Cerebral sinovenous thrombosis as a cause of subdural hemorrhage in the pediatric population: Is there a correlation?

PURPOSE: Cerebral sinovenous thrombosis is an increasingly recognized cause of stroke in children and neonates. Its true incidence appears to be underestimated. Despite being a rare event, certain studies have found a correlation between subdural hemorrhage and cerebral sinus thrombosis. The literature suggests that spontaneous cerebral sinovenous thrombosis in the pediatric population may lead to the occurrence of a subdural hemorrhage. In this report, we present a case of cerebral venous thrombosis associated with chronic subdural hematoma and review the literature to highlight the importance of these conditions. CASE REPORT: An 11-year-old boy was admitted in the neurosurgery department with headache and a neurological examination without changes. The imaging studies identified a heterogeneous subdural collection in the fronto-temporo-parietal region. The patient underwent surgical drainage of the subdural hematoma, and the procedure was performed without complications. The magnetic resonance and angiography showed an extensive thrombosis of the superior sagittal sinus, extending downward to the occipital sinus and partially to the right transverse sinus. CONCLUSIONS: Appropriate management in the diagnosis and an early treatment of dural sinus thrombosis associated with subdural hemorrhage can reduce the risk of recurrence and improve the clinical outcome.

[Comparison of methods of treatment of meningiomas invading the superior sagittal sinus]. / Sravnitel'naya otsenka metodov lecheniya meningiom, invaziruyushchikh verkhnii sagittal'nyi sinus.

There are various approaches to the treatment of patients with parasagittal meningiomas. OBJECTIVE: To optimize treatment strategy for meningiomas invading the superior sagittal sinus. MATERIAL AND METHODS: The study included 87 patients with benign parasagittal meningiomas between 2010 and 2012. Of these, 34 patients underwent surgery alone, 27 - radiotherapy, 26 - surgery and subsequent radiotherapy. Both groups were comparable in male-to-female ratio, age and localization of tumors in relation to superior sagittal sinus. The follow-up period was at least 5 years. We analyzed the effect of treatment on neurological status, Karnofsky score and tumor growth control. RESULTS: Mean volume of tumors was 43.3 cm3 in patients undergoing surgery and 6.7 cm3 in the radiotherapy group. In the combined treatment group, mean volume was 65.8 cm3 before surgery and 8.8 cm3 before irradiation. General cerebral symptoms (84%), epileptic seizures (37%) and movement disorders (31%) prevailed. Surgery provided the best results in patients with small meningiomas (<14 cm3) causing focal neurological symptoms. Isolated radiotherapy was the most effective in asymptomatic patients. Large tumors required surgery with adjuvant irradiation. CONCLUSION: Benign parasagittal meningiomas followed by focal neurological symptoms require surgical intervention regarding the best functional outcomes and tumor growth control. Radiotherapy without surgery is advisable for progressive asymptomatic tumors. Resection followed by irradiation is preferable if total resection without the risk of damage to veins and cortex is impossible.

Adaptative Diploic Vein Bypass of the Superior Sagittal Sinus in a Large Falcine Meningioma.

We describe an adaptative bypass at the posterior third of the superior sagittal sinus (SSS) through the parietal diploe veins related to a large falcine meningioma on a 55-year-old lady with progressive headaches and mild left hemiparesis. Cranial imaging revealed a large tumor at the posterior third of the cerebral falx, compatible with meningioma. Imaging also revealed lack of continuity of the superior sagittal sinus at that region. Large diploic veins were seen bypassing the segment of the SSS affected by the tumor. An "L"-shaped modified posterior interhemispheric craniotomy was performed to avoid traversing the diploic veins. Near-total resection of the meningioma was accomplished. Postoperative imaging revealed a small remnant invading the SSS, which was treated with adjuvant radiotherapy. The patient tolerated the procedure well and was discharged to rehabilitation unit on postoperative day 5 with no neurologic deficits.

Primary Intracranial Ewing Sarcoma Invading the Superior Sagittal Sinus with EWSR1-FLI1 Gene Fusion and EWSR1 Gene Mutation: A Case Report and Literature Review.

BACKGROUND: Primary intracranial Ewing sarcoma (ES) is an extremely rare intracranial malignant tumor, mostly occurring in children and adolescents. Because of its rarity, the magnetic resonance imaging (MRI) features and treatment strategies of primary intracranial ES are still unclear. METHODS: The purpose of this study was therefore to report a case of primary intracranial ES, whose molecular features included both EWSR1-FLI1 (EWS RNA binding protein 1- Friend leukemia integration 1) gene fusion and EWSR1 gene mutation. It is worth noting that this is the first reported case of ES invading the superior sagittal sinus and mostly causing occlusion. At the same time, there were polymorphisms of four drug metabolism-related enzymes in the tumor. Subsequently, we conducted a literature review to characterize the clinical features, imaging findings, pathological features, treatments, and prognoses of primary intracranial ESs. RESULTS: A 21-year-old female was admitted to the hospital with headache with nausea and vomiting for 2 weeks. An MRI showed a 3.8 × 4.0 cm large heterogeneous mass in the bilateral parietal lobe with peritumoral edema. The tumor invaded the superior sagittal sinus and mostly caused occlusion of the middle segment of the superior sagittal sinus. The mass was successfully removed using a neuromicroscope. Postoperative pathology indicated a primary intracranial ES. High throughput sequencing (next generation sequencing) showed that there was EWSR1-FLI1 gene fusion and EWSR1 gene mutation in the tumor, with polymorphisms of four drug metabolism-related enzymes and low tumor mutational burden. Subsequently, the patient received intensity modulated radiation therapy. The patient has signed an informed consent form. CONCLUSIONS: The diagnosis of primary intracranial ES depended on histopathology, immunohistochemistry staining, and genetic testing. At present, total tumor resection combined with radiotherapy and chemotherapy is the most effective treatment. We report the first case of primary intracranial ES invading the superior sagittal sinus and causing middle segment occlusion, accompanied by EWSR1-FLI1 gene fusion and EWSR1 gene mutation.

Microsurgery of Meningiomas Involving the Superior Sagittal Sinus.

Meningiomas involving major dural sinuses can be difficult to resect without proper handling of the sinus. In young patients, a gross total resection should be attempted when feasible. A 24-year-old man presented with headaches, progressive left-sided weakness, and partial motor seizures. He was found to have a parasagittal meningioma in front of the motor cortex that invaded the superior sagittal sinus (SSS). The sinus was still patent, and the walls were preserved. Thus a gross total resection was achieved with primary suturing of the sinus, followed by reinforcement with an AnastoClip GC. Videos 1-3 details the separation of the tumor from the convexity veins and the cortex, removal of the tumor from the SSS, and reconstruction of the SSS. Gross total resection of meningiomas involving the SSS is achievable without sacrificing the sinus when planned correctly and methodically. The patient consented for the procedure and to the publication of these images.

[Surgical treatment of large and giant recurrent meningiomas near the middle and posterior third part of the superior sagittal sinus with extracranial invading].

OBJECTIVE: To investigate the surgical strategy for large and giant recurrent meningiomas near the middle and posterior third part of the superior sagittal sinus with extracranial invading. METHODS: The clinical data of 16 patients with large and giant recurrent meningioma in the middle and posterior third part of the superior sagittal sinus with extracranial invasion who underwent surgery in the Department of Neurosurgery of Peking University Third Hospital from May 2019 to May 2022 were retrospectively analyzed. All the patients underwent brain-enhanced magnetic resonance imaging (MRI), magnetic resonance venography (MRV), computed tomography angiography (CTA) and three-dimensional skull computed tomography (CT) before, to evaluate the extent of tumor invasion, the edema of brain tissue, the degree of skull damage, the blood supply of the tumor, and the degree of compression of the superior sagittal sinus, etc, and to formulate an individualized surgical plan. The neurological function of the patients was evaluated 1 week, 1 month, and 3 months after the operation, and the tumor condition was evaluated by brain-enhanced MRI 3 months, 6 months, and 1 year after the operation. RESULTS: The tumors in the 16 patients were all located in the middle and posterior 1/3 part of the superior sagittal sinus and invaded extracranially. Among them, 8 cases were operated for the second time, 6 cases for the third time, and 2 cases for the fourth time; In the last operation, the bone flap was used to repair the skull in 4 cases, and the titanium mesh was used in 12 cases; Tumor arterials of 3 cases were embolized under digital subtraction angiography (DSA). Tumors of 10 cases were resected at Simpson grade Ⅰ, and 6 cases at Simpson grade Ⅱ; 2 cases underwent decompressive craniectomy during operation, and 14 cases underwent cranioplasty at the same time; scalp incisions of 14 cases were directly sutured, and flap transposition was used in 14 cases. When evaluating nerve function after operation, the limb muscle strength was improved compared with that before operation, and the Karnofsky performance scale (KPS) score reached 100 points 3 months after operation. During the follow-up, 1 patient's tumor recurred after 1 year and received Gamma Knife treatment, and the rest of the patients had no recurrence during the follow-up period. CONCLUSION: Surgical treatment is the first choice for large and giant recurrent meningiomas near the middle and posterior third part of the superior sagittal sinus with extracranial invading. It is a safe and effective surgical method to take individualized surgical plan after detailed preoperative assessment of cerebral edema, tumor blood supply, venous sinus compression, and scalp invasion.

A novel rat model for cerebral venous sinus thrombosis: verification of similarity to human disease via clinical analysis and experimental validation.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare neurovascular disorder with highly variable manifestations and clinical courses. Animal models properly matched to the clinical form of CVST are necessary for elucidating the pathophysiology of the disease. In this study, we aimed to establish a rat model that accurately recapitulates the clinical features of CVST in human patients. METHODS: This study consisted of a clinical analysis and animal experiments. Clinical data for two centres obtained between January 2016 and May 2021 were collected and analysed retrospectively. In addition, a Sprague-Dawley rat model of CVST was established by inserting a water-swellable rubber device into the superior sagittal sinus, following which imaging, histological, haematological, and behavioural tests were used to investigate pathophysiological changes. Principal component analysis and hierarchical clustering heatmaps were used to evaluate the similarity between the animal models and human patients. RESULTS: The imaging results revealed the possibility of vasogenic oedema in animal models. Haematological analysis indicated an inflammatory and hypercoagulable state. These findings were mostly matched with the retrospective clinical data. Pathological and serological tests further revealed brain parenchymal damage related to CVST in animal models. CONCLUSIONS: We successfully established a stable and reproducible rat model of CVST. The high similarity between clinical patients and animal models was verified via cluster analysis. This model may be useful for the study of CVST pathophysiology and potential therapies.

A subset of arachnoid granulations in humans drain to the venous circulation via intradural lymphatic vascular channels.

OBJECTIVE: The discovery of dural lymphatics has spurred interest in the mechanisms of drainage of interstitial fluid from the CNS, the anatomical components involved in clearance of macromolecules from the brain, mechanisms of entry and exit of immune components, and how these pathways may be involved in neurodegenerative diseases and cancer metastasis. In this study the authors describe connections between a subset of arachnoid granulations (AGs) and the venous circulation via intradural vascular channels (IVCs), which stain positively with established lymphatic markers. The authors postulate that the AGs may serve as a component of the human brain's lymphatic system. METHODS: AGs and IVCs were examined by high-resolution dissection under stereoscope bilaterally in 8 fresh and formalin-fixed human cadaveric heads. The superior sagittal sinus (SSS) and adjacent dura mater were immunostained with antibodies against Lyve-1 (lymphatic marker), podoplanin (lymphatic marker), CD45 (panhematopoietic marker), and DAPI (nuclear marker). RESULTS: AGs can be classified as intradural or interdural, depending on their location and site of drainage. Interdural AGs are distinct from the dura, adhere to arachnoid membranes, and occasionally open directly in the inferolateral wall or floor of the SSS, although some cross the infradural folds of the dura's inner layer to meet with intradural AGs and IVCs. Intradural AGs are located within the leaflets of the dura. The total number of openings from the AGs, lateral lacunae, and cortical veins into the SSS was 45 ± 5.62 per head. On average each cadaveric head contained 6 ± 1.30 intradural AGs. Some intradural AGs do not directly open into the SSS and use IVCs to connect to the venous circulation. Using immunostaining methods, the authors demonstrate that these tubular channels stain positively with vascular and lymphatic markers (Lyve-1, podoplanin). CONCLUSIONS: AGs consist of two subtypes with differing modes of drainage into the SSS. A subset of AGs located intradurally use tubular channels, which stain positively with vascular and lymphatic markers to connect to the venous lacunae and ultimately to the SSS. The present study suggests that AGs may function as a component of brain lymphatics. This finding has important clinical implications for cancer metastasis to and from the CNS and may shed light on mechanisms of altered clearance of macromolecules in the setting of neurodegenerative diseases.

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.

Diploic veins as collateral venous pathways in patients with dural venous sinus invasion by meningiomas.

BACKGROUND: Although it is known that diploic veins frequently communicate with the dural venous sinuses, the role of diploic veins in patients with venous sinus invasion from meningiomas remains unknown. METHODS: We retrospectively examined the medical records of 159 patients who underwent their first craniotomies for intracranial meningiomas. Contrast-enhanced magnetic resonance imaging was used to evaluate diploic vein routes, and digital subtraction angiography (DSA) was used to evaluate diploic vein blood flow. When high blood flow was visualized concurrently with the venous sinuses, the veins were classified as of the "early type." Diploic vein routes were classified into five routes. RESULTS: DSA was performed in 110 patients, with 14 showing superior sagittal sinus (SSS) invasion (SSS group) and 23 showing non-SSS venous sinus invasion (non-SSS group). The proportion of early type diploic veins was significantly higher in the SSS group (27.1%) than in other patients (patients without venous sinus invasion, 2.1%; non-SSS, 4.3%) (p < 0.01). In patients not in the SSS group, diploic veins were sacrificed during craniotomy in 76 patients, including four patients with veins of the early type. No patients demonstrated new neurological deficits postoperatively. In the SSS group, diploic veins were sacrificed in all patients, and early type diploic veins were cut in five patients. Two of these five patients showed postoperative neurological deficits. CONCLUSIONS: In the SSS group, diploic veins may function as collateral venous pathways, and attention is recommended for their interruption. In patients without SSS invasion, diploic veins, even of the early type, can be sacrificed.

Evaluation of fluid channels in the human dura and superior sagittal sinus in older patients.

AIM: Recent studies suggest the leptomeninges may have a lymphatic drainage system connecting the subarachnoid space with dorsal cervical lymph nodes. The distribution and histologic features of any dural "lymphatics" has not been established or extensively studied. MATERIAL AND METHODS: Duras from 113 patients were evaluated including 96 formalin-fixed dural samples (mean age 62 years) collected from 2010 to 2015. An additional 17 samples were collected from Alzheimer's disease (AD) patients (mean age 81) autopsied between 1995 and 1997. Two, 2 cm length coronal sections were taken from mid-convexity dura, parallel to the middle meningeal artery, 3-5 cm below and perpendicular to the superior sagittal sinus (SSS). Sections of twenty-two cases were also taken of the SSS and peri-SSS dura. To screen for possible lymphatics, 52 dural and 22 SSS samples from these cases were evaluated with CD31 and podoplanin (D240) immunohistochemistry. RESULTS: Numerous unlined microscopic channels were found in 101 of 113 (89 %). In non-AD duras, 86 of 92 (93 %) had numerous channels. Duras with AD had significantly less channels i.e. 15 of 21(71 %, P = 0.048). None of the channels had lymphocytes, or neutrophils in their lumena. In the superior sagittal sinus, 9 of 9 non-AD and 12/13 AD SSS duras had fluid channels. Congo red stains revealed no amyloid-like material in the AD duras. Immunohistochemically, CD31 was not found in fluid channels but was in endothelium in 36 of 36 non-AD duras and in most blood vessels including 16 of 16 AD patients. Seven of 36 (19 %) with non-AD and 1 of 16 (6%) with AD had podoplanin in thin walled vessels suggestive of lymphatics but none showed staining in fluid channels. CONCLUSIONS: Unlined fluid channels are present in the dura but not clearly lymphatic.

A Rare Case of Cryptococcus gattii Meningitis in Advanced HIV Disease, Sagittal Thrombosis, and Immune Reconstitution Syndrome, Resolved With Isavuconazonium.

Cryptococcus gattii is a species that has received more recognition in the recent past as distinct from Cryptococcus neoformans. C gattii is known to cause meningeal disease in both immunocompetent and immunosuppressed hosts. Patients may be clinically asymptomatic until immunosuppressive conditions occur such as corticosteroid treatment or an HIV infection. HIV-associated cryptococcal infections are most often due to C neoformans. C gattii is found in a minority. Speciation and subtyping of Cryptococcus are not always accomplished. In many parts of the world, there is no availability for speciation of Cryptococcus. Travel history may provide a clue to the most probable species. This case demonstrates a case of C gattii meningitis with a multiplicity of complications. These include advanced HIV disease secondary to nonadherence, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. The patient represented diagnostic and therapeutic dilemmas over time. Headache was the primary symptom in cryptococcal meningitis, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. All are discussed in detail as potential etiologies for the primary disease. Isavuconazonium is a relatively new broad-spectrum antifungal azole that was used as salvage therapy.

Microsurgical Resection of a Primary Intraosseous Meningioma Encasing the Superior Sagittal Sinus.

Primary intraosseous meningiomas (PIMs) are an infrequent variant of meningiomas characterized by hyperostosis and brain compression. En bloc surgical resection of giant PIMs involving critical structures such as venous sinuses or cranial nerves could be associated with significant morbidity. The objective of this report is to demonstrate the safety and feasibility of piecemeal resection of PIMs involving the superior sagittal sinus and frontal sinus. A 54-year-old female with a large 5 cm thick bifrontal primary intra-osseous meningioma encasing the anterior segment of the superior sagittal sinus and frontal sinus underwent a bifrontal craniotomy with piecemeal microsurgical resection of the lesion, complete frontal sinus exoneration, and a synthetic cranioplasty. Clinical outcome was measured by extent of resection, preservation of cortical draining veins and postoperative course. A Simpson grade I resection of the lesion was achieved following piecemeal resection of the giant PIM without clinical or radiographic evidence of venous infarct or injury. The postoperative course was uncomplicated, and the patient was discharged home 3 days after cranioplasty. A complete resection of a giant bifrontal PIM with superior sagittal sinus encasement and frontal sinus involvement can be achieved safely via a piecemeal approach without significant intra-operative morbidity.

Parasagittal meningiomas.

Parasagittal meningiomas are defined as meningiomas that grow into at least one wall of the superior sagittal sinus. Long- and short-term morbidity is, in addition to cortical function, related to management of venous structures and flow. Clinical management needs to address the extent of removal in the sinus wall and to address relations to the adjacent cortex, which is highly eloquent in the Rolandic and calcarine areas.

Intracranial venous myxoma - An incidental finding.

Myxomas are the commonest type of benign cardiac tumors, however, myxomas of an extracardiac origin are rare. This case report presents the postmortem finding of a myxoma arising in the superior sagittal sinus of a 76-year-old woman in the absence of a cardiac primary tumor.

Remote Leptomeningeal Dissemination in Olfactory Neuroblastoma Mimicking Multiple Parasagittal Meningiomas: Diagnostic and Therapeutic Challenge.

BACKGROUND: Olfactory neuroblastoma (ON) is a highly aggressive and locally recurrent neoplasm. Distant systemic metastases are not uncommon, but remote leptomeningeal dissemination is extremely rare. CASE DESCRIPTION: We report 2 cases of ON previously treated with endoscopic endonasal radical surgical resection and radiotherapy. After a relatively long period of disease-free survival, multiple leptomeningeal lesions were seen around the sagittal sinus giving a radiologic appearance of parasagittal meningiomas. Both patients underwent surgery and multimodal treatment with radiotherapy and chemotherapy for the disseminated disease. Pathologic examination confirmed the parasagittal lesions as metastatic ON. CONCLUSIONS: A high suspicion of secondary disease should be maintained in patients with previous history of ON and parasagittal leptomeningeal enhancing lesion, particularly when multiple lesions are detected around the sagittal sinus. Radical resection and multimodal treatment are warranted to improve long-term outcome. Understanding the venous drainage route as a potential pathway for remote seeding from the primary site of disease has therapeutic implications. We postulate that en-bloc tumor resection and proximal sagittal sinus ligation might reduce potential for leptomeningeal metastasis.

Dural Extranodal Marginal Zone Lymphoma in an XRCC2 Mutation Carrier.

Dural extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is a rare entity without an associated recurrent genetic abnormality. Only one case has been described in a woman with history of breast carcinoma without a known genetic predisposition. Here, we report a case of a 56-year-old woman heterozygous for XRCC2 mutation with a history of Graves' disease and bilateral breast carcinomas, who was found to have a diffusely infiltrative extra-axial mass in the high parietal convexity with infiltration into the adjacent superior sagittal sinus. The morphologic, immunophenotypic, and molecular findings were diagnostic of MALT lymphoma. Staging bone marrow demonstrated involvement by the neoplasm. Although the study was limited to only the clinically significant laboratory evaluation, it may serve as an important addition to the current knowledge of the pathogenic potential of a loss of function mutation in this rarely reported cancer predisposition gene.

Establishment of a Rat Model of Superior Sagittal-Sinus Occlusion and Recanalization via a Thread-Embolism Method.

There are many uncontrollable factors in the pathogenesis of cerebral venous sinus thrombosis (CVST). In order to further explore the pathophysiology and morphology of CVST, it is necessary to establish a highly compatible CVST animal model that can standardize the site and stage of venous thrombosis. The present study employed the insertion of a self-made thread embolism into the superior sagittal sinus (SSS) to establish a rat model of SSS occlusion that emulates CVST. The thread embolism was removed after 6 h of SSS occlusion in order to achieve recanalization. After successful preparation of the model, the cerebral blood flow (CBF) status and ultrastructural changes of the blood-brain barrier (BBB) were monitored. This CVST model was able to achieve continuously high occlusion of SSS. The parasagittal venous-collateral circulation underwent extensive compensation and recombination, which alleviated blood flow stasis and brain tissue hypoxia caused by restricted reflux. Removing SSS occlusion significantly improved cerebral circulation, reduced brain edema, and accelerated the receding of brain edema. This study established a new model of acute occlusion and recanalization of SSS in rats via a thread-embolism method, which standardized the ischemic site and stage of venous thrombosis. In addition, our study suggests that promoting collateral circulation may be a potential treatment for promoting brain protection.

Endovascular stenting of the superior sagittal sinus to alleviate venous compression caused by a parasagittal meningioma.

Idiopathic intracranial hypertension (IIH) is a challenging disease with unclear pathophysiology. Recognition of venous sinus stenting to improve intracranial pressure is increasing.We present a 56-year-old man diagnosed with IIH. A parasagittal meningioma abutting the sagittal sinus causing venous compression was found. Venous sinus stenting via endovascular approach using a WALLSTENT was performed. Intravascular pressures recorded after stenting demonstrated resolution of the pressure gradient.The patient had no complications from the procedure and reported substantial symptomatic improvement. Subsequent ophthalmologic exam demonstrated resolution of the bilateral papilledema noted prior to stenting. Endovascular treatment of venous sinus stenosis in the treatment of IIH is an emerging technique. Treatment of venous compromise due to a mass lesion with stenting is a rarely described concept. For our patient, endovascular stenting was the primary treatment modality, allowing the tumour to be followed with serial imaging.