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Sinus Pericranii

Answer: C

This child exhibits sinus pericranii, a congenital venous malformation that connects directly to the intracranial dural sinuses.  It is typically found on the midline and may increase in size with Valsalva maneuver.  Sinus pericranii may present at any age, but it typically becomes apparent in childhood to the third decade.  It may be associated with craniosynostosis (prematurely fused skull bones), arteriovenous malformations, or developmental delay.  Adolescents and adults may present with unrelenting headaches and nausea.

Below is a schema of how sinus pericranii develops as an outcropping of the dural sinus:
Picture
In the absence of fever, erythema, or tenderness to palpation and in the presence of a slow in onset non-inflamed midline mass, incision and drainage (A) could cause disastrous results.  Similarly, treating this lesion as a skin tie (acrochordon) (B) would likely complicate his management.

Given the child is otherwise well, an emergent MRI is not indicated.  Even if this resource were elected to be used in the ED, special caution must be applied when considering imaging studies in young children.  If this child were to need sedation, his young age puts him at risk for apnea.  Conservative sedation guidelines for young children include admission for infants born full term (greater than 37 weeks gestation) who are given any anesthetic-sedative agent under 3 months of age.  Premature infants (born < 37 weeks gestation) and under 60 weeks conceptional age should also be admitted for monitoring post-sedation. 
 
That is, a full-term baby under 3 months of age or a preterm infant under 60 weeks post-conception generally should not undergo moderate or deeper sedation and discharged on the same day,
due to higher risk of delayed apneic episodes.
  Nevertheless, this child’s workup requires forethought and planning, appropriate for the lack of urgency in the diagnosis.

Watchful waiting and referral to the child’s primary medical doctor will facilitate serial examinations by a single invested provider and allow for proper follow up.  On elective scheduled MRI, the  child shows evidence of sinus pericranii:
Picture
The MRI will now allow for proper surgical planning on an elective basis.


References
 
Anegawa S, Hayashi T, Torigoe R et al. Sinus Pericranii with Severe Symptoms Due to
Transient Disorder of Venous Return. Neurol Med Chir. 1991; 31:287-291.
 
Kamble RB, Venkataramana, Naik L et al. Sinus pericranii presenting with macrocephaly
and mental retardation. J Pediatr Neurosci. 2010 Jan-Jun; 5(1): 39–41. 
 
Peoples JD. [Presentation] Sinus pericranii. December, 2009. Bend, OR.
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