Changes in venous drainage after posterior cranial vault distraction and foramen magnum decompression in syndromic craniosynostosis

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  • 1 Departments of Pediatric Neurosurgery,
  • | 2 Pediatric Neuroradiology, and
  • | 3 Cranio-Facial Surgery Unit, Santobono-Pausilipon Children’s Hospital, AORN, Naples;
  • | 4 Department of Neurosurgery, "Federico II" University School of Medicine, Naples; and
  • | 5 Biostructure and Bioimaging Institute, National Research Council, Naples, Italy
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OBJECTIVE

The authors’ objective was to measure the effect of posterior cranial vault distraction (PCVD) plus foramen magnum decompression (FMD) on dural sinus volume and venous flow in patients with syndromic craniosynostosis.

METHODS

The volumes of the sagittal, straight, transverse, and sigmoid sinuses of 5 consecutive patients with syndromic craniosynostosis who underwent PCVD+FMD were calculated in cubic centimeters with T2-weighted volumetric MRI sequences before surgery, immediately after surgery, and after the end of the distraction process. Tridimensional reconstructions of phase-contrast magnetic resonance angiography (PC-MRA) images were obtained with multiplanar reconstruction (MPR).

RESULTS

The average total volume of all dural sinuses increased immediately after surgery (from 10.06 cm3 to 12.64 cm3) and continued to increase throughout the 30-day distraction period (from 12.64 cm3 to 14.71 cm3) (p = 0.04), except that the right sigmoid sinus remained stable after the initial increase. The most important increases were observed for the left transverse sinus (+113.2%), right transverse sinus (+104.3%), left sigmoid sinus (+91.3%), and sagittal sinus (+41.8%). Less important modifications were evident for the right sigmoid sinus (+33.7%) and straight sinus (+23.4%). Significant improvements in venous flow were noted on the tridimensional reconstructions of the PC-MRA images. Venous obstruction grading score improved in 4 patients (average [range] 2.4 [ 2–5]) (p = 0.023) and remained stable in 1 patient. All patients had chronic tonsillar herniation (CTH) (mean [range] 16.6 [8–26] mm), and 3 had syringomyelia. CTH showed improvement on the last follow-up MRI evaluation in 4 patients (mean [range] 10.5 [0–25] mm) and worsened from 15 mm to 19 mm in 1 patient. Syringomyelia improved in 2 patients and remained unchanged in 1.

CONCLUSIONS

This study has provided the first radiological evidence of the impact of craniofacial surgery on dural sinus anatomy and venous drainage. The venous anomalies described in patients with syndromic craniosynostosis are not static, and PCVD+FMD triggers a dynamic process that can lead to significant modifications of intracranial venous drainage. The traction exerted by the distracted bone flap onto the occipitoparietal dura mater adherent to the inner calvaria may account for the enlargement of the dural sinus throughout the distraction period. The impact of these modifications on venous pressure, intracranial pressure, CTH, and hydrocephalus remains to be determined.

ABBREVIATIONS

CoS = confluence of the dural sinuses; CTH = chronic tonsillar herniation; FMD = foramen magnum decompression; ICC = intraclass correlation coefficient; MIP = maximum intensity projection; MPR = multiplanar reconstruction; MRV = magnetic resonance venography; PC-MRA = phase-contrast magnetic resonance angiography; PCVD = posterior cranial vault distraction; PCVR = posterior cranial vault remodeling; ROI = region of interest; SigS = sigmoid sinus; SSS = superior sagittal sinus; StrS = straight sinus; TS = transverse sinus; VOGS = venous obstruction grading score; VR = volume-rendering.

Supplementary Materials

    • Supplementary Data Tables 1 and 2 (PDF 481 KB)

Illustration from Cinalli et al. (pp 330–341). Printed with permission from © CC Medical Arts.

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