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This commentary critiques the study "Route patterns of the collateral venous pathway in patients with tumors invading the superior sagittal sinus" by Pawit Jirawisan et al., highlighting its limitations in discussing parafalcine venous collaterals, reliance on invasive imaging modalities, and lack of structured assessments. It suggests improvements by incorporating alternative imaging techniques, acknowledging crucial venous structures, and providing grading systems for surgical decision-making.

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Meningiomas typically manifest as benign, slow-growing, and well-defined tumors on a macroscopic level and are usually asymptomatic. However, the mass effect caused by large meningiomas may lead to various neurological symptoms, commonly headaches and visual problems. Radiological imaging can establish the diagnosis, and a biopsy can provide a definitive diagnosis. Our case report describes the surgical intervention for bilateral parasagittal-falcine meningioma in a 57-year-old male who presented to the emergency department with a tonic-clonic seizure. On examination, he had a bifrontal longitudinal mass. Magnetic resonance imaging (MRI) revealed a large anterior superior falcine extra-axial mass, measuring about 5.7 x 5.3 x 3.1 cm, with surrounding vasogenic edema and superior sagittal sinus invasion. He underwent surgery for tumor resection involving the anterior third and middle third of the superior sagittal sinus without radiotherapy. He did not develop any intraoperative complications, and during the post-operative evaluation, he was symptom-free. A follow-up MRI with contrast performed three months later showed no neurological complications or recurrent tumor. To achieve better outcomes, surgical intervention for parasagittal and falcine meningiomas involving the superior sagittal sinus should aim to eliminate clinical signs, control tumor growth, and prevent neurological deterioration post-operatively.

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Chronic occlusion of the superior sagittal sinus (SSS) by tumors in the midsagittal region causes the collateral venous pathway (CVP). Understanding common patterns of CVP is helpful in reducing surgical complications. This study aimed to investigate the CVP found in patients with SSS-invading tumors, and to provide information on the prevention of operative venous complications. From January 2015 to December 2022, this retrospective study collected patients with tumors that invaded the SSS and underwent digital subtraction angiography of intracranial vessels. Data collected included sex, age, tumor pathology, tumor location along the SSS, tumor side, degree of obstruction of the SSS, types and route patterns of the CVP, and the distance between the tumor and the diploic vein (DV). Twenty patients (6 males, 14 females) were recruited. The prevalence of CVP types was 90% for DV, 35% for end-to-end anastomosis of superficial cortical vein, 15% for meningeal vein, and 20% for other types of CVP. The pteriofrontoparietal and occipitoparietal diploic routes were found on the cerebral hemisphere contralateral to the tumor significantly more than in the cerebral hemisphere ipsilateral to the tumor. Of all patients with presence of collateral DV, 61% had a very close (less than 1 cm) distance between the nearest DV and tumor attachment in the SSS. DV in the cerebral hemisphere contralateral to the tumor was the most common type of CVP found in patients with tumor-induced SSS obstruction. Most of the collateral DV was located very close to the SSS tumor attachment. Neurosurgeons should realize these findings when planning a craniotomy.

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Transvenous treatment of paralysis is a concept less than a decade old. The Stentrode (Synchron, Inc, New York, USA) is a novel electrode on stent device intended to be implanted in the superior sagittal sinus adjacent to the motor cortex. Initial animal studies in sheep demonstrated the safety of the implant as well as its accuracy in detecting neural signals at both short and long term. Early human trials have shown the safety of the device and demonstrated the use of the Stentrode system in facilitating patients with paralysis to carry out daily activities such as texting, email, and personal finance. This is an emerging technology with promise, although certainly more research is required to better understand the capabilities and limitations of the device.

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BACKGROUND: Transvenous embolization of high-grade dural arteriovenous fistulas (dAVFs) is challenging particularly when the direct sinus access is favorable due to the complex venous anatomy which prohibits endovascular access via the transfemoral approach. METHOD: The procedure was conducted in the hybrid operating suite, where a burr hole was performed, followed by direct catheterization of the superior sagittal sinus. Coil embolization was then executed to achieve complete obliteration of the fistula. CONCLUSION: The direct puncture of the superior sagittal sinus is a safe and effective method for treating complex dAVFs. This approach grants access to the fistula channel which facilitates curative embolization.

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BACKGROUND AND PURPOSE: The main feeding artery of a dural arteriovenous fistula (DAVF) involving the superior sagittal sinus (SSS) is the middle meningeal artery (MMA). MMA extends continuously from the proximal part to SSS in DAVF involving SSS. It is possible to diagnose DAVF involving SSS by evaluating the proximal part of MMA on routine three-dimensional time-of-flight MR angiography (MRA). We termed the finding in an anteroposterior maximum intensity projection (MIP) image of routine MRA in which MMA was continuously visualized at the top of the imaging slab (the upper corpus callosum level) without tapering as the MMA sign. The purpose of the present study was to examine the frequency of the MMA sign on routine MRA in patients with DAVF involving SSS and control patients. MATERIALS AND METHODS: Subjects comprised 18 patients with DAVF involving SSS confirmed by angiography and 871 control subjects who underwent routine MRA. The presence of the MMA sign was retrospectively evaluated using an anteroposterior MIP image of routine MRA in patients with DAVF involving SSS and control patients. RESULTS: The MMA sign was observed in 17 of the 18 (94%) patients with DAVF involving SSS. In one patient with DAVF involving the posterior part of SSS without the MMA sign, the main feeding artery was the occipital artery, not MMA. The MMA sign was observed in 13 of the 871 (1.5%) control patients. CONCLUSION: The MMA sign on routine MRA is useful, suggesting DAVF involving SSS.

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OBJECTIVE: Dural arteriovenous fistulas (dAVFs) of the superior sagittal sinus (SSS) are uncommon and represent 5%-12% of all intracranial dAVFs. SSS dAVFs can be divided into two main subtypes. The first type involves direct arterialization of the SSS, whereas the second type consists of a parasagittal arteriovenous shunt draining into a cortical vein directly lateral to the SSS and has retrograde cortical venous drainage with only secondary involvement of the SSS. Descriptions of the latter type of SSS dAVF are limited. As such, the authors present a consecutive case series of parasagittal SSS dAVFs from their institution. They detail clinical presentation, treatment strategies, and clinical and radiographic outcomes. METHODS: The authors retrospectively reviewed a prospectively collected database of dAVFs that were treated between 2017 and 2023. All dAVFs characterized by an arterialized parasagittal vein directly lateral to the SSS were included in this study. Baseline demographic, clinical, radiological, treatment, and outcome-specific variables of interest were abstracted. RESULTS: One hundred fifty-four dAVFs were seen at the authors' institution over the 6-year period of interest. Eight (5.2%) were parasagittal dAVFs. At initial diagnostic imaging, 7 were Cognard grade III and 1 was grade IV. All patients initially underwent embolization of their dAVF. Three patients did not have complete obliteration of their dAVF after the first embolization. One patient underwent further treatment with repeat embolization, and 1 underwent microsurgical disconnection-both resulted in complete occlusion of the dAVF. Seven dAVFs were obliterated at final follow-up and 1 remained patent as the patient refused further treatment despite angiographic progression of dAVF. All symptomatic patients had resolution of their symptoms, and the average length of follow-up was 16.8 months. CONCLUSIONS: Treatment of parasagittal dAVFs consists of occluding the proximal portion of the parasagittal arterialized draining vein. Endovascular therapy with liquid embolic agents is usually the first line of treatment. Surgical ligation is a valid option if the fistula cannot be successfully obliterated with embolization. Symptoms related to the SSS dAVF resolve after their obliteration.

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Background: Cerebral venous thrombosis (CVT) is a challenging condition with potential long-term consequences, but it is also a treatable disorder that offers the possibility of complete recovery. This study was conducted to comprehensively investigate the clinical features, brain imaging findings, and treatment outcomes of patients diagnosed with cerebral venous thrombosis. Materials and Methods: Conducted as a cross-sectional descriptive study, patients diagnosed with cerebral venous thrombosis were enrolled at Can Tho Central General Hospital between January 2021 and June 2022. Results: Notably, a substantial proportion of patients (83.4%) exhibited signs of brain damage, with intracranial hemorrhage (50%), brain infarction (30.9%), subarachnoid hemorrhage (16.6%), and hemorrhagic infarct (4.7%) being the predominant findings. Thrombosis primarily affected the superior sagittal sinus (85.7%), transverse sinus (52.4%), and sigmoid sinus (42.8%). All patients received anticoagulation treatment, resulting in a favorable recovery upon hospital discharge for the majority (90.5%), while a small percentage (9.5%) experienced critical illness or death. Conclusion: Our study on cerebral venous thrombosis found diverse clinical presentations, primarily headache. Intracranial hemorrhage was common, affecting superior sagittal, transverse, and sigmoid sinuses. Most patients achieved favorable recoveries with anticoagulation treatment, emphasizing early intervention's importance.

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OBJECTIVES: Studies focusing on intracranial hemorrhage (ICH) in patients with cerebral venous thrombosis (CVT) are limited; thus, we aimed to identify factors associated with the occurrence of ICH in Thai patients with CVT. METHODS: This retrospective cohort study recruited patients with CVT admitted to a tertiary university-based hospital between 2002 and 2022. The baseline characteristics, clinical presentations, radiographic findings, and etiologies were compared between the ICH and non-ICH groups. The factors with p < 0.2 in the univariate analysis were further analyzed using multivariable logistic regression analysis to identify independent factors associated with ICH in patients with CVT. RESULTS: Of 228 screenings, 202 patients were eligible. The incidence rate of ICH was 36.63%. The ICH group showed a higher prevalence of focal neurological deficits (63.51% vs. 26.56%, p < 0.001), seizures (68.92% vs. 21.88%, p < 0.001), dependency status at admission (60.81% vs. 39.84%, p = 0.004), superior sagittal sinus thrombosis (71.62% vs. 39.07%, p < 0.001), superficial cortical vein thrombosis (36.49% vs. 10.16%, p < 0.001), and hormonal use (17.57% vs. 7.03%, p = 0.021) than the non-ICH group. In contrast, the ICH group showed a lower prevalence of isolated increased intracranial pressure (10.81% vs. 21.88%, p = 0.048) than the non-ICH group. Seizures (adjusted odds ratio [aOR], 4.537; 95% confidence interval [CI], 2.085-9.874; p < 0.001), focal neurological deficits (aOR, 2.431; 95% CI, 1.057-5.593; p = 0.037), and superior sagittal sinus thrombosis (aOR, 1.922; 95% CI, 1.913-4.045; p = 0.045) were independently associated with ICH in the multivariable logistic regression analysis. CONCLUSIONS: Seizures, focal neurological deficits, and superior sagittal sinus thrombosis are associated with ICH in patients with CVT.

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Objective: The superior sagittal sinus (SSS) is an important structure, but few studies have analyzed it using computed tomography angiography (CTA). Methods: This study was performed to examine the angiographic anatomy of the SSS and its adjacent structures using CTA in Han Chinese participants. According to age, participants were divided into elderly and nonelderly groups. The parameters of the SSS and adjacent structures were measured, recorded and analyzed statistically. Results: A total of 500 Han Chinese participants were enrolled in this study, including 346 in the elderly group and 154 in the nonelderly group. In the elderly group, regarding inferior sagittal sinus (ISS) development, 187 ISSs were absent, 85 were visible, and 74 were clear. In the nonelderly group, 62 ISSs were absent, 54 were visible, and 38 were clear. In the elderly group, the Rolandic bridging vein diameter was 3.6 ± 0.8 mm; in the nonelderly group, the diameter was 3.9 ± 1.1 mm. The statistical results showed a difference in ISS development between the elderly and nonelderly groups (P < 0.05). The relationship of age with ISS development was assessed using linear regression analysis, and the results indicated that ISS became gradually occluded with age (P < 0.05). The statistical results also showed a difference in the Rolandic bridging vein diameter between the elderly and nonelderly groups (P < 0.05). The relationship of age with the Rolandic bridging vein diameter was assessed using linear regression analysis, and the results indicated that the Rolandic bridging vein tended to become thinner with age (P < 0.05). Conclusion: This study found that more ISSs may become occluded and that the Rolandic bridging vein may become thinner with age. Other parameters of the SSS and its adjacent structures may not be affected by aging. In addition, our study also provided normal CTA parameters of the SSS and its adjacent structures in Han Chinese people.

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BACKGROUND: The hemodynamics of the cerebral sinuses play a vital role in understanding blood flow-related diseases, yet the hemodynamics of the cerebral sinuses in normal adults remains an unresolved issue. PURPOSE: To evaluate hemodynamics in the cerebral sinus of adults using 4-dimensional flow MRI (4D Flow MRI). STUDY TYPE: Cross-sectional. POPULATION: Ninety-nine healthy volunteers (mean age, 42.88 ± 13.16 years old; females/males, 55/44). FIELD STRENGTH/SEQUENCE: 3 T/4D Flow MRI. ASSESSMENT: The blood flow velocity, average blood flow rate (Q), and vortexes at the superior sagittal sinus (SSS), straight sinus (STS), transverse sinus, sigmoid sinus, and jugular bulb of each volunteer were evaluated by two independent neuroradiologists. The relationship between the total cerebral Q and sex and age was also assessed. Twelve volunteers underwent two scans within a month. STATISTICAL TESTS: The intraclass correlation coefficient (ICC) evaluated the inter-observer agreement. Blood flow parameters among volunteers were compared by the independent-sample t-test or Mann-Whitney U test. The multiple linear regression equation was used to evaluate the relationship between total cerebral Q and age and sex. P < 0.05 indicated statistical significance. RESULTS: The test-retest and interobserver reliability of average velocity and Q were moderate to high (ICC: 0.54-0.99). Cerebral sinus velocity varied by segment and cardiac cycle. The SSS's velocity and Q increased downstream and Q near torcular herophili was 3.5 times that through the STS. The total cerebral Q decreased by 0.06 mL/s per year (ß = -0.06 ± 0.013) and was sex-independent within the group. Vortexes were found in 12.12%, 8.9%, and 59.8% of torcular herophili, transverse-sigmoid junction, and jugular bulb, respectively, and were related to higher upstream flow. DATA CONCLUSION: Cerebral sinuses could be measured visually and quantitatively in vivo by 4D Flow MRI, providing a basis for future research on pulsating tinnitus, multiple sclerosis, and other related diseases. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 1.

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This video demonstrates use of the Synaptive 3D exoscope to enhance complex meningioma resection. The patient was a 58-year-old female who presented with new-onset seizures. Workup revealed a parasagittal meningioma over the bilateral cortices. She was started on 750 mg of Keppra twice daily and tapered dexamethasone and discharged. MR venography demonstrated segmental occlusion of the superior sagittal sinus. She then underwent a diagnostic angiogram and tumor Onyx embolization of the bilateral middle meningeal artery feeders. She then underwent a craniotomy for meningioma resection using 3D exoscope guidance. She awoke with a stable examination in the intensive care unit and worked with physical therapy on postoperative day 1. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23164.

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@#We present a 66-year-old male presenting with sudden onset of headache. Medical decompression was done and neuroimaging of plain cranial CT angiogram (CTA) and CT venogram (CTV) showed components of subarachnoid hemorrhage, intracerebral hemorrhage and hyperdense appearance of the superior sagittal sinus and proximal left transverse sinus. The following were done to look for etiologic factors: 1. fungal swab to determine the cause of the intracerebral hemorrhage secondary to venous thrombosis as the patient presented with a chronic history of sinusitis, 2. coagulopathy workup to look for a hypercoagulable state, and 3. workup for systemic disease of autoimmune in etiology. Anticoagulation was safely initiated within several days given the regression of the intracerebral hemorrhage along with stable findings of subarachnoid hemorrhage. Here we report cerebral venous sinus thrombosis rarely presenting as acute subarachnoid hemorrhage and intracerebral hemorrhage.

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A dural arteriovenous fistula (dAVF) involving the superior sagittal sinus (SSS) is relatively rare, and its clinical course is usually aggressive. Its concomitance with a tumor has rarely been reported. Here, we present a case of SSS dAVF due to meningioma invasion, which was treated with sinus reconstruction and endovascular embolization. A 75-year-old man who had undergone tumor resection for parasagittal meningioma 4 years prior presented with intra-ventricular hemorrhage. Computed tomography angiography and magnetic resonance imaging revealed recurrent tumor invasion into the SSS causing occlusion. Cerebral angiography revealed multiple shunts along the occluded segment of the SSS, diffuse deep venous congestion, and cortical reflux. Borden type 3 SSS dAVF was diagnosed. We first performed direct tumor resection, followed by stenting for the occluded SSS and partial embolization of the shunts. After a 6-month interval, transvenous occlusion of the SSS was performed along the stent, resulting in complete obliteration of the dAVF. Sinus reconstruction therapy was effective in the immediate improvement of venous hypertension, obtaining the access route to the fistulas, and eradicating the shunts.

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PURPOSE: Owing to their vicinity near the superior sagittal sinus, parasagittal and parafalcine meningiomas are challenging tumors to surgically resect. In this study, we investigate key factors that portend increased risk of recurrence after surgery. METHODS: This is a retrospective study of patients who underwent resection of parasagittal and parafalcine meningiomas at our institution between 2012 and 2018. Relevant clinical, radiographic, and histopathological variables were selected for analysis as predictors of tumor recurrence. RESULTS: A total of 110 consecutive subjects (mean age: 59.4 ± 15.2 years, 67.3% female) with 74 parasagittal and 36 parafalcine meningiomas (92 WHO grade 1, 18 WHO grade 2/3), are included in the study. A total of 37 patients (33.6%) exhibited recurrence with median follow-up of 42 months (IQR: 10-71). In the overall cohort, parasagittal meningiomas exhibited shorter progression-free survival compared to parafalcine meningiomas (Kaplan-Meier log-rank p = 0.045). On univariate analysis, predictors of recurrence include WHO grade 2/3 vs. grade 1 tumors (p < 0.001), higher Ki-67 indices (p < 0.001), partial (p = 0.04) or complete sinus invasion (p < 0.001), and subtotal resection (p < 0.001). Multivariable Cox regression analysis revealed high-grade meningiomas (HR: 3.62, 95% CI: 1.60-8.22; p = 0.002), complete sinus invasion (HR: 3.00, 95% CI: 1.16-7.79; p = 0.024), and subtotal resection (HR: 3.10, 95% CI: 1.38-6.96; p = 0.006) as independent factors that portend shorter time to recurrence. CONCLUSION: This study identifies several pertinent factors that confer increased risk of recurrence after resection of parasagittal and parafalcine meningiomas, which can be used to devise appropriate surgical strategy to achieve improved patient outcomes.

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Cerebral venous thrombosis is a rarely reported complication of iatrogenic intracranial hypotension. We discuss a rare case of a 46-year-old woman presenting with a week-long history of severe orthostatic headaches two weeks following L4-L5 microscopic discectomy for symptomatic lumbar disc herniation. Computed tomography venography of the head revealed evidence of superior sagittal sinus thrombosis while contrast-enhanced magnetic resonance imaging of the brain revealed signs of intracranial hypotension consisting of pachymeningeal enhancement, bilateral subdural hygromas, enlarged pituitary gland, effacement of the basal ambient cisterns, and low-lying cerebellar tonsils. Additional lumbar spine imaging revealed the culprit to be a large epidural fluid collection extending from the epidural space to the superficial subcutaneous fat, suggestive of a cerebrospinal fluid leak. The patient was managed with admission, bed rest, isotonic intravenous fluids, caffeine, and therapeutic dosing of low molecular weight heparin. In such cases, clinical suspicion and early recognition and management are of paramount importance to prevent devastating consequences. Management, whether conservatively or with surgical intervention, should be made on a case-by-case basis.

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The term parasagittal meningioma applies to those tumors that are associated with the superior sagittal sinus (SSS), originating from the dura mater in close relation to the parasagittal wall or angle, with no intervening brain tissue, possibly extending to the dura of the convexity and/or falx cerebri.(Cushing et al., Meningiomas: their classification, regional behaviour, life history, and surgeical and results. Hafner, 1938) They make up about 20-30% of all meningiomas. There is a vast literature correlating the Simpson grade of resection with later recurrence. Frequent involvement of the superior sagittal sinus (SSS) by these tumors means that the optimal treatment recommended in the literature-complete resection, including of the dural base-is one of the most challenging.

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Superior sagittal sinus (SSS) obstruction causes intracranial hypertension, often requiring surgical stenting. Consensus on treating brain venous sinus stenosis, another cause, is lacking. This study reports a case of SSS stenosis and intracranial hypertension treated with venous stenting, improving bilateral papilledema. A 51-year-old with a headache and visual disturbance had papilledema and visual field loss. MR venography showed SSS stenosis, leading to a neurosurgery referral. Lumbar puncture confirmed intracranial hypertension (>35 cmH2O), prompting venous stenting. Post-procedure, papilledema, headache, and visual field loss improved. Venous stenting could be effective for SSS stenosis with clinically proven or recurrent pressure differences. Further cases are needed for standardization.

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Background: Intracranial dural arteriovenous fistulas (DAVFs) have been documented to occasionally spontaneously regress. However, the mechanism responsible for this occurrence remains speculative. Methods: We present a case of a Borden II - Cognard IIa+b DAVF involving the superior sagittal sinus (SSS) with bilateral external carotid artery supply that regressed spontaneously. A systematic literature review was conducted to explore the current theories explaining the spontaneous regression of DAVFs according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Results: A total of 26 studies and 54 cases were included in our results. Of the included cases, 57.14% of cases were Borden I, 16.33% were Borden II, and 26.53% were Borden III. Ruptured status or intracranial hemorrhage was documented in 24.1% of all cases, the majority of which (69.2%) were in cases with aggressive lesions (Borden II or greater). The most commonly involved location was the transverse sinus (38.89% of cases, n = 21), and the SSS was only involved in 12.96% of all cases. 50% of included cases proposed a mechanism responsible for spontaneous regression. The most frequently proposed mechanisms were thrombosis of the involved sinus/chronic inflammatory changes or direct endothelial injury, endoluminal stasis, and thrombogenic effects of contrast medium during angiography. We present the case of a 54-year-old woman with an aggressive ruptured DAVF that likely developed following a pediatric traumatic brain injury that was left untreated before she presented to our institution after significant delay. Her DAVF regressed on repeat angiography before neurovascular intervention without a clear identifying mechanism as proposed by the current literature. Conclusion: Our results suggest that spontaneous regression is not necessarily associated with lower risk DAVFs. The present case offers a unique long-term insight into the natural history of an aggressive ruptured DAVF of the SSS that regressed without intervention. Further research into the natural history of DAVFs will be helpful in deducing key factors leading to spontaneous regression.