THE “OTHER SIDE OF THE

MOUNTAIN”
Anatomy, Pathology and Imaging of the Cranial Venous System

Anne G. Osborn, M.D.

INTRACRANIAL VENOUS
SYSTEM
Components
• Dural venous sinuses
• Superior group
• Inferior/lateral group
• Cerebral veins
• Superficial veins
• Deep veins
• Posterior fossa veins
 INTRACRANIAL VENOUS
SYSTEM
Dural Venous Sinuses

• Formed by dural layers

• Outer (periosteal)
• Inner (meningeal) SSS

• Receive cortical veins

• Contain intradural Cortical Vein

venous channels
• Potential source of collateral
venous drainage
 INTRACRANIAL VENOUS
SYSTEM
Dural Venous Sinuses

• Fenestrated, septated,
multi-channeled
• Contain arachnoid
granulations, villi
• Arachnoid, SAS extend
through dural wall into
lumen of venous sinus
• Return CSF to venous
circulation
 DURAL VENOUS SINUSES
Superior Group

• Superior sagittal sinus SSS

• Hugs inner calvarial vault

• Runs posterioly in midline
• Crista galli → sinus confluence ISS

• Receives cortical veins, vein

of Trolard
• Inferior sagittal sinus
• Variable
• Runs posteriorly in inferior
margin of falx cerebri
• Terminates at tentorial
apex
 DURAL VENOUS SINUSES
Superior Group

• Straight sinus formed by

• ISS
VofG
• Vein of Galen SS
• Basal vein of Rosenthal
• Contained within leaves BVR
of falx, tentorium
 DURAL VENOUS SINUSES
Inferior/Lateral Group
• Transverse sinuses
• Between attachment of tentorial
leaves to calvarium
• Torcular laterally to petrous
Torcular
temporal bone
• Receive tentorial veins, vein of
Labbe
• Often asymmetric (R>L)
• Hypoplastic/absent segments TS
common
• Sinus confluence (torcular
Herophili)
• Formed from SSS, SS, TSs
• Intersinus connections often
asymmetric, variable
 DURAL VENOUS SINUSES
Inferior/Lateral Group

Sigmoid Sinus

• Sigmoid sinuses
• S-shaped anteroinferior
continuation of TSs JV/Bulb
• Terminate by becoming
internal jugular
bulb/veins
 DURAL VENOUS SINUSES
Inferior/Lateral Group

• Complex interconnected Vein of Labbe

system
• Receives venous drainage
from entire brain
• Cerebral hemispheres via SSS, IS
(superficial), v of G/SS (deep)
• Most important hemispheric
cortical tributary: vein of Labbe
• Tributaries from tentorium,
cerebellum, inferior
temporal/occipital lobes
• Posterior fossa
INTRACRANIAL VENOUS
SYSTEM
Common/Normal Imaging Variants
That May Be Mistaken For Disease
• Arachnoid granulations
• Hypoplastic segments
• Most common = TS
• Less common = SSS
• Off-midline SSS
• Jugular bulb variations
• “High-riding” bulb
• Jugular diverticulum
• Dehiscent bulb
 ARACHNOID
GRANULATIONS

• Round/ovoid filling
defects
• CSF-filled
• May be trabeculated
• TS > SSS
• Normal variant
• Should not be
mistaken for thrombus
Multiple Arachnoid
Granulations
 “GIANT” ARACHNOID
GRANULATIONS:
70% do not follow CSF on all sequences!
 INTRACRANIAL VENOUS
SYSTEM
Superficial Cortical Veins

• Highly variable
• Number, configuration
• Organized into three
groups
• Superior
• Middle
• Inferior
 SUPERFICIAL CORTICAL
VEINS
Superior Group

• 8-12 variably-sized veins

• Generally follow sulci
• Ascend to convexity
• Cross subarachnoid space
• Pierce arachnoid, inner
dura
V of Trolard
• Join SSS at right angles
• Only named vein = vein of
Trolard
 SUPERFICIAL CORTICAL
VEINS
Middle Group
• Superficial middle cerebral
vein
• Inconstant
• Variable size/dominance SMCV V of Labbe
• Over surface of lateral
(sylvian) fissure
• Terminates in cavernous or
sphenoparietal sinus or
pterygoid venous plexus
• Vein of Labbé
• From posterior Sylvian fissure
• Terminates in TS
• Can be major drainage of
temporal lobe
 SUPERFICIAL CORTICAL
VEINS
Middle Group

• Vein of Labbe
• Drains posterior
temporal lobe
• Occlusion → V of Labbe

venous infarct

AP DSA
 SUPERFICIAL CORTICAL
VEINS
Inferior Group

• Deep middle cerebral veins

• Drain temporal lobe
• Anastomose with anterior
cerebral veins
• Form basal vein (of
Rosenthal) DMCV
• Basal veins (of Rosenthal)
• Begin near anterior
perforated substance BVR

• Anterior cerebral, DMCV

tributaries (temporal lobe,
insula, basal ganglia, )
• Curve posteriorly around
cerebral peduncles
• Drain into vein of Galen
 INTRACRANIAL VENOUS SYSTEM
Deep Cerebral Veins

• Medullary veins
• Subependymal veins
• Internal cerebral (deep
paramedian) veins
• Great cerebral vein
(vein of Galen)
 DEEP CEREBRAL VEINS
Medullary Veins

• Small, linear veins

• Originate 1-2 cm below
cortex
• Course centrally towards
ventricles
• Drain deep white matter
• Terminate in
subependymal veins 3T SWI
 DEEP CEREBRAL VEINS
Subependymal Veins

• Septal veins
• Thalamostriate veins
• Septal veins, TSVs
• Terminate at
interventricular foramen
(of Monro)
• Unite to form internal
cerebral veins
 DEEP CEREBRAL VEINS
Internal Cerebral Veins

• Paired, paramedian
• Course posteriorly in
velum interpositum
• Below corpus
callosum splenium,
above pineal gland
• ICVs + basal veins of
Rosenthal form vein
of Galen
 DEEP CEREBRAL VEINS
Vein of Galen

• Short, U-shaped midline

vein
• Curves posteriorly,
superiorly under corpus
callosum splenium
• Terminates at tentorial
apex
• Unites with ISS to form
straight sinus
 DEEP CEREBRAL VEINS
Imaging the “Galenic” System

• Internal cerebral
veins and vein of
Galen well seen,
smaller subependymal
veins usually not
apparent

CTV
 Intracranial Venous System
Vascular Territories

• More variable, less well

known
• SSS/superficial/Trolard
• Deep cerebral system
• TS/vein of Labbe
• SMCV, CS
INTRACRANIAL VENOUS
SYSTEM
Pathology
• Congenital malformations
• Vascular malformations
• Cortical dysplasias
• Neurocutaneous syndromes
• Venous “strokes”
• Dural sinus occlusion
• Superficial cortical vein occlusion
• Deep venous occlusion
• Venous vasculitis
 CONGENITAL VENOUS
VASCULAR MALFORMATIONS
• Developmental venous anomaly
• Vein of Galen malformation
• Sinus pericranii
 DEVELOPMENTAL VENOUS
ANOMALY (VENOUS “ANGIOMA”)
• Pathology
• Thin-walled dilated veins
• Embedded in normal brain
• Hemorrhage, Ca++ rare
• Often mixed with CM
• Epidemiology
• Most common vasc malf
• Seen in 2.5-9% T1C+ scans
• Solitary (unless BRBN
syndrome)
• Clinical = asymptomatic
• Imaging
• “Medusa head”
DEVELOPMENTAL VENOUS
ANOMALY:
Imaging

DSA 3D DSA

CECT/CTA MR (T1C+)
 VEIN OF GALEN
MALFORMATION
• Pathology
• Persistent embryonic median
prosencephalic vein
• Aneurysmally dilated venous pouch
• Choroidal feeders
• 50% persistent falcine sinus, absent SS
• Epidemiology/clinical
• < 1% of all CVMs
• High-output CHF in neonates
• Imaging
• Mass compressing posterior 3rd ventricle
• Choroidal, mural types
 INTRACRANIAL VEINS:
Other Congenital Malformations
• Neurocutaneous syndromes
• Sturge Weber Syndrome
• Blue rubber bleb nevus syndrome
• Cortical dysplasias
• Polymicrogyria
• Lissencephaly
 STURGE-WEBER:
Clinical

• “Port wine” nevus

• CN V most common
1

• Seizures develop in
first year of life
• Progressive (hemi-
paresis in 30%)
STURGE-WEBER:
Pathology/Imaging
STURGE-WEBER SYNDROME
BLUE RUBBER BLEB NEVUS
SYNDROME
Multiple DVAs +/- Sinus Pericranii
CORTICAL DYSPLASIAS
Persistent Embryonic Dysplastic
Leptomeningeal Veins (50%)
 VENOUS OCCLUSIONS
• 1% of “strokes”
• Clinical dx often difficult, elusive
• Variable clinical presentation
• Common: H/A, nausea,  MS
• Early imaging findings may be subtle, often
overlooked/misdiagnosed
• Etiology
• Genetic (resistance to activated protein C)
• Trauma, infection/inflammation
• Pregnancy, oral contraceptives
• Metabolic (dehydration, thyrotoxocosis, etc)
• Coagulopathy
• Collagen-vascular, vasculitis (APLA, Behcet)
 DURAL SINUS OCCLUSION:
Pathology

• Dural sinus +/-

cortical v. occluded
• SSS>TS>SS>CS
• Adjacent cortex
• Edema
• Early (often
petechial)
hemorrhage
• Up to 50% progress
to frank venous
infarct
 DURAL SINUS OCCLUSION:
CT
• NECT
• Hyperdense dural sinus
• Hyperdense vein
(“cord sign”)
• Cortical/subcortical
petechial hemorrhage,
edema
• CECT
• “Empty delta” sign
• “Shaggy” falx or
tentorium, irregular
veins
DURAL SINUS OCCLUSION:
MR (findings vary with clot age)
DURAL SINUS OCCLUSION

DSA CTA
CHRONIC DURAL SINUS
OCCLUSION
CHRONIC DURAL SINUS
OCCLUSION
SSS + CORTICAL VEIN
OCCLUSIONS
ISOLATED ANASTOMOTIC
VEIN OCCLUSION:
Vein of Trolard
VEIN OF LABBE
OCCLUSION
DEEP CEREBRAL VEIN
OCCLUSION
DEEP CEREBRAL VEIN OCCLUSION
Imaging

• Hyperdense ICVs +/-

vein of Galen, SS
• Hypodense thalami, +/-
basal ganglia
DEEP CEREBRAL VEIN
OCCLUSION
Imaging

T2WI MR DSA
DURAL SINUS/VENOUS
OCCLUSION MIMICS

High HCT
VENOUS VASCULITIS
Pathology
Behcet, clinical
VENOUS VASCULITIS:
Behcet
 SUMMARY
• Venous circulation = “other side of the
mountain
• Less familiar anatomy
• Less familiar vascular territory
• Pathology less familiar but important
• Congenital malformations
• Venous occlusive disease