings, including the following: (1) cranial/bone defect (30.4%), with direct communication with the central nervous system in 28.6%; (2) venous malformations (25%); or (3) central nervous system abnormalities (12.5%). Meningeal heterotopia in 34.6% (9/26) was the most common neuroectodermal association. Sinus pericranii, paraganglioma, and combined nevus were also identified.

LIMITATIONS

The partial retrospective design and predominant recruitment from the dermatology department are limitations of this study.

CONCLUSIONS

Infants with HCS or HTS are at high risk for underlying neurovascular anomalies. Magnetic resonance imaging scans should be performed in order to refer the infant to the appropriate specialist for management.

Determination of sinus pericranii resectability by external compression during angiography: technical note

Sinus pericranii is an uncommon congenital cranial venous malformation that may become symptomatic in the pediatric population. Both dominant and accessory sinus pericranii, as determined by the intracranial venous drainage pattern, have been described. The dominant variety drain a significant proportion of the intracranial venous outflow while the accessory variety have minimal or no role in this. Classic teachings hold that dominant sinus pericranii should never be treated while accessory sinus pericranii may be safely obliterated. This determination of dominance is solely based on a qualitative assessment of standard venous phase catheter cerebral angiography, leaving some doubt regarding the actual safety of obliteration. In this paper the authors describe a simple and unique method for determining whether intracranial venous outflow may be compromised by sinus pericranii treatment. This involves performing catheter angiography while the lesion is temporarily obliterated by external compression. Analysis of intracranial venous outflow in this setting allows visualization of angiographic changes that will occur once the sinus pericranii is permanently obliterated. Thus, the safety of surgical intervention can be more fully appraised using this technique.

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.

Sinus pericranii with unusual features: multiplicity, associated dural venous lakes and venous anomaly, and a lateral location

Anomalous connections between an extracranial venous sac and intracranial dural sinuses through dilated diploic and emissary veins of the skull result in sinus pericranii (SP). In this study, two patients with the rare presentation of multiple, congenital SP with associated dural venous lakes and venous anomalies are described. In one patient, multiple SPs were located in the frontal, parasagittal region with an associated subcortical venous angioma; and, in the other, peritorcular and juxta-transverse-sigmoid sinus junction SP coexisted. The venous anomalies drained into venous lakes in close proximity to major sinuses. They also communicated with extracranial tributaries via interosseous veins leading to the development of venous hypertension that presumably caused pressure erosion of the skull. This may have been responsible for the pathogenesis of multiple subgaleal venous sacs of SP and may also lead to profuse hemorrhage, cortical venous thrombosis, or air embolism. Multiplicity, associated venous lakes, venous angioma, and a lateral location are unique presentations of SP. Sac excision, transcranial venous anastomotic channel blockage, and reinforcement/replacement of the underlying bone are the recommended modalities of treatment.

Endovascular embolization with Onyx in the management of sinus pericranii: a case report

Sinus pericranii (SP) is an uncommon and usually asymptomatic communication between intra- and extracranial venous drainage pathways in which blood flow can circulate bidirectionally through abnormal dilated veins through a skull defect. Diagnosis and evaluation of the venous drainage pattern is important if treatment is contemplated. Cerebral angiography with the use of Dyna CT can be helpful in the diagnosis of SP and its relationship with the skull defect. The authors report what is, to the best of their knowledge, the first case of SP treated by means of endovascular embolization with Onyx.

Blocked ventriculoperitoneal shunt causing raised intracranial pressure diagnosed by prominent sinus pericranii

We present a 3.5-year-old male infant who had been treated at 3 weeks of age with a ventriculoperitoneal (VP) shunt for intraventricular haemorrhage with resultant hydrocephalus. Since his initial treatment he had normal developmental milestones. On this occasion he presented with difficulty in walking, vomiting and irritability. His mother was concerned this was due to his shunt malfunctioning. It had not required revision since insertion as a neonate. He was initially managed at a peripheral hospital without neurosurgical services for 4 weeks as an outpatient. The major clinical concern was a gradually enlarging lesion confined to the top of his head consistent with a vascular malformation. Investigations were focused towards this, with an initial diagnosis made of a cerebral arteriovenous malformation (AVM) with involvement of scalp vessels. His initial head CT scan did not show enlarged ventricles and the shunt was clinically assessed as functioning satisfactorily. The patient's condition worsened and he was referred with a diagnosis of scalp AVM for neurosurgical attention. After neurosurgical review a clinical diagnosis of raised intracranial pressure (ICP) due to shunt malfunction was made. This was supported by a CT scan that showed an enlarging ventricular system. After revision of the shunt there was complete resolution of the pulsatile scalp swelling with clinical recovery of the child. To our knowledge this is the first reported incidence of a blocked VP shunt causing raised ICP presenting with a localised extracranial pulsatile venous dilation consistent with a "true" sinus pericranii.

[Sinus pericranii: a rare transcranial venous anomaly]

INTRODUCTION

Sinus pericranii is a rare midline cranial venous anomaly. It should be diagnosed radiologically. We report an asymptomatic case in a six-year-old female patient.

CASE REPORT

The patient consulted for a congenital asymptomatic bluish mediofrontal swelling. The complaint was strictly esthetic. A color US and MR angiography allowed diagnosing a sinus pericranii. Simple surveillance was decided because of a limited esthetic prejudice and the absence of any functional disorder.

DISCUSSION

Sinus pericranii is a communication between extra- and intracranial venous systems. Its diagnosis is suspected when a subcutaneous mass is located on the scalp close to the midline, the volume of which changes with the head's position. It is confirmed by MRI, which usually shows a drainage in the superior sagittal sinus. Surgical treatment is a complex procedure and rarely indicated. A simple follow-up is often proposed because of the usual absence of complications.

Endovascular transvenous embolization of sinus pericranii. Case report

Sinus pericranii (SP) is an abnormal communication between the intra- and extracranial venous drainage pathways. Treatment of this condition has mainly been recommended for reasons of cosmesis and prevention of hemorrhage. The authors report a novel endovascular transvenous route for definitive treatment of SP.

Spontaneous involution of two sinus pericranii - a unique case and review of the literature

Sinus pericranii is a rare vascular anomaly in which an abnormal communication exists between the extracranial venous system and the dural venous sinuses. The natural history is of increasing size and potential life-threatening complications, including thrombosis and haemorrhage. Thus surgical management is the mainstay of treatment. We present a unique case of spontaneous involution of two sinus pericranii in a 1-year-old patient, the second reported case of spontaneous involution in the literature, and the first in which regression occurred at such a young age. The clinical, diagnostic and management options are discussed.

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.