A simple and successful treatment for rupture and defect of the posterior third superior sagittal sinus caused by open depressed skull fracture: A case report / 中华创伤杂志(英文版)

It is extremely dangerous to treat the posterior third of the superior sagittal sinus (PTSSS) surgically, since it is usually not completely ligated. In this report, the authors described the case of a 27-year-old man with a ruptured and defective PTSSS caused by an open depressed skull fracture, which was treated by ligation of the PTSSS and the patient achieved a positive recovery. The patient's occiput was hit by a height-limiting rod and was in a mild coma. A CT scan showed an open depressed skull fracture overlying the PTSSS and a diffuse brain swelling. He underwent emergency surgery. When the skull fragments were removed, a 4 cm segment of the superior sagittal sinus (SSS) and the adjacent dura mater were removed together with bone fragments. Haemorrhage occurred and blood pressure dropped. We completed the operation by ligating the severed ends of the fractured sagittal sinus. One month after the operation, apart from visual field defects, he recovered well. In our opinion, in primary hospitals, when patients with severely injured PTSSS cannot sustain a long-time and complicated operation, e.g., the bypass using venous graft, and face life-threatening conditions, ligation of the PTSSS is another option, which may unexpectedly achieve good results.

Extracerebral Pterional Metastasis from Malignant Meningioma: A Case Report

Anaplastic or malignant meningiomas that are classified as World Health Organization (WHO) grade III account for less than 1% of all meningiomas diagnosed. Despite the aggressive course, distant metastases are a rarity, occurring in only 0.1% to 0.2% of cases. We report the case of a 56-year-old woman who presented with parasagittal benign meningioma that underwent malignant transformation along with metastasis into the right orbitosphenoid region. The clinical, radiological, and histopathological aspects are highlighted, with an emphasis on the natural history of meningiomas.

Superior Sagittal Sinus Invasion by Malignant Glioma: Case Report and Literature Review

Anaplastic oligodendrogliomas (AOs) correspond to 23% of all oligodendrogliomas. They correspond to a tumor with malignant histological characteristics, focal or diffuse, associated with a worse prognosis. In the present case report, we describe the case of a 30-year-old female submitted to resection of a right parietal lesion whose histology showed to be an AO. She underwent complementary treatment with chemotherapy and radiotherapy according to the Roger Stupp protocol. Four years after the initial diagnosis, there was tumor recurrence within the superior sagittal sinus, with no evidence of recurrence elsewhere. In the literature, we have found no similar published case reinforcing the rarity of this condition.

Feasibility and Effectiveness of Direct Puncture and Onyx Embolization for Transverse Sinus Dural Arteriovenous Fistula

Direct puncture and embolization of the transverse sinus (TS) for treatment of dural arteriovenous fistula (DAVF) is typically performed with coils with or without glue. We report a case of DAVF at the left TS that was treated with Onyx embolization via direct puncture of the TS. A 75-year-old woman presented with tremor, festinating gait, and dysarthria. A left TS-DAVF with retrograde superior sagittal sinus and cortical venous reflux (Cognard type IIa+b) was identified on cerebral angiography, and both TSs were occluded with thrombi. We considered that achieving complete cure by transvenous embolization via the femoral vein or transarterial embolization via occipital feeders would be difficult. Thus, we performed a small craniotomy at the occipital bone to puncture the TS. The midportion of the TS was directly punctured with a 21-G microneedle under fluoroscopic guidance. We inserted a 5-F sheath into the TS. A microcatheter was then navigated into the affected sinus. Coils were placed through the microcatheter to support Onyx formation by reducing the pressure of shunting flow. Onyx embolization was performed with the same microcatheter. The DAVF was almost completely occluded except for the presence of minimal shunting flow to the proximal TS. After 1 week, time-of-flight magnetic resonance angiography showed complete resolution of DAVF. The patient showed resolved tremor and markedly improved mental status at 1-month follow up. Direct puncture and embolization of the TS using coils and Onyx is effective and feasible method for the treatment of DAVF when other approaches seem difficult.

Relationship between Clinical Outcomes and Superior Sagittal Sinus to Bone Flap Distance during Unilateral Decompressive Craniectomy in Patients with Traumatic Brain Injury: Experience at a Single Trauma Center / 대한신경손상학회지

OBJECTIVE: This retrospective study was conducted to investigate the relationship between the superior sagittal sinus (SSS) to bone flap distance and clinical outcome in patients with traumatic brain injury (TBI) who underwent decompressive craniectomy (DC). METHODS: A retrospective review of medical records identified 255 adult patients who underwent DC with hematoma removal to treat TBI at our hospital from 2016 through 2017; of these, 68 patients met the inclusion criteria and underwent unilateral DC. The nearest SSS to bone flap distances were measured on postoperative brain computed tomography images, and patients were divided into groups A (distance ≥20 mm) and B (distance < 20 mm). The estimated blood loss (EBL) and operation time were evaluated using anesthesia records, and the time spent in an intensive care unit (ICU) was obtained by chart review. The clinical outcome was rated using the extended Glasgow Outcome Scale (GOS-E) at 3 and 6 months postoperatively. RESULTS: The male to female ratio was 15:2 and the mean subject age was 55.12 years (range, 18–79 years). The mean EBL and operation times were significantly different between groups A and B (EBL: 655.26 vs. 1803.33 mL, p < 0.001; operation time: 125.92 vs. 144.83 min, p < 0.001). The time spent in the ICU and GOS-E scores did not differ significantly between the groups. CONCLUSION: We recommend that when DC is indicated due to TBI, an SSS to bone flap distance of at least 20 mm should be maintained, considering the EBL, operation time, and other outcomes.

Postpartum Superior Sagittal Sinus Thrombosis: A Case Report / 대한신경손상학회지

Cerebral venous sinus thrombosis (CVST) is a rare disease. Early diagnosis and treatment are important, as CVST is potentially fatal. Pregnancy and puerperium are known risk factors for CVST. Here, we report the case of a patient who developed superior sagittal sinus thrombosis after a normal vaginal delivery. A 20-year-old woman presented with a headache and seizures two days after a normal vaginal delivery. Initially, brain computed tomography (CT) showed a subarachnoid hemorrhage in the right parietal lobe and sylvian fissure, together with mild cerebral edema. CT angiography revealed superior sagittal sinus thrombosis. Multiple micro-infarctions were seen on diffusion-weighted magnetic resonance images. An intravenous infusion of heparin and mannitol was administered immediately. Two days after treatment initiation, the patient showed sudden neurological deterioration, with left-sided hemiplegia. Brain CT showed moderate brain edema and hemorrhagic densities. Emergency decompressive craniectomy was performed, and heparin was re-administered on post-operative day (POD) 1. On POD 9, the patient's mental state improved from stupor to drowsy, but the left-sided hemiplegia persisted. CT angiography showed that the superior sinus thrombosis had decreased. Superior sagittal sinus thrombosis is an uncommon complication, with an unfavorable outcome, after delivery. Timely diagnosis and treatment are important for preventing neurological deterioration.

A case of eccrine carcinoma presenting with neurological manifestations

INTRODUCTION: Eccrine  carcinoma  is  an  extremely  rare  skin tumor where only 1/13000 specimens have been submitted to dermatopathological  laboratories  in  the  United  States.There  is  no  data  yet  to compare the Philippines with the international  incidence  of  eccrine  carcinoma.  This is a case of a 69-year-old Filipino female who presented with a recurring invasive indolent tumor at the right fronto-parietal area who presented with left sided hemiparesis and seizure.CASE: The patient was presented with a recurrent invasive indolent  mass  on  her  right  front-parietal  area,  grossly measuring five by four centimeters, nodular flesh colored,which  extended  intracranially.This was associated with left sided hemiparesis and due to the extent of the tumor encroaching through the brain parenchyma, patient was noted  to  have  seizure  episodes.  The  patient  was  given surgical and radiologic options however, she did not comply and died last December 2015.RESULTS: A cranial MRI with MRA showed a  heterogenous enhancing intracranial mass with extracranial component with compressed entrapped and depressed superior sagittal sinus  by  the  axial  mass  witin  calvarial  penetration  and scalp involvement compressing on the right parietal lobe with parenchyma edema. Biopsy was eventually done and findings were consistent with an eccrine carcinoma.CONCLUSION: This is the first case of eccrine carcinoma in our institution. Due to the paucity of data, there are no guidelines to the management of an eccrine carcinoma. Hence the imperative need to raise awareness regarding this rare tumor because,  without  a  high  index  of  suspicion  this  rare  entity may be overlooked or misdiagnosed. When presented with an indolent invasive recurrent tumor a high index of suspicion that  an  eccrine  Carcinoma  may  be  suspected.Excision biopsy may be done for correct identification of the tumor.

A case of eccrine carcinoma presenting with neurological manifestations

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> Eccrine  carcinoma  is  an  extremely  rare  skin tumor where only 1/13000 specimens have been submitted to dermatopathological  laboratories  in  the  United  States.There  is  no  data  yet  to compare the Philippines with the international  incidence  of  eccrine  carcinoma.  This is a case of a 69-year-old Filipino female who presented with a recurring invasive indolent tumor at the right fronto-parietal area who presented with left sided hemiparesis and seizure.<br /><strong>CASE:</strong> The patient was presented with a recurrent invasive indolent  mass  on  her  right  front-parietal  area,  grossly measuring five by four centimeters, nodular flesh colored,which  extended  intracranially.This was associated with left sided hemiparesis and due to the extent of the tumor encroaching through the brain parenchyma, patient was noted  to  have  seizure  episodes.  The  patient  was  given surgical and radiologic options however, she did not comply and died last December 2015.<br /><strong>RESULTS:</strong> A cranial MRI with MRA showed a  heterogenous enhancing intracranial mass with extracranial component with compressed entrapped and depressed superior sagittal sinus  by  the  axial  mass  witin  calvarial  penetration  and scalp involvement compressing on the right parietal lobe with parenchyma edema. Biopsy was eventually done and findings were consistent with an eccrine carcinoma.<br /><strong>CONCLUSION:</strong> This is the first case of eccrine carcinoma in our institution. Due to the paucity of data, there are no guidelines to the management of an eccrine carcinoma. Hence the imperative need to raise awareness regarding this rare tumor because,  without  a  high  index  of  suspicion  this  rare  entity may be overlooked or misdiagnosed. When presented with an indolent invasive recurrent tumor a high index of suspicion that  an  eccrine  Carcinoma  may  be  suspected.Excision biopsy may be done for correct identification of the tumor.</p>

Clinical and Radiologic Features of Pediatric Cerebral Venous Thrombosis in Korea

PURPOSE: Cerebral venous thrombosis (CVT) is a rare cause of pediatric stroke. Our goal was to describe the clinical CVT features among pediatric patients presenting at a tertiary referral center. METHODS: Patient data was retrospectively collected from the charts of all pediatric patients (newborn to 18 years old) who were diagnosed with CVT at Seoul National University Children's Hospital between 2000 and 2016. Magnetic resonance imaging or venography was conducted for diagnostic confirmation. Modified Rankin Scale (mRS) was used to evaluate neurologic outcome. RESULTS: Twenty patients were diagnosed with CVT during the study period (16 male, 4 female). Median age was 4 years. The most common risk factor was systemic infection (6/20, 30.0%). Twelve patients initially presented with headache or vomiting (12/20, 60.0%). Seizure was in only 3 patients within 48 hours of symptom onset; however, as the clinical course progressed, seizure was the symptom that most frequently led to brain imaging (12/20, 60.0%). Thrombosis in the superior sagittal sinus was frequently associated with intracranial hemorrhage (4/11, 36.4%) and clinical seizure (9/11, 81.8%). Anticoagulation and/or antiplatelet agents were used in 16 patients (16/20, 80%). At the 3-month follow-up, 14 patients (14/20, 70%) had an mRS of 0 or 1, showing that most of these patients had no neurologic impairment. CONCLUSION: Seizure and signs of increased intracranial pressure are the most common manifestation of pediatric CVT. However, clinical features are diverse and include age at symptom onset and underlying risk factors. Despite diagnostic delay, neurologic outcome is favorable in most patients.

Interêt du scanner dans le diagnostic précoce d'une plaie traumatique du Sinus sagittal supérieur: à propos d'un cas à Cotonou

Introduction : Lors des traumatismes crâniens, le scanner permet un bilan exhaustif des collections intracrâniennes et des lésions osseuses et parenchymateuses. Nous rapportons le cas d'une plaie traumatique inhabituelle du sinus sagittal supérieur par embarrure ouverte du vertex.Observation : Patient de 18 ans, sans antécédents particuliers, admis pour une plaie crânio-cérébrale du vertex avec coma d'emblée. A l'admission, l'examen neurologique notait un Glasgow à 5/15 avec des pupilles isocores et réactives. Localement, il existait une large plaie du vertex pariéto-occipital. Le patient fut admis en réanimation. Il a été intubé et sédaté. Le scanner cérébral a été réalisé le jour de son admission et mettait en évidence une embarrure multi-esquilleuse en regard de la portion moyenne du sinus sagittal supérieur. Une craniectomie a été réalisée en urgence. A 18 mois postopératoire,le sujet était sans séquelles neurologiques.Conclusion : La gestion efficiente d'une plaie du sinus sagittal supérieur est facilitée par la réalisation urgente du scanner cérébral

A Case of Cerebral Venous Thrombosis in a Patient with Graves' Disease / 고신대학교의과대학학술지

Superior sagittal sinus thrombosis is an uncommon disease, and 25% of cases are considered to be idiopathic. Hypercoagulability, local bloodstream stasis, and vessel wall abnormalities may contribute to the development of this condition. The thyrotoxic phase of Graves’ disease is associated with venous thrombosis caused by hypercoagulability, which is in turn induced by increased levels of homocysteine and factor VIII and decreased fibrinolytic activity. Here, we report the case of a 39-year-old male who presented with superior sagittal sinus thrombosis and concomitant hyperthyroidism.

Treatment of the Superior Sagittal Sinus Thrombosis with the Mechanical Thrombectomy Using Stent-Retriever Device

Cerebral venous sinus thrombosisis an uncommon entity and its clinical presentations are highly variable. We present the case of superior sagittal sinus thrombosis. Although it was medical refractory, successfully treated with mechanical thrombectomy using the Solitaire FR device. A 27-year-old man who presented with venous infarction accompanied by petechial hemorrhage secondary to the superior sagittal sinus (SSS) thrombosis. Due to rapid deterioration despite of anticoagulation therapy, the patient was taken for endovascular treatment. We deployed the Solitaire FR device (4×20 mm) in the anterior portion of the thrombosed SSS, and it was left for ten minutes before the retraction. Thus, we removed a small amount of thrombus. But the sinus remained occluded. We therefore performed the thrombectomy using the same methods using the Solitaire FR (6×20 mm). Thus, we were successful in removing larger clots. Our case highlights not only that the mechanical thrombectomy using the Solitaire FR is effective in achieving revascularization both rapidly and efficiently available, but also that it might be another option in patients with cerebral venous sinus thrombosis who concurrently had rapid clinical deterioration with devastating consequences.

Clinical Aspects of Cerebral Venous Thrombosis: Experiences in Two Institutions

OBJECTIVE: Cerebral venous thrombosis (CVT) is a rare condition for which few clinical reviews have been conducted in Korea. Our aim was to investigate, risk factors, clinical presentations/courses, and outcomes of 22 patients treated for CVT at two centers. MATERIALS AND METHODS: A retrospective analysis was conducted, selecting 22 patients diagnosed with and treated for CVT at two patient care centers over a 10-year period (January 1, 2004 to August 31, 2015). Patient data, pathogenetic concerns (laboratory findings), risk factors, locations, symptoms, treatments, and clinical outcomes were reviewed. RESULTS: Mean patient age at diagnosis was 54.41 ± 16.19. Patients most often presented with headache (40%), followed by seizure (27%) and altered mental status (18%). Focal motor deficits (5%), visual symptoms (5%), and dysarthria (5%) were less common. Important predisposing factors in CVT included prothrombotic conditions (35%), infections (14%), hyperthyroidism (18%), trauma (14%), and malignancy (4%). By location, 9 patients (40%) experienced thrombosis of superior sagittal sinus predominantly, with involvement of transverse sinus in 20 (90%), sigmoid sinus in 12 (40%), and the deep venous system in 5 (23%). Treatment generally consisted of anticoagulants (63%) or antiplatelet (23%) drugs, but surgical decompression was considered if warranted (14%). Medical therapy in CVT yields good functional outcomes. CONCLUSION: Mean age of patients with CVT in our study exceeded that reported in Europe or in America and had difference in risk factors. Functional outcomes are good with use of antithrombotic medication, whether or not hemorrhagic infarction is evident.

Endovascular Treatment of Dural Arteriovenous Fistulas: Single Center Experience

OBJECTIVE: Treatment of intracranial dural arteriovenous fistulas (dAVFs) remains a challenge. However, after introduction of Onyx, transarterial approach is the preferred treatment option in many centers. We report our experience of dAVFs embolization with special emphasis on transarterial approach. METHODS: Seventeen embolization procedures were performed in 13 patients with dAVFs between Jan 2009 and Oct 2014. Clinical symptoms, location and type of fistulas, embolization methods, complications, radiological and clinical outcomes were evaluated using charts and PACS images. RESULTS: All 13 patients had symptomatic lesions. The locations of fistulas were transverse-sigmoid sinus in 6, middle fossa dura in 4, cavernous sinus in 2, and superior sagittal sinus in 1 patient. Cognard types were as follows : I in 4, IIa in 2, IIa+IIb in 5, and IV in 2. Embolization procedures were performed > or =2 times in 3 patients. Nine patients were treated with transarterial Onyx embolization alone. One of these required direct surgical puncture of middle meningeal artery. Complete obliteration of fistulas was achieved in 11/13 (85%) patients. There were no complications except for 1 case of Onyx migration in cavernous dAVF. Modified Rankin scale score at post-operative 3 months were 0 in 11, and 3 in 2 patients. CONCLUSION: Transarterial Onyx embolization can be a first line therapeutic option in patients with dAVFs. However, transvenous approach should be tried first in cavernous sinus dAVF because of the risk of intracranial migration of liquid embolic materials. Furthermore, combined surgical endovascular approach can be considered as a useful option in inaccessible route.

Anatomical Variations of Cerebral MR Venography: Is Gender Matter? / 신경중재치료의학

PURPOSE: Knowledge of variations in the cerebral dural venous sinus anatomy seen on magnetic resonance (MR) venography is essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST). Very limited data is available on gender difference of the cerebral dural venous sinus anatomy variations. MATERIALS AND METHODS: A retrospective study was conducted to study the normal anatomy of the intracranial venous system and its normal variation, as depicted by 3D MR venography, in normal adults and any gender-related differences. RESULTS: A total of 1654 patients (582 men, 1072 women, age range 19 to 86 years, mean age: 37.98±13.83 years) were included in the study. Most common indication for MR venography was headache (75.4%). Hypoplastic left transverse sinus was the most common anatomical variation in 352 (21.3%) patients. Left transverse sinus was hypoplastic in more commonly in male in comparison to female (24.9% versus 19.3%, p = 0.009). Most common variation of superior sagittal sinus (SSS) was atresia of anterior one third SSS (15, 0.9%). Except hypoplastic left transverse sinus, rest of anatomical variations of the transverse and other sinuses were not significantly differ among both genders. CONCLUSION: Hypoplastic left transverse sinus is the most common anatomical variation and more common in male compared to female in the present study. Other anatomical variations of dural venous sinuses are not significantly differ among both genders.

Failed First Craniotomy and Tumor Removal of Parasagittal Meningioma with Severe Peritumoral Brain Edema

Parasagittal meningioma often presents as peritumoral brain edema (PTBE). The risk of edema increases when the tumor occludes the superior sagittal sinus (SSS). Although PTBE may be expected based on the patient’s symptoms or radiologic findings, extensive brain swelling and extracranial herniation during elective surgery are rare. Herniation during surgery could lead to irreversible neurological damage and even brain rupture. We report a case of a failed routine craniotomy for a parasagittal meningioma with complete occlusion of the posterior third of the SSS in a 30-year-old male patient. The patient developed extensive brain swelling and extracranial herniation during surgery.

Cerebral venous thrombosis in a patient with Crohn's disease

Patients with inflammatory bowel disease (IBD) have an elevated risk of venous thromboembolism compared with the general population. The most common sites of venous thromboembolism in IBD patients are the deep veins of the legs, the pulmonary system, and portal and mesenteric veins. However, cerebral venous thrombosis is rarely associated with IBD. This report describes a case of cerebral venous thrombosis in a patient with Crohn's disease. A 17-year-old girl, diagnosed 4 years earlier with Crohn's disease, presented with headache and vomiting. Magnetic resonance imaging of the brain with venography showed venous thrombosis in the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. The patient immediately started anticoagulation therapy with intravenous heparin infusion followed by daily oral rivaroxaban 10 mg. Follow-up imaging after 2 weeks showed resolution of the thrombosis, with recanalization of the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. She continued rivaroxaban therapy for 6 months, and remained well, without neurologic sequelae. A high level of concern for cerebral venous thrombosis may be important when treating active IBD patients, because anticoagulation treatment can prevent fatal complications.

Pulsatile Tinnitus due to Intracranial Dural Arteriovenous Fistula after Head Trauma by a Golf Ball / 대한이비인후과학회지

Diagnosis of traumatic arteriovenous fistula (AVF) is usually delayed because it takes time to be enlarged enough to emerge radiologically or because symptoms occur a few months after the trauma. A 56-year-old woman presented with a newly developed tinnitus immediately after a head trauma. Pulsatile high-frequency tinnitus was heard also by examiner and recorded using a transcanal microphone. Angiography revealed an intracranial dural AVF fed by the middle meningeal artery, draining the superior sagittal sinus on the affected side. After percutaneous transarterial embolization, tinnitus successfully disappeared. The clinical presentation, radiologic and angiographic features, and management are discussed. To our knowledge, this is the first reported case of pulsatile tinnitus caused by AVF developed immediately after a trauma. We emphasize that precise physical examination, laboratory tests, and appropriate radiographic imaging are essential for accurate diagnosis and treatment when a patient presents with pulsatile tinnitus, especially after a head trauma.

Paediatric Primary Pachymeningeal Xanthogranuloma with Scattered Foci Displaying Reticulohistiocytoma-like Features

We report a unique case of a 4-year-old girl with an intriguing fibrohistiocytic tumour. Magnetic resonance imaging scans showed a dural mass of variegated intensity compressing the left occipital pole and apparently extending toward the superior sagittal sinus. Grossly, the cut surface of the surgical specimen was yellow, pale, and soft with reddish kernel-like crusts. Histologically, the yellow areas resembled cholesterol granulomas with widespread coagulative necrosis, cholesterol clefts, powdery calcification, foreign body-type giant cells, and foamy macrophages, while the scattered red spots contained numerous multinucleated giant cells of foreign-body and Touton types, the former with amphophilic to slightly eosinophilic cytoplasm. Immunoperoxidase reactions confirmed the expression of histiocytic markers and vimentin. As far as we know, no tumour displaying these peculiar morphological features has yet been described.

Traumatic Dural Venous Sinus Injury / 대한신경손상학회지

OBJECTIVE: The importance of traumatic dural venous sinus injury lies in the probability of massive blood loss at the time of trauma or emergency operation resulting in a high mortality rate during the perioperative period. We considered the appropriate methods of treatment that are most essential in the overall management of traumatic dural venous sinus injuries. METHODS: We conducted a retrospective review of all cases involving patients with dural venous sinus injury who presented to our hospital between January 1999 and December 2014. RESULTS: Between January 1999 and December 2014, 20 patients with a dural venous sinus injury out of the 1,200 patients with severe head injuries who had been operated upon in our clinic were reviewed retrospectively. There were 17 male and 3 female patients. In 11 out of the 13 patients with a linear skull fracture crossing the dural venous sinus, massive blood loss from the injured sinus wall could be controlled by simple digital pressure using Gelfoam. All 5 patients with a linear skull fracture parallel to the sinus over the venous sinus developed massive sinus bleeding that could not be controlled by simple digital pressure. CONCLUSION: When there is a linear skull fracture parallel to the sinus over the dural venous sinus or a depressed skull fracture penetrating the sinus, the surgeon should be prepared for the possibility of potentially fatal venous sinus injury, even in the absence of a hematoma.