J Cerebrovasc Endovasc Neurosurg.  2019 Sep;21(3):163-168. 10.7461/jcen.2019.21.3.163.

Symptomatic Sinus Pericranii with Adult Onset Headache: A Case Report with Pathologic Perspective

• Chung YS
• Kim JJ
• Kim SH
• Chung J
• Lee JW
• Park KY

• KMID: 2465247
• DOI: http://doi.org/10.7461/jcen.2019.21.3.163

Abstract

Sinus pericranii (SP) is a rare vascular anomaly of the scalp that consists of an abnormal pericranial venous channel connected to adjacent dural venous sinuses. Most SP are asymptomatic and are found in the pediatric age group. We aim to report a case of symptomatic SP in adult and describe the clinical, radiological, and pathohistological findings to help understand and differentiate this lesion from other scalp lesions. A 40-year-old man with a scalp mass was admitted to our hospital complaining of headache. The lesion enlarged when the patient was in a recumbent position or during Valsalva maneuver. The radiologic imaging suggested its diagnosis as an accessory type of SP with bone erosion. Surgical resection and cranioplasty were successfully performed, and the related headache also gradually subsided. At the 3-year follow-up, there was no recurrence on magnetic resonance imaging.

Keyword

Sinus pericranii; Vascular malformation; Headache

MeSH Terms

Adult*
Diagnosis
Follow-Up Studies
Headache*
Humans
Magnetic Resonance Imaging
Recurrence
Scalp
Sinus Pericranii*
Valsalva Maneuver
Vascular Malformations

Figure

• 

  Fig. 1 Computed tomography (CT) scan. (A) Sagittal view, isodense round-shaped mass (arrow) located above the skull. (B) Sagittal view of bone window setting, the related calvarial erosion (arrow) was noted. (C) Complete removal of sinus pericranii and well-formed cranial vault with mesh plate was noted in postoperative CT scan.

• 

  Fig. 2 Preoperative magnetic resonance (MR) imaging showed heterogenous signals and flow voids within the mass in both T1 (A) and T2 (B) weighted images. Gadolinium-enhanced T1-weighted MR imaging (C) showed a contrast-enhancing mass between galea aponeurotica and skull. Three year's follow-up gadolinium-enhanced T1-weighted MR imaging (D) showed a complete obliteration of mass without any recurrence.

• 

  Fig. 3 Digital subtraction angiography (DSA) findings of sinus pericranii (SP). (A) Internal carotid angiography lateral view; in late venous phase, a majority of the cerebral venous outflow occurred through the superior sagittal sinus (SSS, arrow). Small contrast filling of extracranial–intracranial venous channel was also identified (arrowhead). (B) External carotid angiography AP view; in late venous phase, the SP (arrowhead) was connected with SSS (arrow). (C) External carotid angiography lateral view; in late venous phase, only a part of the extracranial venous outflow was draining through the SP (arrowhead). These findings indicated an accessory type SP.

• 

  Fig. 4 Pathologic findings of sinus pericranii (SP). (A) H&E staining (× 100); it showed a single-layer flattened endothelium (arrow) with thick venous stroma (asterisk), which suggested a congenital type of SP. (B) CD-31 staining (× 100); thin brownish endothelial layers showed the vascular nature. (C) D2–40 staining (× 40); it showed the absence of lymphatic wall.

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