Superior Sinus Research Articles

Sonographic Evaluation of the Superior Sinus Sagittalis

Objective: The aim of this study was to characterize the normal ultrasonographic growth of the fetal superior sinus sagittalis (SSS) throughout gestation. Patients and Methods: In a prospective cross-sectional study, measurements of the fetal sinus sagittalis were obtained in patients undergoing elective fetal anatomical surveys or fetal growth scan at between 16.6 and 34.7 weeks of gestation. Special attention was given to the SSS of the fetal brain. On the coronal plane, the SSS may be easily identified immediately below the frontal bone, and anterior to the fetal head parenchyma. Results: 206 fetuses were scanned. A regression line of the SSS was created throughout gestation and a first-degree correlation was found between gestational age (GA) and the SSS height (r = 0.418; p < 0.0001; SSS = -0.015 + 0.0178 × GA). Normal values were established for different gestational weeks. Conclusion: We provide ultrasonographic dimensions of the fetal SSS across pregnancy. This data potentially allows for prenatal diagnosis of abnormal appearance of the SSS.

Cerebral venous thrombosis associated with homozygous factor V Leiden mutation in a 15-year-old girl of Tunisian origin

Cerebral venous thrombosis (CVT) is a rare disease. It has numerous and complex etiologies. Inherited or acquired prothrombotic states play a key role in the development of this disease, such as factor V G1691A mutation (FV Leiden). A 15-year-old girl presented to the Department of Neurology with a complaint of severe headache with visual blurring. The diagnosis of CVT was not initially suspected because of the patient's condition on presentation. An MRI showed thrombosis in the superior sagittal sinus, confirming venous stroke. Anticardiolipin and antiphospholipid antibodies were assessed. In addition, inherited prothrombotic defects, such as protein C, protein S, and antithrombin deficiencies, and genetic mutations for FV Leiden, prothrombin gene G20210A (FII G20210A), and methyltetrahydrofolate reductase C677T (MTHFR C677T) were studied. All results were unremarkable except for the unique homozygous FV Leiden mutation, which likely contributed to this prothrombotic situation. This study highlights the fact that FV Leiden may play a significant role in the onset of CVT in young patients.

Childhood Ischemic Stroke: a Report of Two Cases

Rationale: Unlike in adults, stroke is uncommon in children. Even when it occurs, it is commonly haemorrhagic unlike ischemic predominance in adults. There is always a risk factor in childhood stroke. Aim: To present two case reports of childhood ischemic stroke managed conservatively. Case reports: case summary 1: A thirteen year old male Cameroonian Sickle with generalised body weakness, jaundice and right hemiparesis. Brain Computed tomogram (CT) showed premature generalised cerebral and cerebellar atrophy with supervening left parietal lobar ischaemic infarction. Bone window showed widened diploe. Abdomino-pelvic echogram revealed autosplenectomy and choleliathiasis. Case 2: A sixteen month old semi-conscious male Cameroonian with fever and left hemiplegia. Past medical history is Tetralogy of Fallot and Meningitis at 10 month of age. Brain Magnetic resonance imaging (MRI) showed right fronto-parietal cerebral venous infarct due to Superior sagital sinus thrombosis as evidenced by ‘Empty delta sign’. Conclusion: Though stroke in children is uncommon more cases will be discovered with availability of neuro-imagings. The prognosis and prevention of stroke-repeat in Sicklers are better with blood transfusion.

Hematoma intradiploico: tratamento cirúrgico e relato de caso

ResumoO hematoma intradiploico é uma lesão rara do crânio. Foi descrita inicialmente em 1934 e até hoje a sua patogênese não é conhecida. Trata-se de uma lesão rara e secundária a um processo reativo benigno após traumas cranianos leves ou coagulopatias. Paciente de 42 anos apresentava quadro progressivo de perda da marcha e alteração visual. Foi identificada massa na região occipital do paciente, de caráter progressivo. Os estudos radiológicos demonstravam lesão de aspecto heterogêneo, erosiva da calota craniana e com expansão intracraniana. Realizou angiografia digital que demonstrou trombose de seio sagital superior. Foi submetido à biópsia seguida de ressecção da lesão associada à cranioplastia. Houve melhora do padrão visual e do desempenho de marcha do paciente, em relação ao pré-operatório. Os autores relatam um caso raro de hematoma intradiploico, analisaram os diagnósticos diferenciais e discutem as opções cirúrgicas dessa rara doença.

Subcostal real-time three-dimensional echocardiography of interatrial communications: reconstruction of an oval fossa defect, a superior sinus venosus defect with partially anomalous pulmonary venous drainage, an infero-posterior oval fossa defect, and a coronary sinus defect

Real-time three-dimensional echocardiography can surpass simple cross-sectional echocardiography in providing precise details of cardiac lesions. For the purpose of optimising treatment, we describe our findings with real-time three-dimensional echocardiography when interrogating different types of communications permitting interatrial shunting. A three-dimensional reconstruction of defects within the oval fossa enabled reliable identification of location, size, and integrity of surrounding rims. In the superior sinus venosus defect associated with partially anomalous pulmonary venous drainage, three-dimensional reconstruction helped to provide a better understanding of the relationship between the interatrial communication, the orifice of the superior caval vein, and the connections of the right upper pulmonary vein. In the defect opening infero-posteriorly within the oval fossa, three-dimensional reconstruction helped to avoid the risk of potentially inappropriate closure of the defect by suturing the hyperplastic Eustachian valve to the atrial wall, which could have diverted the inferior caval venous return into the left atrium, or obstructed the caval venous orifice. In the coronary sinus defect, three-dimensional echocardiography provided a 'face to face' view of the entire coronary sinus roof, showing a circular defect communicating with the cavity of the left atrium. Acquisition of the full-volume data sets took less than 2 minutes for the patients having defects within the oval fossa, and no more than 3 minutes for the patients with the sinus venosus and coronary sinus defects. Post-processing for the defects in the oval fossa took from 5 to 8 minutes, and from 12 to 16 minutes for the more complicated defects. Cross-sectional two-dimensional echocardiography can establish correct diagnosis in all types of atrial communications; however, real-time three-dimensional reconstruction provides additional value to the surgeon and interventionist for better understanding of spatial intracardiac morphology.

Cerebral Venous Sinus Thrombosis Associated With Cerebral Hemorrhage

The current recommended treatment for cerebral venous sinus thrombosis (CVST) is anticoagulation, and the presence of intracranial hemorrhage (ICH) is not a contraindication. We present a case of ICH associated with CVST in which heparin treatment was associated with rebleeding, and we review current evidence of anticoagulation safety in patients with ICH associated with CVST. A 65-year-old man presented with right hemiparesis and loss of consciousness. Brain computed tomography showed a left frontoparietal hemorrhage. Angiographic studies with magnetic resonance imaging showed the presence of a partial superior saggital sinus thrombosis. With a diagnosis of CVST, intravenous heparin was administered. After 24 hours the patient had a symptomatic increase in ICH size, and 2 days later the patient developed a status epilepticus with new evidence of rebleeding. Anticoagulant treatment was stopped and the patient experienced neurological improvement, with no new episodes of rebleeding. Evidence for the safety of anticoagulants in CVST comes from 2 small trials involving a total of 79 patients, but only 18 had some degree of bleeding in baseline computed tomography. A meta-analysis suggested that in CVST patients who are treated with anticoagulants, the risk of ICH is low, but acknowledged that an impact of up to 9% of new ICH cannot be ruled out. As there is not enough evidence for the safety of anticoagulant therapy in patients with early ICH associated with CVST, the therapeutic decision must be individualized and the rebleeding risk should be weighed in those patients.

Cerebral Venous Thrombosis in a Mexican Multicenter Registry of Acute Cerebrovascular Disease: The RENAMEVASC Study

Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular disease that is usually not mentioned in multicenter registries on all-type acute stroke. We aimed to describe the experience on hospitalized patients with CVT in a Mexican multicenter registry on acute cerebrovascular disease. CVT patients were selected from the RENAMEVASC registry, which was conducted between 2002 and 2004 in 25 Mexican hospitals. Risk factors, neuroimaging, and 30-day outcome as assessed by the modified Rankin scale (mRS) were analyzed. Among 2000 all-type acute stroke patients, 59 (3%; 95% CI, 2.3-3.8%) had CVT (50 women; female:male ratio, 5:1; median age, 31 years). Puerperium (42%), contraceptive use (18%), and pregnancy (12%) were the main risk factors in women. In 67% of men, CVT was registered as idiopathic, but thrombophilia assessment was suboptimal. Longitudinal superior sinus was the most frequent thrombosis location (78%). Extensive (>5 cm) venous infarction occurred in 36% of patients. Only 81% of patients received anticoagulation since the acute phase, and 3% needed decompressive craniectomy. Mechanical ventilation (13.6%), pneumonia (10.2%) and systemic thromboembolism (8.5%) were the main in-hospital complications. The 30-day case fatality rate was 3% (2 patients; 95% CI, 0.23-12.2%). In a Cox proportional hazards model, only age <40 years was associated with a mRS score of 0 to 2 (functional independence; rate ratio, 3.46; 95% CI, 1.34-8.92). The relative frequency of CVT and the associated in-hospital complications were higher than in other registries. Thrombophilia assessment and acute treatment was suboptimal. Young age is the main determinant of a good short-term outcome.

Superior Mesotympanic Sinus

This study of the posterior tympanum was performed to better define the anatomy of this complex area of the middle ear. A sinus previously not described was examined. The posterior tympanum of 49 temporal bones was studied by microscopic techniques. The sinus depth, the opening into the sinus, and the relationship of the facial nerve to the sinus were documented. A sinus lying in the superior part of the posterior tympanum was discovered: the superior mesotympanic sinus. The depth of the sinus was from 0.5 to 2 mm, and it was present in 42 of the 49 specimens (86%). The superior border of the sinus is the facial nerve, which was dehiscent in 9 cases. The surgeon can remove disease with more confidence from the tympanum if he or she knows that disease may harbor in this sinus, and that injury to the facial nerve must be avoided.

Oftalmoplejía dolorosa recurrente secundaria a displasia fibrosa poliostótica del seno maxilar con afectación de la hendidura esfenoidal

Fibrous dysplasia is a bone disease that is usually accompanied by asymptomatic lesions but which may sometimes display neurological manifestations due to the involvement of the craniofacial bones.A 25-year-old female, with a history of migraines, who visited at the age of 18 due to pain in the right retro-ocular and maxillary region, although with characteristics that were unlike those of her usual migraines, and which was associated with ipsilateral ophthalmoparesis. The condition had a self-limiting course and responded well to corticoids, although it was recurring. Examination revealed intense pain on palpation of the right-hand maxillary sinus and incomplete paralysis of the ipsilateral oculomotor nerve with palpebral ptosis. Results of complementary studies were normal, except for magnetic resonance imaging of the head and computerised axial tomography of the face, which revealed an expansive lesion with involvement of the right superior maxillary sinus and the greater wing of the sphenoid bone, with probable compromise of the superior orbital fissure, consistent with the diagnosis of fibrous dysplasia, which was confirmed by means of a pathology study.Fibrous dysplasia is a benign bone disorder, of unknown causation, in which normal bone tissue is replaced by amorphous conjunctive tissue. There is sometimes craniofacial involvement and a hypertrophic bone mass is formed which can fill the paranasal sinuses and the orbit, resulting in exophthalmus and visual disorders. To date the scientific literature does not include any reports of this disease manifesting as bouts of recurrent painful ophthalmoparesis which responds to corticoids, as happened in the case of our patient.

Endoscopic supraorbital extradural approach to the cavernous sinus: a cadaver study

The cavernous sinus is a small complex structure located at the central base of the skull. Recent extensive use of endoscopy has provided less invasive approaches to the cavernous sinus via endonasal routes, although transcranial routes play an important role in the approach to the cavernous sinus. The aims of this study were to evaluate the feasibility of the purely endoscopic transcranial approach to the cavernous sinus through the supraorbital keyhole and to better understand the distorted anatomy of the cavernous sinus via endoscopy. Eight fresh cadavers were studied using 4-mm 0° and 30° endoscopes to develop a surgical approach and to identify surgical landmarks. The endoscopic supraorbital extradural approach was divided into 4 stages: entry into the extradural anterior cranial fossa, exposure of the middle cranial fossa and the periorbita, exposure of the superior cavernous sinus, and exposure of the lateral cavernous sinus. This approach provided superb views of the cavernous sinus structures, especially through the clinoidal (Dolenc) triangle. The lateral wall of the cavernous sinus, including the infratrochlear (Parkinson) triangle and anteromedial (Mullan) triangle, was also clearly demonstrated. An endoscopic supraorbital extradural approach offers excellent exposure of the superior and lateral walls of the cavernous sinus with minimal invasiveness via the transcranial route. This approach could be an alternative to the conventional transcranial approach.

Sinus venosus atrial septal defect in a 31-year-old female patient: a case for surgical repair

A 31-yr-old female patient previously diagnosed with idiopathic pulmonary arterial hypertension (PAH) was referred to our centre for further evaluation. Cardiac magnetic resonance imaging (MRI) and echocardiography revealed a superior sinus venosus atrial septal defect (ASD) with partial anomalous pulmonary venous drainage. Following re-diagnosis, surgical repair was considered. Despite a disproportionately high mean pulmonary artery pressure (P(pa)) of 47 mmHg relative to the patient's age and defect, the decision to operate was based on the absence of oxygen desaturation (either at rest or during exercise), cyanosis or abnormally elevated haemoglobin. Other operability criteria included normal sinus rhythm at rest, vasoreactivity and a pulmonary to systemic blood flow ratio of 1.9 at rest. Surgical repair and continued advanced therapy with bosentan 125 mg b.i.d. and aspirin 75 mg o.d. proved successful, with post-operative improvements in exercise capacity and dyspnoea, and a reduction in P(pa) to 25 mmHg. Keen to start a family, the risks of pregnancy were discussed. This case illustrates the importance of secondary PAH in sinus venosus ASD and the need to exclude a sinus venosus ASD in unexplained right ventricular dilatation. Access to expertise in congenital heart disease and use of cardiac MRI can improve diagnosis and, in turn, treatment decisions.

Syndrome du sinus silencieux et ossification intrasinusienne

The silent sinus syndrome (SSS) is a rare cause of diplopia and facial asymmetry. It is commonly attributed to a sinus atelectasis secondary to ostiomeatal obstruction. Surgical dissection of the maxillary sinus mucosal lining is known to cause auto-obliteration by bone formation. A 45 year-old female patient was referred for vertical diplopia with enophthalmia, and a slight depression of the left cheekbone. Antrostomy was performed for chronic obstructive maxillary sinusitis six months before. CT scan revealed a major collapse of superior, anterior, and posterior left maxillary sinus with expansion of the orbital volume. The de novo maxillary sinus ossification evolved over two years of follow-up. It was normal lamellar bone. The left orbital floor was rebuilt. Diplopia progressively resolved. The association of SSS and intraluminal osteogenesis has never been reported. The first might be due to a peroperative dissection of the maxillary sinus mucosal lining. SSS was due to meatal obstruction secondary to inadequate antrostomy.

Appliance of 3D-CT venography for the preoperative evaluation of parasagittal meningioma

Objective The authors investigated applying of3D-CTvenography (3D-CTV) to identify the superior sagittal sinus and parietal vein of Rolando for the preoperative surgerical plan for parasagittal and falx meningiomas. Methods A series of 11 consecutive patients with parasagittal and falx meningiomas were surgically treated in our department from June 2008 to February 2010. All patients underwent 3D-CTV preoperative to explore the involved superior saggitial sinus and important cortical drainage vein before operation.Result According to Simpson's scale, 9 procedures were Grade Ⅰ resection, 2 were Grade Ⅱ resection. The postoperative course was tncomplicated and all the patinets had satisfactory outcome on discharge. Among 11 patients with parasagittal meningiomas invading the sagittal sinus, 3D-CTV demonstrated the sagittal sinus were completely obstructed in 4 cases preoperative, which the radical resection of the tumor including the invaded part of sinus was made; 4 cases with meningiomas partial invading the sagittal sinus and the sintus still unobstructed demonstrated by 3D-CTV, which the radical resection of the tumor including the invaded wall of sinus was made and the sagittal sinus was reconstructed in 3 cases; 3 cases with meningiomas invading the lateral wall of the sagittal sinus demonstrated by 3D-CTV, which the resection of the tumor including the outer layer of the lateral wall of sinus was made in 1 case. There were no tumor recurrence at the last follow-up.Conclusions Comparing with MRV and DSA, 3D-CTV can examine the parasagittal meningiomas including the involved sagittal sinus and cortical drainage vein more easily and exactly, and it should be performed and scrutinized carefully before planning the surgical treatment for the parasagittal meningiomas. Key words: 3D-CT venography; Meningoma; Sagittal sinus

Orbital subperiosteal hematoma associated with sinus infection

There are few reports of orbital subperiosteal hematomas as a result of sinusitis complications. The present study reports on 2 such cases and presents a literature review regarding this condition. We report 2 cases of orbital subperiosteal hematoma, and reviewed previous literature reports. Including the 2 current patients, 11 cases of orbital subperiosteal hematoma involving sinusitis appear in the literature. The current cases involved 2 older females presenting with proptosis. One had frontal sinusitis and the other a postoperative frontoethmoid mucocele. Both patients underwent a superior orbitotomy and sinus surgery, which resolved the orbital symptoms. Orbital subperiosteal hematomas can develop associated with sinus infection. Such a condition should be treated as a sinusitis complication and the associated sinus infection must be treated concomitantly.

Bone Removal With a New Ultrasonic Bone Curette During Endoscopic Endonasal Approach to the Sellar-Suprasellar Area

Accessing intradural lesions via an extended endoscopic endonasal approach requires a relatively large bony removal over the skull base. We describe the Sonopet ultrasonic bone curette with a new dedicated endonasal hand-piece. We used this ancillary device in 27 nonconsecutive endonasal procedures for different skull base lesions (18 standard pituitary operations and 9 extended approaches for either meningiomas or craniopharyngiomas). The ultrasonic bone curette with endonasal hand-piece was easy to use and effective during the removal of the bone covering or when close to the carotid and optic prominences, as well as in preserving the integrity of the superior intercavernous sinus. In only 1 case was small tearing of the dura mater observed during the bony removal. No cases of injury to the major neurovascular structures occurred. The Sonopet ultrasonic bone curette is a useful tool during endoscopic endonasal skull base surgery.

How many leads through persistent left superior vein cava and coronary sinus?

In the modern implanting era with progressive expanding indications to resynchronization therapy, upgrading procedure is a relatively common event. Persistent left superior vena cava (PLSVC), the most common venous abnormality, may exacerbate technical difficulties. We describe the procedure of upgrading from a dual chamber pacemaker to resynchronization/defibrillation system with a total of 4 leads through a PLSVC entering a dilated coronary sinus (CS) never described before. The case report, in addition to the description of a unique technical approach, raises a lot of clinical questions about how many leads we can introduce in such a venous structure and inside CS without hemodynamic impact on venous drainage potentially leading to life-threatening situations.

Trombosis venosas cerebrales en la edad pediátrica: presentación clínica, factores de riesgo, diagnóstico y tratamiento

Since its first description at the beginning of the 19th century, greater awareness of this disorder has been achieved, becoming nowadays a recognized but sometimes underdiagnosed cause of ischemic stroke in childhood. AIM. To describe a population of children with cerebral venous thrombosis, analyzing clinical presentation, risk factors, treatment and evolution. A descriptive, retrospective and longitudinal review of children from 0 to 17 years of age diagnosed with sinovenous thrombosis was conducted, during the period of time between 2004 and 2009. Thirty one cases with cerebral sinus thrombosis were identified, 18 of them were boys. Clinical presentation included 18 patients with seizures and 13 with high intracranial pressure. We found infections as a risk factor in 23 patients, 3 newborns with obstetric trauma, 5 patients with prothrombotic states, 4 with chronic systemic diseases, 5 with more than one risk factor and 1 with none. Diagnosis was done by magnetic resonance imaging in 18 patients, computed tomography in 11 and magnetic resonance angiography in the other 2. Regarding location, 16 patients showed compromise of the transverse sinus, 4 of the superior longitudinal sinus, another 4 an affectation of the sigmoid sinus, 2 of the cavernous sinus and 5 with a combination of them. Anticoagulation therapy was done in 21 patients and treatment abstention in 10. None of the patients suffered complications or death due to anticoagulation therapy or sinovenous thrombosis. No recurrent symptomatic thrombosis in long term follow up was found. Sinovenous cerebral thromboses are an important but underestimated cause of stroke in childhood. Clinical suspicion should be high, in patients with risk factors and intracranial hypertension or seizures.

Role of intraoperative echocardiography in surgical correction of the superior sinus venosus atrial septal defect

Superior type of sinus venosus atrial septal defect (SVASD) is invariably associated with the unroofing of right upper pulmonary vein (RUPV). Warden procedure and pericardial patch repair with rerouting of the RUPV are commonly performed operations for the superior SVASD. Both operations involve the risk of obstruction to the flow of superior vena cava or rerouted pulmonary vein in the postoperative period. The sinus venosus defects are well visualized on the transesophageal echocardiography (TEE) because of the proximity of the TEE probe to these structures. We are reporting two cases operated for the superior SVASD with unroofed RUPV, highlighting the intraoperative echocardiographic features before and after the surgery.

The answer lies in the bubbles: a patient with superior sinus venosus defect, persistent left superior vena cava, and absent innominate vein

A 38-year-old woman with atypical chest pain and exertional dyspnoea was referred to our service for a diagnostic work-up. Transthoracic echocardiography showed an enlarged coronary sinus (CS) and enlarged right-sided heart chambers without obvious atrial septal defect ( Panel A ). After injection of agitated saline contrast into the left cubital vein, immediate appearance of bubble contrast was noted in the CS and the right atrium …

Transesophageal Echocardiography and Intraoperative Diagnosis of Persistent Left Superior Vena Cava

Isolated persistent left superior vena cava has an incidence of 0.5% in the normal population, but in patients with congenital cardiopathy its incidence ranges from 3% to 10%. The objective of this report was to present a case of intraoperative diagnosis with transesophageal echocardiography and to emphasize the importance of its routine use in surgical procedures for correction of congenital cardiopathies. This is a 16-year old male patient, ASA II, with a diagnosis of superior sinus venosus interatrial communication (IAC) with partial anomalous drainage of the pulmonary veins scheduled for the surgical correction of the cardiopathy. After induction of general anesthesia, transesophageal echocardiography (TEE) showed initially a dilation of the right cardiac chambers, a 17-mm superior sinus venosus IAC, anomalous drainage of the right superior pulmonary vein draining into the right superior vena cava (SVC), and dilation of the coronary sinus raising the possibility of persistent left superior vena cava. To confirm this suspicion, 10 mL of NS (works as a contrast in echocardiography) were injected in the venous access of the left arm, and microbubbles crossing the coronary sinus were observed immediately afterwards confirming the diagnosis of persistent left superior vena cava. Routine intraoperative transesophageal echocardiography in patients with congenital cardiopathy is a fundamental auxiliary method, not only for the surgeon, often having direct influence on the surgical technique used, but also for the anesthesiologist, who can get useful information for the hemodynamic management of the patient.