Intracranial venous sinus hypertension: cause or consequence of hydrocephalus in infants?

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✓ From a previous study of achondroplasia as well as from the observation of patients with hydrocephalus associated with craniostenosis, the authors have concluded that an increased superior sagittal sinus venous pressure (SSVP) could be the cause of the enlarged ventricles. However, other workers have demonstrated that an increased SSVP could be the consequence of increased intracranial pressure (ICP). Therefore, the authors undertook a study to determine if there was a physiological test that could distinguish between rare instances of increased SSVP caused by structural and irreversible narrowing of the sinus and those caused by increased ICP.

In 20 hydrocephalic infants and children, pressure was simultaneously measured in the lateral ventricle, the superior sagittal sinus, and the jugular vein. Stable baseline pressures were recorded, as well as the variations observed after the withdrawal of an amount of cerebrospinal fluid (CSF) sufficient to lower ICP to zero. Similar recordings were taken after reinjection of an equal quantity of CSF. In all of the patients, SSVP was increased, but not as much as the ICP. In the cases of hydrocephalus without any associated cranial malformation, and therefore without any likely anatomical interruption of the sinus, CSF withdrawal induced a simultaneous decrease of ICP and SSVP. However, whereas ICP could be lowered to zero, SSVP never fell below the jugular venous pressure, which remained stable (around 5 mm Hg) throughout the recording session. Results were different when sinography demonstrated an anatomical interruption of the sinus, as in cases of hydrocephalus associated with achondroplasia or craniostenosis. In these cases, although ICP was normally lowered by CSF withdrawal, SSVP remained nearly unchanged, usually greater than the jugular venous pressure.

The present study demonstrated that SSVP recording during ICP variations induced by CSF withdrawal permits differentiation between a reversible collapse of the sigmoid sinus due to increased ICP and a fixed obstructive lesion of the sinuses. Based upon this test and the results of sinography, the authors inserted a venous bypass between the lateral sinus and a jugular vein in three patients.

Article Information

Address reprint requests to: Jean-François Hirsch, M.D., Department of Neurosurgery, Hôpital Necker, 149 Rue de Sevres, 76016 Paris, France.

© AANS, except where prohibited by US copyright law.

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Figures

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    Variations of cerebrospinal fluid pressure (CSFP) and sagittal sinus venous pressure (SSVP) during removal (−60 cc) and reinjection (+60 cc) of CSF in an infant with hydrocephalus and myelomeningocele. P = pressure. Left: Slow-speed recordings. Right: Enlargement of recording at points A, B, and C at left, at a faster speed.

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    Simultaneous recordings of cerebrospinal fluid pressure (CSFP), sagittal sinus venous pressure (SSVP), and jugular venous pressure (JVP) during removal (−30 cc) and reinjection (+30 cc) of CSF in an infant with Apert's syndrome. Left: Slow-speed recordings. Right: Enlargement of recording at points A, B, and C at left, at a faster speed. P = pressure; Cal = calibration, and indicates the point where automatic calibration of the recorder occurred.

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    Simultaneous recordings of cerebrospinal fluid pressure (CSFP), sagittal sinus venous pressure (SSVP), and jugular venous pressure (JVP) during removal (−30 cc) and reinjection (+30 cc) of CSF in an infant with achondroplasia and a fixed partial obstruction of the lateral sinuses. P = pressure. Left: Slow-speed recording. Right: Enlargement of recording at points A and B at left, at a faster speed.

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    Simultaneous preoperative recordings of cerebrospinal fluid pressure (CSFP), sagittal sinus venous pressure (SSVP), and jugular venous pressure (JVP) during removal (−60 cc) and reinjection (+60 cc) of CSF in an infant with Crouzon's disease and a fixed partial obstruction of the lateral sinuses. Left: Slow-speed recording. Right: Enlargement of recording at points A, B, and C at left, at a faster speed. P = pressure; Cal = calibration, and indicates the point where automatic calibration of the recorder occurred.

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    Same patient as in Fig. 4. Sagittal sinography, front (left) and lateral (right) views, in an infant with communicating hydrocephalus associated with craniostenosis. There is stenosis of the right lateral sinus and complete obstruction of the left (S). Collateral venous circulation (C) developed on both sides. A large occipital emissary vein (V) is seen.

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    Differences of cerebrospinal fluid pressure minus sagittal sinus venous pressure (CSFP — SSVP) before and after ventricular puncture, and after reinjection of CSF. The values of the 16 cases with reversible collapse are included in the hatched area, because their difference was small. The values of the four cases with irreversible obstruction are all outside this area because the difference between CSFP and SSVP increased after CSF tapping.

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    Same patient as in Figs. 4 and 5. Sagittal sinography, front (left) and lateral (right) views, 6 months postoperatively showing patency of the bypass (G), disappearance of the collateral channels, and persistence of a narrower occipital emissary vein (V).

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    Intracranial pressure (ICP) recordings in the same patient as in Figs. 4, 5, and 7. Upper: Before surgery. Lower: Six months after insertion of the venous graft.

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    Same patient as in Figs. 4, 5, 7, and 8. Computerized tomography scans taken at the same level, 18 mm above the foramen of Monro, preoperatively (left), at 6 months (center), and at 1 year (right).

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    Same patient as in Figs. 4, 5, 7, 8, and 9. Simultaneous recordings of cerebrospinal fluid pressure (CSFP), sagittal sinus venous pressure (SSVP), and jugular venous pressure (JVP) 6 months postoperatively, during removal (−25 cc) and reinjection (+25 cc) of CSF. Left: Slow-speed recordings. Right: Recordings at points A, B, and C at left, at a faster speed. P = pressure.

  • View in gallery

    Sinography in a patient with craniosynostosis and hydrocephalus. A: Before surgery, there is stenosis of the left lateral sinus (arrows S) and a huge venous collateral circulation of the scalp. B: One month after the operation, a narrow but patent venous graft (arrows G) is seen. C: Six months postoperatively, the venous graft is patent and dilated (arrows G).

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