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Dallas J, Lane JR, Hopkins BS, Chang M, Borchert M, Gonzalez NR, Chiarelli PA, Chu JK. Supracerebellar infratentorial resection of a torcular lesion causing fulminant intracranial hypertension: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 6:CASE23363. [PMID: 38109719 PMCID: PMC10732318 DOI: 10.3171/case23363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/13/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Venous sinus stenosis has been implicated in intracranial hypertension and can lead to papilledema and blindness. The authors report the unique case of a cerebellar transtentorial lesion resulting in venous sinus stenosis in the torcula and bilateral transverse sinuses that underwent resection. OBSERVATIONS A 5-year-old male presented with subacute vision loss and bilateral papilledema. Imaging demonstrated a lesion causing mass effect on the torcula/transverse sinuses and findings of increased intracranial pressure (ICP). A lumbar puncture confirmed elevated pressure, and the patient underwent bilateral optic nerve sheath fenestration. Cerebral angiography and venous manometry showed elevated venous sinus pressures suggestive of venous hypertension. The patient underwent a craniotomy and supracerebellar/infratentorial approach. A stalk emanating from the cerebellum through the tentorium was identified and divided. Postoperative magnetic resonance imaging showed decreased lesion size and improved sinus patency. Papilledema resolved and other findings of elevated ICP improved. Pathology was consistent with atrophic cerebellar cortex. Serial imaging over 6 months demonstrated progressive decrease in the lesion with concurrent improvements in sinus patency. LESSONS Although uncommon, symptoms of intracranial hypertension in patients with venous sinus lesions should prompt additional workup ranging from dedicated venous imaging to assessments of ICP and venous manometry.
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Affiliation(s)
- Jonathan Dallas
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jessica R Lane
- Department of Neurological Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Benjamin S Hopkins
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Melinda Chang
- Division of Ophthalmology, Children’s Hospital Los Angeles, Los Angeles, California
| | - Mark Borchert
- Division of Ophthalmology, Children’s Hospital Los Angeles, Los Angeles, California
| | - Nestor R Gonzalez
- Department of Neurological Surgery, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Peter A Chiarelli
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Surgery, Division of Neurological Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jason K Chu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Surgery, Division of Neurological Surgery, Children’s Hospital Los Angeles, Los Angeles, California
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Mehta RI, Mehta RI. Giant Arachnoid Granulations: A Systematic Literature Review. Int J Mol Sci 2023; 24:13014. [PMID: 37629195 PMCID: PMC10455743 DOI: 10.3390/ijms241613014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
Giant arachnoid granulations (GAGs) are minimally investigated. Here, we systematically review the available data in published reports to better understand their etiologies, nomenclature, and clinical significance. In the literature, 195 GAGs have been documented in 169 persons of varied ages (range, 0.33 to 91 years; mean, 43 ± 20 years; 54% female). Prior reports depict intrasinus (i.e., dural venous sinus, DVS) (84%), extrasinus (i.e., diploic or calvarial) (15%), and mixed (1%) GAG types that exhibit pedunculated, sessile, or vermiform morphologies. GAG size ranged from 0.4 to 6 cm in maximum dimension (mean, 1.9 ± 1.1 cm) and encompassed symptomatic or non-symptomatic enlarged arachnoid granulations (≥1 cm) as well as symptomatic subcentimeter arachnoid granulations. A significant difference was identified in mean GAG size between sex (females, 1.78 cm; males, 3.39 cm; p < 0.05). The signs and symptoms associated with GAGs varied and include headache (19%), sensory change(s) (11%), and intracranial hypertension (2%), among diverse and potentially serious sequelae. Notably, brain herniation was present within 38 GAGs (22%). Among treated individuals, subsets were managed medically (19 persons, 11%), surgically (15 persons, 9%), and/or by endovascular DVS stenting (7 persons, 4%). Histologic workup of 53 (27%) GAG cases depicted internal inflammation (3%), cystic change consistent with fluid accumulation (2%), venous thrombosis (1%), hemorrhage (1%), meningothelial hyperplasia (1%), lymphatic vascular proliferation (1%), and lymphatic vessel obliteration (1%). This review emphasizes heterogeneity in GAG subtypes, morphology, composite, location, symptomatology, and imaging presentations. Additional systematic investigations are needed to better elucidate the pathobiology, clinical effects, and optimal diagnostic and management strategies for enlarged and symptomatic arachnoid granulation subtypes, as different strategies and size thresholds are likely applicable for medical, interventional, and/or surgical treatment of these structures in distinct brain locations.
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Affiliation(s)
- Rupal I. Mehta
- Department of Pathology, Rush University Medical Center, Chicago, IL 60612, USA
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL 60612, USA
| | - Rashi I. Mehta
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA;
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA
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Hett K, McKnight CD, Eisma JJ, Elenberger J, Lindsey JS, Considine CM, Claassen DO, Donahue MJ. Parasagittal dural space and cerebrospinal fluid (CSF) flow across the lifespan in healthy adults. Fluids Barriers CNS 2022; 19:24. [PMID: 35313906 PMCID: PMC8935696 DOI: 10.1186/s12987-022-00320-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/04/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Recent studies have suggested alternative cerebrospinal fluid (CSF) clearance pathways for brain parenchymal metabolic waste products. One fundamental but relatively under-explored component of these pathways is the anatomic region surrounding the superior sagittal sinus, which has been shown to have relevance to trans-arachnoid molecular passage. This so-called parasagittal dural (PSD) space may play a physiologically significant role as a distal intracranial component of the human glymphatic circuit, yet fundamental gaps persist in our knowledge of how this space changes with normal aging and intracranial bulk fluid transport. METHODS We re-parameterized MRI methods to assess CSF circulation in humans using high resolution imaging of the PSD space and phase contrast measures of flow through the cerebral aqueduct to test the hypotheses that volumetric measures of PSD space (1) are directly related to CSF flow (mL/s) through the cerebral aqueduct, and (2) increase with age. Multi-modal 3-Tesla MRI was applied in healthy participants (n = 62; age range = 20-83 years) across the adult lifespan whereby phase contrast assessments of CSF flow through the aqueduct were paired with non-contrasted T1-weighted and T2-weighted MRI for PSD volumetry. PSD volume was extracted using a recently validated neural networks algorithm. Non-parametric regression models were applied to evaluate how PSD volume related to tissue volume and age cross-sectionally, and separately how PSD volume related to CSF flow (significance criteria: two-sided p < 0.05). RESULTS A significant PSD volume enlargement in relation to normal aging (p < 0.001, Spearman's-[Formula: see text] = 0.6), CSF volume (p < 0.001, Spearman's-[Formula: see text] = 0.6) and maximum CSF flow through the aqueduct of Sylvius (anterograde and retrograde, p < 0.001) were observed. The elevation in PSD volume was not significantly related to gray or white matter tissue volumes. Findings are consistent with PSD volume increasing with age and bulk CSF flow. CONCLUSIONS Findings highlight the feasibility of quantifying PSD volume non-invasively in vivo in humans using machine learning and non-contrast MRI. Additionally, findings demonstrate that PSD volume increases with age and relates to CSF volume and bi-directional flow. Values reported should provide useful normative ranges for how PSD volume adjusts with age, which will serve as a necessary pre-requisite for comparisons to persons with neurodegenerative disorders.
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Affiliation(s)
- Kilian Hett
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colin D McKnight
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jarrod J Eisma
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason Elenberger
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer S Lindsey
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ciaran M Considine
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel O Claassen
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA. .,Division of Behavioral and Cognitive Neurology, Village at Vanderbilt, 1500 21st Avenue South, Nashville, TN, 37212, USA.
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Tsutsumi S, Ono H, Ishii H. Arachnoid granulations bulging into the transverse sinus, sigmoid sinus, straight sinus, and confluens sinuum: a magnetic resonance imaging study. Surg Radiol Anat 2021; 43:1311-1318. [PMID: 33635406 DOI: 10.1007/s00276-021-02719-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/18/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Few studies have explored arachnoid granulations (AGs) bulging into the cranial dural sinuses using contrast-enhanced magnetic resonance imaging (MRI). This study aimed to explore such AGs in the transverse (TS), sigmoid (SigS), and straight (StS) sinuses, and confluens sinuum (ConfS) using thin-sliced, contrast MRI. METHODS A total of 102 patients with intact dural sinuses underwent thin-sliced, contrast MRI in the axial, coronal, and sagittal planes. RESULTS In 88.2%, more than one AG was identified in the TS and SigS, StS, and ConfS. In the TS, AGs were identified in 40.2% on the right side and 37.3% on the left and were frequently located in the middle and lateral thirds. In the SigS, AGs were identified on the right in 17.6% and on the left in 18.6% in the distal region. In the StS, AGs were identified in 35.3% of cases, most frequently located in the proximal third, followed by the distal third. In the ConfS, AGs were identified in 20.6% of cases. Furthermore, in 23.5%, a collection of multiple AGs of varying sizes was found in the TS. A statistical difference was not shown between the mean age of 90 patients with AGs and that of 12 patients without identifiable AGs. CONCLUSIONS Bulging AGs may more frequently found in the TS. Thin-sliced, contrast MRI is useful for delineating AGs.
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Affiliation(s)
- Satoshi Tsutsumi
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Hideo Ono
- Division of Radiological Technology, Medical Satellite Yaesu Clinic, Tokyo, Japan
| | - Hisato Ishii
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
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Ogul H, Guven F, Izgi E, Kantarci M. Evaluation of giant arachnoid granulations with high-resolution 3D-volumetric MR sequences at 3T. Eur J Radiol 2019; 121:108722. [DOI: 10.1016/j.ejrad.2019.108722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/17/2019] [Accepted: 10/20/2019] [Indexed: 11/15/2022]
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Mamaliga T, Hadi M. An unusual vermiform giant arachnoid granulation. Radiol Case Rep 2019; 14:1525-1528. [PMID: 31709020 PMCID: PMC6831846 DOI: 10.1016/j.radcr.2019.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 09/22/2019] [Accepted: 09/22/2019] [Indexed: 12/22/2022] Open
Abstract
Arachnoid granulations are outpouchings of arachnoid membrane which extend into the dural sinuses or calvarium, surrounded by a capsule of dense connective tissue. Within dural sinuses, these appear as well-defined, nodular, rounded, or ovoid structures of focal localization. However, it is important to be aware of their variability in presentation in order to correctly identify them and distinguish them from other dural sinus pathology, especially a misdiagnosis of venous sinus thrombosis with risks of unnecessary anticoagulation, intravascular thrombolysis/thrombectomy, or invasive intracranial pressure monitoring. Here we demonstrate a case of a previously unreported giant intrasinus arachnoid granulation of an unusual vermiform morphology, unduly elongated up to 6 cm in length, involving a significant segment of the superior sagittal sinus. The proof of this diagnosis was the radiologic appearance on multiple modalities and an unchanged appearance over the long-term.
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Affiliation(s)
- Tatiana Mamaliga
- Medical student, University of Louisville School of Medicine, 530 S Jackson Street, Louisville, KY, 40205, USA
| | - Mohiuddin Hadi
- Department of Radiology, University of Louisville School of Medicine, 530 S Jackson Street, Louisville, KY, 40205, USA
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Giant arachnoid granulation mimicking dural sinus thrombosis. North Clin Istanb 2017; 4:185-187. [PMID: 28971178 PMCID: PMC5613268 DOI: 10.14744/nci.2017.93063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 02/27/2017] [Indexed: 11/20/2022] Open
Abstract
Arachnoid granulations (AG) are composed of dense, collagenous connective tissue that includes clusters of arachnoid cells. They tend to invaginate into the dural sinuses, through which cerebrospinal fluid enters the venous system. AG are most commonly seen at the junction between the middle and lateral thirds of the transverse sinuses near the entry sites of the superficial veins. Presently described is the case of a 21-year-old female who presented at the clinic with recurrent headaches. Magnetic resonance (MR) imaging revealed a 3.5-cm lesion, which extended from confluens sinuum through the superior sagittal sinus. The lesion had created a scallop-shaped area of erosion in the neighboring occipital bone. To exclude sinus thrombosis, MR venography was performed, which displayed a maintained venous flow around the lesion. Headaches were treated symptomatically with medical therapy. Giant AG can be misdiagnosed as dural sinus thrombosis. MR imaging combined with MR venography is the most useful diagnostic tool to differentiate giant AG from dural sinus thrombosis.
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Brain Herniation into Giant Arachnoid Granulation: An Unusual Case. Case Rep Radiol 2017; 2017:8532074. [PMID: 28392955 PMCID: PMC5368369 DOI: 10.1155/2017/8532074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/21/2017] [Accepted: 03/05/2017] [Indexed: 11/17/2022] Open
Abstract
Arachnoid granulations are structures filled with cerebrospinal fluid (CSF) that extend into the venous sinuses through openings in the dura mater and allow the drainage of CSF from subarachnoid space into venous system. Usually they are asymptomatic but can be symptomatic when large enough to cause sinus occlusion. We report a rare case of a brain herniation into a giant arachnoid granulation in an asymptomatic elderly male patient, which was discovered incidentally.
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Umeh R, Oskouian RJ, Loukas M, Tubbs RS. Giant Arachnoid Granulation Associated with Anomalous Draining Vein: A Case Report. Cureus 2017; 9:e1065. [PMID: 28409066 PMCID: PMC5375954 DOI: 10.7759/cureus.1065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Giant arachnoid granulations (AG) can mimic intracranial lesions. Knowledge of these structures can help avoid misdiagnosis when interpreting imaging. Here, we report a child who presented with a mass within the superior sagittal sinus and an anomalous draining vein. Herein, the diagnosis of a giant AG was made. Clinicians who view or interpret imaging of the head should be aware of these anatomical variants and though when very large, apparently, do not necessarily result in pathology. Based on our case report, giant AG might also demonstrate anomalous draining veins.
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Affiliation(s)
- Randle Umeh
- Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies
| | | | - Marios Loukas
- Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies
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De Keyzer B, Bamps S, Van Calenbergh F, Demaerel P, Wilms G. Giant arachnoid granulations mimicking pathology. A report of three cases. Neuroradiol J 2014; 27:316-21. [PMID: 24976198 DOI: 10.15274/nrj-2014-10047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/16/2014] [Indexed: 11/12/2022] Open
Abstract
We describe three cases of incidentally found lesions in the dural venous sinuses on magnetic resonance imaging, that other had erroneously considered pathological entities. We made the diagnosis of giant arachnoid granulations. The differential diagnosis with thrombosis or intrasinusal tumoral lesions was easily made on the basis of three typical radiological features of the granulations: the hyperintensity of the lesions on FLAIR, a blood vessel within the lesion and bone erosion.
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Affiliation(s)
- Bart De Keyzer
- Department of Radiology, UZ Leuven, Campus Gasthuisberg; Leuven, Belgium -
| | - Sven Bamps
- Department of Radiology, UZ Leuven, Campus Gasthuisberg; Leuven, Belgium
| | | | - Philippe Demaerel
- Department of Radiology, UZ Leuven, Campus Gasthuisberg; Leuven, Belgium
| | - Guido Wilms
- Department of Radiology, UZ Leuven, Campus Gasthuisberg; Leuven, Belgium
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Abstract
Arachnoid granulation is often found incidentally in the dural sinuses and skull. It may also enlarge the dural sinus or inner table of the skull. We report a 46-year-old woman who presented with occipital headaches and arachnoid granulations in both transverse sinuses and torcular herophili. Neurological examination was normal. Fundoscopic examination, visual fields and acuity were normal. The headache resolved with medical treatment. No intervention for these lesions was planned. The patient was followed up with magnetic resonance imaging studies.
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Lu CX, Du Y, Xu XX, Li Y, Yang HF, Deng SQ, Xiao DM, Li B, Tian YH. Multiple occipital defects caused by arachnoid granulations: Emphasis on T2 mapping. World J Radiol 2012; 4:341-4. [PMID: 22900137 PMCID: PMC3419866 DOI: 10.4329/wjr.v4.i7.341] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 06/23/2012] [Accepted: 06/30/2012] [Indexed: 02/06/2023] Open
Abstract
A 56-year-old man presented with a 6-mo history of headache. Although neurological and laboratory examinations were normal, computed tomography (CT) scan was performed which revealed multiple occipital osteolytic lesions, which were suspected to be multiple myeloma. Subsequently nuclear magnetic resonance imaging (MRI) showed that these lesions presented with a cerebrospinal fluid (CSF)-like signal intensity, no diffusional restriction and intrinsic mass-like enhancement on conventional sequences were seen. T2 relaxation time was similar to that of CSF in the ventricles and adjacent subarachnoid space on T2-mapping. Single photon emission CT with 99mTc-Methyl diphosphonate was performed which revealed no increased radiotracing accumulation. Finally, these lesions were diagnosed as mutiple arachnoid granulations (AGs). The headache was treated symptomatically with medical therapy. On follow up examination after 6 mo no evidence of tumor was detected. This report aimed to illustrate the appearance and differentiation of occipital defects caused by multiple AGs on CT and MRI, with emphasis on the findings from T2 mapping.
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