Dural sinus malformation (DSM) is a rare vascular malformation characterized by the dilatation of a dural venous sinus with or without an anomalous jugular bulb. Its presentation with venous-reflux-related secondary proptosis is anecdotal, with only six such cases reported so far. We report a 17-month-old boy who presented with a progressive proptosis of the right eye secondary to a DSM of the transverse sinus and torcula. Following endovascular embolization of the arterio-venous fistula, complete thrombosis of the venous lake and improvement in proptosis was noted at 6-month follow-up. Prognosis of this rare malformation is variable and dependent on specific angio-architectural features.

The dural venous sinus (DVS) is a thin-walled blood channel composed of dura mater that is susceptible to injury during common neurosurgical approaches. DVS injuries are highly underreported, which is reflected by a lack of literature on the topic. Neurosurgeons should be familiar with appropriate techniques to successfully repair an injured DVS and prevent associated complications. This study presents a literature review on the surgical techniques for DVS repair after DVS injury during common neurosurgical approaches. The databases PubMed and Scopus were queried using the terms \"cranial sinuses,\" \"superior sagittal sinus,\" \"transverse sinuses,\" \"injury,\" and \"surgery.\" A total of 117 articles underwent full-text review and were analyzed for surgical approach, craniotomy, lesion location, lesion characteristics, and surgical repair techniques. A literature review was performed, and a comprehensive summary is presented. Data from publications describing DVS lacerations related to pathological conditions (eg, meningioma) were excluded. A total of 9 techniques aiding with bleeding control, hemostasis, and sinus repair and reconstruction were identified, including compression, hemostatic agents, bipolar cautery, dural tenting and tack-up suturing, dural flap, direct suturing, autologous patch, venous bypass, and ligation. The advantages and drawbacks of each technique are described. Multiple options to treat DVS injuries are available to the neurosurgeon. Treatment type is based on anatomic location, complexity of the laceration, cardiovascular status, the presence of air embolism, and the dexterity and experience of the surgeon.

BACKGROUND: Dural arteriovenous fistulas of the marginal sinus (DAVFms) are uncommon and complex, with varied symptoms. Their complexity is heightened by the region\'s dense anastomotic network, posing risks for endovascular treatment. Surgical intervention can be effective, but this depends on thorough pre-operative understanding and optimal intra-operative visualization of the fistula.
OBJECTIVE: To review the relevant anatomy, presentation patterns of DAVFms, and provide insights for surgical treatment.
METHODS: Recent literature on DAVFms was reviewed, and three surgical cases are discussed to highlight treatment principles.
RESULTS: The symptoms of a DAVFms vary depending on its venous drainage pattern. Drainage may be either ascending towards the cranial compartment or descending towards the spinal canal. Patients suffering from DAVFms may experience hemorrhage, particularly when venous drainage is directed upwards. Congestive symptoms of the spinal cord or brainstem can occur in cases of downward venous drainage. Compared to the endovascular approach, open surgery has a higher success rate in obliterating the fistula and yields better outcomes in cases of perimedullary venous drainage. Achieving surgical success necessitates thorough preoperative evaluation and adequate surgical exposure. Brainstem hyperintensity observed on T2-weighted MRI scans is linked to a poorer prognosis for recovery.
CONCLUSIONS: Treating complex DAVFms often requires surgery, as endovascular methods may not be feasible. Successful surgery hinges on a precise understanding of the fistula\'s venous architecture and its spatial relationships, assessed using digital substraction angiography (DSA), angio-MRI, and angio-CT. Optimal intraoperative exposure is crucial for effective surgery.

Cerebral venous thrombosis is a rare cause of stroke in young mostly female adults which is frequently overlooked due to its variable clinical and radiological presentation. This review summarizes current knowledge on it risk factors, management and outcome in adults and highlights areas for future research. Females are 3 times more commonly affected and are significantly younger than males. The presenting symptoms can range from headache to loss of consciousness. However, the often-nebulous nature of symptoms can make the diagnosis challenging. Magnetic resonance imaging with venography is often the diagnostic imaging of choice. While unfractionated or low molecular-weight heparin is the mainstay of treatment, endovascular intervention with thrombolysis or thrombectomy and decompressive craniectomy may be required depending on clinical status. Nevertheless, approximately 80% of patients have a good recovery but mortality rates of -5% to 10% are not uncommon. Diagnosing cerebral venous thrombosis can be challenging but with vigilance and expert care patients have the best chance of a good clinical outcome.

OBJECTIVE: Although venous sinus stenting (VSS) improves cerebrospinal fluid reabsorption and decreases intracranial pressure in patients with idiopathic intracranial hypertension (IIH), the underlying pathophysiology of IIH is not well understood. We present a review and meta-analysis of the literature on VSS for IIH treatment, focusing on the rates of restenosis and symptom recurrence.
METHODS: We performed a systematic review of PubMed and Embase databases between January 1, 2011, and December 31, 2021. Articles including ≥5 patients with IIH and venous sinus stenosis treated with VSS and post-treatment rates of restenosis (de novo stenosis at a different anatomic location along the dural sinuses or restenosis within or adjacent to the stent) were selected. Demographic, procedural, and outcomes data were collected and analyzed. Mean values for variables collected were pooled, and a mean value was calculated with a 95% CI.
RESULTS: Twenty-four articles were included, comprising 694 patients and 781 VSS cases. The mean age was 33.9 (CI, 31.5-36.2) years. The mean body mass index was 35.3 (CI, 32.9-37.7) kg/m 2 . Before VSS, 98.8% (CI, 96.8%-100.0%) of patients experienced headaches, 87.7% (CI, 80.6%-95.5%) had visual acuity issues, 78.7% (CI, 69.9%-88.5%) had papilledema, 58.3% (CI, 46.0%-73.9%) had tinnitus, and 98.8% (96.4%-100.0%) had symptoms refractory to previous therapies. After VSS, 77.7% (CI, 71.1%-84.95%) experienced symptom improvement and 22.3% (CI, 15.1%-29.0%) had persistent or worsened symptoms. Pooled restenosis rate was 17.7% (CI, 14.9%-20.9%).
CONCLUSIONS: VSS is effective in alleviating IIH signs and symptoms, but the associated high rates of restenosis and persistent symptoms highlight the need for further investigation of this procedure and other adjunctive treatments for IIH.

Few studies have discussed the disease nature and treatment outcomes for bilateral cavernous sinus dural arteriovenous fistula (CSDAVF). This study aimed to investigate the clinical features and treatment outcomes of bilateral CSDAVF. Embase, Medline, and Cochrane library were searched for studies that specified the outcomes of bilateral CSDAVF from inception to April 2022. The classification, clinical presentation, angiographic feature, surgical approach, and treatment outcomes were collected. Meta-analysis was performed using the random effects model. Eight studies reporting 97 patients were included. The clinical presentation was mainly orbital (n = 80), cavernous (n = 52) and cerebral (n = 5) symptoms. The most approached surgical route was inferior petrosal sinus (n = 80), followed by superior orbital vein (n = 10), and alternative approach (n = 7). Clinical symptoms of 88% of the patients (95% CI 80-93%, I2 = 0%) were cured, and 82% (95% CI 70-90%, I2 = 7%) had angiographic complete obliteration of fistulas during follow up. The overall complication rate was 18% (95% CI 11-27%, I2 = 0%). Therefore, endovascular treatment is an effective treatment for bilateral CSDAVF regarding clinical or angiographic outcomes. However, detailed evaluation of preoperative images and comprehensive surgical planning of the approach route are mandatory owing to complexity of the lesions.

Dural sinus malformations (DSMs) are rare congenital vascular diseases characterized by a giant venous pouch with or without arteriovenous shunts. We present a neonatal case of DSM that was diagnosed prenatally and treated via endovascular intervention in the early postnatal period. The patient presented with a large DSM involving the torcular Herophilion prenatal magnetic resonance imaging (MRI). Enlargement of the head circumference and respiratory failure rapidly progressed after birth. On the 5th day after birth, the neonate underwent endovascular occlusion via the umbilical artery. The arteriovenous shunt was occluded, and the reflux from the enlarged venous pouch to the dural sinus was decreased. No additional procedure other than ventriculoperitoneal shunting was required. The neonate\'s development slowly caught up to normal parameters. Follow-up MRI demonstrated the successful development of the venous drainage system. DSMs are characterized by an abnormally dilated dural sinus, which can block the venous return and ultimately increase intracranial pressure and cerebral ischemia. Long-term follow-up indicates that an abnormally developed dural sinus can be reconstructed by appropriate and timely treatment.

Classically, the torcular Herophili is described as the symmetric junction between the superior sagittal sinus (SSS), transverse sinuses (TSs), and straight sinus (SS). However, finding this pattern in practice is not standard. Anatomical variations are common, and different drainage patterns should be expected. Existing literature proposes highly detailed descriptions and classifications of this region. Still, a simplified and practical categorization is not available.
We present an anatomical finding of the torcular Herophili discovered on a cadaveric dissection. Then, we conducted a retrospective study examining the 100 most recent cranial magnetic resonance venographies (MRVs) from the Mayo Clinic, labeling them with a new proposed dural sinus classification system. Images were initially classified by two authors and further validated by a board-certified neurosurgeon and a board-certified neuroradiologist from our institution. To measure consistency in image identification, two additional international neurosurgeons were asked to classify a subset of the same MRV images, and their answers were compared.
Of the MRV cohort, 33 patients were male and 67 were female. Their ages ranged from 18 to 86 years, with a mean of 47.35 years and a median of 49 years. Upon examination, 53 patients presented as confluent (53%), 9 as SSS divergent (9%), 25 as SS divergent (25%), 11 as circular (11%), and 2 as trifurcated (2%). The inter-rater reliability ranked very good; agreement between the two neurosurgeons was 83% (κ = 0.830, p < 0.0005).
The confluence of the venous sinuses is a highly variable anatomical area that is rarely evaluated with neuroimaging before surgery. The classic textbook configuration is not the rule. Using a simplified classification system may increase awareness and hopefully patient safety by preparing the physician for anatomical variations that they will encounter in a surgical or clinical scenario.

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The mastoid emissary vein (MEV) describes a transosseous connection between the sigmoid dural venous sinus and the suboccipital venous plexus. In cases of outflow stenosis or malformation, the MEV may become dilated and a source of pulsatile tinnitus (PT) amenable to treatment. We describe a case of PT secondary to MEV treated successfully via endovascular coil embolization and conduct a systematic review of the literature.
We performed a systematic review without meta-analysis of studies involving management of dilated MEV on January 14, 2022, and describe a case of PT secondary to an enlarged MEV treated via coil embolization.
A total of 13 studies were selected for full review. Reports identified MEV presenting as PT in 60% (12 of 20) of cases, intraoperative hemorrhage in mastoid surgery in 15% (3 of 20), a compressive scalp mass in 10% (2 of 20), and thrombophlebitis, facial swelling, or an incidental finding in 5% (1 of 20) each. Forty-five percent (9 of 20) underwent treatment, with all experiencing symptom resolution or improvement. Surgery included transvenous coil embolization in 33.3% (3 of 9), flap reconstruction in 22.2% (2 of 9), and surgical packing, ligation, and thrombectomy in 11.1% (1 of 9) each. Dilated MEV was reported concurrently with impeded drainage pathways in 35% (7 of 20) of reports.
Dilated MEV has been reported as an etiology of pulsatile tinnitus and appears amenable to treatment via open and endovascular means. Endovascular coil embolization appears to offer effective symptom resolution, however, available literature exists only in case reports and small series. Further investigation is highly warranted.