Acute-onset diplopia from intracranial hypertension due to torcular herophili obstruction by an hemorrhagic intradiploic epidermoid cyst

Background: Epidermoid cysts are benign slow-growing congenital lesions, constituting approximately 1% of all cranial tumors. Most of these lesions are located intradurally, while about 10–25% of them are located within the diploic spaces. Intradiploic epidermoid cysts are usually discovered incidentally and may remain asymptomatic for many years, but in rare instances, they may grow intracranially and produce brain compression. Sometimes, intradiploic epidermoid cysts may occlude the main cranial venous sinuses causing intracranial hypertension. Case Description: We present the case of a 24-year-old male harboring a paramedian right occipital intradiploic cyst with erosion of both outer and inner bony tables, which occluded the torcular herophili producing a worsening symptomatology with acute-onset diplopia from right sixth cranial nerve palsy; the patient also presented bilateral papilledema, but only reported mild headache and dizziness. Neuroradiological studies evidentiated a lesion compatible with intradiploic epidermoid cyst with intralesional hemorrhagic component, overlying and almost completely occluding the torcular herophili. Considering the fast worsening of symptomatology and the evidence of intracranial hypertension, the patient was operated on immediately after completion of clinical and radiological assessment. The lesion was radically removed with almost immediate reversal of signs and symptoms. Histopathology confirmed the diagnosis of epidermoid cyst with intralesional hemorrhagic components. Conclusion: Intradiploic epidermoid cysts may cause intracranial hypertension by occlusion of main cranial venous sinuses; intralesional hemorrhage may act as precipitating factor in occlusion of the torcular herophili, producing rapidly worsening intracranial hypertension, which requires prompt surgical treatment to reverse symptomatology. Radical surgical resection is necessary to avoid recurrence.

Depressed Skull Fracture over Cranial Venous Sinuses

Background Depressed skull fracture overlying venous sinuses deserves a special attention among skull fractures. It puts high demand on every neurosurgeon, as the management of this kind of trauma carry high risk of mortality. It is considered as one of the most dangerous complications of head injuries. Either it is due to fatal venous bleeding, or disturbing the intracranial pressure via thrombosis or stenosis. Therefore, knowledge of appropriate treatment of this kind of head injury is essential. Moreover, it should always be treated with high cautions. Aim of the Work This study aims at reviewing available scientific data based on clinical trials about the proper management approaches for the treatment of depressed skull fractures overlying major cranial venous sinuses. Either through surgery or medical and conservative management. Patients and Methods The study review yielded 22 relevant papers, with a total number of 85 patients. These patients presented to different institutes, at the period between 1996 and 2017. Diagnosed with depressed skull fracture overlying major venous sinuses. The cases divided according to the way of management as follow: 72% of patients treated with surgical approaches. While 28% of patients treated with conservative care. Results In total surgical intervention showed to be successful in 53 patients, out of 85 patients included in the study, without any intraoperative complication of bleeding. While 6 patients passed away during the surgical interventions. On the other hand, 18 patients who treated conservatively did not need any further intervention. While 2 studies reported the need of medication following surgery. Furthermore, 6 studies reported failure of conservative management, and needed urgent surgical elevation of the depressed fragment that compressing the sinus. Based on the results, the mortality rate over all was 7%; death was mainly due to inability to control the profusely bleeding from the injured sinuses. With a success rate over the surgical cases in 87%. While it was 75% over the conservative cases. However, this pooled data need further statistical analysis to obtain guiding evidence for current practice. Conclusions Clinical decision making must be tailored to each patient independently. In the presence of clinical and radiographic evidence of sinus occlusion surgery is preferred. In such instances where there is a clear need for surgery, adequate precautions should be taken, and an expertise in neurotrauma should always be available. Delayed intracranial hypertension is a possible complication and should always be considered in all patients.

Cranial venous sinus dominance: what to expect? Analysis of 100 cerebral angiographies

ABSTRACT We report an analysis of the cranial venous sinuses circulation, emphasizing morphological and angiographic characteristics. Methods Data of 100 cerebral angiographies were retrospectively analyzed (p = 0.05). Results Mean age was 56.3 years, 62% female and 38% male. Measurements and dominance are shown in the Tables. There was no association between age or gender and dominance. Right parasagittal division of the superior sagittal sinus was associated with right dominance of the transverse sinus, sigmoid sinus and internal jugular vein; and left parasagittal division of the superior sagittal sinus was associated with left dominance of the transverse sinus, sigmoid sinus and internal jugular vein. Conclusion A dominance pattern of cranial venous sinuses was found. Age and gender did not influence this pattern. Angiographic findings, such as division of the superior sagittal sinus, were associated with a pattern of cranial venous dominance. We hope this article can add information and assist in preoperative venous analysis for neurosurgeons and neuroradiologists.

Occipital Emissary Foramina in South Indian Modern Human Skulls

An occipital emissary foramen has been traditionally described as a foramen present in the squamous part of the occipital bone at the occipital protuberance transmitting a vein that connects the confluence of sinuses with the occipital vein. The present study was done on 221 South Indian adult modern human skulls of unknown sex in the Department of Anatomy, St John’s Medical College, Bangalore, India. The foramen was observed in 21/221 (9.50%) skulls, 6/21 (28.57%) to the right of, 10/21 (47.61%) to the left of, and 2/21 (9.52%) on the External Occipital Crest. It was seen more often near the posterior margin of foramen magnum rather than at the External Occipital Protuberance as has been traditionally described. A new finding is that bilateral foramina were observed in 3 skulls (14.28%). The incidence was higher than seen in other Indian population. Since it is present near the foramen magnum in most cases, knowledge of the number and position of the foramen is important for suboccipital craniotomies. The extensive connections of the veins with cranial venous sinuses may lead to intracranial infections and vice versa.

Cerebrospinal Fluid Transport: a Lymphatic Perspective

The textbook view that projections of the arachnoid membrane into the cranial venous sinuses represent the primary cerebrospinal fluid (CSF) absorption sites seems incompatible with many clinical and experimental observations. On balance, there is more quantitative evidence suggesting a function for extracranial lymphatic vessels than exists to support a role for arachnoid villi and granulations in CSF transport.