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World Neurosurg. 2018 Aug 6. pii: S1878-8750(18)31740-6. doi: 10.1016/j.wneu.2018.07.260. [Epub ahead of print]

Intracranial Venous Hypertension in Craniosynostosis: Mechanistic Underpinnings and Therapeutic Implications.

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United States Environmental Protection Agency, Arlington, Virginia, USA; Department of Toxicology, Purdue University, West Lafayette, Indiana, USA.
Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA; Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA. Electronic address:
Department of Medicine, Inova Alexandria Hospital, Alexandria, Virginia, USA; Department of Urological Surgery, El Gomhoureya General Hospital, Alexandria, Egypt.
Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA.
Division of Plastic and Reconstructive Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA.
Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA.


Patients with complex, multisutural, and syndromic craniosynostosis (CSO) frequently exhibit intracranial hypertension. The intracranial hypertension cannot be entirely attributed to the craniocephalic disproportion with calvarial restriction because cranial vault expansion has not consistently alleviated elevated intracranial pressure. Evidence has most strongly supported a multifactorial interaction, including venous hypertension along with other pathogenic processes. Patients with CSO exhibit marked venous anomalies, including stenosis of the jugular-sigmoid complex, transverse sinuses, and extensive transosseous venous collaterals. These abnormal intracranial-extracranial occipital venous collaterals might represent anomalous development, with persistence and subsequent enlargement of channels normally present in the fetus, either as a primary defect or as nonregression in response to failure of the development of the jugular-sigmoid complexes. It has been suggested by some investigators that venous hypertension in patients with CSO could be treated directly via jugular foraminoplasty, venous stenting, or jugular venous bypass, although these options are not in common clinical practice. Obstructive sleep apnea, occurring as a consequence of midface hypoplasia, can also contribute to intracranial hypertension in patients with syndromic CSO. Thus, correction of facial deformities, as well as posterior fossa decompression, could also play important roles in the treatment of intracranial hypertension. Determining the precise mechanistic underpinnings underlying intracranial hypertension in any given patient with CSO requires individualized evaluation and management.


Craniosynostosis; Hydrocephalus; ICP; Intracranial hypertension; Jugular; Transverse sinus; Venous


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