CRANIAL MENINGES

AND DURAL VENOUS

SINUSES

1
CRANIAL MENINGES
• Definition: These are connective tissue membranes
covering the brain.
• Function: they provide the following
1. Provides stability and protection of the soft and
gelatinous brain.
2. Supporting framework for Arteries, Veins and Venous
sinuses.
3. Enclosed fluid-filled cavity for CSF.

2
 CRANIAL MENINGES
◼ Made up of Three layers
1. Dura mater (dura): tough, thick
external fibrous layer.
2. Arachnoid mater (arachnoid):
thin intermediate layer.
3. Pia mater (pia): delicate internal
vasculated layer.

3
 The Meninges of Brain
◼ Cerebral dural mater D (Also called
pachymeninx (G. pachy, thick + G. menix,
membrane)
◼ The intermediate and internal layers
(arachnoid and pia) are continuous
membranes that collectively comprise the
leptomeninx (G. slender membrane).
◼ A potential and real space exists deep to the
dura and arachnoid, respectively, the
subdural and subarachnoid spaces.
 No epidural space in the skull. 4
◼ The arachnoid is separated from the pia by the
subarachnoid (leptomeningeal) space, which contains
cerebrospinal fluid (CSF). This fluid-filled space helps
maintain the balance of extracellular fluid in the brain.
◼ CSF is a clear liquid similar to blood plasma in the
constitution. It provides nutrients but has less protein
and a different ion concentration.
◼ The choroid forms CSF plexuses of the four ventricles of
the brain. This fluid leaves the ventricular system and
enters the subarachnoid space between the arachnoid
and pia mater, where it cushions and nourishes the brain.

5
 Cerebral dural mater
Characters
◼ A thick and dense inelastic membrane that is composed of two layers,
an inner or meningeal and outer periosteal or endosteal layers
◼ It is in loose contact with calvaria and most strongly adherent to the
base of the skull

6
PERIOSTEAL LAYER OF DURA MATTER
◼ Firmly lines cranial cavity, and
adhesion is solid at the sutures,
cranial base and around
foramen magnum.
◼ Continues with the pericranium
through the sutures and
foramina.
◼ Continues with the orbital
periosteum through the
superior orbital fissure
7
 Cerebral dural mater
◼ Between these two layers, the
dural venous sinuses are
located.
◼ They are responsible for the
venous vasculature of the
cranium, draining into the
internal jugular veins.

8
◼ EPIDURAL SPACE: A POTENTIAL
space above the dura
◼ Because dura is adherent to the
skull, it is nonexistent.
◼ But in the vertebra, it is an actual
space (occupied by fat and
venous sinuses)
◼ Where pus, blood and tumour
cells may accumulate
 Endosteal layer
◼ Does not extend to the Spinal
Cord
◼ Goes out to the ext. surface of
the bone (periosteum) Clinical Note: epidural anesthesia
 Meningeal layer can not ascend to enter the skull.
◼ Dura matter proper Epidural space is none existent in
◼ Extends to the Spinal Cord the skull
9
Dura mater
◼ Forms 4 septa (DURAL
REFLECTIONS)
 Restricts ROTATORY displacement
of brain
◼ In the spinal cord: It Covers the
spinal cord
◼ Tapers to coccygeal ligament
◼ Epidural space separates dura
mater from the walls of the
vertebral canal

10
DURAL REFLECTIONS
◼ The meningeal layer of the
dura folds inwards to form
four septa that partially divide
the cranial cavity into freely
communicating spaces in
which the brain’s subdivisions
are lodged.
◼ These are
 Cerebral falx,
 Cerebellar tentorium,
 Cerebellar falx and
 Sellar diaphragm

11
Septa of Dura Matter
I. Falx Cerebri
 Sickle-shaped fold
between cerebral
hemispheres
◼ The largest dural
◼ Related sinuses (2 layers fused)
infolding lies in the  Superior Sagittal sinus
longitudinal cerebral ◼ Upper
fissure that separates ◼ Fixed margin of the falx
 Inferior Sagittal sinus
the right and the left ◼ Lower
cerebral hemispheres. ◼ Free margin of the falx
 Straight sinus
◼ Along the attachment of tentorium cerebelli
12
◼ Attachment
 Anteriorly
◼ Internal frontal
crests and crista
galli
 Posteriorly
◼ Blend with
tentorium cerebelli

13
II. Tentorium Cerebelli
 Crescent-shaped dural fold
located between cerebellum and
occipital lobes of cerebral
hemispheres
 Roof over the post. Cranial fossa
◼ Tentorial Notch
◼ For passage of the midbrain
 Attachment
 Post. Clinoid Process
 Petrous bone
◼ Front of temporal
◼ Occipital bone

 Related sinus
◼ Straight sinus
◼ Sup. Petrosal Sinus
◼ Transverse Sinus Tentorial Notch
14
15
III. Falx Cerebelli
 Small, sickle shaped
fold between
Cerebellar
hemispheres
 Attachment to
Internal occipital crest
◼ Occipital sinus
 Only sinus related to
it
 Post. Fixed sinus

16
17
IV. Diaphragma Sella Diaphragma sella

IV. Diaphragma Sella

 Small, circular fold
 Roof of sella turcica
 Central opening allows passage
of Hypophyseal stalk
◼ Clinical Note: pituitary tumours
will cause this septum to be
displaced superiorly
◼ Can lead to endocrine
symptoms (obesity, genital
shrinking, etc.) due to the
involvement of the pituitary and
hypothalamus superiorly 18
 Sellae Diaphragm
◼ Can also compress the optic
chiasm – leading to bitemporal
hemianopia (or blindness in
temporal halves of the visual
field, “tunnel vision”)

19
Blunt Trauma to the Head
◼ A blow to the head can detach the periosteal layer of dura
mater from the calvaria without fracturing the cranial bones.
◼ A cranial base fracture usually tears the dura and results in
leakage of CSF.
 Because the two dural layers are firmly attached and difficult to
separate from the bones.

20
Tentorial Herniation
◼ The tentorial notch is the opening in
the cerebellar tentorium for the
brainstem.
◼ Hence space-occupying lesions, such
as tumours in the supratentorial
compartment, produce increased
intracranial pressure and may cause
part of the adjacent temporal lobe of
the brain to herniate through the
tentorial notch.
21
Tentorial Herniation
◼ During tentorial herniation, the
temporal lobe may be
lacerated by the tough
cerebellar tentorium and the
oculomotor nerve (CN III)
may be stretched,
compressed, or both.

22
Dural Venous Sinus
◼ It drains ALL blood from the brain, Diploe, Orbits and Internal
ear via the jugular foramen;
 continuous with cerebral veins;
 have no valves;
 lined with endothelium;
 no muscles in their walls;
 Moves via pressure

◼ Equivalent to the internal vertebral venous plexus in the spinal

cord, the venous sinuses (usually) lie between the periosteal
and endosteal layers of the cranial dura.
23
 Sinuses of dura mater
1. Superior sagittal sinus
2. Inferior sagittal sinus
3. Straight sinus
4. Confluence of sinus
5. Transverse sinus
6. Sigmoid sinus
7. Superior petrosal sinuses
8. inferior petrosal sinuses
9. anterior and posterior
intercarvenous sinuses
10. Occipital
24
Superior Sagittal Sinus
◼ Lies in the median plane on the
superior border of the falx cerebri
◼ 60% of them end in the right
transverse sinus
◼ receives superior cerebral veins
◼ Clinical Note: these veins are
clinically important as they can be
torn following a blow to the “front” of
the head; this results in a subdural
haemorrhage.
◼ It contains protrusions from
subarachnoid space called
arachnoid villi – which return CSF
into the venous system 25
Superior Sagittal Sinus

26
Subdural hemorrhage

27
Extradural hematoma vs subdural hematoma

◼ History and mechanism of injury

◼ Extradural (EPIDURAL) hematoma
 The typical presentation is of a young patient involved in a head
strike (either during sport or a result of a motor vehicle accident)
who may or may not lose consciousness transiently. Following the
injury, they regain a normal level of consciousness (lucid
interval), but usually have an ongoing and often severe headache.
 Over the next few hours, they gradually lose consciousness.

28
History and mechanism of injury
◼ Subdural hematoma
◼ In adults' Subdural hematomas are due to falls, and
there may not be a clear history of trauma. In young
children, non-accidental injury is a significant cause. The
patient’s level of consciousness gradually decreases
with increasing mass effect, and confusion is often
encountered in the elderly.

29
Source
◼ Extradural hematoma
◼ Almost always arterial,
explaining the progressive
growth of the haematoma.
Classically due to injury of
the middle meningeal artery,
a branch of the maxillary
artery (from the Ext Carotid
Artery).

30
◼ Subdural hematoma
◼ Almost always venous due to
tearing of subdural cortical
bridging veins, which extend to
the dural sinuses. The reason is
generally a strike on the front or
rear of the head, leading to the
excessive anteroposterior
displacement of the brain inside
the skull. Therefore, the
cerebral veins in the subdural
space (bridging veins) are
unduly stretched and torn.
31
Radiographic features
◼ Distribution and appearance
◼ Extradural hematoma
 Typically, lentiform (lens-shaped,
biconvex, lemon-shaped) and do
not cross sutures as the
periosteum crosses through the
suture continuous with the outer
periosteal layer.

32
 Radiographic features
◼ Subdural hematoma
 Typically, crescentic (crescent
moon-shaped, concave, banana-
shaped) and more extensive than
EDH, with the internal margin
paralleling the cortical margin of
the adjacent brain.
 As these occur in the subdural
space, they cross sutures.

33
34
 Treatment and prognosis

◼ EDH: Since bleeding is under ◼ SDH has various management

arterial pressure, the hematoma strategies depending on the size,
may expand rapidly. location and extent of mass effect
◼ Prompt drainage is almost always and is either conservative (monitor
necessary with serial CT) or surgical (drainage
◼ It is treated with expedient with burr holes).
evacuation via a craniotomy. ◼ Prognosis
◼ Prognosis ◼ 50% - 90% mortality. The high
◼ 5%- 10% mortality if treated within morbidity and mortality is due to
the first few hours. Mortality is parenchymal damage underlying
largely due to increased intra- the hematoma and raised
cranial pressure and herniation. intracranial pressure.

35
◼ Surgeons access the cranial cavity and
brain by performing a craniotomy.
◼ The adult pericranium (the periosteum of the
cranium) has poor osteogenic (bone-
forming) properties, and little regeneration
occurs after bone loss.
◼ Surgically produced bone flaps are put back
into place and wired to other parts of the
calvaria or held in place temporarily with
metal plates.
◼ Reintegration is most successful when the
bone is reflected with its overlying muscle
and skin so that it retains its own blood
supply during the procedure and after
repositioning.
36
Inferior Sagittal and straight Sinus
◼ Inferior Sagittal Occupies
posterior 2/3 of the free
inferior edge of the falx cerebri
and ends in the straight sinus.
◼ Straight Sinus – formed by the
inferior sagittal sinus and
great cerebral vein of Galen.
runs inferoposteriorly along falx
cerebri to tentorium cerebelli

37
Inferior Sagittal and straight Sinus
◼ Empties into a transverse
sinus (usually the left)
◼ Helps form confluence of
sinuses –dilation of the
venous channels posteriorly,
where the superior sagittal,
straight, occipital, and
transverse sinuses meet.

38
Transverse Sinuses
◼ Transverse Sinuses – paired
sinuses (left and right) pass lateral
from the confluence of sinuses and
form deep grooves in the occipital
(and part of the parietal) bones.
◼ Become the sigmoid sinus at the
posterior aspect of the petrous
temporal bone as they leave the
tentorium cerebelli.
◼ The transverse sinuses drain blood
received by the confluence of
sinuses, but rarely equally.
Usually, the left sinus is
dominant (larger).
39
Sigmoid Sinuses and
Occipital Sinus
◼ Sigmoid Sinuses – paired
sinuses with an “S-shaped” course
in the posterior cranial fossa
 they receive the inferior petrosal
sinuses directly

◼ Occipital Sinus – found posterior

to foramen magnum
 lies in the attached border of Falx
cerebelli
 communicates inferiorly with
internal vertebral plexus
 drains superiorly in the confluence of
sinuses
40
 Superior and Inferior Petrosal Sinuses
◼ Superior Petrosal Sinuses – paired sinuses that lie superior to the
petrous ridge of the temporal bone

• Drain the cavernous

sinuses and empty
into transverse
sinuses.
• Lie in attached
margin of tentorium
cerebelli

41
Superior and Inferior Petrosal Sinuses
◼ Inferior Petrosal Sinuses – paired sinuses that drain directly into the
internal jugular vein on either side; also drain the cavernous sinuses.

42
Cavernous sinus
◼ Large, paired sinuses (2 cm long,
1 cm wide)
◼ Position: lies on each side of sella
turcica
◼ It is in a dural compartment
bounded by the body of the
sphenoid bone and the anterior
portion of the tentorium.
◼ Differ from the other sinuses as
they are transversed by numerous
trabeculae, which give them a
spongy appearance 43
◼ The cavernous sinus extends anteriorly from the superior orbital
fissure to the apex of the petrous part of the temporal bone
posteriorly.

44
Boundaries and
relations
◼ Superiorly: optic tract, optic
chiasma, internal carotid
artery.
◼ Inferiorly: greater wing of
sphenoid bone.
◼ Medially: Sella turcica and
sphenoidal air sinus.
◼ Laterally: temporal lobe with
uncus.

45
Boundaries and relations

46
Cavernous sinus
◼ Relations of cavernous sinus:
 Internal carotid artery and
abducens nerve run through
the sinus
 (O)Oculomotor and
(T)trochlear nerves and
(O)ophthalmic and
(M)maxillary divisions of
trigeminal nerve lie in the
lateral wall of the sinus One mnemonic for remembering
the contents is "OTOM CAT
47
Structures that transverse the cavernous
sinuses
◼ (C) the internal carotid artery and its
periarterial nervous plexus
(sympathetics)
◼ (A)the abducens nerve (CNVI)
◼ (O)the oculomotor nerve (CNIII)
◼ (T)the trochlear nerve (CNIV)
◼ (O)the ophthalmic (V1) and
(M)maxillary (V2) divisions of the
trigeminal nerve
◼ CNIII, CNIV, and the divisions of CNV
lie laterally in the cavernous sinus
One mnemonic for remembering the contents is
"O TOM CAT

48
Cavernous sinus
◼ It drain through the superior and inferior petrosal sinuses
and emissary veins (to pterygoid plexus)
◼ Receives drainage of the sphenoparietal sinus, middle
cerebral veins, and ophthalmic veins

49
Communications
◼ It receives several veins
(superior ophthalmic,
superficial middle cerebral,
and sphenoparietal sinus). It
communicates (by the petrosal
sinuses) with the transverse
sinus, internal jugular vein,
and opposite cavernous sinus.

50
Communications
◼ The facial vein (via the
ophthalmic veins) communicates
with the cavernous sinus and
hence allows infection around
the nose and upper lip
("danger area") to spread to
intracranial structures.

51
Communications
◼ The veins of exit are to the superior and
inferior petrosal sinuses as well as via the
emissary veins through the foramina of the skull
(mostly through foramen ovale).

There are also connections with the

pterygoid plexus of veins via the
inferior ophthalmic and deep facial
veins. 52
53
 The flowing of the blood in dural
sinus
Sup. sagittal sinus

Inf. sagittal sinus Straight sinus Confluence of sinus Transverse sinus

Sup. petrosal sinus

Sigmoid sinus
Cavernous sinus

Inf. petrosal sinus Internal jugular vein

54
Clinical significance
◼ It is the only anatomic location in the body in which
an artery travels completely through a venous
structure. If the internal carotid artery ruptures within the
cavernous sinus, an arteriovenous fistula is created
(more specifically, a carotid-cavernous fistula).
◼ Lesions affecting the cavernous sinus may affect isolated
nerves or all the nerves traversing through it.

55
Clinical significance
◼ An abnormally growing pituitary adenoma, sitting on the bony sella
turcica, will expand in the direction of least resistance and eventually
compress the cavernous sinus.
◼ Cavernous sinus syndrome may result from mass effect of these
tumours and cause
 Ophthalmoplegia (from compression of the oculomotor nerve, trochlear
nerve, and abducens nerve),
 Ophthalmic sensory loss (from compression of the ophthalmic nerve[
Trigeminal nerve V1]), and
 Maxillary sensory loss (from compression of the maxillary nerve
[Trigeminal nerve V2]).

56
Clinical significance
◼ Because of its connections
with the facial vein, it is
possible to get infections in
the cavernous sinus from an
external facial injury within
the Danger area of the face.
◼ This is especially likely as
the facial vein has no
valves, allowing blood to
pass in both directions.

57
Danger area of the face.
◼ Danger area consists of the area from
the angle of the mouth to the bridge of
the nose, including the nose and
maxilla.
◼ Retrograde infection from the nasal
area can spread to the brain causing
cavernous sinus thrombosis,
meningitis or brain abscess due to
the communication between the facial
vein, pterygoid plexus and cavernous
sinus.
58
Clinical significance
◼ In thrombophlebitis of the facial vein, pieces of the clot
may break off and enter the cavernous sinus, forming
a cavernous sinus thrombosis. From there, the
infection may spread to the dural venous sinuses.
◼ Infections may also be introduced by facial lacerations
and bursting pimples in the areas drained by the facial
vein.

59
Cavernous sinus thrombosis.

60
Emissary Veins
◼ The emissary veins connect the extracranial venous system
with the intracranial venous sinuses.
◼ They connect the veins outside the cranium to the venous
sinuses inside it.
◼ They drain from the scalp, through the skull, into the larger
meningeal veins and dural venous sinuses.
◼ Clinically important because infections within the scalping
plane can spread to the bone via these veins or the foramina.
They contain no valves; thus, blood can potentially flow
in both directions
61
 Emissary Veins
1. Size and number vary: Frontal
emissary vein – passes through
foramen cecum
1. connects superior sagittal sinus with
veins of the frontal sinuses and nasal
cavities
2. Parietal emissary vein (parietal
foramen)
3. Mastoid emissary vein – passes
through the mastoid canal
1. connects sigmoid sinus with occipital or
posterior auricular vein
4. Posterior condylar emissary vein
- passes through the condylar canal
1. Connects sigmoid sinus through the
condylar canal
62
Vasculature and Innervation of the Dura
Mater
◼ Blood supply to the dura is
scanty
◼ The middle meningeal artery is
the largest and most important

◼ Supplies most of the supratentorial

dura except the floor of the
anterior cranial fossa (which is
supplied by branches of the ant.
and post. ethmoidal arteries from
the ophthalmic artery)

63
Vasculature and Innervation of the Dura
Mater
◼ The middle meningeal artery
◼ Branch of the maxillary artery
(from the external carotid artery)
enters the middle cranial fossa via
foramen spinosum and forms deep
grooves in the inner lamina of
bone; thus, subject to injury

64
Vasculature and Innervation of the Dura
Mater
◼ A skull fracture can shear the
meningeal arteries (or veins), which
leads to an epidural haemorrhage
– blood collects outside the
endosteal layer of the dura
◼ Patient with epidural haemorrhage
usually has a blow to the side of the
head in the area of the pterion; they
may lose motor function
contralaterally
65
Leptomeninges (arachnoid
+ pia mater)
◼ Consists of arachnoid (“spider-
like”; a thin, delicate membrane)
and pia mater (adherent to brain
tissue), connected with each
other by the arachnoid
trabeculae but otherwise
separated by the subarachnoid
space, which collapses after
death.

66
Arachnoid Mater
◼ The arachnoid mater is the middle layer of the meninges, lying
directly underneath the dura mater.
◼ It consists of layers of connective tissue, is avascular, and receives
no innervation.
◼ Underneath the arachnoid is a space known as the subarachnoid
space. It contains cerebrospinal fluid, which acts to cushion the
brain.
◼ Small projections of the arachnoid mater into the dura (known
as arachnoid granulations) allow CSF to re-enter the circulation via
the dural venous sinuses.

67
◼ Arachnoid villi
 Arachnoid granulations
◼ Grouped protrusion of
arachnoid villi
◼ Drains into the dural venous
sinus
◼ Drains CSF via diffusion

◼ CSF
 Produced by choroid plexus
◼ Made up of capillaries

◼ Found in VENTRICLES

◼ All ventricles make CSF

◼ Flow is always from up going

down
68
Subarachnoid space
◼ Subarachnoid space
consists of…
 Arachnoid trabeculae,
a network of
connective tissue
 Cerebrospinal fluid
(CSF) which bathes
the brain tissue and
helps distribute and
equalize pressure
within the skull.
69
Subarachnoid space

◼ Blood vessels – all major

vessels of the brain lie in the
subarachnoid space before
entering the parenchyma

70
Cisterns
◼ Cisterns – dilations or
enlargements of the
subarachnoid space where CSF
pools.
◼ Remember, the pia is attached to
the brain’s surface, while the
arachnoid closely follows the
shape of the dura.
◼ Interpeduncular cistern – lies
over the ventral surface of the
brain in the area of the midbrain
71
Cisterns
◼ Cerebellomedullary cistern (or
cisterna magna) – spans
between the cerebellum's
posteroinferior surface and the
medulla's posterior part. This is
the largest cistern.
◼ Pontine cistern – lies over the
pons of the hindbrain.

72
Cisternal Puncture
◼ CSF may be obtained from the
posterior cerebellomedullary
cistern through a cisternal
puncture for diagnostic or
therapeutic purposes.
◼ The needle is carefully inserted
through the posterior atlanto-
occipital membrane into the
cistern.

Cisternal puncture is done mainly if lumbar puncture is contraindicated.

73
Cisternal Puncture
Cerebellomedullary cistern

A short-beveled needle is introduced below

the occipital bone, between the first cervical
lamina and the rim of the foramen magnum
74
Cisterns

◼ Lumbar cistern - extends inferiorly from approximately the level

of L2 to the level of S2 where the dural sac ends. It is in direct
communication with the CSF of the brain.
◼ Clinical note: doctors take advantage of the lumbar cistern to
obtain samples of the CSF (a lumbar puncture or spinal tap) or
to administer drugs.
◼ IMPORTANT: Never take a spinal tap when a space-occupying
lesion is suspected within the brain.

75
 Subarachnoid hemorrhage
◼ Subarachnoid haemorrhage – rupture of a
blood vessel within the subarachnoid space
(where the CSF travels)
◼ Usually due to rupture of an aneurysm
◼ An aneurysm within the circle of Willis is the
most common location for this type of
haemorrhage. This condition is called a
Berry aneurysm.

76
Subarachnoid hemorrhage
◼ Rupture of a vessel in the subarachnoid space will turn the CSF
red or pink.
◼ The increased ICP will cause the brain to herniate through the
tentorial notch.
◼ Unlike subdural (a blow to the front of the head) and epidural (a
blow to the side of the head) haemorrhages, a subarachnoid
haemorrhage usually does not occur following head trauma.
◼ ICP: intracranial pressure

77
Subarachnoid hemorrhage
◼ Never take a spinal tap, obtaining CSF from the lumbar cistern
with a syringe when a mass occupying lesion is suspected.
◼ Patient will present with the three cardinal symptoms
1. A sudden onset of the “worst headache of their life”,
2. Nuchal rigidity (stiff neck), and
3. Loss (or decreased level) of consciousness

78
Pia Mater
◼ The pia mater is located underneath the sub-arachnoid
space. It is very thin, and tightly adhered to the surface
of the brain and spinal cord.
◼ It is the only covering to follow the contours of the
brain (the gyri and fissures).
◼ Like the dura mater, it is highly vascularized, with blood
vessels perforating through the membrane to supply the
underlying neural tissue.
79
Cerebral pia mater
◼ Innermost layer
Closely invests brain surface; in
some areas, the pia invaginates into
ventricles to take part in the
formation of choroids plexus,
Descend into the sulci
◼ Fused with Epineurium of Cranial
Nerves
◼ Cerebral arteries: Carry a sheath
of pia as they enter the brain
substance

80