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Lateral sinus pericranii
Surg Neurol 1986;25:487-90
487
Lateral Sinus Pericranii Junichi Nozaki, M.D., Hirokazu Kawano, M.D., Masanori Kabuto, M.D., Kazuo Hirose, M.D., and Minoru Hayashi, M.D. Department of Neurosurgery, Kaga Central Hospital, Kaga, Ishikawa, Japan, and Department of Neurosurgery, Fukui Medical School, Matsuoka, Fukui, Japan
Nozaki J, Kawano H, Kabuto M, Hirose K, Hayashi M. Lateral sinus pericranii. Surg Neurol 1986;25:487-90.
Most reported cases of sinus pericranii have been situated near the midline. This report describes a case of laterally situated sinus pericranii and discusses its origin. KEYWORDS: Lateral sinus pericranii; Diploic vein; Congenital; Treatment
Since the first report of sinus pericranii by H e c k e r in 1845 [4], this lesion has been reported many times in the literature. In most cases, the lesion is located near the midline. We have, however, observed a case of a laterally situated sinus pericranii with abnormally developed diploic veins.
about 5 cm from the midline, a small area of thinning was observed in the right frontal bone. On the lateral view, markedly developed diploic veins showing a mosaic pattern were observed in the parietal and frontal bone. Computed tomography revealed that the tumor was slightly more enhanced than the brain. Under the tumor, a depression and a small channel through the skull were found (Figure 1). Selective angiographic studies of both internal and external carotid arteries showed no abnormalities. Needle aspiration of the tumor demonstrated venous blood, and did not alter the size of the tumor. Direct injection of contrast medium showed an epicranial varix, diploic veins, and several channels of communication into the sphenoparietal sinus via the middle meningeal veins. A small outflow into the extracranial venous circulation was also found (Figure 2). Operation
Case Report A 2-year-old girl was in good health until the age of 1.5 years. At that time, her mother noticed a soft mass on her head in the right frontal region that appeared when the girl cried and disappeared when the girl stood. Although her mother reported the girl had struck her head many times while learning to walk, she had no history of skull fractures, severe head trauma, or a tendency to bleed. She was born at full term without any injury. On examination, with the patient recumbent, a 3 x 3-cm tumor was observed in the lateral frontal region. The tumor was soft, fluctuant, and completely reducible by compression with the fingers. When the patient stood, the tumor would disappear. Although there were no abnormalities of the skin over the tumor, a depressed area could be palpated in the skull at the site of the tumor. On the anteroposterior plain x-ray film of the skull,
Address reprint requests to: Junichi Nozaki, M.D., Department of Neurosurgery, Kaga Central Hospital, Daishoji, Kaga, Ishikawa 922, Japan.
© 1986 by ElsevierSciencePublishing Co., Inc.
The tumor was located beneath the galea, and was carefully detached from the surrounding periosteum. During this procedure, many tiny vascular connections were dissected. Five orifices in the skull were observed after removal of the tumor. Bleeding from these openings was controlled with bone wax. A part of the depressed area shown in the radiologic study was covered with periosteum (Figure 3). Histologically, the inner surface of the cyst was lined with endothelium. There were no muscles around the cyst (Figure 4). Discussion Reducible tumors beneath the scalp usually have communication with either the intracranial venous systems or the subarachnoid space. O f tumors connecting with the intracranial venous system, Volkman [ 13] classified two types of sinus pericranii: "true" and "pseudo." H e defines true sinus pericranii as a blood-filled cyst, which fills with increased intracranial pressure and disappears completely with the compression of the tumor. Pseudosinus pericranii, however, is a tumor consisting of a 0090-3019/86/$3.50
488
Surg Neurol 1986;25:487-90
Nozaki et al
Figure 2. Injection of contrast medium into the tumor shows a varix and abnormally developed diploic veins with anterior and posterior stars, These usually become manifest at about 5 years of age. A sphenoparietal sinus is shown, which is filled with contrast medium via the middle meningeal veins.
A
Figure 1. Computed tomography reveals that there is no connection between the cerebral circulation and the tumor (A). The tumor is slightly more enhanced than the brain. The outer surface of the skull is depressed, and one of the channels through the skull is observed (B).
hemangioma or a cavernoma, mainly o f venous components. In the latter case, the t u m o r does not disappear completely with compression. N e w t o n and Troost [ 10] believe the tumor to be a venous malformation, and classified three groups: varix communicans, varix herniosus sagittalis, and varix spurius communicans. H e described varix communicans as a typical communication between the extracranial and intracranial venous circulations via large, tortuous, thin-walled vascular channels. These channels communicate between the extracranial lesion and the intracranial venous systems, either directly or by way of dural veins. Ohta et al [11] defined sinus pericranii as "a mass o f nonmuscular venous blood vessels or a venous hemangioma which adheres tightly to the outer surface o f the skull, in which there is found direct communication with the intracranial venous sinus via a multitude of diploic veins o f various size." O u r case had communication with the intracranial venous circulation system, and several openings in the skull. Markedly developed diploic veins were found anterior and posterior to the extracranial lesion. These findings may m e e t the requirements for diagnosis of sinus pericranii [11], and may also be considered as a varix communicans [ 10]. Diploic veins usually become apparent at about 5 years of age [5]. Angiographically and in the skull films, our case showed abnormally developed veins. H o w e v e r , the mosaic patterns of diploic veins are similar to those found in x-ray films of the adult skull, in which diploic veins show anterior and posterior stars [7]. In our case, the outer surface of the skull was depressed on com-
Lateral Sinus Pericranii
Surg Neurol 1986;25:487-90
489
A
Figure 3. (A) The varix in the subgaleal space. (B) After removal of the varix, the depressed area in the skull is revealed. In this area, five orifices of channels connecting varix, diploic veins, and cranial venous circulations are seen (arrows). Part of the depressed area is covered with pericranium.
Figure 4. Histologic study shows that the inner wall of the varix is lined with endothelial cells (arrow). (Anti-Factor VIII PAP stain x I00.)
490
Surg Neurol 1986;25:487-90
puted tomography, and operative findings showed some part of this lesion covered with pericranium. Many etiologies for sinus pericranii have been proposed. One of them is head trauma. Hahn [2] described in detail the histologic appearance of a typical sinus pericranii, and concluded that the condition follows minor head trauma. Research on a similar disorder, posttraumatic subepicranial varix, shows that although this varix has channels with diploic veins, there is no sign of communication with the intracranial circulation [8]. In addition, these varices were situated laterally, not near the midline. A spontaneous or congenital origin of sinus pericranii has also been considered. The possibility of spontaneous occurrence due to a rarefying osteitis originating from the resorptive action of a pacchionian granulation has been proposed [6]. With regard to congenital origin, Newton and Troost [10] stated that it is most common and that congenital sinus pericranii is usually observed with other vascular formations such as venous angiomas, aneurysmal malformations of the internal cerebral vein [9], or venous angiomas of the gastrointestinal tract [12]. Sometimes the skin over the anomalies is hairless and bluish. Pathophysiologically, congenital sinus pericranii includes unusually rich and multiple channels between the intracranial venous circulation and the cranial vault [10]. Determining the origin of this lesion is difficult, and a histologic examination is necessary. According to Cohn [ 1], the endothelial lining of the wall of a sinus pericranii differentiates the congenital from the acquired types, which have a connective tissue lining. In this case, the inner surface of the cyst was lined with endothelial cells, and the lesion was diagnosed as congenital. Although spontaneous regression of sinus pericranii has been reported [3], cosmetic surgery as well as surgical procedures to prevent massive hemorrhage and traumatic air emboli must be considered. Most instances of sinus pericranii are located near the midline and are common in the frontal region. They
Nozaki et al
appear less often in the parietal and occipital regions. A lateral location, as in our case, is highly unusual.
References 1. Cohn I. Sinus pericranii (Stromeyer). Report of a case; review of the literature. Surg Gynecol Obstet 1926;42:614-24. 2. Hahn V. Sinus pericranii (reducible blood tumor of the cranium). Its origin and its relation to hemangioma and abnormally arteriovenous communication; report of a case. Arch Surg 1928;16:31-43. 3. Hayakawa I, Fujiwara K, Sasaki A, Hirata T, Yanagibashi K, Tsuchida T. Spontaneous regression of sinus pericranii. Report of a case. No Shinkei Geka 1978;6:91-5. 4. Hecker CF. Erfahrungen und Abhandlungen im Gebiete der Chirurgie und Augenheilkunde. Cited in ref. 11. 5. Lindblom K. A roentgenographic study of the vascular channels of the skull. Acta Radiol (Stockh) 1936;30(suppl). 6. Mastin WM. Venous blood tumors of the cranium in communication with the intracranial venous circulation, especially the sinuses of the dura mater. JAMA 1886;7:309-20. 7. Meschan I. The normal adult cranial vault. Semin Roentgenol 1974;9:125-36. 8. Mori K, Yoneda S, Handa H. Posttraumatic subepicranial varix. Surg Neurol 1976;5:337-9. 9. Nakayama T, Matsukado Y. Sinus pericranii with aneurysmal malformation of the internal cerebral vein. Surg Neurol 1975;3:133-7. 10. Newton TH, Troost BT. Arteriovenous malformations and fistulae. In: Newton TH, Ports DG, eds. Radiology of the skull and brain. Vol 4, book 2, St. Louis: CV Mosby, 1974;2490-565. 11. Ohta T, Waga S, Handa H, Nishimura S, Mitani T. Sinus pericranii. J Neurosurg 1975;42:704-12. 12. Sherry R, Walker M, Olds M. Sinus pericranii and venous angioma in the blue-rubber bleb nevus syndrome. AJNR 1984;5:832-4. 13. Volkmann J. Ein Beitrag zum sogenannten Sinus pericranii (Stromeyer). Zentralbl Chir 1950;75:1389-94.
Editor's Note: The accompanying article by Nozaki and his associates describes the surgical removal of a lateral sinus pericranii. The editors of SURGICAL NEUROLOGY have encountered similar lesions, but have elected not to remove them as it is their experience that they cause no trouble and disappear spontaneously. PAUL C. BUCY, M.D., Editor
487
Lateral Sinus Pericranii Junichi Nozaki, M.D., Hirokazu Kawano, M.D., Masanori Kabuto, M.D., Kazuo Hirose, M.D., and Minoru Hayashi, M.D. Department of Neurosurgery, Kaga Central Hospital, Kaga, Ishikawa, Japan, and Department of Neurosurgery, Fukui Medical School, Matsuoka, Fukui, Japan
Nozaki J, Kawano H, Kabuto M, Hirose K, Hayashi M. Lateral sinus pericranii. Surg Neurol 1986;25:487-90.
Most reported cases of sinus pericranii have been situated near the midline. This report describes a case of laterally situated sinus pericranii and discusses its origin. KEYWORDS: Lateral sinus pericranii; Diploic vein; Congenital; Treatment
Since the first report of sinus pericranii by H e c k e r in 1845 [4], this lesion has been reported many times in the literature. In most cases, the lesion is located near the midline. We have, however, observed a case of a laterally situated sinus pericranii with abnormally developed diploic veins.
about 5 cm from the midline, a small area of thinning was observed in the right frontal bone. On the lateral view, markedly developed diploic veins showing a mosaic pattern were observed in the parietal and frontal bone. Computed tomography revealed that the tumor was slightly more enhanced than the brain. Under the tumor, a depression and a small channel through the skull were found (Figure 1). Selective angiographic studies of both internal and external carotid arteries showed no abnormalities. Needle aspiration of the tumor demonstrated venous blood, and did not alter the size of the tumor. Direct injection of contrast medium showed an epicranial varix, diploic veins, and several channels of communication into the sphenoparietal sinus via the middle meningeal veins. A small outflow into the extracranial venous circulation was also found (Figure 2). Operation
Case Report A 2-year-old girl was in good health until the age of 1.5 years. At that time, her mother noticed a soft mass on her head in the right frontal region that appeared when the girl cried and disappeared when the girl stood. Although her mother reported the girl had struck her head many times while learning to walk, she had no history of skull fractures, severe head trauma, or a tendency to bleed. She was born at full term without any injury. On examination, with the patient recumbent, a 3 x 3-cm tumor was observed in the lateral frontal region. The tumor was soft, fluctuant, and completely reducible by compression with the fingers. When the patient stood, the tumor would disappear. Although there were no abnormalities of the skin over the tumor, a depressed area could be palpated in the skull at the site of the tumor. On the anteroposterior plain x-ray film of the skull,
Address reprint requests to: Junichi Nozaki, M.D., Department of Neurosurgery, Kaga Central Hospital, Daishoji, Kaga, Ishikawa 922, Japan.
© 1986 by ElsevierSciencePublishing Co., Inc.
The tumor was located beneath the galea, and was carefully detached from the surrounding periosteum. During this procedure, many tiny vascular connections were dissected. Five orifices in the skull were observed after removal of the tumor. Bleeding from these openings was controlled with bone wax. A part of the depressed area shown in the radiologic study was covered with periosteum (Figure 3). Histologically, the inner surface of the cyst was lined with endothelium. There were no muscles around the cyst (Figure 4). Discussion Reducible tumors beneath the scalp usually have communication with either the intracranial venous systems or the subarachnoid space. O f tumors connecting with the intracranial venous system, Volkman [ 13] classified two types of sinus pericranii: "true" and "pseudo." H e defines true sinus pericranii as a blood-filled cyst, which fills with increased intracranial pressure and disappears completely with the compression of the tumor. Pseudosinus pericranii, however, is a tumor consisting of a 0090-3019/86/$3.50
488
Surg Neurol 1986;25:487-90
Nozaki et al
Figure 2. Injection of contrast medium into the tumor shows a varix and abnormally developed diploic veins with anterior and posterior stars, These usually become manifest at about 5 years of age. A sphenoparietal sinus is shown, which is filled with contrast medium via the middle meningeal veins.
A
Figure 1. Computed tomography reveals that there is no connection between the cerebral circulation and the tumor (A). The tumor is slightly more enhanced than the brain. The outer surface of the skull is depressed, and one of the channels through the skull is observed (B).
hemangioma or a cavernoma, mainly o f venous components. In the latter case, the t u m o r does not disappear completely with compression. N e w t o n and Troost [ 10] believe the tumor to be a venous malformation, and classified three groups: varix communicans, varix herniosus sagittalis, and varix spurius communicans. H e described varix communicans as a typical communication between the extracranial and intracranial venous circulations via large, tortuous, thin-walled vascular channels. These channels communicate between the extracranial lesion and the intracranial venous systems, either directly or by way of dural veins. Ohta et al [11] defined sinus pericranii as "a mass o f nonmuscular venous blood vessels or a venous hemangioma which adheres tightly to the outer surface o f the skull, in which there is found direct communication with the intracranial venous sinus via a multitude of diploic veins o f various size." O u r case had communication with the intracranial venous circulation system, and several openings in the skull. Markedly developed diploic veins were found anterior and posterior to the extracranial lesion. These findings may m e e t the requirements for diagnosis of sinus pericranii [11], and may also be considered as a varix communicans [ 10]. Diploic veins usually become apparent at about 5 years of age [5]. Angiographically and in the skull films, our case showed abnormally developed veins. H o w e v e r , the mosaic patterns of diploic veins are similar to those found in x-ray films of the adult skull, in which diploic veins show anterior and posterior stars [7]. In our case, the outer surface of the skull was depressed on com-
Lateral Sinus Pericranii
Surg Neurol 1986;25:487-90
489
A
Figure 3. (A) The varix in the subgaleal space. (B) After removal of the varix, the depressed area in the skull is revealed. In this area, five orifices of channels connecting varix, diploic veins, and cranial venous circulations are seen (arrows). Part of the depressed area is covered with pericranium.
Figure 4. Histologic study shows that the inner wall of the varix is lined with endothelial cells (arrow). (Anti-Factor VIII PAP stain x I00.)
490
Surg Neurol 1986;25:487-90
puted tomography, and operative findings showed some part of this lesion covered with pericranium. Many etiologies for sinus pericranii have been proposed. One of them is head trauma. Hahn [2] described in detail the histologic appearance of a typical sinus pericranii, and concluded that the condition follows minor head trauma. Research on a similar disorder, posttraumatic subepicranial varix, shows that although this varix has channels with diploic veins, there is no sign of communication with the intracranial circulation [8]. In addition, these varices were situated laterally, not near the midline. A spontaneous or congenital origin of sinus pericranii has also been considered. The possibility of spontaneous occurrence due to a rarefying osteitis originating from the resorptive action of a pacchionian granulation has been proposed [6]. With regard to congenital origin, Newton and Troost [10] stated that it is most common and that congenital sinus pericranii is usually observed with other vascular formations such as venous angiomas, aneurysmal malformations of the internal cerebral vein [9], or venous angiomas of the gastrointestinal tract [12]. Sometimes the skin over the anomalies is hairless and bluish. Pathophysiologically, congenital sinus pericranii includes unusually rich and multiple channels between the intracranial venous circulation and the cranial vault [10]. Determining the origin of this lesion is difficult, and a histologic examination is necessary. According to Cohn [ 1], the endothelial lining of the wall of a sinus pericranii differentiates the congenital from the acquired types, which have a connective tissue lining. In this case, the inner surface of the cyst was lined with endothelial cells, and the lesion was diagnosed as congenital. Although spontaneous regression of sinus pericranii has been reported [3], cosmetic surgery as well as surgical procedures to prevent massive hemorrhage and traumatic air emboli must be considered. Most instances of sinus pericranii are located near the midline and are common in the frontal region. They
Nozaki et al
appear less often in the parietal and occipital regions. A lateral location, as in our case, is highly unusual.
References 1. Cohn I. Sinus pericranii (Stromeyer). Report of a case; review of the literature. Surg Gynecol Obstet 1926;42:614-24. 2. Hahn V. Sinus pericranii (reducible blood tumor of the cranium). Its origin and its relation to hemangioma and abnormally arteriovenous communication; report of a case. Arch Surg 1928;16:31-43. 3. Hayakawa I, Fujiwara K, Sasaki A, Hirata T, Yanagibashi K, Tsuchida T. Spontaneous regression of sinus pericranii. Report of a case. No Shinkei Geka 1978;6:91-5. 4. Hecker CF. Erfahrungen und Abhandlungen im Gebiete der Chirurgie und Augenheilkunde. Cited in ref. 11. 5. Lindblom K. A roentgenographic study of the vascular channels of the skull. Acta Radiol (Stockh) 1936;30(suppl). 6. Mastin WM. Venous blood tumors of the cranium in communication with the intracranial venous circulation, especially the sinuses of the dura mater. JAMA 1886;7:309-20. 7. Meschan I. The normal adult cranial vault. Semin Roentgenol 1974;9:125-36. 8. Mori K, Yoneda S, Handa H. Posttraumatic subepicranial varix. Surg Neurol 1976;5:337-9. 9. Nakayama T, Matsukado Y. Sinus pericranii with aneurysmal malformation of the internal cerebral vein. Surg Neurol 1975;3:133-7. 10. Newton TH, Troost BT. Arteriovenous malformations and fistulae. In: Newton TH, Ports DG, eds. Radiology of the skull and brain. Vol 4, book 2, St. Louis: CV Mosby, 1974;2490-565. 11. Ohta T, Waga S, Handa H, Nishimura S, Mitani T. Sinus pericranii. J Neurosurg 1975;42:704-12. 12. Sherry R, Walker M, Olds M. Sinus pericranii and venous angioma in the blue-rubber bleb nevus syndrome. AJNR 1984;5:832-4. 13. Volkmann J. Ein Beitrag zum sogenannten Sinus pericranii (Stromeyer). Zentralbl Chir 1950;75:1389-94.
Editor's Note: The accompanying article by Nozaki and his associates describes the surgical removal of a lateral sinus pericranii. The editors of SURGICAL NEUROLOGY have encountered similar lesions, but have elected not to remove them as it is their experience that they cause no trouble and disappear spontaneously. PAUL C. BUCY, M.D., Editor