Cerebral Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke indicated by the formation of blood clots within the dural venous sinuses. These are large venous conduits that are situated between the 2 layers of the dura mater which are responsible for draining blood from the brain and returning it to the systemic circulation. Cortical venous thrombosis refers to the blockage of veins on the brain's cortical surface. Cerebral venous thrombosis encompasses both dural and cortical vein occlusions.

Magnetic Resonance Imaging of Dural Sinus Malformation in a Fetus: A Case Report.

BACKGROUND: Dural sinus malformation (DSM) is a rather rare congenital condition that can be encountered in the fetus and infants. The cause and etiology of DSM remain unclear. Obstetric ultrasound plays a key role in screening fetal brain malformations, and MRI is frequently used as a complementary method to confirm the diagnosis and provide more details. OBJECTIVE: Here, we present a fetus with DSM by multiple imaging methods to help better understand the imaging characteristics of this malformation. CASE PRESENTATION: A 22-year-old primipara was referred to our hospital at 25 weeks of gestation following the detection of a fetal intracranial mass without any symptoms. A prenatal ultrasound performed in our hospital at 25 + 2 gestational weeks showed a large anechoic mass with liquid dark space, while no blood flow was detected. After the initial evaluation, this primipara received a prenatal MRI in our hospital. This examination at 25 + 5 gestational weeks delineated a fan-shaped mass in the torcular herophili, which was iso-to hyperintense on T1WI and hypointense on T2WI. At the lower part of this lesion, a quasi-circular hyperintense on T1WI and a signal slightly hyperintense on T2WI could be seen. Meanwhile, the adjacent brain parenchyma was compressed by the mass. CONCLUSION: We reviewed the current literature to obtain a better understanding of the mechanisms, imaging characteristics, and survival status of DSM. Although the primipara of the present study regretfully opted for elective termination of pregnancy, the reevaluation of DSM survival deserves more attention because of the better survival data from recent studies.

Endovascular treatment in bilateral cavernous sinus dural arteriovenous fistulas: a systematic review and meta-analysis.

Few studies have discussed the disease nature and treatment outcomes for bilateral cavernous sinus dural arteriovenous fistula (CSDAVF). This study aimed to investigate the clinical features and treatment outcomes of bilateral CSDAVF. Embase, Medline, and Cochrane library were searched for studies that specified the outcomes of bilateral CSDAVF from inception to April 2022. The classification, clinical presentation, angiographic feature, surgical approach, and treatment outcomes were collected. Meta-analysis was performed using the random effects model. Eight studies reporting 97 patients were included. The clinical presentation was mainly orbital (n = 80), cavernous (n = 52) and cerebral (n = 5) symptoms. The most approached surgical route was inferior petrosal sinus (n = 80), followed by superior orbital vein (n = 10), and alternative approach (n = 7). Clinical symptoms of 88% of the patients (95% CI 80-93%, I2 = 0%) were cured, and 82% (95% CI 70-90%, I2 = 7%) had angiographic complete obliteration of fistulas during follow up. The overall complication rate was 18% (95% CI 11-27%, I2 = 0%). Therefore, endovascular treatment is an effective treatment for bilateral CSDAVF regarding clinical or angiographic outcomes. However, detailed evaluation of preoperative images and comprehensive surgical planning of the approach route are mandatory owing to complexity of the lesions.

Catastrophic Outcome Following Apparently Trivial Nondominant Transverse Sinus Injury During Resection of a Tentorial Meningioma: Case Report.

A 52-year-old man was admitted to our hospital with symptoms of raised intracranial pressure and cerebellar dysfunction caused by a medium-sized (4 cm in diameter) tentorial meningioma with an infratentorial extension. Preoperative magnetic resonance imaging showed that the tumor indented and possibly partially invaded the adjacent junction of the nondominant transverse and sigmoid sinuses. The contralateral dominant transverse sinus was fully patent. Total surgical removal of the lesion was done through the left retrosigmoid approach. During dissection of the meningioma, some bleeding from the venous sinus was noted, which was easily controlled by packing with hemostatic materials. The initial postoperative period was unremarkable, but approximately 48 h after surgery, acute clinical deterioration caused by hemorrhagic venous infarction of the left cerebellar hemisphere and brain stem developed and necessitated urgent reoperation for the evacuation of hematoma and brain decompression. Thereafter, the patient remained in a prolonged coma with a severe neurological deficit. After several years of extensive neurorehabilitation, he was able to walk with support but had a tracheostomy, required a feeding tube, and voided with a urinary catheter. Such a catastrophic outcome after an apparently trivial nondominant transverse sinus injury during resection of a tentorial meningioma raises the question whether reconstruction of the sinus wall with preservation of its patency might have prevented this complication in our patient.

Giant Arachnoid Granulations: Diagnostic Workup and Characterization in Three Symptomatic Adults.

Giant arachnoid granulations (GAGs) are poorly investigated. Here, we document clinical findings associated with five new GAGs and illustrate the anatomical composition of these structures as well as diagnostic considerations in three symptomatic adults. The GAGs ranged from 1.1 to 3.6 cm (mean, 2.2 cm) in maximum dimension and manifested in middle-aged individuals who presented with long-standing brain mass and/or chronic headache. On imaging examinations, the tissues appeared as irregular parasagittal and/or perisinus structures that demonstrated heterogeneous internal elements. The GAGs abutted dura, extended through calvarial marrow spaces, and impinged on dural venous sinuses, causing their stenosis. The histologic workup of two GAG specimens resected from separate individuals revealed central collagen with pronounced internal vascular proliferation. One specimen additionally exhibited reactive changes within the lesion, including venous thrombosis, hemorrhage, and conspicuous inflammation. The salient immune component consisted of a foam cell-rich infiltrate that obstructed subcapsular and internal sinusoidal GAG spaces. Within this specimen, meningothelial hyperplasia was also appreciated. Notably, proliferated lymphatic vascular elements were additionally observed within the structure, extending into deep central collagen regions and engulfing many extravasated erythrocytes in the subcapsular space. In both surgically treated patients, symptoms resolved completely following resection. This report is the first to definitively depict reactive vascular and immunological changes within GAGs that were clinically associated with headache. The frequency of reactive changes within these meningeal structures is unclear in the literature, as GAGs are rarely sampled and investigated. Further systematic analyses are warranted to elucidate the causes and consequences of GAG genesis and their roles in physiology and disease states.

Analysis of the efficacy of microdissection of paravebous sinus meningiomas invading large venous sinuses.

OBJECTIVE: The management of paravebous sinus meningiomas that invade major venous sinuses is a subject of debate, particularly concerning the necessity of complete resection of the tumor and reconstruction of the venous sinus. This article aims to demonstrate the outcomes of total removal of the lesion (including the invading venous sinus portion) and the effects of restoring or not restoring venous circulation in terms of recurrence of the tumor, mortality, and post-operative complications. METHODS: The authors conducted a study involving 68 patients with paravebous sinus meningiomas. Of the 60 parasagittal meningiomas, 23 were located in the anterior third, 30 in the middle third, and 7 in the posterior third. Additionally, 3 lesions were located in the sinus confluence area, and 5 in the transverse sinus. All patients underwent surgery, and the degree of venous sinus involvement was classified into six types. For type I meningiomas, the outer layer of the sinus wall was stripped off. For types II to VI, two strategies were employed: non-constitutional, wherein the tumor and affected venous sinuses were removed without repair, and reconstructive, wherein the tumor was completely removed and the venous sinuses were sutured or repaired. Karnofsky Performance Status (KPS) scale and Magnetic Resonance Venography (MRV) were utilized to assess the outcomes of the surgical procedures. RESULTS: The study group of 68 patients underwent complete tumor resection in 97.1%, with sinus reconstruction attempted in 84.4% of cases with sinus wall and sinus cavity invasion. The recurrence rate of this group was 5.9%, with follow-up ranging from 33 to 57 months. It was found that the recurrence rate was significantly higher in cases with incomplete resection than in those with complete resection. The overall mortality rate was 4.4%, with all cases resulting from malignant brain swelling due to the failure to perform venous reconstruction after resectioning of the meningioma type VI. Furthermore, 10.3% of patients experienced worsening symptoms of neurological deficits or complete loss of neurological function, with a significantly higher incidence in those without venous reconstruction than in the venous reconstruction group (P < 0.0001, Fisher test). No statistically significant pre-operative and post-operative KPS differences were observed in patients with type I to V. However, in patients with type VI (who did not receive venous reconstruction), the post-operative KPS score was significantly worse. CONCLUSION: The results of this study suggest the necessity of a complete resection of the tumor, including the invasive venous sinus component, as the recurrence rate was found to be relatively low at 5.9%. Moreover, patients who did not undergo venous reconstruction showed significant deterioration in their clinical condition compared to other subgroups, thus highlighting the importance of venous sinus reconstruction.

New Insights into the Communications of the Facial Vein with the Dural Venous Sinuses.

Background and Objectives: Anastomoses of the extracranial and intracranial venous system have been described in the literature. The presence of such anastomoses may facilitate a possible spread of infection into the dural venous sinuses. However, the frequency and relevance of such anastomoses is highly debated. The aim of this study was to quantify frequencies of anastomoses between the facial vein and the dural venous sinuses. Materials and Methods: In 32 sides of 16 specimens, latex was injected into the facial vein. Dissection was carried out to follow and described these anastomoses, yielding the presence of latex in the intracranial venous system. Results: In 97% of cases, a dispersal of latex into the cavernous sinus as well as anastomoses was observed. A further dispersal of latex into other dural venous sinuses was found at rates ranging between 34% (transverse sinus)-88% (superior petrosal sinus), respectively. Conclusions: The presence of anastomoses between the extracranial and intracranial venous system in a majority of cases needs to be considered when dealing with pathologies as well as procedures in the facial region.

Arachnoid Granulation Causing Unilateral Pulsatile Tinnitus Treated With Dural Venous Sinus Stenting.

BACKGROUND: Large arachnoid granulations that protrude into dural venous sinuses and partially obstruct outflow are an underappreciated etiology of pulsatile tinnitus (PT). Endovascular dural venous sinus stenting is thought to diminish turbulent venous outflow and may relieve obstruction caused by arachnoid granulations. METHODS: Four patients at two institutions were evaluated for unilateral PT. Magnetic resonance imaging and digital subtraction angiography revealed moderate-to-severe stenoses from large arachnoid granulations within the implicated transverse sinus. All patients underwent venous manometry and endovascular sinus stenting. RESULTS: All patients experienced immediate and complete remission of their PT. Stenoses were relieved by a mean of 93% by Warfarin-Aspirin Symptomatic Intracranial Disease criteria. There were no procedural or periprocedural complications. All patients continued to report complete symptom resolution at a mean of 8-month follow-up. CONCLUSIONS: PT from arachnoid granulations are an underappreciated pathomechanism. Endovascular dural venous sinus stenting is an effective intervention for treating unilateral PT secondary to large arachnoid granulation.

Efficacy of Dural Sinus Quantitative Measurements in Idiopathic Intracranial Hypertension : A Practical Diagnostic Feature.

BACKGROUND AND PURPOSE: This study aimed to investigate the potential contribution of quantitative measurements of dural venous sinuses to the diagnosis of idiopathic intracranial hypertension (IIH) and the relationship between IIH and dural venous sinus dimensions on 3D post-gadolinium T1-weighted magnetic resonance (MR) images. MATERIAL AND METHODS: A total of 129 individuals (57 IIH patients and 72 controls) who complained of headache and underwent both magnetic resonance venography (MRV) and precontrast/postcontrast 3D T1-weighted MR imaging between 2018 and 2021 were included in this retrospective study. Dural venous sinus and jugular vein diameters were measured in all cases using post-gadolinium 3D T1 TFE images. The presence of transverse sinus (TS) hypoplasia and occipital sinus variation, the number and size of arachnoid granulations in the TS, and the presence of brain parenchymal herniation were also evaluated. Cut-off values that maximized accurate diagnosis of IIH were established on the receiver operating characteristic curve. The sensitivity and specificity of the diagnosis of IIH based on quantitative measurements of the dural sinus were calculated. RESULTS: The ratios of the maximum to minimum TS diameters and the minimum TS diameters to minimum sigmoid sinus (SS) diameters were significantly higher in IIH patients than in the control group (p < 0.001). The diagnostic sensitivity and specificity values of TSmax/TSmin and TSmin sum/SSmin sum parameters for the detection of IIH were 84.2%, 84.7% and 83.3%, 84.2%, respectively. CONCLUSION: Practical measurements from multiplanar T1 sequences can be useful for both quantitative assessment and overcoming misinterpretation due to anatomical variation.

Combined Arterial and Venous Phase Computed Tomographic Imaging of the Skull Base in Pulsatile Tinnitus.

OBJECTIVE: To describe the demographic, clinical, and radiologic findings in a consecutive series of patients presenting with a chief complaint of pulsatile tinnitus (PT). STUDY DESIGN: Retrospective review of 157 patients undergoing a combined arterial/venous phase computed tomographic (CT) imaging study. SETTING: Tertiary referral center. PATIENTS: Adult patients referred to neurotology faculty for evaluation of PT between 2016 and 2020. INTERVENTIONS: Triple phase high-resolution arteriography/venography/temporal bone CT. MAIN OUTCOME MEASURES: Prevalence of osseous, venous, and/or arterial pathology, clinicodemographic characteristics. RESULTS: One hundred fifty-seven adults (mean age, 52 years; 79.6% female) were evaluated. A history of migraine headaches was common (19.7%). The average body mass index was 30.0 (standard deviation, 6.8), and 17.2% of subjects had a diagnosis of obstructive sleep apnea. Idiopathic intracranial hypertension was diagnosed by elevated opening pressure on lumbar puncture in 13.4%. Comorbid depression and anxiety were common (25.5% and 26.1%, respectively). Overall, abnormalities were found in 79.0% of scans, with bilateral transverse sinus stenosis (TSS) seen in 38.9% and unilateral TSS found in 20.4%. Fifteen subjects (9.6%) had evidence of osseous etiologies, including superior canal dehiscence or thinning in 8.9% and sigmoid sinus dehiscence in one subject. There were 3 dural arteriovenous fistulae identified. Unilateral PT was ipsilateral to the side of TSS in 84.4% of subjects with unilateral TSS. CONCLUSION: In a large consecutive series of patients with PT referred for CT venography/arteriography, transverse sinus stenosis was the most common finding at 59%. Venous etiologies for PT should be suspected when patients are referred to neurotologists for evaluation.

Acquired dural arteriovenous fistula after cerebellopontine angle meningioma: A case report.

RATIONALE: Intracranial brain surgeries, including ventriculostomy, burr hole, craniotomy, and craniectomy, are the most common causes of acquired dural arteriovenous fistula (dAVF). Here we report a case of acquired dAVF after a cerebellopontine angle meningioma surgery. PATIENT CONCERNS: A 51-year-old woman was diagnosed with a 40-mm cerebellopontine angle meningioma. The patient underwent surgery via a retrosigmoid suboccipital approach. A small craniotomy and an additional craniectomy were performed. At 7 months after the surgery, she presented with pulsating tinnitus and headache. DIAGNOSIS: Magnetic resonance imaging and digital subtraction angiography showed a dAVF that was fed by the occipital artery and drained into transverse and sigmoid sinuses. INTERVENTIONS: We performed Onyx® (Irvine, CA) embolization. OUTCOMES: The patient's symptoms completely improved. LESSONS: Craniectomy defects, partially exposed sinuses, and incomplete cranioplasty might be risk factors for iatrogenic dAVF after a retrosigmoid suboccipital craniotomy or craniectomy. Complete reconstructive cranioplasty is an essential procedure to prevent a direct connection between the venous sinus and the external carotid artery.

Dural Venous Sinus Arachnoid Granulations in Patients with Pulsatile Tinnitus.

OBJECTIVE: To determine the relationship, if any, between dural venous sinus arachnoid granulations (AGs) and pulsatile tinnitus. STUDY DESIGN: Retrospective case-control study. METHODS: Between October 1999 and March 2020, magnetic resonance imaging of patients with tinnitus (pulsatile [PT] and nonpulsatile [NPT]) were assessed for the presence of dural venous sinuses AG. During the same interval, patients with AGs found incidentally on all magnetic resonance imagings ordered without an indication of tinnitus were reviewed. Demographic variables recorded included patient age, sex, race, body mass index, and a history of idiopathic intracranial hypertension (IIH) or obstructive sleep apnea. Location of AGs, when present, were recorded. RESULTS: A total of 651 (PT 250, NPT 401) were found to have AGs. AGs had a higher prevalence in PT patients (10.4% [n = 26]) versus NPT patients (0.3% [n = 1]; odds ratio, 31.0; confidence interval 4.1-234; p < 0.001). Of the 77,607 patients who had an indication for imaging other than tinnitus, 230 patients (0.30%) were found to have incidental AGs, suggesting that the NPT cohort was an adequate control. Patients with PT were more likely to have a higher body mass index, be female, be non-White, and have an existing diagnosis of IIH. For all patients with AGs, AGs were more likely to be found in the lateral sinuses (i.e., sigmoid, transverse) in the PT group (odds ratio, 8.1; confidence interval, 1.1-61.1; p = 0.0218). CONCLUSIONS: This study evaluates the association between AG and PT, finding higher rates of AG in patients with PT than in NPT. However, despite the increased prevalence of AG in patients with IIH, these data combined with existing literature would suggest that AGs are not necessarily the missing link to explain PT pathophysiology in IIH.

Dilatation of the bridging cerebral cortical veins in childhood hydrocephalus suggests a malfunction of venous impedance pumping.

Dogs with a naturally occurring form of hydrocephalus have an elevated transmural venous pressure leading to cortical vein dilatation. The purpose of this study is to discover if there is vein dilatation in childhood hydrocephalus and to estimate the pressure required to maintain any enlargement found. Children with hydrocephalus between the ages of 4 and 15 years were compared with a control group. Magnetic resonance venography (MRV) and flow quantification were performed. The arterial inflow, sagittal sinus and straight sinus venous outflow were measured and the outflow percentages compared to the inflow were calculated. The cross-sectional area of the veins were measured. There were a total of 18 children with hydrocephalus, compared to 72 age and sex matched control MRV's and 22 control flow quantification studies. In hydrocephalus, the sagittal sinus venous return was reduced by 12.9%, but the straight sinus flow was not significantly different. The superficial territory veins were 22% larger than the controls but the vein of Galen was unchanged. There is evidence of a significant increase in the superficial vein transmural pressure in childhood hydrocephalus estimated to be approximately 4 mmHg. An impedance pump model is suggested to explain these findings.

A clinico-radiological study of deep cerebral venous thrombosis.

PURPOSE: Isolated deep cerebral venous thrombosis (DCVT) may have different presentation and outcome compared to DCVT with additional sinus thrombosis. We compare clinico-radiological findings and outcomes of patients with isolated DCVT with those having additional sinus thrombosis. METHODS: Forty-one DCVT patients with or without additional sinus thrombosis were included. Deep CVT was diagnosed if there was thrombosis of straight sinus, vein of Galen, internal cerebral vein, or basal vein of Rosenthal on MR venography (MRV). Isolated DCVT patients were classified as Group A and those with additional sinus thrombosis as Group B. The clinical features, risk factors, MRI findings, and outcomes at 1, 3, and 6 months were compared between Groups A and B. RESULTS: Median age was 28 years, and 22 (54%) were females. Eight (19.5%) patients were in Group A and 33 (80.5%) in Group B. Group B patients had shorter duration of illness (7 vs 30 days; p = 0.01), frequent vomiting [25 (75.7%) vs 2 (25%); p = 0.01], and papilledema [13 (39%) vs 0 (0%); p = 0.04]. Risk factors were comparable. MRI revealed bilateral thalamic [5 (62.5%) vs 6 (18.2%)] and basal ganglia [(4 (50%) vs 6 (18.2%)] lesions more frequently in Group A. At 1 month, 2 (6%) patients died in Group B and none in Group A, and 24 had good outcome (50% Group A and 60.6% in Group B). At 3 months, 30 had good outcome (62.5% Group A and 80.6% in Group B). Improvement after 3 months was negligible. CONCLUSION: Isolated DCVT is rare, and additional sinus thrombosis is associated with more severe illness and death. However, long-term outcomes in the survivors are similar between the two groups.

Brain herniation (encephalocele) into arachnoid granulations: prevalence and association with pulsatile tinnitus and idiopathic intracranial hypertension.

PURPOSE: Brain herniation into arachnoid granulations (BHAG) of the dural venous sinuses is a recently described finding of uncertain etiology. The purpose of this study was to investigate the prevalence of BHAG in a cohort of patients with pulsatile tinnitus (PT) and to clarify the physiologic and clinical implications of these lesions. METHODS: The imaging and charts of consecutive PT patients were retrospectively reviewed. All patients were examined with MRI including pre- and post-contrast T1- and T2-weighted sequences. Images were reviewed separately by three blinded neuroradiologists to identify the presence of BHAG. Their location, signal intensity, size, presence of arachnoid granulation, and associated dural venous sinus stenosis were documented. Clinical records were further reviewed for idiopathic intracranial hypertension, history of prior lumbar puncture, and opening pressure. RESULTS: Two hundred sixty-two consecutive PT patients over a 4-year period met inclusion criteria. PT patients with BHAG were significantly more likely to have idiopathic intracranial hypertension than PT patients without BHAG (OR 4.2, CI 1.5-12, p = 0.006). Sixteen out of 262 (6%) patients were found to have 18 BHAG. Eleven out of 16 (69%) patients had unilateral temporal or occipital lobe herniations located in the transverse sinus or the transverse-sigmoid junction. Three out of 16 (19%) patients had unilateral cerebellar herniations and 2/16 (13%) patients had bilateral BHAG. CONCLUSION: In patients with PT, BHAG is a prevalent MRI finding that is strongly associated with the clinical diagnosis of IIH. The pathogenesis of BHAG remains uncertain, but recognition should prompt comprehensive evaluation for IIH.

Magnetic resonance imaging findings of intracranial hypotension.

PURPOSE: This study aims to evaluate the differences in the sizes and configurations of various structures on brain MRIs of patients with intracranial hypotension (ICH) compared to normal individuals. METHODS: The present study consisted of two study groups as 21 patients with intracranial hypotension and 21 healthy individuals. Cranial MRI findings of patients with intracranial hypotension were compared retrospectively with MRI findings of patients without any pathology. Pachymeningeal enhancement, mamillopontine distance, venous sinus diameters, transverse and straight sinus distension, pituitary gland enlargement, tonsillar herniation, bleeding (subdural, epidural), pontomesencephalic angle, lateral ventricular angle, and pituitary infundibular angle were evaluated on MRI. RESULTS: Intracranial hypotension developed spontaneously in 6 cases and secondary in 15 patients. Diffuse pachymeningeal enhancement was observed in all intracranial hypotension cases. In addition, transverse sinus distension was observed in 19 cases, straight sinus distension in 17 cases, subdural effusion in 7 cases, spinal epidural effusion in 3 cases, tonsillar herniation in 2 cases, and thrombosis in dural sinuses in 2 cases. The intracranial hypotension group vs control group had dominant transverse sinus diameter 10 ± 1.75 vs 7.52 ± 1.2 mm, straight sinus diameter 4.76 ± 0.92 vs 3.69 ± 0.57 mm, superior sagittal sinus diameter 8.35 ± 1.57 vs 6.37 ± 0.71 mm, pontomesencephalic angle 46.67 ± 9.73° vs 56.27° ± 8.9°, mamillopontine distance 5.83 ± 1.5 vs 6.85 ± 1.1 mm, lateral ventricular angle 131.13° ± 6.17° vs 135.19° ± 5.28°, pituitary infundibular angle 44.42° ± 12.09° vs 63.3° ± 11.56°, and pituitary gland height 8.5 ± 1.83 vs 5.5 ± 1.27 mm, respectively. CONCLUSION: In cases with clinically suspected intracranial hypotension, MRI findings may contribute to the diagnosis of intracranial hypotension with quantitative evaluations.

Cerebral venous sinus thrombosis as a consequence of shunt hyperdrainage: a proposal of the pathophysiological mechanism and case report.

BACKGROUND AND AIM: Shunt dysfunction is a common event, especially in children who have this intervention performed early in life. The consequences of chronic shunt overdrainage can be multiple since the cerebral hydrodynamics is altered. A thrombotic event with consequent symptoms of intracranial hypertension is discussed in this article. MATERIAL AND METHODS: We performed a detailed review of cerebral hydrodynamics and intracranial pressure compensation mechanisms and how this can alter cerebral venous circulation. Next, we report the case of a 4-year-old child with such a clinical presentation that was conducted by our team. RESULTS: A child with a history of hydrocephalus treated with a ventriculo-peritoneal (VP) shunt in his early childhood presented with symptoms of intracranial hypertension, initial computed tomography (CT) demonstrating reduced-sized ventricles. Complementary investigation showed bilateral papilledema, cranial suture closure, changes compatible with Chiari type I, and venous sinus thrombosis (transverse and sigmoid, bilaterally). The case was managed conservatively with full anticoagulation with enoxaparin. Four months after the onset of symptoms, there was an improvement in the clinical and imaging status. CONCLUSION: A condition of severe headache in a patient with an apparently functioning shunt and small ventricles on initial CT should open up a range of diagnostic possibilities, with pseudotumor cerebri syndrome and cerebral venous sinus thrombosis being suggested. The therapeutic approach in these cases must be individualized.

Pulsatile Tinnitus Due to Stenosis of the Marginal Sinus: Diagnosis and Endovascular Treatment.

BACKGROUND AND PURPOSE: Venous pulsatile tinnitus is a disabling condition mainly caused by a stenosis of the lateral sinus. Here, we aimed to report a novel cause of venous pulsatile tinnitus, stenosis of the marginal sinus. MATERIALS AND METHODS: We retrospectively analyzed patients with isolated venous pulsatile tinnitus for which the suspected cause was a stenosis of the marginal sinus, treated or not, between January 2017 and December 2020. Patient charts and imaging were systematically reviewed. All patients underwent noncontrast temporal bone CT and MR imaging. RESULTS: Eight patients (7 women; median age, 36 years) were included. Six patients (75%) were overweight, and 1 patient had idiopathic intracranial hypertension. All patients presented with a typical venous pulsatile tinnitus. The stenosis of the marginal sinus was detected using oblique reconstructions on postcontrast 3D MR imaging. There was no other pathologic finding except ipsilateral stenosis of the lateral sinus in 3 patients. Four patients underwent endovascular therapy with placement of a stent in the marginal sinus, leading to complete resolution of the pulsatile tinnitus for all of them. No complication occurred. Of note, the symptoms of intracranial hypertension also regressed after stent placement in that patient. CONCLUSIONS: Marginal sinus stenosis is a novel cause of venous pulsatile tinnitus, which can be easily detected on MR imaging. Marginal sinus stent placement is safe and efficient. We hypothesized that the marginal sinus stenosis pathophysiology is similar to that of lateral sinus stenosis, which is a common and well-known cause of venous pulsatile tinnitus, explaining the similar clinical presentation and endovascular management.

Dural Venous Sinus Variations in Idiopathic Subarachnoid Hemorrhage: A New Indicator of the Venous Origin with Diagnostic Usefulness?

OBJECTIVE: Venous hypertension associated with a primitive basal vein of Rosenthal (BVR) has been noted as the most likely cause of idiopathic subarachnoid hemorrhage (iSAH). Other types of venous drainage variations have been scarcely studied but may further explain the cases not associated with a BVR anomaly. Our aim was to investigate if dural venous sinus (DVS) anomalies are related with iSAH. METHODS: A total of 76 patients diagnosed with iSAH were identified from a prospectively maintained database and their angiographic findings compared with 76 patients diagnosed with aneurysmal subarachnoid hemorrhage. RESULTS: On top of the BVR variations, our data showed a higher prevalence of transverse sinus hypoplasia (47.4% vs. 28.9%; P = 0.019), superior petrosal sinus hypoplasia (32.9% vs. 13.2%; P = 0.003), and clival plexus hyperplasia (65.8% vs. 43.4%; P = 0.005) in patients with iSAH. Analyzing by total number of angiograms, the iSAH group showed also a higher prevalence of inferior petrosal sinus hyperplasia (36.2% vs. 25%; P = 0.003). Of the patients with iSAH without a primitive BVR, 84% harbored ≥1 perimesencephalic DVS variation and the overall number of venous drainage variations was significantly higher in patients with iSAH. CONCLUSIONS: In addition to the well-documented BVR anomalies, there seems to be a significant relationship of other DVS variations in patients with iSAH. Transverse sinus hypoplasia, superior petrosal sinus hypoplasia, inferior petrosal sinus hyperplasia, and clival plexus hyperplasia were significantly more frequent in patients with iSAH. The presence of ≥3 of those variations would increase the suspicion of a nonaneurysmatic subarachnoid hemorrhage and could help avoid a second angiogram.