Note → I prepared this notes first watching Dr Najeeb & when solving mcqs I found

some points which I added. Circulate to others if you find them useful.
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MENINGES
Introductions
 Brain and Spinal cord covered by 3 layers called meninges.
 From deep to Superficial are
 Pia mater
 Arachnoid mater
 Dura mater
 Mn → PAD

 Dura mater, relatively tough and thick layer.

 Dura means → strong
 Mater meaning mother → provides protection.
 Highly vascular → contains a number of blood vessels → for instance meningeal artery runs in
dura mater
 Also contains branches of trigeminal nerve – CN 5
 Dura matter further 2 layers
 1 - Outer Periosteal layer aka endosteal layer
 2 – Inner Meningeal layer.
 The Superficial periosteal layer is strongly adhered to the surface of the bone.
 Deeper meningeal layer is closely adhered to the arachnoid mater below it.
 Periosteal layer only surround brain and does not extend down to surround spinal cord.
 Outside of foramen magnum – Periosteal layer folds back and surrounds the outer bones of
skull.
 Therefore, the spinal cord is only surrounded by meningeal layer of dura matter. NO img
 Dura Mater is pierced by blood vessels ????
 The two layers are closely attached to each other.
 At some points the two layers are not attached to each other, here they form a space between
them called Dural venous sinus (discussed ahead).
 Significance → Dural venous sinus receive deoxygenated blood and CSF (for drainage out
of the subarachnoid space into the heart)

 Arachnoid mater
 Relatively avascular
 Impermeable (so CSF does not leak out from inside)
 Arachnoid means → like a spider
 Mater means → mother, provide protection.
 Arachnoid mater has multiple connective tissue trabeculae which gives it sponge like or
irregular appearance.
 Small finger like projections / processes from Arachnoid matter into dural venous sinuses are
called Arachnoid villi. (details in next chapter)
 OLD CSF passes from the subarachnoid space into the dural venous sinuses via Arachnoid
villi.
 Blood from veins of the brain also drain into dural venous sinuses.

 Normally Pia matter and Arachnoid matter closely attached together.

 At some points of sub arachnoid spaces – the pia mater and arachnoid mater are not closely
attached.
 Because of this loosening, there is a slight bulge in the sub arachnoid space in between these
meningeal layers & they shows a bulge / swellings at these points.
  CSF pools in these areas (present in greater amount). These swelled areas with ↑ CSF in the
subarachnoid space are called Arachnoid cisterns or Cisterns.

 Pia mater →
 Pia → soft
 Matter → mother
 Very closely adhered to the surface of the brain as if a component of the brain itself.
 Dura matter and arachnoid matter attached closely together
 Pia matter and brain closely attached together
 Sub Arachnoid space → Space between pia mater and arachnoid mater
 A true space under physiological conditions.
 Filled with CSF.
 The brain along with pia mater, floats around in this CSF space

 Pia mater → Highly vascular like dura matter ( for instance → contains cerebral artery and
cerebral veins are present in sub arachnoid space)
 Processes called trabeculae extend from the Arachnoid to Pia mater.
 Arachnoid and pia mater, collectively called Leptomeninges,
 Leptomeninges → derived from neural crest cells.
 Mn → Assistant President has Leprosy + Neural crest disorder.
 Dura mater is derived from mesoderm.

 Dural Partitions
 The inner layer of dura mater (meningeal layer) expands + folds internally to form partitions
that separate portions of the brain.
 The four well defined dural partitions due to folding of meningeal dura mater are →
  Tentorium cerebelli
 Falx cerebri,
 Falx cerebelli,
 Diaphragma Sellae
 Significance → foldings provide extra support to brain.

 Tentorium cerebelli
 A horizontal tent like partition (as the name implies)
 Lies in posterior cranial fossa.
 It separates the posterior part of the cerebrum (occipital lobe) from the hindbrain
(medulla oblongata, pons and cerebellum) inferiorly.
 Because of the partition - cerebrum lies → Supra tentorially.
 Hindbrain lies → Infra tentorially.
  A large opening/ passage is present on anterior border of T. cerebelli called tentorial
notch. T
 Through this passage midbrain passes (or lie in this passage)
 Some say → the supratentorial region communicates with infratentorial regions
through tentorial notch

 Its attachments are along the groove for transverse sinuses on the occipital bone
posteriorly, the superior border of the petrous part of temporal bone laterally, and the
posterior and anterior clinoid processes anteriorly.
 Attachments → unimportant.
 Tentorial cerebelli has 3 dural venous sinuses →
 Straight Sinus
ⱺ Where Falx Cerebri joins with Tentorial Cerebelli (discussed ahead)
 Transverse Sinus
 Superior Petrosal sinus

 Falx Cerebri and Falx Cerebelli

 Are dural partitions in sagittal plane.
 Falx cerebri partitions the cerebral hemispheres in the longitudinal fissure.
 Falx cerebri has anterior & posterior end
 Anterior end narrow, Posterior end wider.

 Dural venous sinuses in Falx Cerebri

 Posterior portion of falx cerebri joins with tentorium cerebelli & this junction has dural
venous sinus named → Straight Sinus.
 In superior border dural venous sinus name → Superior sagittal sinus
 In Inferior border dural venous sinus name → Inferior Sagittal Sinus.
 Falx cerebelli partitions cerebellar hemispheres
 A very small fold of dura mater from posterior aspect project anterior-ward from the
skull and into the space between the cerebellar hemispheres
 Falx cerebelli not that deep/not that prominent.
 Dural venous sinuses in Falx Cerebelli
 Only one → Occipital sinus

 Significance of Falx → mainly provide stability & reduce movement of the brain within the
cranial vault.
 The attachment of Falx cerebri is from the crista galli of ethmoid bone anteriorly, to the
middle of the tentorium cerebelli posteriorly.
 The attachment of Falx cerebelli is from the middle of the tentorium cerebelli superiorly, to
the internal occipital crest inferiorly.
 Diaphragma Sellae
 Provides roof to the Hypophyseal fossa in the Sella turcica of the sphenoid bone,
 It has a small opening through which the infundibulum of the pituitary gland passes.
 Has no dural venous sinus.

 All the Dural Venous Sinus are interconnected and ultimately drain into Internal Jugular Vein
 IJV drain into SVC

 SVC drain in RA
  System of drainage of DVS is not imp for mcqs.

 Meningeal Features of the Brain

 Dura mater is highly sensitive to pain
 Intracranial lesions that stretch or damage the dura mater lead to pain in different areas:
 The dura mater of Anterior cranial fossa is innervated by ophthalmic division of
trigeminal nerve (CN V1).
 Thus, pain from lesions in this region is referred to the region of the forehead.
 The dura mater of middle cranial fossa is innervated by mandibular division of
trigeminal nerve (CN V3) laterally and maxillary division of trigeminal nerve (CN V2)
medially.
 Pain caused by lesions in this region is referred to maxillary and mandibular regions.
 The dura mater of the Posterior cranial fossa is innervated by meningeal branches of
vagus (CN X) nerve and meningeal branches of anterior rami of C1-C3 spinal nerves.
 Pain caused by lesions in infra-tentorial region is referred to the back of the head and
neck.

 Meningeal Features of the Spinal Cord

 Teeth-like processes called denticulate projections extend laterally from the pia mater on each
side of the spinal cord.
 They penetrate through the subarachnoid space → the arachnoid mater + dura mater.
 Function → in doing so prevent excessive motion of the spinal cord in the vertebral canal.
 Recall → Pia matter is so closely attached to the spinal cord as if a component of spinal cord
itself.

 Spinal cord ends at the level of LI/ LII Vertebrae

 The terminal end of spinal cord is called conus medullaris.
 The subarachnoid space (as well as dura mater & arachnoid mater) does not terminate at this
level.
 Instead, it extends down & terminates at about S2 vertebral level.

 Pia matter → also terminates at the level of L1/L2 at the conus medullaris of the spinal cord,
 But a long thin process of pia mater extends inferiorly inside the subarachnoid space & attach
at the terminal end of arachnoid mater, which ends at level of S2 vertebra.
 The interval between L2 and S2 ( between the conus medullaris and the inferior termination of
the subarachnoid space ) is used to draw CSF fluid via Lumbar puncture.
  Advantages
 It avoids the spinal cord injury ,
 Vertebral canal is incomplete at Lumbar Levels, with spaces between the vertebral arches
for insertion of a needle.
 L 4 or L5 intervertebral space is used for LP.
 Reason → spinal cord can extend as far as L3 in adults (and even further in children),
 LIII/ LIV may also be used in adults.

 Meningitis
 Inflammation of meninges → meningitis.
 Usually, inflammation occurs of pia + arachnoid matter (as the two are closely attached)
 Pia matter + arachnoid matter → together called Leptomeninges.
 So, meningitis also commonly referred as → inflammation of Leptomeninges

 Meningeal spaces
 3 main meningeal spaces →
 Extradural Space / Epidural Space
 Subdural Space
 Subarachnoid Space
o Hemorrhage mcq favorite section
 Bleeding can occur into →
 Any of the meningeal spaces, i.e.,
 Epidural Space OR Sub dural Space OR Sub arachnoid space.
 In the substance of the brain itself (intracerebral bleed).

 Epidural / Extradural Hemorrhage

 Extradural space / Epidural Space → Potential space between the two layers of dura mater
(outer periosteal and inner meningeal layer)
 Recall → periosteal and meningeal dura are closely adhered at most locations but separate to
form dural venous sinuses in some places.
 Significance → these spaces receive blood and CSF (for drainage out of the subarachnoid
space)
 The epidural space is called potential → because in case of ↑ CSF this space has capacity to
expand.
Hemorrhage in Extra dural
 The middle meningeal arteries branch of maxillary artery run above the two layers of dura
 mater.
 Rupture of the middle meningeal arteries result in extradural hemorrhage,
 It most commonly involves the anterior branch of the middle meningeal artery which lies
deep to the pterion where the suture lines of the frontal, sphenoidal, parietal and temporal
bones meet and bone is thin.

Cause →
 Trauma to the skull in this fragile region (i.e., blow to the temple) result in skull fracture
→ which damage to the anterior branch of middle meningeal artery.
Clinically → patients present with:
 History of skull trauma to the Temporal region
 An acute loss of consciousness may or may not occur following the blow. If it occurs, it is likely
 due to acute contusion to the brain, but recovery follows quickly.
 A subsequent asymptomatic lucid interval follows while the hematoma develops
 Once the hematoma has enlarged, the patient begins to experience gradual loss of consciousness
defined by lower scores on Glasgow coma scale.
 CT investigations reveal a bi-convex “lens-shaped” hematoma (pic above) that is restricted to
spreading by sutural lines. This occurs because the dural layers are very strongly adhered to
sutural ligaments that extend deeply from the sutural lines,
 This result in a high-pressure hematoma that bulges inward into the cranial cavity and
compresses the brain but remains limited.
 Treatment involves drilling burr holes to evacuate the epidural hematoma to reduce intracranial
pressure.

 Subdural Hemorrhage
 Subdural space → Potential space between dura matter and arachnoid matter.
 It does not exist physiologically.
 However, it develops due to pathology resulting in separation of the meningeal dura into
 A Superficial layer which remains attached to the periosteal dura,
 A Deep layer which remains attached to the arachnoid membrane.
 It is sometimes loosely described as a space between the meningeal dura and the subarachnoid
membrane; however, this is not entirely accurate.
Hemorrhage in Subdural
 Veins which drain blood from cerebral hemisphere → Cerebral veins
 Cerebral veins lie in the substance of the brain. These veins traverse all three dural layers
and empty into different dural venous sinuses.
 Also called Bridging veins
 Of all the meninges they traverse → bridging veins are most strongly adhered to dura
mater.
Causes →
 The brain along with pia mater float in this CSF-filled cavity.
 In case of sudden deceleration injuries, the brain move rapidly within the cranial cavity and
this result in tearing of the cerebral veins/bridging veins.
 Because of impact → relationship between the brain and cerebral veins suddenly disturbed
at the meningeal dura matter because they are most strongly attached here.
 Resulting hemorrhage separates the two dura layers → producing a subdural hemorrhage.
Risk factors for decelerations:
 Being prone to falls (e.g., epileptics and alcoholics)
 Elderly age, ↑ risk to fall + brains in elderly shrinks and
 Smaller brain → greater mobility → greater chances to tear bridging veins.
 Anticoagulant use. This type of bleeding can progress very slowly; an anti-coagulative
profile leads to likelihood of prolonged bleeding which might otherwise be asymptomatic.
 Because no tight connections like in dura mater at sutural lines → hematoma is not localized
  Produced a large crescent shaped lesion that tracts past sutural lines (pic above)
 Clinical problems arise gradually.
 Symptomatically,
 Patients present with a gradual loss of consciousness.
 However unlike in Extradural hemorrhage, presentation takes from days to weeks after
the initial deceleration injury.
 The onset is insidious thus, a fall history may not be recalled by the patient or family.
 Subdural hemorrhage should be suspected in unexplained fluctuating loss of
consciousness particularly in those with associated risk factors.

 Subarachnoid Hemorrhage
 Sub Arachnoid space → Space between pia mater and arachnoid mater
 A true space under physiological conditions.
 Filled with CSF.
 The brain along with pia mater, floats around in this CSF space
Recall → Brain is closely adhered to the pia mater.
Hemorrhage
 The subarachnoid space is a CSF-filled space with trabeculae (trabeculae from
arachnoid matter)
 Recall → Cerebral arteries and cerebral veins lie in the sub arachnoid space.
 Subarachnoid hemorrhage → extensive + spreads through out CSF filled cavity (brain +
spinal cord). Therefore, symptoms takes longer time to develop.
 Cause
Two common etiologies for Subarachnoid hemorrhage
 1- Berry aneurysms, →
Aneurysm → a bulging, weakened area in the wall of a blood vessel.
 resulting in an abnormal ballooning vessel's normal diameter.
 Can be present in both arteries & veins.
 More common in arteries

In Brain → aneurysm commonly present in the arteries of the Circle of Willis, particularly at
points where arteries branch off.
 These commonly occur as a hereditary weakness of the blood vessels.
 80% causes of SA hemorrhage are berry aneurysm
 2- Congenital arteriovenous malformations.
 These are fistulae between arteries and veins without an interconnecting capillary bed.
 The lack of a capillary bed results in exposure of the veins to undampened high pressures
which cause rupture of vessel.

 Clinically
 After spontaneous rupture of vessel → patient presents with a sudden onset of extremely severe
excruciating headache.
 No importance of history of head trauma.
 Bleeding in sub arachnoid space ↑ pressure of CSF
 LP if conducted shows RBCs in CSF –
 Lumbar puncture contraindicated in this case because raised intracranial pressure which puts
the patient at risk for brain herniation.
 CT scan should show a more diffuse hemorrhage than either extradural or subdural hemorrhage;
 often it will reveal outlines of the sulci of the brain.

 Intracerebral Hemorrhage
 Occurs due to bleeding of the branches of the cerebral artery in the substance of the brain.
 Risk factors for intracerebral hemorrhage include
 Chronic hypertension → results in formation of microaneurysms in these vessels.
 presents with neurological deficits in the specific part of the brain affected.