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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 30-33

Transverse sinus aneurysm presented as fetal intracranial hemorrhage: A new case report


1 Department of Neurosurgery, Tripoli University Hospital, Tripoli, Libya
2 Department of Radiology, Tripoli University Hospital, Tripoli, Libya

Date of Submission13-Feb-2022
Date of Acceptance10-Jun-2022
Date of Web Publication11-Aug-2022

Correspondence Address:
Prof. Faisal S Taleb
Department of Neurosurgery, Tripoli University Hospital, Tripoli
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ljms.ljms_7_22

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  Abstract 


A transverse sinus aneurysm is a very rare vascular pathology. Limited cases were reported in the literature. Here, we report a new case of a transverse sinus aneurysm presented as fetal intracranial hemorrhage of third-trimester pregnant women.

Keywords: Computed tomography angiography, intracranial hemorrhage, petrosquamous sinus, transverse sinus


How to cite this article:
Taleb FS, Ajaj S, Abograra A. Transverse sinus aneurysm presented as fetal intracranial hemorrhage: A new case report. Libyan J Med Sci 2022;6:30-3

How to cite this URL:
Taleb FS, Ajaj S, Abograra A. Transverse sinus aneurysm presented as fetal intracranial hemorrhage: A new case report. Libyan J Med Sci [serial online] 2022 [cited 2022 Oct 5];6:30-3. Available from: https://www.ljmsonline.com/text.asp?2022/6/1/30/353693




  Introduction Top


Aneurysm of the transverse sinus is a rare anomaly of the venous system. An extensive literature review revealed ten cases worldwide that have been reported up to our knowledge.[1] In our report, the diagnosis of a right transverse sinus aneurysm was an accidental finding after proper diagnostic imaging modalities. Our aim of this case report is to illustrate this rare phenomenon and to revisit in brief the anatomical venous system and the possible embryological sequence related to the transverse venous sinus aneurysm formation.


  Case Report Top


A healthy 25-year-old female in her third trimester undergoes an antenatal checkup at her obstetrician visit before delivery was informed of unexpected fetal intracranial hemorrhage after an ultrasound test was done. There were no complications or abnormal observations during the pregnancy according to her obstetrician. After the assurance of the parents, the mother transferred to our neurosurgery department for consultation. Intrauterine magnetic resonance imaging (MRI) showed posterior cranial fossa blood contained cystic mass with high suspicion of a right transverse sinus aneurysm [Figure 1]a and [Figure 1]b. The mother was scheduled for an elective cesarean section by her obstetrician. At birth, the infant was a 3.5 kg boy, with no obvious physical abnormality. We arranged with the pediatric intensive care unit for admission for monitoring and carry on the diagnostic images. A diagnosis of a right transverse sinus aneurysm was made utilizing computed tomography angiography (CTA) and MRI [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d and [Figure 3]a and [Figure 3]b.
Figure 1: a and b Sagittal and axial spin-echo T2-weighted imaging intrauterine MRI shows slow flow posterior cranial fossa blood contained cystic mass (Arrows). MRI: Magnetic resonance imaging

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Figure 2: (a and b) Axial and sagittal spin-echo T2-weighted imaging MRI shows slow flow posterior cranial fossa blood contained cystic mass (arrows), (c and d) Coronal T1 MRI wit contrast and Sagital CT scan angiography venous phase shows posterior cranial fossa blood contained cystic mass (arrows). MRI: Magnetic resonance imaging, CT: Computed tomography

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Figure 3: (a and b) MRV; Illustrate complete effacement right transverse sinus with loss of patency in contrast to left transverse sinus (Arrows). MRV: Magnetic resonance venography

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  Discussion Top


The cranial venues system in humans is quite complex. In humans, the majority of cerebral venous drainage reaches the posterior fossa before being directed primarily toward the internal jugular veins or the vertebral venous system.[2] The transverse sinus (TSS) is one of paired dural sinus that arises from the confluence of superior sagittal, occipital, and straight sinus at the torcular Herophili. The transverse sinus in the early human embryo is oriented vertically and follows a craniocaudal course. Then, a caudal expansion of the cerebrum over the cerebellum during fetal development will later displace the transverse sinus from a vertical to a horizontal position and this leads to the regression of the petrosquamous sinus (PSS), with the sigmoid sinus then becoming the major outflow pathway of the transverse sinus.[3]

The PSS is a large embryonic emissary vein that passes anterolaterally through the petrous bone during fetal development, connecting the rostral part of the transverse sinus with the veins of the temporal fossa. Its origin is from the dorsolateral portion of the transverse sinus at the junction with the sigmoid sinus, close to the ostium of the superior petrosal sinus. It usually regresses later in the prenatal stage before birth, but partial regression could explain the persistence of a venous pouch. Therefore, based on embryological studies,[2],[4],[5] the authors suggest that a TSS aneurysm possibly represents an enlarged partial remnant of a PSS.[6]

Presenting symptoms of transverse sinus aneurysm in an infant is not well known, in our case, the infant was delivered by cesarean section in a healthy young mother and admitted to a nursery intensive care unit for monitoring. No obvious specific symptoms were observed in our case, motor examination and reflexes were normal. Furthermore, no signs of increased intracranial pressure in the infant postdelivery are noted. Intracranial venous sinuses can be visualized using various methods, including conventional angiography, magnetic resonance (MR) venography, and computed tomography venography.[7] We ordered MRI, magnetic resonance venography, and venous phase CTA in our case, it showed slow flow posterior cranial fossa blood contained cystic mass confirming our diagnosis of a right transverse sinus aneurysm

Our treatment approach to this infantile TSS aneurysm is depending on several factors: extreme age, neurological status, and parents' expectations after any interventions. In our case, initially, we decided to observe the infant for any signs of increased intracranial hypertension which may translate into hydrocephalus, which may necessitate immediate surgical intervention. From the point of view of transverse sinus aneurysm, we seek the parents' consent to go for a selective DSA venous phase. Full treatment options including advantages and disadvantages for both open surgery and endovascular intervention were discussed in detail with the parents, but the parents decided to wait and see. The infant is well up to the time of this report. Similar to our treatment plan, multiple treatment approaches were reported in the literature: open surgical coagulation and reconstruction of the aneurysm or endovascular intervention by stent placement at the neck of aneurysm and embolization.[8],[9]


  Conclusion Top


A transverse sinus aneurysm is an extremely rare pathology of the cranial venous system. The underline etiology is still not fully known up to our knowledge, but view authors in the literature highlight the persistence of PSS as an embryological cause of this pathology. The options of treatments for the transverse sinus aneurysm are open surgery or endovascular interventions. Thus, the treatment should be tailored individually. Our treatment plan regarding this case is to wait for parents' permission to do the surgical treatment as they decided to not intervene at this time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Acknowledgments

The parents have provided consent for the case report and use of photographs. The authors wish to thank the cooperating family members for the necessary medical data and photographs for publication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dong Y, Liu Q. Fusiform aneurysm of transverse sinus associated with growth retardation. Neurol India 2012;60:249-50.  Back to cited text no. 1
  [Full text]  
2.
San Millán Ruíz D, Gailloud P, Yilmaz H, Perren F, Rathgeb JP, Rüfenacht DA, et al. The petrosquamosal sinus in humans. J Anat 2006;209:711-20.  Back to cited text no. 2
    
3.
Conroy G. A study of the cerebral vascular evolution in primates. In: Armstrong E, Falk D, editors. Primate Brain Evolution. New York: Plenum Press; 1982. p. 247-61.  Back to cited text no. 3
    
4.
Reis CV, Deshmukh V, Zabramski JM, Crusius M, Desmukh P, Spetzler RF, et al. Anatomy of the mastoid emissary vein and venous system of the posterior neck region: Neurosurgical implications. Neurosurgery 2007;61:193-200.  Back to cited text no. 4
    
5.
Marsot-Dupuch K, Gayet-Delacroix M, Elmaleh-Bergès M, Bonneville F, Lasjaunias P. The petrosquamosal sinus: CT and MR findings of a rare emissary vein. AJNR Am J Neuroradiol 2001;22:1186-93.  Back to cited text no. 5
    
6.
Lenck S, Mosimann PJ, Labeyrie MA, Houdart E. Pulsatile tinnitus caused by an aneurysm of the transverse-sigmoid sinus: A new case report and review of literature. J Neuroradiol 2012;39:276-9.  Back to cited text no. 6
    
7.
Widjaja E, Griffiths PD. Intracranial MR venography in children: Normal anatomy and variations. Am J Neuroradiol 2004;25:1557-62.  Back to cited text no. 7
    
8.
Gologorsky Y, Meyer SA, Post AF, Winn HR, Patel AB, Bederson JB. Novel surgical treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus: technical case report. Neurosurgery 2009;64:E393-4.  Back to cited text no. 8
    
9.
Zenteno M, Murillo-Bonilla L, Martínez S, Arauz A, Pane C, Lee A, et al. Endovascular treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus. Case report. J Neurosurg 2004;100:120-2.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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