Management of a Persistent Oblique Occipital Sinus with Staged Ligation in a Case of Medulloblastoma: A Case Report

<b><i>Introduction:</i></b> A patent persistent occipital sinus (OS) can be seen in 10% of adults. The presence of such a dominant draining OS can present as a challenge for posterior fossa surgeries. Occlusion or division of the sinus can cause venous hypertension, causing a cerebellar bulge or increased intra-op bleeding. <b><i>Case report:</i></b> A 3-and-a-half-year-old female child presented with a vermian medulloblastoma with hydrocephalus. MR venography (MRV) revealed a large patent OS draining from the torcula to the right sigmoid sinus. She underwent a left Frazier’s point VP shunt followed by a midline suboccipital craniotomy for the lesion. The OS was divided during a “Y”-shaped durotomy. Following the sinus ligation, there was a significant cerebellar bulge and excessive bleeding from the lesion. We released cisternal CSF and punctured the tumor cysts to allow the brain bulge to settle. Hemostasis was secured, and surgery was deferred, an augmented duroplasty was done, and bone flap was removed to allow for intracranial pressure decompression. The patient was electively ventilated for 24 h and weaned off gradually. A repeat MRV at 7 days showed the reorganization of the venous outflow at the torcula. Reexploration with tumor resection was done on post-op day 10. The patient recovered well from the surgery and was referred for adjuvant therapy. <b><i>Conclusion:</i></b> Surgeons should carefully analyze venous anatomy before posterior fossa surgeries. The persistent dominant OS, when present, should be taken care of while planning the durotomy. A hypoplastic but persistent transverse sinus allowed us to ligate and divide the OS. By doing a staged division of the sinus, reorganization of the venous outflow from the torcula can be allowed to occur, and the lesion can be resected.

Idiopathic intracranial hypertension with stenosis of a solitary occipital venous sinus treated with stenting

A 47-year-old live kidney-donor woman presented with headaches and blurred vision. Neuro-ophthalmological examination demonstrated papilledema and right eye inferior nasal defect. Brain MRV showed no sinus thrombosis but solitary right venous sinus draining the torcular Herophili to right jugular bulb. Lumbar puncture revealed elevated CSF opening pressure of 40 cm H2O with normal composition. She was diagnosed with idiopathic intracranial hypertension (IIH). She did not tolerate medical management and declined CSF diversion surgery. Cerebral angiography and venography showed venous outflow drainage from torcular Herophili through a solitary occipital sinus which has distal severe stenosis and pressure gradient of 10 mmHg. Balloon angioplasty and stenting of the occipital sinus were performed. Post-stenting, the stenosis and pressure gradient resolved. At 3-months follow-up, her symptoms and papilledema had resolved and CSF opening pressure was normal at 15 cm H2O. Aberrant cerebral venous anatomy may cause IIH and can be treatable with neuroendovascular techniques.

Unique Case Series of Occipital Sinus and Its Thrombosis- A Radiological Marvel

Background: Variations of the dural venous sinuses may result in inaccurate imaging interpretation or complications during surgical approaches. One of these variations reported infrequently is the occipital sinus with an overall incidence of under 10%.When present, it may get thrombosed or become source of intracranial bleeds or pose difficulty during occipital craniotomies. Our review suggests that the thrombosis of this unique venous sinus variant is a rare condition as there are very few case reports of the same. Herein, we present a case series of persistent occipital sinus and the unusual combination of a persistent occipital sinus and its thrombosis. Subjects and Methods: The study included 4 paediatric cases that presented with neonatal seizuressecondary to different underlying aetiologies and in retrospect had either persistent andpatent occipital sinus or a thrombosed occipital sinus. A descriptive study of the aforementioned cases was carried out. MRI scanner PHILIPS Achieva 1.5 Tesla was used for diagnosis. Results: One case had thrombosis of bilateral persistent occipital sinuses and superficial cortical veins with minimal intraventricular haemorrhage in bilateral lateral ventricles.Second case had persistent and thrombosed right occipital sinus; while two other cases had persistent but patent occipital sinuses. Conclusion: A comprehensive knowledge of cerebral venous anatomy and meticulous recognition of venous variations essentially helps when dealing with a pathology, which presents along with a particular venous variation, no matter how rare this combination is.

Additional Assessment of Developed Occipital Sinus Using Intraoperative Indocyanine Green Videoangiography for a Safe Foramen Magnum Decompression—Technical Case Report

BACKGROUND AND IMPORTANCE Although foramen magnum decompression (FMD) with expansive duraplasty is a popular procedure for treating chiari malformation (CM), the common Y-shaped dural incision can lead to a life-threatening cerebral venous circulation disturbance in patients with a developed occipital sinus. Here, we describe the effectiveness of intraoperative indocyanine green video angiography (ICG-VA) for a CM type 1 (CM1) patient with a highly developed unilateral occipital sinus. CLINICAL PRESENTATION A 40-yr-old woman presented with sensory disturbance on the left side of the body. Magnetic resonance imaging (MRI) revealed cerebellar tonsil herniation into the foramen magnum with cervical syringomyelia, and computed tomography additionally revealed skull anomalies: fontanel closure insufficiencies, cranial dysraphism, thin cranial bone, and dentition abnormalities. We diagnosed as symptomatic CM1 with syringomyelia associated with cleidocranial dysplasia, which is a dominantly inherited autosomal bone disease. Cerebral angiography revealed a developed right occipital sinus and hypoplasia of the bilateral transverse sinus. We performed FMD, paying special attention to the developed occipital sinus using ICG-VA to ensure a safe duraplasty. The angiography clearly highlighted a right-sided occipital sinus with a high contrast ratio, and no left-sided occipital sinus was visible. After a dural incision in a unilateral curvilinear fashion was safely completed, expansive duraplasty was performed. The sensory disorders experienced by the patient disappeared postoperatively. Postoperative MRI revealed elevation of the cerebellar tonsil and decreasing of the syringomyelia. CONCLUSION Additional assessment using intraoperative ICG-VA provides useful information for a safe FMD, particularly in patients with complicated cerebral venous circulation anomalies.

Persistent Enlarged Occipital Sinus with Absent Unilateral Transverse Sinus

The occipital sinus may occasionally remain patent, but the incidence is extremely low and observed in less than 10% of cases. A persistent patent occipital sinus (POS) may be associated with other venous sinus abnormality. The absence of transverse sinus in association with POS is an extremely rare condition and not reported yet. The neuroradiologist, neurosurgeons, otolaryngologist, and neurologist must be aware of the possible existence of POS and other associated venous sinus anomaly, as its warrants very crucial modification of surgical planning, selection of appropriate approaches, and, additionally, may also critically limit the extent of surgical exposure of target, and may hinder intended extent of surgical excision of tumor and associated possibility of injury to POS, which may produce catastrophic hemorrhage, brain swelling, and neurosurgical morbidity. The authors report a 35-year-old male who underwent suboccipital craniotomy for right-side giant acoustic schwannoma. Following the raising bone flap, a markedly prominent, turgid, occipital sinus was observed, not placed exactly in the midline but deviated to the right side, causing further restraining of dural opening. Surgical nuances and intraoperative difficulty encountered along with pertinent literature is reviewed briefly.

Features of blood selection in kurchat broilers of different age

Depending on age and live weight in the bird, blood can be taken in different places: by performing a puncture of the shoulder (subclavian), jugular, medial tibial veins, of the occipital sinus, of the heart, and through decapitation in the day-old young. But not all of these methods are practical and suitable for all types and periods of time in the poultry. The article describes two practical methods of life-time selection of blood in chickens-broilers of the cross-breed COBB-500 of different ages. Blood in day-old chicks is taken for the purpose of early diagnosis of deficiency of micro-and macro elements. In chickens that were hatched after 12 hours at a mass of at least 30 grams of blood, they were taken from a right jugular vein with an insulin syringe of 1 ml and then received 0,5-0,6 ml of whey individually from each chicken. Thanks to this, the chick remains alive and after 7 days it allows you to take blood again for further research. A subcutaneous vein subunit for taking blood in broiler chickens after 7 days and up to 17 days is better to use a syringe of 2 ml, as this is less injurious to the vein, but it is better to carry out this procedure with the assistant. It is more practical to make blood collection in chickens from 18 to 42 days using an injection needle with a pink cannula (18 G) and a polypropylene tube with a tufted lid that will allow it to remove up to 5 ml of blood from one bird and get enough serum for it biochemical studies. An important stage in the diagnosis of internal bird diseases, in particular metabolic etiology, is blood research. This allows us to diagnose the subclinical stages of illness associated with an imbalance of metabolic processes in an organism of productive and exotic birds. Therefore, one of the important measures in the establishment and confirmation of the diagnosis, as well as the study of the effectiveness of therapeutic treatments – is the selection of blood. Anatomical features of the body structure of various types of agricultural and exotic birds require the modification and modernization of blood selection technologies and make adjustments to the selection of the appropriate sites for manipulation. Blood in the bird collapses fast enough – 20-30 seconds, which makes it impossible to remove enough of it in young birds. In order to obtain the required volume of quality blood and its serum, it is necessary to take into account the age, physiological and productive qualities of birds. The most recent features were the development of new and improved existing methods of blood sampling in poultry. In the bird, blood can be taken by performing a puncture of the shoulder (subclavian), jugular, medial tibial veins, of the occipital sinus, of the puncture of the heart, and of the decapitation in a day-old youngster. The bird has a relatively small percentage of blood volume by weight, approximately 6-7,5%. The amount of blood that can be taken will depend on the weight of the bird, the skill of the researcher and the rate of blood coagulation. It is not necessary to take more than 1% of the blood from the body weight or 10% of the total blood volume, and the next selection is desirable to do not earlier than 14 days. Also, after the selection, hematoma may develop, which may lead to vascular collapse, so it is advisable to introduce warm isotonic solutions. Blood was taken with a 1 ml insulin syringe with a removable needle (29 g) from the right jaw vein. The jugular vein is the largest peripheral vein in the bird, in smaller species and chickens, this may be the only large enough place to select a significant amount of blood for diagnostic testing. The puncture was carried out in day-old chicks, 12 hours after hatching. Before the blood was taken, a clinical examination was performed, and weighing chickens. In those whose body weight was less than 30 grams blood was not taken. Fixed the chick in the left hand a little while turning to the left side, holding his neck between the index and the without limbs, pressing the chicken body with his thumb to the palm, thus best visualizing the jugular vein. At the site of the puncture, a fluff was pulled out and rubbed with 70% ethyl alcohol. Then gently at an angle of 10-20 ° the needle was injected into the vein and the blood was drawn slowly. As a rule, when a needle is correctly placed in the vein, the blood begins to fill the syringe reservoir. When selecting a syringe, use the thumb and forefinger, and slowly pull the syringe piston gently without tilting the needle. If the blood does not enter the syringe, the beveled edge may be against the vein or the needle may get stuck. Gently release the pressure on the piston and slightly bend the tip. Injecting needles, needleless needles or syringes of 2-10 ml may be used for venous puncture. To prevent blood coagulation, the lumen of the needle can be pre-moistened with a 5% solution of heparin. Blood can be taken from glass, polypropylene or fluoroplastic test tubes. Key words: broilers chickens, blood selection, jugular vein, subcrine vein.