Superior Sagittal Sinus Occlusion Research Articles

Venous Hemorrhagic Infarct Leading to Delayed Brain Abscess Formation: A Case Report

AbstractVenous sinus thrombosis is a common neurovascular problem with multifactorial etiology, infection being one of the common causes. Cerebral abscess causing thrombophlebitis and venous sinus occlusion is a known entity. In contrast, venous hemorrhagic infarct leading to abscess formation is extremely uncommon. We report a rare case of such delayed abscess formation in a venous hemorrhagic infarct secondary to superior sagittal sinus occlusion.

Aluminium Chloride instead of Ferric chloride for inducing superior sagittal sinus thrombosis to reduce ferromagnetic artifacts on MRI-imaging in experimental models

Using ferric chloride (FeCl3) to induce experimental superior sagittal sinus (SSS) thrombosis might interfere with magnetic resonance imaging (MRI)-assisted visualization and evaluation of the thrombus, the brain parenchyma, and the quality of the occlusion. The aim of this study was to investigate whether aluminum chloride (AlCl3)-induced thrombosis of the SSS has comparable properties to those of FeCl3 without causing artifacts in MRI. SSS thrombosis was induced in 14 male Wistar rats by exposure of the SSS and subsequent topical application of a filter paper strip soaked in AlCl3 (n = 7) or FeCl3 (n = 7) over a period of 15 min. The animals with AlCl3-induced SSS thrombosis showed a constant and complete occlusion with in histological analysis large thrombi. Blood flow measurements indicated a significant reduction on the first and seventh postoperative day compared to preoperative measurements. MRI enabled visualization and subsequent evaluation of the thrombus and the surrounding parenchyma. In comparison, FeCl3-induced SSS thrombosis could not be evaluated by MRI due to artifacts caused by the paramagnetic properties and increased susceptibility of FeCl3. The occluded sinus and the surrounding area appeared hypointense. The quality of SSS occlusion by AlCl3 was comparable to that of FeCl3. AlCl3 therefore represents a significant alternative substance in experimental SSS thrombosis ideally suited for studies using MRI.

Meningioma involving the superior sagittal sinus: long-term outcome after robotic radiosurgery in primary and recurrent situation.

Treatment for meningiomas involving the superior sagittal sinus (SSS) is challenging and proved to be associated with higher risks compared to other brain locations. Therapeutical strategies may be either microsurgical (sub-)total resection or adjuvant radiation, or a combination of both. Thrombosis or SSS occlusion following resection or radiosurgery needs to be further elucidated to assess whether single or combined treatment is superior. We here present tumor control and side effect data of robotic radiosurgery (RRS) in combination with or without microsurgery. From our prospective database, we identified 137 patients with WHO grade I meningioma involving the SSS consecutively treated between 2005 and 2020. Treatment decisions were interdisciplinary. Patients underwent RRS as initial/solitary treatment (group 1), as adjuvant treatment after subtotal resection (group 2), or due to recurrent tumor growth after preceding microsurgery (group 3). Positive tumor response was assessed by MRI and defined as reduction of more than 50% of volume. Study endpoints were time to recurrence (TTR), time to RRS, risk factors for decreased survival, and side effects. Overall and specific recurrence rates for treatment groups were analyzed. Side effect data included therapy-related morbidity during follow-up (FU). A total of 137 patients (median age, 58.3 years) with SSS meningiomas WHO grade I were analyzed: 51 patients (37.2%) in group 1, 15 patients (11.0%) in group 2, and 71 patients (51.8%) in group 3. Positive MR (morphological response) to therapy was achieved in 50 patients (36.4%), no response was observed in 25 patients (18.2%), and radiological tumor progression was detected in 8 patients (5.8%). Overall 5-year probability of tumor recurrence was 15.8% (median TTR, 41.6 months). Five-year probabilities of recurrence were 0%, 8.3.%, and 21.5% for groups 1-3 (p = 0.06). In multivariate analysis, tumor volume was significantly associated with extent of SSS occlusion (p = 0.026) and sex (p = 0.011). Tumor volume significantly correlated with TTR (p = 0.0046). Acute sinus venous thrombosis or venous congestion-associated bleedings did not occur in any of the groups. RRS for grade I meningiomas with SSS involvement represents a good option as first-line treatment, occasionally also in recurrent and adjuvant scenarios as part of a multimodal treatment strategy.

Utility of MRI in surgical planning for parasagittal meningiomas.

Surgical resection is the standard treatment for parasagittal meningioma (PSM), but complete resection may be challenging due to superior sagittal sinus (SSS) involvement. The SSS may be partially or completely obstructed, and collateral veins are commonly present. Thus, knowing the status of the SSS in PSM cases prior to treatment is essential to a successful outcome. MRI is utilized prior to surgery in order to determine SSS status and to check for presence of collateral veins. The objective of this study is to evaluate the reliability of MRI in predicting both SSS involvement and presence of collateral veins in subsequent comparison to actual intra-operative findings, and to report on complications and outcomes. 27 patients were retrospectively analyzed for this study. A blinded radiologist reviewed all pre-operative images, noting SSS status and collateral vein presence. Intraoperative findings were obtained from hospital records to similarly categorize SSS status and collateral vein presence. Sensitivity of the MRI to SSS status was found to be 100% and specificity was 93%. However, sensitivity and specificity of MRI to collateral vein presence was only 40% and 78.6%, respectively. Complications were experienced by 22% of patients, the majority neurologic in nature. MRI accurately predicted SSS occlusion status, but was less consistent in identification of collateral veins. These findings suggest MRI should be used with caution prior to PSM resection surgery particularly with regards to the presence of collateral veins which may complicate resection.

Compensation pathways for venous drainage of the brain in superior sagittal sinus occlusion by parasagittal meningioma

This study aims to determine the existing pathways of collateral cerebral circulation in parasagittal meningiomas that cause superior sagittal sinus occlusion based on literature review and analysis of own clinical observations. Results of clinical and instrumental examination of 221 patients treated in Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov from 2000 to 2021 were subjected to retrospective and prospective analysis. Inclusion criteria were: patient age of 18+, parasagittal extracerebral tumor according to computed tomography/magnetic resonance imaging, histologically verified meningioma, superior sagittal sinus occlusion (type V-VI according to M.P. Sindou and J.E. Alvernia) according to selective cerebral angiography. This study is based on the analysis of examination of 43 patients who met the inclusion criteria. The selected patients were analyzed for demography (sex, age), brain computed tomography/magnetic resonance imaging before and after intravenous contrast enhancement, and computed tomography angiography and selective cerebral angiography data. Transformed venous drainage pathways were analyzed depending on the location of superior sagittal sinus occlusion by parasagittal meningioma: anterior, middle, or posterior third of the superior sagittal sinus. It was determined that preoperative diagnosis of parasagittal meningiomas that, based on brain computed tomography/magnetic resonance imaging, has signs of type V or VI superior sagittal sinus invasion according M.P. Sindou and J.E. Alvernia, must include selective cerebral angiography. Dynamic images of selective cerebral angiography in the venous phase allows to fully assess the established pathways of collateral blood flow and the blood flow direction. Information on collateral venous circulation in case of superior sagittal sinus occlusion by parasagittal meningioma is extremely important in a surgery planning. It helps avoiding iatrogenic damage to eloquent veins, which increases radical tumor removal with maintaining/improving a patient’s functional state in the early postoperative period and improving long-term treatment outcomes.

Rescue of inadvertent superior sagittal sinus occlusion during middle meningeal artery embolization.

Middle meningeal artery embolization is increasingly becoming popular in the treatment of chronic subdural hematomas. The safety and efficacy of the procedure has previously been demonstrated in the literature; however, complications do arise from time to time. Here we present the case of an elderly gentleman who experienced inadvertent embolization of the superior sagittal sinus through an occult arteriovenous fistula between the middle meningeal artery and the superior sagittal sinus. Multiple rescue techniques including aspiration and stent retriever thrombectomy were performed with restoration of venous flow and an overall optimal result.

59 Behçet disease with CNS thrombophlebitis

Abstract Background Behçet's disease is a peculiar vasculitis that affects both small and large vessels of the arterial and venous circulations. Objectives We present the case of two school-aged boys who presented with acute cerebral venous thrombosis, leading to the diagnosis of Behçet’s disease. Case presentation - An 8-year-old boy is admitted for severe headaches with nausea. The clinical examination notes a febrile child with marked aphtosis (with a history of genital “burns”). ESR and CRP are slightly elevated, while cerebral CT angiography reveals superior sagittal sinus occlusion. Angio-MRI confirms thrombophlebitis. - Another 9-year-old boy is referred for abdominal and spinal pain with intense headaches; accompanied with a subacute fever for >15 days. CT angiography revealed (reveals) stenosis of the longitudinal sinuses. For both children, the pathergy test, skin biopsy, and ophthalmic examination completed the whole picture of the Behçet disease. Discussion Major vascular manifestations of Behçet's disease include venous and/or arterial occlusion and aneurysm. Cerebral venous thrombosis (CVT) is very particular and might lead to an intracranial hyper-pressure, as in our cases. Steroids remain the initial reference treatment, with particular attention to anticoagulation and the addition/relay with colchicine. Conclusion Cerebral venous thrombosis may reveal Behçet's disease, especially in the pediatric population. The prognosis is poor and requires a rigorous, multidisciplinary follow-up.

Outcomes of Cerebral Venous Thrombosis in Al-Yarmook Teaching Hospital

Background: Cerebral venous thrombosis (CVT) is a disease with multiple causes and has a low incidence rate. Seizure is one of the most common complications of CVT. The rate at which seizure occurs following CVT and the risk factors associated with that occurrence is a debated issue. Objectives: The aim of this study was to evaluate the incidence of seizure and its associated and risk factors for patients with CVT. Subjects and Methods: This was an observational study that included a total of 30 adult patients with CVT. Data, including age, sex, clinical manifestations such as fever, headache, vomiting, altered consciousness, and focal neurologic signs, such as sensory disturbances, were collected. Imaging findings that included hemorrhagic lesion, infarction, and thrombus site were also reported. Patients were followed up for 6 months from the initial diagnosis to recognize the development of seizures. Results: Within 6 months of follow-up, 13 (43.3%) patients developed generalized seizures, which was the most common type of CVT. The superior sagittal sinus (SSS) occlusion was recognized in 84.62% of patients with seizures and 48.06.5% in patients without seizures. Similarly, the right lateral sinus was occluded in 84.62% of patients with seizures as compared with 41.18% among those without seizures. Contraceptive use was reported in 61.54%of patients with seizures versus 17.65% in those without seizures with a significant difference. Conclusion: The involvement of SSS and lateral right sinus occlusion and use of contraceptives could be warning signs and a risk factor for the development of seizures in patients with CVT.

A Novel Mouse Model for Cerebral Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke resulting in parenchymal injuries associated with heterogeneous clinical symptoms and prognosis. Therefore, an experimental animal model is required to further study underlying mechanisms involved in CVST. This study is aimed at developing a novel murine model suitable and relevant for evaluating injury patterns during CVST and studying its clinical aspects. CVST was achieved in C57BL/6J mice by autologous clot injection into the superior sagittal sinus (SSS) combined with bilateral ligation of external jugular veins. Clot was prepared ex vivo using thrombin before injection. On days 1 and 7 after CVST, SSS occlusion and associated-parenchymal lesions were monitored using different modalities: in vivo real-time intravital microscopy, magnetic resonance imaging (MRI), and immuno-histology. In addition, mice were subjected to a neurological sensory-motor evaluation. Thrombin-induced clot provided fibrin- and erythrocyte-rich thrombi that lead to reproducible SSS occlusion at day 1 after CVST induction. On day 7 post-CVST, venous occlusion monitoring (MRI, intravital microscopy) showed that initial injected-thrombus size did not significantly change demonstrating no early spontaneous recanalization. Microscopic histological analysis revealed that SSS occlusion resulted in brain edema, extensive fibrin-rich venular thrombotic occlusion, and ischemic and hemorrhagic lesions. Mice with CVST showed a significant lower neurological score on post-operative days 1 and 7, compared to the sham-operated group. We established a novel clinically CVST-relevant model with a persistent and reproducible SSS occlusion responsible for symptomatic ischemic and hemorrhagic lesions. This method provides a reliable model to study CVST physiopathology and evaluation of therapeutic new regimens.

Giant Parasagittal Meningioma with Complete Visual Loss in Young Female: A Case Report

Parasagittal meningioma is a benign extra-axial tumor from the arachnoid cap cell that fills the parasagittal angle. This case report presents a case of a 21-years old young female with a history of complete visual loss, left side paresthesia, and progressive blunt headache. Brain MRI and MRV revealed a giant enhancing tumor measuring 9.2 cm x 8.41 cm x 7.5 cm on the right parietooccipital lobe with obstruction of the posterior third of the superior sagittal sinus. Gross total removal was achieved. The pathology reports confirmed a WHO grade I meningioma. The paresthesia and headache were improved, but the loss of visions did not change. Giant parasagittal meningioma may invade the superior sagittal sinus leading to intracranial hypertension. The surgical strategy should target the survival and postoperative quality of life. Occlusion of posterior third superior sagittal sinus affects deficiency venous return resulting in visual loss.

Can safe and radical resection of all types of parasagittal meningiomas be achievable? —the introduction of a simplified surgical strategy

ABSTRACT Background: Surgery of parasagittal meningiomas (PSMs) is still technically challenging, for the balance between radical resection and preservation of venous circulation. In this article, we’d systemically introduce the technical nuances of a simplified strategy for radical resection of all types of PSMs. All the cases were operated by one single neurosurgeon from a single institution. Methods: Clinical charts of patients with PSMs between 2014 and 2020were retrospectively reviewed. A simplified classification method was adopted, which was based on the relationship between the tumor and superior sagittal sinus (SSS). Surgery aiming at radical resection and venous flow preservation was performed. Only in case of total occlusion of SSS, we performed tumor resection without reconstruction of the venous sinus. Results: Clinical data obtained in 55 consecutive patients (47 primary and 8 recurrent cases) were analyzed, among which 20 were with patent sinus, 27 were with partially occluded sinus and 8 were with completely occluded sinus. Forty-two (76.4%) and 13 patients (23.6%) had the same and improved functional status as compared to that of pre-operation, respectively. Four patients (7.3%) experienced transient neurological deterioration but improved to the normal level in the long-term follow-up. All patients achieved Simpson I/II radical resection. No patients suffered from post-operative recurrence in the follow-up duration of 27.05 ± 19.55 (2–91) months. Conclusion: Radical and safe resection of all types of PSMs is achievable and not difficult if the simplified surgical strategy mentioned in the article is adopted, no matter to which extent the sinus is invaded.

Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury.

This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome. We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome. Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI. Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

Hydrocephalus Following Giant Transosseous Vertex Meningioma Resection

Introduction Meningiomas are among the most common primary intracranial tumors. While well-described, there is limited information on the outcomes and consequences following treatment of giant-sized vertex-based meningiomas. These meningiomas have specific risks and potential complications due to their size, location, and involvement with extracalvarial soft tissue and dural sinuses. Herein, we present four giant-sized vertex transosseous meningioma cases with involvement and occlusion of the sagittal sinus, that postoperatively developed external hydrocephalus and ultimately required shunting. Methods A retrospective chart review identified patients with large vertex meningiomas that were: (1) large (>6 cm) with hemispheric (no skull base) location, (2) involvement of the superior sagittal sinus resulting in complete sinus occlusion, (3) involvement of dura resulting in a large duraplasty area, (4) transosseous involvement requiring a 5 cm or larger craniectomy for resection of invaded calvarial bone. Results Tumors were resected in all four cases, with all patients subsequently developing external hydrocephalus which required shunting within 2 weeks to 6 months postsurgery. Conclusion We believe this may be the first report of the development of hydrocephalus following surgical resection of these large lesions. Based on our observations, we propose that a combination of superior sagittal sinus occlusion and changes in brain elasticity and compliance affect the brain's CSF absorptive capacity, which ultimately lead to hydrocephalus development. We suggest that neurosurgeons be aware that postoperative hydrocephalus can quickly develop following treatment of giant-sized vertex-based meningiomas, and that correction of hydrocephalus with shunting can readily be achieved.

Falcine Sinus and Parafalcine Collateral Veins in Meningiomas Invading the Superior Sagittal Sinus

Venous collaterals form because of occlusion of the superior sagittal sinus (SSS), thus preserving venous drainage. Previous studies have focused on the evaluation and protection of sinuses and cortical veins and have neglected the collaterals between the SSS and deep venous system, which are important for surgical planning. We aimed to study the venous compensatory patterns inside and on both sides of the cerebral falx(parafalx) in patients with meningioma invading theSSS. Conventional magnetic resonance imaging, magnetic resonance venography, and a three-dimensional reconstructed venous model of 45 patients were analyzed. The venous collateral pattern of the parafalx was divided into 4 types: A), with cerebral medial cortical vein displacement or hyperplasia; B), collaterals connect the 2 ends of the occluded segment of the SSS; C), collaterals connect the occluded segment of the SSS with the deep cerebral venous system; and D), recanalization or secondary formation of a falcine sinus. The incidence of each type in different occlusion grades and positions of the SSS was analyzed. The 4 types of venous collaterals were ranked according to their prevalence: A, 46.7%; C, 15.6%; D, 8.9%; and B, 4.4%. The collaterals of types B, C, and D were found only in patients with severe SSS occlusion, and both types C and D were found only in middle and posterior occlusions of the SSS. In meningiomas invading the SSS, especially with complete posterior SSS occlusion, the parafalcine collateral veins and falcine sinus should be evaluated preoperatively to avoid iatrogenic injury.

Establishment of a Rat Model of Superior Sagittal-Sinus Occlusion and Recanalization via a Thread-Embolism Method

There are many uncontrollable factors in the pathogenesis of cerebral venous sinus thrombosis (CVST). In order to further explore the pathophysiology and morphology of CVST, it is necessary to establish a highly compatible CVST animal model that can standardize the site and stage of venous thrombosis. The present study employed the insertion of a self-made thread embolism into the superior sagittal sinus (SSS) to establish a rat model of SSS occlusion that emulates CVST. The thread embolism was removed after 6 h of SSS occlusion in order to achieve recanalization. After successful preparation of the model, the cerebral blood flow (CBF) status and ultrastructural changes of the blood–brain barrier (BBB) were monitored. This CVST model was able to achieve continuously high occlusion of SSS. The parasagittal venous-collateral circulation underwent extensive compensation and recombination, which alleviated blood flow stasis and brain tissue hypoxia caused by restricted reflux. Removing SSS occlusion significantly improved cerebral circulation, reduced brain edema, and accelerated the receding of brain edema. This study established a new model of acute occlusion and recanalization of SSS in rats via a thread-embolism method, which standardized the ischemic site and stage of venous thrombosis. In addition, our study suggests that promoting collateral circulation may be a potential treatment for promoting brain protection.

Lumbo Peritoneal Shunt in Management of Cases of Depressed Skull Fractures with Superior Sagittal Sinus Occlusion

AbstractBackground: Patients with depressed skull fractures overlying the superior sagittal sinus (SSS) present an ongoing challenge. Many surgeons would opt for a conservative man-agement of these cases if there was no associated deficit to avoid risky sinus surgery. A variable percentage of patients presenting with such fractures suffer from SSS occlusion resulting in Benign Intracranial Hypertension (BIH).Aim of Study: We aim to evaluate SSS patency, evaluate intracranial tension and evaluate options for management in patients with simple depressed skull fractures overlying posterior 2/3 of SSS and not surgically indicated.Patient and Methods: Prospective study of cases which admitted to Cairo University Hospitals, and Bani sueif Uni-versity Hospital, Department of Neurosurgery, Accidents and Emergency between Jan. 2014 and December 2015.Patients with simple and compound depressed skull frac-tures overlying the SSS and not indicated for surgery, with no other intracranial abnormality, with a Glasgow Coma Scores (GCS) of 12 or better were admitted to the study. Patients underwent Magnetic Resonance Venography (MRV) to determine SSS patency on admission, they were clinically followed up using Computerized Tomography (CT) and repeat MRV when needed. Patients underwent serial lumbar manom-etry, and were given medical treatment in the form of aceta-zolamide, furosemide plus low molecular weight heparin and anti platelets. Patients were then assessed and evaluated to be admitted for LP shunt surgery and followed-up.Results: A total of 12 cases were included in the study, 7 patients had complete SSS occlusion and 5 cases has nar-rowing with patent SSS. The 5 cases with incomplete SSS occlusion had a stable course with only one case (20%) developing elevated intracranial pressure (ICP) not responding to medications and requiring LP shunt. Of the 7 patients with complete occlusion, 100% developed elevated ICP not re-sponding to medical treatment, and all required LP Shunt insertion, 5 patients developed multiple contusions due to anticoagulant therapy on top of SSS occlusion, with discon-tinuation of anticoagulants and deterioration of conscious level, 8 patients had LP surgery and showed a stable improving post operative course, 2 patients had restored SSS patency on repeat MRV.Conclusion: Management of depressed skull fractures overlying the SSS remains controversial, patients with partial occlusion have a better prognosis, patients with complete occlusion can improve with best medical treatment. LP shunt is recommended for all cases of SSS occlusion.

Poor Brain–Tumor Interface–Related Edema Generation and Cerebral Venous Decompensation in Parasagittal Meningiomas

Parasagittal meningioma (PSM) has a high incidence of peritumoral edema and unclear pathogenesis. The venous compression theory has been proposed as a pathomechanism; however, this is controversial, and the various edema patterns have not been recognized. We sought to establish the relationship between venous circulation status with different edema patterns in PSM and the neurologic outcomes of these different patterns. We performed a retrospective study of 60 consecutive patients who underwent surgical treatment for PSM. Patients were divided into 3 groups: no edema, poor brain-tumor interface-related edema (PIRE), and strong brain-tumor interface-related edema (SIRE). Single-blinded observers scored venous circulation for each patient based on the degree of superior sagittal sinus (SSS) occlusion, the number of involved cortical veins, and venous collateral grade. PIRE and SIRE were analyzed using multivariate analysis. Finally, we evaluated the functional independence and mobility score for every patient. The PIRE group showed the highest rate of cerebral venous decompensation at 75% (n= 15) compared with 38.5% (n= 5) in the SIRE group and 22.2% (n= 6) in the no-edema group. We observed a significant correlation between venous decompensation and PIRE generation on multivariate analysis (P= 0.029). The PIRE group showed the worst immediate functional status, and the SIRE group had the best improvement in complete dependence rate (23%) at late evaluation. The generation of PIRE, but not SIRE, may depend on venous decompensation in PSM. PIRE generation is predictive of worse neurologic outcome. Future studies into the pathogenesis of peritumoral edema should distinguish the different edema patterns.

Venous collateral drainage patterns predict clinical worsening in dural venous sinus thrombosis

BackgroundDural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. The condition of approximately...

Abstract TP329: Venous Collateral Drainage Patterns Predict Clinical Worsening in Dural Venous Sinus Thrombosis

Background: Dural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. Approximately 23% of patients with DVST will worsen after initial presentation, as a result of restricted venous outflow and venous hypertension, but early identification of this subset is challenging. A venous collateral scale (VCS) that grades alternative drainage routes may improve prediction of clinical deterioration. Methods: From our institutional database, we identified patients with documented DVST on dedicated venous imaging (MR, CT or catheter angiography) from January 2010 to July 2016. Patients were excluded for thrombosis related to arteriovenous fistulae. The VCS (Table) was created and scores were determined from cerebrovascular venous imaging at presentation by two reviewers blinded to subsequent imaging and clinical data. Results: Among 28 patients that met criteria, median age was 42 (IQR 24-57) and 50% (14/28) were female. Presentation symptoms included intracranial hemorrhage in 40% (11/28) and headache without hemorrhage in 18% (5/28). Transverse sinus occlusion was present in 68% (19/28), and superior sagittal sinus occlusion in 39% (11/28). 82% (23/28) of patients were treated with anticoagulation, and 18% (5/28) with endovascular thrombectomy. New hemorrhage or expansion of initial hemorrhage occurred in 21% (6/28). In-hospital mortality occurred in 18% (5/28). VCS was 0 in 18% (5/28), 1 in 39% (11/28), and 2 in 46% (12/28). Lower VCS was significantly associated with development of new hemorrhage or expansion of initial hemorrhage (62% vs. 0%, VCS 0-1 vs. 2, p<0.01). VCS demonstrated excellent discrimination for in-hospital clinical worsening (C-statistic 0.85). Conclusions: The type and quality of venous collaterals influence outcome in DVST. VCS helps identify patients who are likely to deteriorate and may need additional early interventions.

Microsurgical treatment of parasagittal meningiomas in central gyrus region

Objective To evaluate the surgical methods and outcomes of parasagittal meningiomas in central gyrus region. Methods Clinical data regarding 42 parasagittal meningiomas in central gyrus region were analyzed, which were admitted into the First Affiliated Hospital of Zhengzhou University during the time from January of 2007 to January of 2015. Sagittal sinus, rolandic veins, draining veins and peritumoral brain cortices were well protected during surgeries. In case of occlusion of superior sagittal sinus, it was resected together with tumor while draining veins were protected well. Radiosurgery was postoperatively conducted for residual tumors in sagittal sinus or adhered to nearby draining veins. Results Among 42 cases of parasagittal meningiomas in central gyrus region, Simpson Ⅰ grade resection was conducted in 7 cases, Ⅱ grade resection in 17 cases, Ⅲ grade in 16 cases, and Ⅳ grade in 2 cases. Motor and sensory deficits, newly developed or worsening, were observed in 14 cases postoperatively, among which 12 cases gradually recovered in 3 months, incomplete limb paralysis remained in 2 cases, and one developed seizure. Morbidity rate was calculated to be 7% with no deaths. Forty-one patients were followed up for 1.3-9.3 years (mean 5.1 years) and the tumor recurrence rate was 12%. Two patients having received Simpson Ⅳ resection reported meningioma recurrence 1-3 year postopertively and a second surgical operation were conducted for them. Conclusion Sufficient preoperative imaging evaluation, proper intraoperative dealing with superior sagittal sinus, protection of the rolandic vein、drainage vein、peritumoral brain cortex would ensure and improve the surgical outcomes. Key words: Meningioma; Superior sagittal sinus; Microsurgery; Treatment outcome