Sinus pericranii: diagnosis and management in 21 pediatric patients

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Sinus pericranii (SP) is a rare venous anomaly abnormally connecting the intracranial dural sinuses with the epicranial veins. In the present study the authors aimed to clarify this clinicoradiological entity, define the role of angiography in its preoperative assessment, and suggest a diagnostic-therapeutic flow chart for management purposes.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors retrospectively reviewed the clinical charts and neuroimages of 21 patients with SP. All patients underwent brain MRI, MR venography, and craniocerebral CT. Diagnostic digital subtraction angiography was performed in 19 of 21 patients, and the SPs were categorized as dominant (draining the majority of the intracranial venous outflow) or accessory (draining only a minority of the intracranial venous outflow).</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>SP was median or paramedian in 20 patients and lateral in 1 patient. There were 5 dominant and 14 accessory SPs. The dominant SPs were not treated. Among the patients with accessory SP, 4 were not treated, 2 underwent surgical ligature, and 8 were treated endovascularly (with either transvenous or percutaneous embolization). No complications were observed, and symptoms disappeared after treatment in all cases.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Accepted guidelines or recommendations concerning the management, diagnosis, and treatment of SP are still lacking. The authors define here a diagnostic-therapeutic flow chart, in which angiography plays a crucial role in the classification of SP and choice of the optimal treatment. Only accessory SP is amenable to treatment, whereas dominant SP must be preserved. The endovascular approach is becoming increasingly relevant and has proven to be safe and effective.</jats:p></jats:sec>

Determination of sinus pericranii resectability by external compression during angiography: technical note

“…23 Classification of sinus pericranii as dominant or accessory has arguably been the most important criterion for determining whether this anomaly may be safely obliterated. 23,45 In our opinion, the compression technique we describe for functionally, but reversibly, obliterating sinus pericranii provides additional assurance that intracranial venous outflow will not be compromised by resection or embolization. Discordant pre-and postcompression venous phase angiography favors conservative management.…”

“…Although rare traumatic associations have been reported, most suggest a congenital etiology for this malformation, given its association with developmental venous anomalies and other vascular lesions. 22,23,41,45 Sinus pericranii was first described by Hecker in 1845 and elaborated by Stromeyer in 1850. Of this curiosity Stromeyer wrote that it "…consists of a blood bag on the skull, which stands in connection with the veins of the diploe and through these with the sinuses of the brain…."…”

“…Reports of an association with hemorrhage, sinus thrombosis, intracranial hypertension, and infection have led some to aggressively treat asymptomatic sinus pericranii. 17,45 Decision making is complicated by difficulty in determining which sinus pericranii are safe for surgical intervention.…”

“…It is believed that dominant sinus pericranii must be preserved while accessory sinus pericranii are candidates for surgical intervention. 45 Although we have found the aforementioned classification scheme helpful for surgical decision making, we have developed a protocol for additional angiographic interrogation of sinus pericranii that may further ensure the safety of intervention. The lesion compression technique we describe here enables one to make an assessment of the adequacy of intracranial venous outflow during temporary functional absence of a sinus pericranii.…”

Le sinus pericranii : une malformation vasculaire rare

“…Le traitement est donc proposé dans un but esthétique ou en présence d'un risque hémorragique. Une angiographie cérébrale préalable est indispensable à une bonne évaluation préopératoire pour réduire les risques hémorragiques peropératoires [5]. En raison de l'absence de préjudice esthétique notable, une surveillance régulière a été décidée pour l'enfant de notre observation.…”