Sinus pericranii

Sinus pericranii associated with syntelencephaly: a case report

Background

Sinus pericranii is a rare cranial venous malformation resulting in a subcutaneous mass due to abnormal communication between intracranial and subperiosteal/interperiosteal veins. To date, to the best of our knowledge, there are no reports of sinus pericranii associated with syntelencephaly, a subtype of lobar holoprosencephaly. We herein report a case of sinus pericranii associated with syntelencephaly. This report can provide us better understanding of the etiology of sinus pericranii, the potential risks, and the treatment options for these patients.

Case presentation

A 2-year-4-month old female patient who received the diagnosis of syntelencephaly as a neonate presented with a subcutaneous mass in the parietal region. The mass was soft, nonpulsatile, 3 × 2 cm in size, and showed enlargement in the lying position. Color cranial Doppler ultrasound, head magnetic resonance imaging (MRI), and cerebral angiography revealed a dilated vessel passing through the parietal bone and forming a communication between the superior sagittal sinus and scalp veins. Based on these findings, sinus pericranii was diagnosed. The head MRI also showed coronal craniosynostosis, a tight posterior fossa. At age 2 years and 7 months, the patient underwent a transection of the sinus pericranii and the mass resolved without any complications or recurrences for more than 2.5 years to date.

Conclusion

Sinus pericranii is a rare cranial and venous malformation sometimes accompanied by brain malformations or craniosynostosis that may become more apparent as the brain and skull develop. Since this condition can be complicated by intracranial hemorrhage and sinus thrombosis, early detection is necessary to determine the treatment options. Physicians should be alert to the possibility of this condition if they observe a soft cranial mass that appears to decrease in size in the sitting position and bulge in the lying position.

Endovascular Embolization of Sinus Pericranii using a Plastic Cup during Glue Injection: A Case Report

BACKGROUND

Sinus pericranii (SP) is a rare abnormal connection between the intra- and extracranial venous drainage pathways through the osseous channels. Herein we present the case of a patient with growing SP, which was successfully treated using endovascular transvenous embolization through external compression with a plastic cup for preventing glue migration into the subcutaneous veins.

CASE DESCRIPTION

A 9-month-old boy presented with a gradually growing mass on the midline cranial vertex after his birth for which transvenous embolization was performed. A microcatheter was successfully navigated into the SP from the superior sagittal sinus. Because the subcutaneous drainages were confirmed to be multidirectional, we compressed the drainages through the skin using a plastic cup during the glue injection step for preventing glue migration. Subsequently, the SP was completely obliterated. The postoperative course was uneventful.

CONCLUSIONS

Manual compression using a plastic cup was useful not only for embolization but also for reducing the physician's exposure to radiation as compared with that in the finger compression method. When a direct puncture is required, a plastic cylinder can also be used.

Characteristics of Recurrent Congenital Sinus Pericranii: Case Report and Review of the Literature

INTRODUCTION

Sinus pericranii (SP) involves transosseous vessels that connect the intra- and extracranial venous systems. Accessory-type SP can be cured by surgical or endovascular treatment. Reports of recurrence are, however, rare.

CASE

A boy presented with a soft-tissue mass on the left parietal region of the head. Computed tomography and magnetic resonance imaging revealed the congenital SP with several small transosseous vessels surrounded by an area of thin bone. At the initial surgery, the vascular mass was completely excised by coagulating and cutting the -transosseous vessels. The skull defect was filled with bone wax. Two years later, SP recurred at the same site. At the second surgery, the skull defect and surrounding area were sealed with acrylic resin. The boy has been followed up for 6 years without recurrence.

DISCUSSION

Potential risk factors for recurrence proposed in the existing literature include an unusually large number of emissary veins, rich circulation between intra- and extracranial venous systems, large bone defects, raised intracranial pressure, and association of other developmental venous anomalies. Our case demonstrates that thin skull bone around the original lesion can be another risk factor for recurrence.

CONCLUSION

Removing all abnormal vessels and sealing the skull defect as well as the surrounding thin bone area are important to prevent recurrence of congenital SP.

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.

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.

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.

Endovascular transvenous embolization combined with direct punction of the sinus pericranii. A case report

SUMMARY

Sinus Pericranii is a rare venous anomaly in which the communication between the intra- and extracranial venous system is constituted by a network of thin-walled veins that form a varix on the external table of the skull. This varix is continuous with the pericranial veins of the scalp. We describe a 31-year-old woman with frontal sinus pericranii treated using an original endovascular technique by transvenous approach combined with direct punction.

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.

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 Associated With Craniosynostosis

Sinus pericranii is a vascular tumor of the head having communication with the dural venous system. The tumor enlarges with increased intracranial pressure when the patient is in the lateral recumbent position. Since Stromeyer used the term "sinus pericranii" in his report in 1850, approximately 170 cases have been reported. However, relatively few cases of sinus pericranii have been reported in association with craniosynostosis or by plastic surgeons. In this study, we report seven cases of sinus pericranii associated with craniosynostosis. There were two patients with Apert syndrome, two with Crouzon syndrome, two with oxycephaly, and one with trigonocephaly. The sites of occurrence were the parietal region in six patients and the frontal region in one patient. In either type of case, the tumor was clinically a soft subcutaneous mass of the head. The clinical characteristics of the tumor were its disappearance when the patient was in a sitting position and its appearance when the patient was in a recumbent position or crying. The patients were preoperatively diagnosed with sinus pericranii from imaging test findings, such as from magnetic resonance imaging and aforementioned clinical findings. In all cases, treatment for sinus pericranii was performed during the surgery for craniosynostosis. For patients with lesions in either site, we did not perform craniotomy, and we used a minimally invasive method of tumor excision and resection of the sites of communication using electrocoagulation. Perioperatively, heavy hemorrhage was not observed, and, postoperatively, no recurrence has been observed in any patient. In this study, we examine the etiology, diagnosis, and treatment of sinus pericranii, in particular for patients with craniosynostosis.

Diagnostic and therapeutic considerations for sinus pericranii

Sinus pericranii is one of the differential diagnoses which should be considered when a physician encounters a patient with a subcutaneous soft scalp mass. Sinus pericranii is a rare vascular anomaly of the venous drainage between the intracranial and extracranial systems via the diploe of the skull. We describe here a 16-year-old female with sinus pericranii following minor head trauma four years prior. CT and MRI scans revealed heterogeneous enhancement of the lesion and three-dimensional CT showed a crater-like depression and multiple honeycomb diploic holes in the skull. Angiography was normal, whereas percutaneous sinusography revealed a connection between the lesion and the superior sagittal sinus. The patient underwent surgery to disconnect her diploic veins from the lesion under general anaesthesia, and her postoperative course was uneventful after six months follow-up. To avoid profuse bleeding and air emboli and to ameliorate cosmetic problems, a specific diagnosis should be made to plan appropriate treatment.

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.

Resident research training conducted in a community hospital general surgery residency program

PURPOSE

Research is educationally important for surgical residents. However, little information exists regarding effective methods for teaching residents scientific methodology in a community hospital. This effort describes an effective program conducted in a community hospital for enhancing scientific opportunities of surgical residents.

METHODS

A strong infrastructure that supports research is necessary. Dedicated nonsalaried teaching faculty serve as mentors and co-investigators. Opportunities to engage in basic research are made available in off-campus basic science laboratories.

RESULTS

Research productivity has been prolific, as demonstrated by numerous publications. Residents interested in sub-speciality training have been able to conduct research that has made them competitive for fellowships and a wider range of practice choices.

CONCLUSION

Rigorous research can be effectively taught in a community hospital, provided adequate educational and funding support is provided and faculty actively mentor residents. Having research capabilities provides added incentive for better-qualified medical students to apply to a surgical residency position in a community hospital. Research productivity also enhances the ability to better recruit new faculty.