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Sinus pericranii: diagnostic and therapeutic considerations in 15 patients

  • Paediatric Neuroradiology
  • Published:
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Abstract

Introduction

Sinus pericranii (SP) is a rare, usually asymptomatic condition characterized by a large communication between the intra- and the extracranial venous drainage pathways in which blood may circulate bidirectionally through dilated veins of the skull. We describe our diagnostic and therapeutic experience with SP, with a special focus on the vascular analysis of digital subtraction angiography (DSA).

Methods

DSA images of 15 patients were evaluated with regard to the delay in opacification of the scalp vessels, the absence or distortion of the superficial cortical veins in the vicinity of the SP, the drainage patterns of the superior sagittal sinus, and the degree of maturation of the venous outlets of the brain. SP were classified either as “dominant”, if the main stream of contrast flow used the SP to drain the brain bypassing usual venous outlets, or as “accessory”, if only a small part of the venous outflow occurred through the extradiploic vessels.

Results

All patients presented with a nonpulsatile, soft-tissue mass. The lesion was on the midline in 14 of 15 patients, frontal in 12 patients, and parietal in 2 patients. In 13 patients, associated intracranial venous anomalies were present, eight of which were developmental venous anomalies. Seven patients had a dominant SP, and eight an accessory SP.

Conclusion

SP can be considered the cutaneous sign of an underlying venous anomaly. If treatment is contemplated, analysis of the drainage pattern of the SP has to be performed. Treatment should be avoided in dominant SP or if its accessory role constitutes the only collateral pathway of an underlying venous anomaly.

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Acknowledgements

We would like to thank Prof. Guy Wilms and one anonymous reviewer for their careful reading of the manuscript, their thoughtful comments, and their very helpful suggestions concerning the different definitions of SP.

Conflict of interest statement

We declare that we have no conflict of interest.

Author information

Authors and Affiliations

  1. Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicetre, 78 rue du General Leclerc, 94275, Le Kremlin-Bicêtre, Paris, France

    Carlo Gandolfo, Timo Krings, Hortensia Alvarez, Augustin Ozanne, Carlos E. Baccin, Wen-Yuan Zhao & Pierre Lasjaunias

  2. Departments of Neuroradiology and Interventional Neuroradiology, G. Gaslini Children’s Research Hospital, Genoa, Italy

    Carlo Gandolfo

  3. Departments of Neuroradiology and Neurosurgery, University Hospital Aachen, Aachen, Germany

    Timo Krings & Meike Schaaf

  4. Med Imagem, Hospital Beneficencia Portuguesa, Sao Paulo, Brazil

    Carlos E. Baccin

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  1. Carlo Gandolfo
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  2. Timo Krings
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  3. Hortensia Alvarez
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  4. Augustin Ozanne
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  7. Wen-Yuan Zhao
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  8. Pierre Lasjaunias
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Corresponding author

Correspondence to Pierre Lasjaunias.

Additional information

Carlo Gandolfo and Timo Krings contributed equally to this work.

Appendix: Clinical and imaging questionnaire

Appendix: Clinical and imaging questionnaire

  1. A.

    General assessment

    List of questions for clinical assessment; if an answer is “No” skip to Pretreatment assessment.

    1. AI.

      Clinical assessment

      • Has any other differential diagnosis been excluded (haemangioma, cephalocele, venous malformation, etc)?

      • Is the SP located in a typical midline position?

      • Are cosmetic problems the only complaint? If no, specify (physical, e.g. size, position or associated dermatological problems; clinical, e.g. visual impairment, headache, bleeding, pain)

      • Can the clinical or physical complaints be treated conservatively?

      • Is there any premature syndromic or non-syndromic fusion of the cranial sutures (craniosynostosis, achondroplasia, etc)?

    2. AII.

      Psychological assessment

      • If the cosmetic problem is the main complaint, is the problem tolerable?

      • Can the patient or the patient’s parents understand that treating a venous anomaly is not mandatory and could be associated with a life-threatening risk? Do they agree with the decision to abstain from treatment?

      • Is the psychological, social and academic development of the patient normal?

  2. B.

    Pretreatment assessment

    If treatment (surgical or endovascular) is under consideration, CT (bone window), MRI (angiographic study, MRA) and DSA (studying the late venous phase) must be performed or reviewed; ‘negative’ answers point to abstention from treatment.

    1. BI.

      CT

      • Is the bony communication between the intra- and extracranial compartments subjacent to the SP single and well-marginated?

      • Have phleboliths been searched for and then excluded (within the lesion)?

    2. BII.

      MRI (MRA and phase-contrast sequence for flow-MRI)

      • Is there a no-flow or slow-flow connection between the SP and the intracranial sinus system?

      • Have any associated venous malformations near the SP been excluded?

    3. BIII.

      DSA

      • Is the role of the SP in the global venous drainage accessory (see main text)?

      • If an associated subjacent venous malformation is present, is the role of the SP in the local venous drainage accessory?

      • Are the normal cerebral venous outlets patent?

      • Are the jugular bulbs mature?

    4. C.

      Treatment

      The choice of treatment depends on the physical and clinical features of the SP as well as on the experience of the treating team and the wishes of the patient. Endovascular embolization can be presurgical

      1. CI.

        Surgical. In patients with an uncomplicated, small, thin-linked, soft SP

      2. CII.

        Endovascular. In patients with a wide-linked, large, stretched-out SP

        • Transvenous (gluing and/or coiling)

        • Percutaneous (gluing)

      3. CIII.

        Abstention from treatment

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Gandolfo, C., Krings, T., Alvarez, H. et al. Sinus pericranii: diagnostic and therapeutic considerations in 15 patients. Neuroradiology 49, 505–514 (2007). https://doi.org/10.1007/s00234-007-0211-7

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  • DOI: https://doi.org/10.1007/s00234-007-0211-7

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