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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 3  |  Page : 328-329

Aneurysm of torcula


1 Department of General Surgery, Kettering General Hospital, Northamptonshire NN16 8UZ(1), United Kingdom
2 Department of Radiology, Leicester Royal Infirmary, Leicester, LE1 5WW, United Kingdom

Date of Submission31-Mar-2013
Date of Decision02-Apr-2013
Date of Acceptance30-May-2013
Date of Web Publication16-Jul-2013

Correspondence Address:
Muhammad Mehdi Masood
Department of General Surgery, Kettering General Hospital, Northamptonshire NN16 8UZ(1)
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.115097

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How to cite this article:
Masood MM, Alam S, Husainy MA, Shah A. Aneurysm of torcula. Neurol India 2013;61:328-9

How to cite this URL:
Masood MM, Alam S, Husainy MA, Shah A. Aneurysm of torcula. Neurol India [serial online] 2013 [cited 2020 Aug 6];61:328-9. Available from: http://www.neurologyindia.com/text.asp?2013/61/3/328/115097


Sir,

This report presents probably the first ever case of an aneurysmal dilatation of the torcula in an adult.

A 30-year-old female presented with 3 days history of headache. There was no loss of consciousness and neurological examination was unremarkable. Glasgow coma scale score was 15. There was no relevant past medical history. Computed tomography (CT) did not reveal any acute hemorrhage or infarction. However, a dilated torcula was noted [Figure 1]. There was no high attenuation within the dural venous sinuses on the non-contrast scan. Magnetic resonance imaging revealed the torcula to be aneurysmal [Figure 2]. The venous sinuses were however unremarkable and there was no dural venous sinus thrombosis. She was managed symptomatically.
Figure 1: Axial images of unenhanced computed tomography showing aneurysmal torcula

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Figure 2: (a and b) T2W axial, (c and d) T2* axial, (e and f) Time Of Flight MRI images showing dilated aneurysmal torcula

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The torcular herophili is formed by a confluence of the superior sagittal sinus, straight sinus and occipital sinus. It acts as a junction between the superficial and the deep cerebral venous system. The superficial venous system drains the superficial surfaces of both cerebral hemispheres and consists of sagittal sinuses and cortical veins, whereas the deep system comprises the lateral sinus, straight sinus and sigmoid sinus and it drains the deeper cortical veins. The internal cerebral vein and the basal veins join to form the great vein of Galen, which then drains into the straight sinus. All veins eventually drain into the internal jugular vein. [1]

Dural arteriovenous malformations (AVM) are rare in adults. These usually present with pulsatile tinnitus or with hemorrhage. In adults, AVM mainly consist of brain arteriovenous shunts and acquired dural arteriovenous fistula, whereas in the neonate and infantile group, vein of Galen aneurysmal malformation (VGAM) is the commonest. [2],[3],[4]

It is well-established that malformation of the great vein of Galen, although being quite rare, is the commonest form of AVM in children. [4] Although, in some cases secondary dilation of the torcula is evident, there is only one published case report of a primary aneurysm of the torcula. [5] VGAM is a not a true aneurysm of the vein of Galen and it develops in the medial vein of prosencephalon, thought to be the embryonic precursor of the vein of Galen. This AVM is made of principally the anterior and posterior choroidal arteries and the anterior cerebral arteries directly feeing into the enlarged medial vein of prosencephalon pouch. The pouch does not communicate with the deep venous system of the brain and drains into the superior sagittal sinus via a falcine sinus. A true aneurysm of the vein of Galen (vein of Galen aneurysmal dilatation) is usually caused by an adjacent deep AVM draining through a dilated vein of Galen with some outflow restriction. [3],[4]

Deep cerebral venous thrombosis affects 3-8% of patients and the presence of thrombus within the aneurismal sac of VGAM can be demonstrated by CT. [6] The thrombus can appear of variable density due to the maturation level of the clot and on contrast enhanced CT, a "Target" sign (central thrombus with peripherally circulating blood along the wall of the sac) and dilatation of the parenchymal vessels can be appreciated. [7]

It is important to be familiar with the "Aneurysm of Torcula" as this rare congenital abnormality could be confused and mistaken for dural venous thrombosis or a small meningioma.

 
  References Top

1.Uddin MA, Haq TU, Rafique MZ. Cerebral venous system anatomy. J Pak Med Assoc 2006;56:516-9.  Back to cited text no. 1
[PUBMED]    
2.Ozanne A, Alvarez H, Krings T, Lasjaunias P. Pediatric neurovascular malformations: Vein of galen arteriovenous malformations (VGAM), pial arteriovenous malformations (pial AVM), dural sinus malformations (DSM). J Neuroradiol 2007;34:145-66.  Back to cited text no. 2
[PUBMED]    
3.Berenstein A, Ortiz R, Niimi Y, Elijovich L, Fifi J, Madrid M, et al. Endovascular management of arteriovenous malformations and other intracranial arteriovenous shunts in neonates, infants, and children. Childs Nerv Syst 2010;26:1345-58.  Back to cited text no. 3
[PUBMED]    
4.Bhattacharya JJ, Thammaroj J. Vein of galen malformations. J Neurol Neurosurg Psychiatry 2003;74 Suppl 1:i42-4.  Back to cited text no. 4
[PUBMED]    
5.Gürsoy G, Tolun R, Bahar S. Aneurysmal dilatation of torcula. Neuroradiology 1979;18:285-8.  Back to cited text no. 5
    
6.van den Bergh WM, van der Schaaf I, van Gijn J. The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis. Neurology 2005;65:192-6.  Back to cited text no. 6
[PUBMED]    
7.Gupta AK, Varma DR. Vein of galen malformations: Review. Neurol India 2004;52:43-5.  Back to cited text no. 7
[PUBMED]  Medknow Journal  


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  [Figure 1], [Figure 2]

This article has been cited by
1 Aneurysmal dilatation of torcular herophili
Muzaffer Saglam,Emre Zorlu,Cihan Meral
Acta Neurologica Belgica. 2017; 117(1): 303
[Pubmed] | [DOI]



 

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