Endovascular treatment of cerebral venous thrombosis.

The article describes a clinical case of cerebral venous thrombosis involving the deep venous system in a 42-year-old patient suffering from acute lymphoblastic leukemia. As the patient’s condition progressively deteriorated despite anticoagulant therapy, endovascular treatment was attempted. Transvenous thrombectomy and local thrombolysis were performed, which made it possible to achieve only partial recanalization. Further prolonged administration of alteplase into the cerebral sinus through a microcatheter facilitated complete recanalization of the direct and transverse sinuses. The restoration of blood flow was accompanied by regression of neurological deficit. This case is discussed in the context of modern approaches to endovascular treatment of cerebral venous thrombosis.

The sentinel node invasion level (SNIL) as a prognostic parameter in melanoma

Sentinel lymph node (SN) tumor burden is becoming increasingly important and is likely to be included in future N classifications in melanoma. Our aim was to investigate the prognostic significance of melanoma infiltration of various anatomically defined lymph node substructures. This retrospective cohort study included 1250 consecutive patients with SN biopsy. The pathology protocol required description of metastatic infiltration of each of the following lymph node substructures: intracapsular lymph vessels, subcapsular and transverse sinuses, cortex, paracortex, medulla, and capsule. Within the SN with the highest tumor burden, the SN invasion level (SNIL) was defined as follows: SNIL 1 = melanoma cells confined to intracapsular lymph vessels, subcapsular or transverse sinuses; SNIL 2 = melanoma infiltrating the cortex or paracortex; SNIL 3 = melanoma infiltrating the medulla or capsule. We classified 338 SN-positive patients according to the non-metric SNIL. Using Kaplan–Meier estimates and Cox models, recurrence-free survival (RFS), melanoma-specific survival (MSS) and nodal basin recurrence rates were analyzed. The median follow-up time was 75 months. The SNIL divided the SN-positive population into three groups with significantly different RFS, MSS, and nodal basin recurrence probabilities. The MSS of patients with SNIL 1 was virtually identical to that of SN-negative patients, whereas outgrowth of the metastasis from the parenchyma into the fibrous capsule or the medulla of the lymph node indicated a very poor prognosis. Thus, the SNIL may help to better assess the benefit-risk ratio of adjuvant therapies in patients with different SN metastasis patterns.

The Investigation of the Diagnostic Values of the T2WI Sequence in Cerebral Venous Sinuses Thrombosis in Comparison With 3D MRV

Cerebral venous sinus thrombosis is an important pathology with various clinical symptoms. Early detection of thrombosis is very important for the improvement of the prognosis. The aim of this study was to calculate the diagnostic value of T2-weighted sequences of magnetic resonance imaging (MRI) in detecting subacute thrombosis. All patients that were suspected of having subacute cerebral venous sinus thrombosis and were referred to the emergency center of Kashani hospital (between September 2018 and September 2019) were entered into the study. Magnetic resonance venography (MRV) and T2-weighted MRI were accomplished for each patient. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of MRI using MRV as the reference method were calculated. A total of 630 patients were entered into the study. A positive subacute venous sinus thrombosis was detected in the MRV of 53 patients; consequently, the sensitivity of 60%, the specificity of 80%, the PPV of 21%, and the NPV of 96% were calculated. MRI was highly specific for detecting the subacute thrombosis of superior sagittal sinus, transverse sinuses, sigmoid sinuses, and straight sinus (specificity>94%). A substantial agreement was detected between MRI and MRV in distinguishing thrombosis of superior sagittal sinus, transverse sinuses, sigmoid sinuses, and straight sinus (kappa>0.6). T2-weighted MRI is a specific method in detecting cerebral venous sinus thrombosis. In a patient with signs of thrombosis in the T2-weighted sequence, additional workups are highly suggested to rule out the pathology.

Dynamic nature of intracranial venous sinuses in idiopathic intracranial hypertension

There is increasing interest in venous sinus stenting in patients with idiopathic intracranial hypertension who are refractory to medical therapy. Often the transverse sinus stenoses are bilateral, however, and there is no clear evidence for whether we should stent one or both sides in these patients. Our practice is to first stent one side, and in this brief case report, we demonstrate complete resolution of the contralateral stenosis in one such patient who underwent stenting. Her symptoms also completely resolved, and so this case highlights the dynamic fluctuant nature of the transverse sinuses.

Concurrent Venous Stenting of the Transverse and Occipito-Marginal Sinuses: An Analogy with Parallel Hemodynamic Circuits

ABSTRACTNonthrombotic intracranial venous occlusive disease (NIVOD) has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH) and various non-IIH headache syndromes. Endovascular stenting of stenotic, dominant transverse sinuses (TSs) may reduce trans-stenosis pressure gradients, decrease intracranial pressure, and alleviate symptoms in a subset of NIVOD patients. We present a case in which concurrent stenting of the occipito-marginal sinus obliterated the residual trans-stenosis pressure gradient across an initially stented dominant TS. We hypothesize that this observation may be explained using an electric-hydraulic analogy, and that this patient’s dominant TS and occipito-marginal sinus may be modeled as a parallel hemodynamic circuit. Neurointerventionalists should be aware of parallel hemodynamic drainage patterns and consider manometry and possibly additional stenting of stenotic, parallel venous outflow pathways if TS stenting alone fails to obliterate the trans-stenosis pressure gradient.

Morphometric Relationship of the Transverse Sinus with Sigmoid Sinus Groove and Jugular Foramen

Cranial venous sinus anatomy is fundamental in neurosurgery and radiology, especially in surgical planning and treatment of neurological diseases. In this study, we aimed to study the morphometric relationship of the transverse sinus with sigmoid sinus groove and jugular foramen and imply if this relationship could aid in diagnosing the transverse sinus thrombosis. This is a retrospective analytical study conducted in our center among 30 patients who underwent Computed Tomography (CT) venogram during a period of 1 year. Diameter of transverse sinus and sigmoid groove at midpoint, and diameter of jugular foramen as it enters the skull base were collected. Relation of transverse sinus with sigmoid sinus groove and jugular foramen was analyzed. There were 60 transverse sinuses in the study with left and right being 50% (30 each). Mean age of patients collected was 53.20 years. There were 43.3% male and 56.7% female patients. Diameter of the Transverse sinus has statistically significantly linear relationship with the diameter of the sigmoid sinus groove and jugular foramen (p<0.001) and was positively correlated (r= 0.651 and 0.624 respectively). Diameter of the transverse sinus has significant positive linear correlation with the sigmoid sinus groove and jugular foramen.

Piezosurgery—A Safe Technique to Perform Lateral Suboccipital Craniotomy?

BACKGROUND Piezosurgery (PS) is a relatively new technique based on microvibrations generated by the piezoelectric effect. It selectively cuts bone tissue and preserves the surrounding soft tissue. OBJECTIVE To evaluate the use of PS for performing lateral suboccipital craniotomy. METHODS PS was used to perform a lateral suboccipital craniotomy in 22 patients who underwent surgery for different cerebellopontine angle (CPA) pathologies in the neurosurgical department. The applicability of PS for lateral suboccipital craniotomy was evaluated with respect to safety, preciseness of bone cutting, and in particular the preservation of the adjacent dura and sigmoid and transverse sinuses. RESULTS Lateral suboccipital craniotomy in 22 patients who underwent surgery for different CPA pathologies (13 vestibular schwannoma, 5 petrous bone meningioma, 1 petroclival meningioma, 2 epidermoid cysts, and 1 petrous bone cholesterol granuloma) was performed with PS without any complications. A burr hole was set before piezosurgical craniotomy in 6 patients, with no prior burr hole in 16 patients. Incidental durotomy during piezosurgical craniotomy occurred in 6 patients, and small lacerations of the sigmoid sinus caused by the piezosurgical device were observed in 3 patients. CONCLUSION Although PS is a safe and selective bone cutting technique that preserves the surrounding soft tissue, it can still lead to unintended dural tears during lateral suboccipital craniotomy. This must be kept in mind when using PS for craniotomies and relying on the selective bone cutting properties of PS.

Superior sagittal sinus and transverse sagittal sinus thrombus secondary to occult meningioma

The superior sagittal sinus is the largest of the venous sinuses. It receives blood from the frontal, parietal, and occipital superior cerebral veins and the diploic veins, which communicate with the meningeal veins. The superior sagittal sinus drains into the transverse sinuses. Central nervous system tumors like meningioma, glomus tumor, and meduloblastoma, often directly compress the veins and sinuses of the brain. Major sites of the occlusion include superior sagittal sinus (SSS) and transverse sinus. Initial days cerebral venous sinus thrombosis (CVST) was diagnosed only on autopsy. Since the advent of modern investigative modalities like magnetic resonance Imaging (MRI), Computerised Tomography Angiography (CTA) and Magnetic Resonance Venography (MRV), more and more cases are being diagnosed confidently.