Sinus pericranii in children: report of 16 patients and preoperative evaluation of surgical risk

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Sinus pericranii (SP) is a rare venous varix in an extracranial location connected to the intracranial venous system. The aim of this retrospective study was to report on 16 pediatric cases of SP with consideration of the preoperative evaluation of surgical risk.


The study population consisted of 10 patients who had undergone surgery for SP and 6 patients with concomitant craniosynostosis and SP. The mean age of the patients at presentation was 3.7 years. To identify characteristics of SP with high operative risk, 8 cases in this report and 11 previously reported cases of SP with sufficient information were categorized on the basis of the number and size of SP, the number and size of transcranial channels, the venous drainage type, and the amount of blood loss. Hemorrhage amounts were classified into 3 grades based on the description of intraoperative blood loss.


Sinus pericranii not associated with craniosynostosis were resected without any postoperative morbidity. Sinus pericranii associated with craniosynostosis were preserved. After craniofacial reconstruction, 2 cases of SP with craniosynostosis regressed, completely in one patient and partially in another. These 2 patients with SP were confirmed to have compromised intracranial sinus before craniofacial reconstruction. Among a total of 19 patients, multiplicity or size (> 6 cm) of SP (p = 0.036) and multiplicity (> 3) or size (> 3 mm) of transcranial channels (p = 0.004) was associated with more severe hemorrhage grade. Sinus pericranii with peripheral venous drainage (drainer type) was not associated with hemorrhage grade after classification into 3 grades (p = 0.192). However, all 3 cases of SP with massive Grade 3 hemorrhage were the drainer type. Hemorrhage grade was correlated with the number of risk factors for SP (r = 0.793, p < 0.001).


Three risk factors of SP and the presence of compromised intracranial sinus are markers for highrisk SP. “Squeezed-out sinus syndrome” is suggested as a concept for SP associated with compromised intracranial sinus, mainly caused by craniosynostosis. Sinus pericranii in squeezed-out sinus syndrome probably serves as a crucial alternative to venous drainage of the brain with intracranial venous compromise. Conservative treatment for such patients with SP is recommended.

Abbreviations used in this paper: DS = digital subtraction; ICP = intracranial pressure; SP = sinus pericranii; TOF = time-of-flight.

Article Information

Address correspondence to: Kyu-Chang Wang, M.D., Ph.D., Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea. email:

© AANS, except where prohibited by US copyright law.



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    Case 1. Upper Row: Contrast-enhanced MR venography demonstrating 3 SP in the right parietal, right occipital, and right retromastoid regions (white arrows). Lower Row: Digital subtraction angiography at the venous phase of vertebral angiography showing 2 of 3 SP. A transcranial venous channel (black arrow) connecting the right occipital SP (white arrow) and the sagittal sinus almost near the confluence of sinuses (T) not found in MR venography could be identified. Another transcranial channel (black triangle) connects the right retromastoid SP (white triangle) and the occipital sinus (O). A right parietal SP was noted only by angiography of the internal carotid artery. Digital subtraction angiography was more accurate in identifying the exact transcranial channel, but entire sacs of SP were more conspicuously identified using MR venography.

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    Case 2. Magnetic resonance venography illustrating the SP of both sides (white arrows) connected to each sigmoid sinus through clearly visualized transcranial channels (black arrows). There was no intracranial venous compromise in this patient.

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    Case 11. Upper Row: Digital subtraction angiography showing 2 SP. The majority of venous drainage flows through the sagittal SP (white arrows) and the left sigmoid SP (black arrows). Intracranial venous drainage routes are almost completely compromised. Lower Row: Three-dimensional CT images showing transcranial channels of SP. The sagittal SP has a 2-mm transcranial channel with a depressed area of skull around it (white arrow). The left sigmoid SP flows out through 3 holes posteroinferior to the mastoid process (black arrows).

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    Three-dimensional bar graph showing that hemorrhage grade is higher when there are more risk factors involved (r = 0.793, p < 0.001).



Alperin NLee SHMazda MHushek SGRoitberg BGoddwin J: Evidence for the importance of extracranial venous flow in patients with idiopathic intracranial hypertension (IIH). Acta Neurochir Suppl 95:1291322005


Azusawa HOzaki YShindoh NSumi Y: Usefulness of MR venography in diagnosing sinus pericranii: case report. Radiat Med 18:2492522000


Bollar AAllut AGPrieto AGelabert MBecerra E: Sinus pericranii: radiological and etiopathological considerations. Case report. J Neurosurg 77:4694721992


Brisman JLNiimi YBerenstein A: Sinus pericranii involving the torcular sinus in a patient with Hunter's syndrome and trigonocephaly: case report and review of the literature. Neurosurgery 55:4332004


Bruhl KStoeter PWietek BSchwarz MHumpl TSchumacher R: Cerebral spinal fluid flow, venous drainage and spinal cord compression in achondroplastic children: impact of magnetic resonance findings for decompressive surgery at the cranio-cervical junction. Eur J Pediatr 160:10202001


Buxton NVloeberghs M: Sinus pericranii. Report of a case and review of the literature. Pediatr Neurosurg 30:96991999


Chen ZFeng HZhu GWu NLin J: Anomalous intracranial venous drainage associated with basal ganglia calcification. AJNR Am J Neuroradiol 28:22242007


Cinalli GSpennato PSainte-Rose CArnaud EAliberti FBrunelle F: Chiari malformation in craniosynostosis. Childs Nerv Syst 21:8899012005


Févre MModec L: Sinus pericranii et tumeurs vasculaires extracraniennes communiquant avec la circulation intracranienne. J Chir (Paris) 47:5615881936


Gandolfo CKrings TAlvarez HOzanne ASchaaf MBaccin CE: Sinus pericranii: diagnostic and therapeutic considerations in 15 patients. Neuroradiology 49:5055142007


Jung SLee JKKim SHKim JHKang SSLee JH: Parietal sinus pericranii: case report and technical note. Surg Neurol 54:2702732000


Kaido TKim YKUeda K: Diagnostic and therapeutic considerations for sinus pericranii. J Clin Neurosci 13:7887922006


Kurosu AWachi ABando KKumami KNaito SSato K: Craniosynostosis in the presence of a sinus pericranii: case report. Neurosurgery 34:109010931994


Linderkamp OVersmold HTRiegel KPBetke K: Estimation and prediction of blood volume in infants and children. Eur J Pediatr 125:2272341977


Marras CMcEvoy AWGrieve JPJager HRKitchen NDVillani RM: Giant temporo-occipital sinus pericranii. A case report. J Neurosurg Sci 45:1031092001


Moritani TAihara TOguma EMakiyama YNishimoto HSmoker WR: Magnetic resonance venography of achondroplasia: correlation of venous narrowing at the jugular foramen with hydrocephalus. Clin Imaging 30:1952002006


Nakayama TMatsukado Y: Sinus pericranii with aneurysmal malformation of the internal cerebral vein. Surg Neurol 3:1331371975


Nemoto EM: Dynamics of cerebral venous and intracranial pressures. Acta Neurochir Suppl 96:4354372006


Osborn AGBlaser SSalzman K: Diagnostic Imaging: Brain Salt Lake CityAmirsys2004


Poole MD: Surgical caution with Carpenter's syndrome. J Craniomaxillofac Surg 21:93951993


Robson CDMulliken JBRobertson RLProctor MRSteinberger DBarnes PD: Prominent basal emissary foramina in syndromic craniosynostosis: correlation with phenotypic and molecular diagnoses. AJNR Am J Neuroradiol 21:170717172000


Sakai KNamba KMeguro TMandai SGohda YSakurai M: Sinus pericranii associated with a cerebellar venous angioma—case report. Neurol Med Chir (Tokyo) 37:4644671997


Sandberg DINavarro RBlanch JRagheb J: Anomalous venous drainage preventing safe posterior fossa decompression in patients with Chiari malformation Type I and multisutural craniosynostosis. Report of two cases and review of the literature. J Neurosurg 106:6 Suppl4904942007


Sawamura YAbe HSugimoto STashiro KNakamura NGotoh S: [Histological classification and therapeutic problems of sinus pericranii.]. Neurol Med Chir (Tokyo) 27:7627681987. (Jpn)


Spektor SWeinberger GConstantini SGomori JMBeni-Adani L: Giant lateral sinus pericranii. Case report. J Neurosurg 88:1451471998


Taylor WJHayward RDLasjaunias PBritto JAThompson DNJones BM: Enigma of raised intracranial pressure in patients with complex craniosynostosis: the role of abnormal intracranial venous drainage. J Neurosurg 94:3773852001


Thompson DNHayward RDHarkness WJBingham RMJones BM: Lessons from a case of kleeblattschadel. Case report. J Neurosurg 82:107110741995


Tuite GFEvanson JChong WKThompson DNHarkness WFJones BM: The beaten copper cranium: a correlation between intracranial pressure, cranial radiographs, and computed tomographic scans in children with craniosynostosis. Neurosurgery 39:6916991996


Waga SHanda H: Scalp veins as collateral pathway with parasagittal meningiomas occluding the superior sagittal sinus. Neuroradiology 11:1992041976


Wakisaka SOkuda SSoejima TTsukamoto Y: Sinus pericranii. Surg Neurol 19:2912981983


Wen CSChang YLWang HSKuo MFTu YK: Sinus pericranii: from gross and neuroimaging findings to different pathophysiological changes. Childs Nerv Syst 21:4824882005




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