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

Clinical article

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Object

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.

Methods

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.

Results

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).

Conclusions

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: kcwang@snu.ac.kr.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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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).

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