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CHAPTER 3

The Posterior Fossa Veins

Albert L. Rhoton, Jr., M.D.


Department of Neurological Surgery, University of Florida, Gainesville, Florida

Key words: Anatomic study, Brainstem, Cerebellum, Posterior fossa, Veins

T
he veins of the posterior fossa are divided into four Deep veins
groups: superficial, deep, brainstem, and bridging
The deep veins course in the three deep fissures between
veins. The superficial veins are divided on the basis of
the cerebellum and brainstem near the roof and walls of the
which of the three cortical surfaces they drain; the tentorial
fourth ventricle and on the three cerebellar peduncles that
surface is drained by the superior hemispheric and superior course within these fissures. The vein of the cerebellomesen-
vermian veins, the suboccipital surface is drained by the cephalic fissure arises in the cerebellomesencephalic fissure
inferior hemispheric and inferior vermian veins; and the and is intimately related to the superior half of the roof; the
petrosal surface is drained by the anterior hemispheric veins vein of the cerebellomedullary fissure courses in the cerebel-
(15, 16). The deep veins course in the three fissures between lomedullary fissure, and is intimately related to the inferior
the cerebellum and the brainstem and on the three cerebellar half of the roof; and the vein of the cerebellopontine fissure
peduncles. The major deep veins in the fissures between the courses in the cerebellopontine fissure is intimately related to
cerebellum and brainstem are the veins of the cerebellomes- the lateral recess and lateral walls of the fourth ventricle.
encephalic, cerebellomedullary, and cerebellopontine fissures, The major veins on the surface of the three cerebellar pe-
and those on the cerebellar peduncles are the veins of the duncles also course within these fissures. The vein of the
superior, middle, and inferior cerebellar peduncles. The veins superior cerebellar peduncle courses on the posterior surface
of the brainstem are named on the basis of whether they drain of the superior cerebellar peduncle in the cerebellomesence-
the midbrain, pons, or medulla and course transversely or phalic fissure; the vein of the inferior cerebellar peduncle
horizontally. The veins of the posterior fossa terminate as ascends on the posterior surface of the inferior cerebellar
bridging veins, which collect into three groups: a galenic peduncle in the cerebellomedullary fissure; and the vein of
group that drains into the vein of Galen; a petrosal group that the middle cerebellar peduncle ascends on the lateral surface
drains into the petrosal sinuses; and a tentorial group of the middle cerebellar peduncle in the anterior part of the
that drains into the tentorial sinuses, which empty into the trans- cerebellopontine fissure. The deep tonsillar veins are also
verse, straight, or superior petrosal sinus (Figs. 3.1 and 3.2). included in this group.

Veins of the brainstem


THE POSTERIOR FOSSA VEINS The veins of the brainstem are named on the basis of three
characteristics: the subdivision of the brainstem drained (mes-
Superficial veins encephalon, pons, or medulla); the surface of the brainstem
drained (median anterior, lateral anterior, etc.); and the direc-
The superficial veins drain the cortical surfaces of the cer- tion in which they course (transverse or longitudinal).
ebellum. They are divided on the basis of whether they drain The longitudinally oriented veins are the median anterior
the tentorial, petrosal, or suboccipital surface and whether pontomesencephalic and the median anterior medullary veins,
they drain the hemisphere or vermis. The tentorial surface is which course in the midline; the lateral anterior pontomesence-
drained by the superior hemispheric and the superior ver- phalic and the lateral anterior medullary veins, which course on
mian veins; the suboccipital surface is drained by the inferior the anterolateral surface of the brainstem; and the lateral med-
hemispheric and the inferior vermian veins; and the petrosal ullary and the lateral mesencephalic veins, which course on the
surface is drained by the anterior hemispheric veins. In addi- lateral surface of the brainstem. The transversely oriented veins
tion, selected cortical veins may be named on the basis of the running in the sulci at the junctions of the pons and mesenceph-
vermian or hemispheric lobule that they drain, or on the basis alon and the pons and medulla are the veins of the pontomes-
of the fissure in which they course. The superficial tonsillar encephalic and the pontomedullary sulci. The transverse pontine
veins are also included in this group. and transverse medullary veins course across the anterior and

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S70 Rhoton

FIGURE 3.1. Drainage patterns of the cerebellar surfaces. A,


tentorial surface. The tentorial surface is drained by the supe-
rior hemispheric and superior vermian veins, which are divided
into an anterior and a posterior group. The anterior group and
the veins from the cerebellomesencephalic fissure empty pre-
dominantly into the vein of Galen and its tributaries. The poste-
rior group drains the posterior part of the tentorial surface and
empties into the tentorial sinuses, which are tributaries of the
straight, transverse, or superior petrosal sinus, or the torcula.
Some of the inferior hemispheric veins from the suboccipital
surface pass forward under the transverse sinus and cross the
posterior part of the tentorial surface to empty into the tentorial
sinuses. B, suboccipital surface. The suboccipital surface is
drained by the inferior hemispheric and inferior vermian veins,
which ascend toward the transverse sinus, but then turn for-
ward below the sinus and commonly empty into the tentorial
sinuses. Some of the inferior hemispheric veins from the suboc-
cipital surface empty into the inferior vermian veins, which in
turn empty into the tentorial sinuses. C, petrosal surface and
anterior surface of the brainstem. The anterior hemispheric
veins, which drain the petrosal surface, and the veins from the
brainstem commonly unite to form the superior petrosal veins
that empty into the superior petrosal sinus. Ant., anterior; Cer.
Mes., cerebellomesencephalic; Fiss., fissure; Hem., hemispheric;
Inf., inferior; Pet., petrosal; Post., posterior; Sup., superior;
Trans., transverse; V., vein; Ve., vermian.

2. Superior hemispheric veins


B. Suboccipital surface
1. Inferior vermian veins
2. Inferior hemispheric veins
3. Retrotonsillar veins
4. Medial and lateral tonsillar veins
C. Petrosal surface
1. Anterior hemispheric veins
II. Deep Veins
A. Cerebellomesencephalic fissure
1. Vein of superior cerebellar peduncle
2. Vein of cerebellomesencephalic fissure
3. Pontotrigeminal vein
lateral surfaces of the pons and medulla, and the peduncular 4. Tectal veins
veins pass around the cerebral peduncles. B. Cerebellomedullary fissure
1. Vein of cerebellomedullary fissure
Bridging veins and major draining groups 2. Vein of inferior cerebellar peduncle
3. Supratonsillar veins
The terminal ends of veins draining the brainstem and
4. Choroidal veins
cerebellum form bridging veins that cross the subarachnoid
C. Cerebellopontine fissure
and subdural spaces to reach the venous sinuses in the dura
1. Vein of cerebellopontine fissure
(3, 6, 20, 21, 25). These bridging veins collect into three groups:
2. Vein of middle cerebellar peduncle
a superior or galenic group that drains into the vein of Galen;
III. Veins of the Brainstem
an anterior or petrosal group that drains into the petrosal si-
A. Longitudinal veins
nuses; and a posterior or tentorial group that drains into the
1. Midline
sinuses converging on the torcula.
a. Median anterior pontomesencephalic vein
An outline of the veins is as follows (Fig. 3.3):
b. Median anterior medullary vein
I. Superficial Veins 2. Anterolateral
A. Tentorial surface a. Lateral anterior pontomesencephalic vein
1. Superior vermian veins b. Lateral anterior medullary vein

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Posterior Fossa Veins S71

FIGURE 3.2. A–D. Venous drainage of the posterior fossa. A, superior surface of the tentorium. Some of the tentorial sinuses can be seen
through the tentorial surface. Veins from both the cerebrum and cerebellum empty into the tentorial sinuses. The veins in the quadrigem-
inal cistern and the cerebellomesencephalic fissure empty into the vein of Galen and its tributaries. B, the left half of the tentorium has
been removed while preserving the tentorial edge. The inferior hemispheric veins from the suboccipital surface cross the posterior part of
the tentorial surface to empty into one of the tentorial sinuses with some of the superior hemispheric veins. Two veins from the right pos-
terior temporal lobe empty into the transverse sinus. C, superolateral view of the tentorium. A complex and variable group of venous
sinuses course within the tentorium and empty into the straight, transverse, and superior petrosal sinuses. The veins draining the suboc-
cipital surface and posterior part of the tentorial surface empty into the tentorial sinuses. The majority of veins from the upper part of the
tentorial surface drain toward the cerebellomesencephalic fissure and empty into tributaries of the vein of Galen. Some veins from the
lateral part of the tentorial surface may empty into the superior petrosal sinus. D, lateral cerebral and cerebellar surfaces. The sinuses in
the tentorium receive drainage from both the cerebrum and cerebellum. Veins from the lateral and inferior surfaces of the cerebral hemi-
sphere pass toward, but often turn medially above the transverse sinus to join the tentorium sinuses that empty into the transverse sinus.
The inferior hemispheric veins from the suboccipital surface ascend toward, but often pass below the transverse sinus to empty into the
tentorial sinuses. A mastoidectomy has been completed to expose the sigmoid sinus and jugular bulb. Cer., cerebellar; Cer. Mes., cerebel-
lomesencephalic; Cist., cistern; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Inf., inferior; Int., internal; Jug., jugular; Occip., occipi-
tal; Ped., peduncle; Pet., petrosal; Quad., quadrigeminal; S.C.A., superior cerebellar artery; Sig., sigmoid; Str., straight; Sup., superior;
Temp., temporal; Tent., tentorial; Trans., transverse; V., vein.

3. Lateral 5. Vein of pontomedullary sulcus


a. Lateral mesencephalic vein 6. Transverse medullary vein
b. Lateral medullary and retro-olivary veins IV. Bridging Veins (Major Draining Groups)
B. Transverse Veins A. Galenic group (to vein of Galen)
1. Peduncular vein B. Tentorial group (to torcula and tentorial
2. Posterior communicating vein sinuses)
3. Vein of pontomesencephalic sulcus C. Petrosal group (to petrosal sinuses)
4. Transverse pontine veins D. Other bridging veins

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FIGURE 3.2. E–H. Venous drainage of the posterior fossa. E, the temporal lobe has been elevated to show a group of veins
that pass from the lower surface of the cerebral hemisphere to the tentorial sinuses. Two large lateral cerebral veins empty
into the right transverse sinus, but the more medial veins exposed by eliminating the temporal lobe empty into tentorial
sinuses. F, the posterior part of the right temporal lobe has been elevated to show the complex of veins on the inferior sur-
face of the hemisphere that empty into the tentorial sinuses. G, the right half of the tentorium has been opened while pre-
serving a large tentorial sinus, which receives drainage from the cerebrum and cerebellum. The temporal and occipital lobes
have been preserved on the left side. H, the posterior lip of the cerebellomesencephalic fissure has been removed. The paired
veins of the superior cerebellar peduncle ascend to join and form the vein of the cerebellomesencephalic fissure, which emp-
ties into the vein of Galen.

SUPERFICIAL VEINS fissures on the tentorial surface overlap onto the superior part
of the petrosal surface, and those on the suboccipital surface
The superficial veins drain the tentorial, suboccipital, and petro-
overlap onto the inferior part of the petrosal surface.
sal surfaces. Each surface has the vermis in the midline and the
The cortical surfaces are drained by a mixture of longitudi-
hemispheres laterally, and is divided by a major fissure named
nal and transverse veins. On some surfaces the predominant
on the basis of the surface that it divides (Figs. 3.1 and 3.3).
drainage is transversely oriented along the interfolial fissures,
The three surfaces are separated by borders that are parallel
and on others the major drainage is longitudinally oriented at
to the major venous sinuses surrounding the cerebellum. The
right angles to these fissures. The veins within the interfolial
tentorial and petrosal surfaces are separated by a border that
fissures may not be visible on the cortical surface.
parallels the superior petrosal sinus; the tentorial and suboc-
cipital surfaces are separated by a border that parallels the
Tentorial surface
transverse sinus; and the suboccipital and petrosal surfaces
are separated by a border that parallels the sigmoid sinus. The The tentorial surface drained by the superior hemispheric
veins from adjoining surfaces frequently join near these bor- and superior vermian veins, conforms to the lower surface of
ders to form common trunks that terminate in a dural sinus. the tentorium (Figs. 3.1-3.5).
The veins from adjoining surfaces often anastomose across
these borders. These anastomoses often take place in the Superior vermian veins
fissures between the folia, which are continuous from one The veins that drain the vermian part of the tentorial sur-
surface to the other. The hemispheric lobules and interfolial face are divided into an anterior group, which ascends toward

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Posterior Fossa Veins S73

FIGURE 3.3. A and B. Veins of


the posterior fossa. The veins
in the posterior are divided
into three groups: a galenic
group (green) that drains into
the vein of Galen; a petrosal
group (blue) that drains into
the petrosal sinuses; and a ten-
torial group (brown) that
drains into the sinuses near the
torcula. A, tentorial surface,
superior view. The tentorium
has been removed except in
the area of the tentorial
sinuses. B, suboccipital surface,
posterior view. The right tonsil
and the medial part of the
biventral lobule have been
removed to expose the struc-
tures on the ventral wall of the
cerebellomedullary fissure. A.,
artery; Ant., anterior; Bas.,
basilar; Br., bridging; Car.,
carotid; Cav., cavernous;
Cer., cerebellar, cerebello,
cerebral; Cer. Mes., cerebel-
lomesencephalic; Ch., choroi-
dal; Com., communicating;
Con., condylar; Em., emissary;
Fiss., fissure; He., hemispheric;
Inf., inferior; Int., internal;
Jug., jugular; Lat., lateral; Lig.,
ligament; Marg., marginal;
Med., medial, medullary; Mes.,
mesencephalic; Mid., mid, mid-
dle; N., nerve; Occ., occipital;
Olf., olfactory; Ped., peduncle;
Pon., pontine; Post., posterior;
Retroton., retrotonsillar; Sag.,
sagittal; Sig., sigmoid; Str.,
straight; Sulc., sulcus; Sup.,
superior; Supraculm., supracul-
minate; Supraton., supratonsil-
lar; Tent., tentorial; Ton., ton-
sillar; Trans., transverse; Trig.,
trigeminal; V., vein; Ve., ver-
mian; Vel., velum; Vert.,
vertebral.

the vein of Galen, and a posterior group, which descends The posterior, or descending, superior vermian veins origi-
toward the torcula (Figs. 3.3-3.5). The anterior, or ascending, nate in or near the tentorial fissure, course posteriorly, and
veins originate near the tentorial fissure and join near the apex drain alone or after joining the inferior vermian veins into the
of the cerebellum to form the superior vermian vein that torcula or a tentorial sinus.
crosses the quadrigeminal cistern to reach the vein of Galen.
The major tributaries of the superior vermian veins are the
vein of the cerebellomesencephalic fissure, to be described Superior hemispheric veins
later; the tectal veins from the quadrigeminal plate; and the These veins are divided into larger anterior and posterior
hemispheric branches from the medial part of the hemisphere. groups and a smaller lateral group (Figs. 3.3-3.5). The veins in

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FIGURE 3.3. C and D. Veins of


the posterior fossa. C, petrosal
surface and left side of the
brainstem, anterolateral view.
D, deep cerebellum and fourth
ventricle, posterior view. The
right cerebellar hemisphere and
the part of the left cerebellar
hemisphere posterior to the
dentate nucleus and tonsil have
been removed to show the roof
of the fourth ventricle and the
cerebellomesencephalic
and cerebellomedullary fissures.

the torcula or the superior


petrosal, transverse, or tentorial
sinuses. The veins in the
smaller lateral group originate
on the lateral part of the tento-
rial surface and drain directly
into the superior petrosal si-
nus or one of its tributaries.

Suboccipital surface
The suboccipital surface,
drained by the inferior hemi-
spheric and inferior vermian
veins and the superficial group
of tonsillar veins, conforms to
the part of the inner surface of
the occipital bone located be-
tween the sigmoid sinuses (Figs.
3.3 and 3.6-3.8). The superficial
group of tonsillar veins is com-
posed of the retrotonsillar and
the lateral and medial tonsillar
veins that converge on the pos-
terior surface of the tonsil and
join to form the inferior ver-
mian vein. There is also a deep
group of tonsillar veins, the su-
pratonsillar veins, which course
in the cerebellomedullary fis-
sure along the inferior part of
the roof of the fourth ventricle
and join the vein of the cerebel-
lomedullary fissure.

the anterior group drain the anterior part of the hemispheric Inferior vermian veins
surface and join the superior vermian vein or the veins in the
cerebellomesencephalic fissure. The other veins in the anterior The inferior vermian veins drain the vermis and the adja-
group cross the anteromedial margin of the cerebellum and cent portion of the hemisphere, including part of the tonsil
dip into and join the veins coursing in the cerebellomesence- (Figs. 3.3 and 3.6-3.8). These paired veins are usually formed
phalic fissure. The veins in the posterior group drain the by the union of the retrotonsillar veins. They ascend along the
posterior part of the tentorial surface. They usually join and vermohemispheric fissures and terminate in the straight or
form a common trunk with the inferior hemispheric veins transverse sinuses or the torcula, either directly or through a
from the suboccipital surface to form bridging veins that enter short tentorial sinus. They may course on the vermis or the

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Posterior Fossa Veins S75

adjacent part of the hemisphere before reaching the vermo- sillar vein and other tributaries from lateral and medial ton-
hemispheric fissure. In a few cases, one inferior vermian vein sillar surfaces.
will cross the vermis to terminate in the inferior vermian vein on
the opposite side. There is often an anastomotic vein that Medial and lateral tonsillar veins
crosses obliquely or transversely from one inferior vermian
The medial tonsillar veins originate on the tonsillar surface
vein to the other. Some interconnect the veins after they leave
facing the other tonsil, and the lateral tonsillar veins arise on
the surface of the cerebellum to form bridging veins (24). The
the lateral side of the tonsil fissure between the tonsil and
tributaries of the inferior vermian vein, beginning caudally,
biventral lobule (Fig. 3.3). These veins usually course posteri-
include veins from the tonsil (the superior and inferior retro-
orly and drain into the superior or inferior retrotonsillar or the
tonsillar and the medial and the lateral tonsillar veins), the
inferior vermian veins.
adjacent part of the vermis and hemisphere, and the postero-
medial part of the tentorial surface.
Petrosal surface
Inferior hemispheric veins This surface, drained by the anterior hemispheric veins,
faces the posterior surface of the petrous bone (Figs. 3.3 and
The inferior hemispheric veins are oriented longitudinally 3.9).
or transversely on the suboccipital surface (Figs. 3.3, 3.6, and
3.7). The majority of the longitudinal veins ascend and cross
the margin between the suboccipital and tentorial surfaces to
Anterior hemispheric veins
join the posterior group of superior hemispheric veins before These veins arise near the border that separates the petrosal
emptying into a sinus in the tentorium. Some join the lower surface from the suboccipital and tentorial surfaces, and pass
part of the inferior vermian vein. The transversely oriented anteriorly to converge on the cerebellopontine fissure and the
veins course along the fissures between the folia and predom- middle cerebellar peduncle. They are divided into supe-
inantly empty into the inferior vermian vein medially, but a rior, middle, and inferior groups. The veins in the inferior
few join the anterior hemisphere veins laterally. group arise on the inferior part of the petrosal surface and
The inferior hemispheric veins are divided into four converge on the caudal part of the cerebellopontine fissure to
groups: the superomedial, inferomedial, superolateral, and form a common trunk. The vein of the cerebellomedullary
inferolateral veins, based on the part of the suboccipital sur- fissure, if it passes dorsal to the flocculus, joins the common
face that they drain. The veins in the superomedial group are trunk of the inferior group. The veins in the middle group
the largest. The major veins in this group usually run longi- drain the middle portion of the petrosal surface and converge
tudinally and drain into the torcular, a tentorial sinus, or the on the apex of the cerebellopontine fissure. The common
inferior vermian vein. Transversely oriented veins in this trunk of the inferior group joins the common trunk of the
group, if well developed, drain into the torcula or the inferior middle group near the flocculus to form the vein of the
vermian vein. The inferomedial group consists of small veins cerebellopontine fissure, which passes to the superior petrosal
that originate and course inferiorly on the biventral lobule to sinus. In a few cases, the common trunk of the middle group
join the inferior retrotonsillar or the inferior vermian veins. does not join the common trunk of the inferior group, but
The veins in the superolateral group usually pass superolat- ascends to drain directly into the superior petrosal sinus. The
erally across the posterior margin of the hemisphere and superior group, the smallest of the three groups, drains the
drain either directly or through a tentorial sinus into the rostral edge of the petrosal surface. These veins course ante-
superior petrosal or transverse sinuses, but some smaller riorly or posteriorly to join either the vein of the cerebellopon-
members of this group may course around the lateral margin tine fissure, the anterolateral marginal vein that courses along
of the hemisphere to join the anterior hemispheric veins on the junction of the tentorial and petrosal surfaces, or one of the
the petrosal surface. The veins in the inferolateral group drain superior hemispheric veins.
the lateral part of the biventral lobule and pass around the
inferior margin of the hemisphere to join the anterior hemi-
spheric veins. DEEP VEINS
The deep veins course in the fissures between the brain-
stem and the cerebellum near the roof and lateral walls of the
Retrotonsillar veins fourth ventricle (Fig. 3.3). The veins most intimately related to
The superior and inferior retrotonsillar veins drain the supe- the superior part of the roof are those that course in the
rior and inferior poles and the posterior surface of the tonsils cerebellomesencephalic fissure; the veins most intimately re-
(Figs. 3.3 and 3.8). They receive tributaries from the medial lated to the inferior part of the roof are those that course in the
and lateral tonsillar surfaces and the adjacent part of the cerebellomedullary fissure; and those most intimately related
vermis and hemisphere. The superior retrotonsillar vein arises to the lateral wall and cerebellopontine angle are those that
near the superior pole and courses posteriorly to join the course in the cerebellopontine fissure. The structures ventral
inferior retrotonsillar vein to form the inferior vermian vein. to the floor of the fourth ventricle are drained by the veins of
The inferior retrotonsillar vein arises near the caudal pole of the brainstem, which are considered in the section on the
the tonsil and courses superiorly to join the superior retroton- veins of the brainstem in this chapter.

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FIGURE 3.3. E and F. Veins of


the posterior fossa. E,
midsagittal section of
cerebellum and fourth
ventricle. Left lateral view.
The left half of the cerebellum
has been removed to expose
the fourth ventricle. F,
brainstem. Anterior view. The
part of the tentorium between
the temporal lobe and the
cerebellum has been
preserved. A–F, the inferior
sagittal sinus joins the straight
sinus at the apex of the
tentorium. The superior
sagittal sinus joins the straight
sinus at the torcula. The
superior petrosal sinus passes
along the petrous ridge and
joins the junction of the lateral
(referred to here as the
transverse sinus) and sigmoid
sinuses posteriorly and the
cavernous sinus anteriorly.
The veins converging on the
tentorium join to form
tentorial sinuses that drain
into the straight, lateral, and
superior petrosal sinuses and
the torcula. The marginal sinus
courses in the dura at the level
of the foramen magnum above
the rostral attachment of the
dentate ligament. The emissary
vein passing through the
condylar foramen joins the
sigmoid sinus. The vertebral
venous plexus anastomoses
with the internal jugular vein.
Bridging veins pass from the
surface of the cerebellum and
brainstem to the dural sinuses.
The superior hemispheric
veins are divided into three
groups: an anterior group that
drains toward the vein of
Galen; a posterior group that
drains into the veins
converging on the straight sinus, torcula, and medial part of the lateral sinus; and a lateral group that drains into the superior
petrosal sinus, the anterolateral marginal vein, and the lateral part of the lateral sinus. The superior vermian veins drain the
tentorial part of the vermis. The veins on the superior part of the tentorial surface of the vermis ascend toward the superior
vermian vein and those on the inferior part of the tentorial surface of the vermis descend toward the torcula. The tributary of
the superior vermian vein draining the tentorial surface of the culmen has been called the supraculminate vein. The declival
vein drains the declive and joins the inferior vermian vein or the torcula. The vein of the postclival fissure courses in the
postclival fissure. The superior petrosal veins are divided into medial, intermediate, and lateral groups, depending on whether
they enter the middle, intermediate, or lateral third of the superior petrosal sinus. The inferior hemispheric veins drain the
hemispheric part of the suboccipital surface, and the inferior vermian veins drain the vermian part of the suboccipital

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Posterior Fossa Veins S77

Cerebellomesencephalic fissure peduncles and then upward on the peduncles, just lateral to
the lingula. They join near the rostral tip of the lingula to form
The major veins in the cerebellomesencephalic fissure are
a single trunk, the vein of the cerebellomesencephalic fissure.
the veins of the cerebellomesencephalic fissure and the supe-
In a few cases, the paired veins do not join but form two
rior cerebellar peduncle, and the pontotrigeminal and lateral
separate veins of the cerebellomesencephalic fissure. Each
mesencephalic veins (Figs. 3.2-3.5 and 3.10).
nerve of the superior cerebellar peduncle anastomoses with
the pontotrigeminal and lateral mesencephalic vein.
Vein of the superior cerebellar peduncle
The paired veins of the superior cerebellar peduncle orig-
inate deep in the cerebellomesencephalic fissure near the cau- Vein of the cerebellomesencephalic fissure
dolateral margin of the superior cerebellar peduncles from This vein, also referred to as the precentral cerebellar vein,
tributaries draining the dentate nuclei, superior cerebellar arises deep in the cerebellomesencephalic fissure from the
peduncles, and the walls of the cerebellomesencephalic fis- union of the veins of the superior cerebellar peduncle. It
sure (Figs. 3.3 and 3.4). They first course medially across the crosses the quadrigeminal cistern anterior to the central lobule

Š
surface. The inferior vermian veins drain toward the tentorium and enter the torcula or a tentorial sinus. The inferior hemi-
spheric veins cross the posterior margin of the cerebellum to reach the tentorial surface, where they often join the superior
hemispheric veins before terminating in the tentorial, lateral, or superior petrosal sinuses or the torcula. The inferior vermian
vein is formed on the posterior surface of the tonsil by the union of the superior and inferior retrotonsillar veins. The medial
and lateral tonsillar veins pass to the retrotonsillar or the inferior vermian veins. The vein of the petrosal fissure passes along
the petrosal fissure. The anterior hemispheric veins that drain the petrosal surface of the cerebellum and are divided into
superior, middle, and inferior groups, depending on whether they drain the superior, inferior, or middle third of the petrosal
surface. The anterior hemispheric veins converge on the lateral cerebellar incisura and join to form the vein of the cerebel-
lopontine fissure that ascends to enter the superior petrosal sinus. The major veins related to the superior half of the roof of
the fourth ventricle are the veins of the cerebellomesencephalic fissure and the superior cerebellar peduncle; the major veins
related to the inferior part of the roof are the veins of the cerebellomedullary fissure and the inferior cerebellar peduncle;
and the major veins in the region of the lateral recesses and lateral walls are the veins of the cerebellopontine fissure and the
middle cerebellar peduncle. In the cerebellomesencephalic fissure, the paired veins of the superior cerebellar peduncle
ascend lateral to the lingula and the superior medullary velum and join to form the vein of the cerebellomedullary fissure,
which ascends to join the superior vermian vein. The internal cerebral, basal, and superior vermian veins enter the vein of
Galen. The lateral mesencephalic and the pontotrigeminal veins course in the cerebellomesencephalic fissure. The lateral
mesencephalic vein courses in the lateral mesencephalic sulcus. The pontotrigeminal vein arises on the superior and middle
cerebellar peduncles and passes rostral to the trigeminal nerve. The tectal veins arise in the region of the colliculi. The vein
of the cerebellomedullary fissure arises on the lateral side of the uvula and nodule and passes laterally through the cerebel-
lomedullary fissure, either dorsal or ventral to the flocculus, to join one of the veins in the cerebellopontine angle. The vein
of the cerebellomedullary fissure receives the medial and lateral supratonsillar veins, which pass along the medial and lateral
edge of the inferior medullary velum above the superior pole of the tonsil. The dentate nucleus is drained by the supratonsil-
lar veins and the vein of the cerebellomedullary fissure. The median posterior medullary vein ascends on the posterior
medulla and divides just below the obex into the paired veins of the inferior cerebellar peduncle. The veins of the inferior
cerebellar peduncle ascend on the inferior cerebellar peduncles and join the lateral medullary veins. The choroidal veins
draining the tela choroidea and choroid plexus are tributaries of the veins of the inferior cerebellar peduncle and the cerebel-
lomedullary fissure. The peduncular veins arise in the interpeduncular fossa and pass laterally to join the basal veins. The pos-
terior communicating vein interconnects the medial ends of the peduncular veins. The longitudinally oriented veins in the
midline on the anterior surface of the brainstem are the median anterior medullary vein, which ascends on the medulla, and
the median anterior pontomesencephalic vein that ascends in the midline on the pons and midbrain. The median anterior
pontomesencephalic vein does not usually extend the full length of the pons. The ends adjoining the absent segment often
join the transverse pontine veins. The transversely oriented veins coursing in the sulci between the subdivisions of the brain-
stem are the veins of the pontomesencephalic and the pontomedullary sulci. Each vein of the middle cerebellar peduncle
arises in the region of the foramen of Luschka near the flocculus and ascends on the middle cerebellar peduncle to join the
vein of the cerebellopontine fissure or one of the superior petrosal veins. The lateral anterior medullary vein courses along
the preolivary sulcus near the hypoglossal nerve. The lateral anterior pontomesencephalic vein passes along the anterolateral
margin of the pons and medulla. The transverse medullary veins pass transversely across the medulla. The retro-olivary vein
courses along the posterior margin of the olive, and the lateral medullary vein courses slightly dorsal to the olive, along the
origin of the rootlets arising from the dorsolateral surface of the medulla. There are diffuse anastomoses between the veins
ventral to the diencephalon and third ventricle and those draining the midbrain. The deep middle cerebral and the anterior
cerebral veins join the basal vein in the region of the anterior perforated substance. (From, Matsushima T, Rhoton AL Jr, de
Oliveira E, Peace D: Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 59:63–105, 1983 [15].)

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FIGURE 3.4. Tentorial surface and cerebellomesencephalic fissure. A, the left half of the tentorium has been removed while
preserving a laterally placed tentorial sinus. A large sinus is seen through the right tentorial surface. B, the right half of the
tentorium has been removed to expose a large inferior hemispheric vein from the suboccipital surface and a smaller superior
hemispheric vein from the tentorial surface emptying into the large tentorial sinus. The superior hemispheric veins, which
drain the tentorial surface, are divided into an anterior group, which empties into the Galenic system, and a posterior group,
like the vein shown, which empties into the tentorial sinuses. Smaller veins from both the left tentorial and suboccipital sur-
faces join the laterally placed tentorial sinus near the junction of the left transverse and superior petrosal sinuses. C, the
straight and tentorial sinuses have been removed. The anterior group drains toward the cerebellomesencephalic fissure and
the vein of Galen, and the posterior group passes backward to empty into the tentorial sinuses. D, the posterior lip of the
cerebellomesencephalic fissure has been removed to expose the veins of the superior cerebellar peduncle, which ascend to
unite and form the vein of the cerebellomesencephalic fissure that empties into the vein of Galen. A transverse pontine vein
and the vein of the cerebellopontine fissure join to form a superior petrosal vein that empties into the superior petrosal sinus.

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Posterior Fossa Veins S79

FIGURE 3.5. Tentorial surface and cerebellomesencephalic fissure. A, the left half of the tentorium has been removed
while preserving the tentorial sinuses. The anterior group of superior vermian and superior hemispheric veins arise on
the upper part of the tentorial surface and ascend to reach the veins exiting the cerebellomesencephalic fissure, which
empty into the vein of Galen. The posterior group of superior vermian and superior hemispheric veins arise on the pos-
terior part of the tentorial surface and descend to empty into tentorial sinuses. The inferior hemispheric veins, which
arise on the suboccipital surface, also empty into the tentorial sinuses. B, both halves of the tentorium have been
removed while preserving the large tentorial sinuses. The superior hemispheric veins from the posterior part of the ten-
torial surface and the inferior hemispheric veins from the suboccipital surface drain into the paired large tentorial sinus
that join the torcula. The veins draining the anterior part of the tentorial surface empty into the tributaries of the vein
of Galen. C, lateral view of the cerebellomesencephalic fissure. The largest vein in the fissure is the vein of the cerebel-
lomesencephalic fissure. The internal cerebral veins pass above the pineal to join the vein of Galen. D, the veins drain-
ing the walls of the cerebellomesencephalic fissure join the vein of Galen, as do the internal cerebral and basal veins. A
pineal vein also joins the Galenic group. Ant., anterior; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Fiss., fissure;
Hem., hemispheric; Inf., inferior; Int., internal; Occip., occipital; Post., posterior; S.C.A., superior cerebellar artery; Str.,
straight; Sup., superior; Temp., temporal; Tent., tentorial; V., vein; Ve., vermian.

Š
E–F, cerebellomesencephalic fissure from another hemisphere. E, the posterior lip of the cerebellomesencephalic fissure has been
removed to expose the tributaries of the vein of the cerebellomesencephalic fissure and the branches of the SCA. The paired veins
of the superior cerebellar peduncle unite to form the vein of the cerebellomesencephalic fissure that empties into the vein of
Galen. F, the branches of the SCA within the cerebellomesencephalic fissure have been removed. The paired veins of the superior
cerebellar peduncle ascend on the superior cerebellar peduncles and join to form the vein of the cerebellomesencephalic fissure.
The veins on the surface of the middle cerebellar peduncle course laterally to join the veins emptying into the superior petrosal
sinus. A., artery; Ant., anterior; Cer., cerebral; Cer. Mes., cerebellomesencephalic; CN., cranial nerve; Fiss., fissure; Hem., hemi-
spheric; Inf., inferior; Int., internal; Mid., middle; N., nerve; Ped., peduncle; Post., posterior; Str., straight; Sup., superior; Tent., ten-
torial; Trans., transverse; V., vein; Ve., vermian.

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FIGURE 3.6. Suboccipital surface. A, the falx cerebelli, which fits into the posterior cerebellar incisura in which the vermis is partially
buried, has been preserved. The inferior hemispheric veins drain the hemispheric portion of the suboccipital surface. A large left inferior
hemispheric vein ascends toward a tentorial sinus. A large right inferior hemispheric vein descends medially to join an inferior vermian
vein, which ascends to empty into the sinuses in the tentorium. The occipital sinus courses within the falx cerebelli and joins the torcula
above and the sigmoid sinus below. B, the falx cerebelli has been removed to expose the inferior vermian veins, which ascend and pass
below the transverse sinus to empty into the tentorial sinuses. The retrotonsillar veins and other veins around the superior pole of the
tonsils ascend to join the inferior vermian veins. C and D, another cerebellum. C, the branches of the PICA supplying the left hemisphere
have been removed, but those on the right have been preserved. The inferior vermian and hemispheric veins on both halves of the suboc-
cipital surface ascend and pass below the transverse sinus to empty into the sinuses in the tentorium. D, enlarged view of the inferior ver-
mian veins that ascend to empty into sinuses in the tentorium. E, another cerebellum. A large right inferior hemispheric vein joins an infe-
rior vermian vein that crosses the upper edge of the suboccipital surface and courses for a short distance on the tentorial surface before
emptying into a tentorial sinus. F, enlarged view of another cerebellum. The large right inferior vermian vein passes forward to join the
sinuses in the tentorium. A superior hemispheric vein from the tentorial surface descends to join a tentorial sinus. In the midline, a supe-
rior and inferior vermian join to empty into a tentorial sinus. A., artery; Cer., cerebellar; Hem., hemispheric; Inf., inferior; Occip., occipi-
tal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Retroton., retrotonsillar; Sig., sigmoid; Sup., superior; Tent., tentorial; Trans.,
transverse; V., vein; Ve., vermian; Vert., vertebral.

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Posterior Fossa Veins S81

FIGURE 3.7. Suboccipital surface and cerebellomedullary fissure. A, the veins from the region of the tonsil empty into the
inferior vermian veins that ascend toward the sinuses in the tentorium. B, gentle retraction of the cerebellar tonsils exposes
the veins of the cerebellomedullary fissure crossing the inferior medullary velum. C, the cerebellar tonsils have been
removed. The tela on the left side has been removed. The veins of the cerebellomesencephalic fissure cross the inferior med-
ullary velum to join the veins in the cerebellopontine angles, which empty into the superior petrosal veins. The medial end of
the veins of the cerebellomedullary fissure anastomose with the veins around the tonsil. D, a portion of the left half of the
cerebellum has been removed. The inferior hemispheric veins from the suboccipital surface ascend and cross the junction of
the suboccipital and tentorial surfaces to course on the posterior part of the tentorial surface, where they often form com-
mon stems with the superior hemispheric veins from the posterior part of the tentorial surface before emptying into the ten-
torial sinuses. A., artery; Cer., cerebellar; Cer. Med., cerebellomedullary; Fiss., fissure; Hem., hemispheric; Inf., inferior; Med.,
medullary; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Retrotons., retrotonsillar; Sup., superior; V., vein; Ve.,
vermian; Vel., velum; Vert., vertebral.

to drain either directly or through the superior vermian vein hemispheric and transverse pontine veins may drain into the
into the vein of Galen (Figs. 3.2-3.5 and 3.10). Its tributaries are pontotrigeminal vein.
from the posterior aspect of the midbrain and the walls of the
cerebellomesencephalic fissure, and occasionally include the Tectal veins
tectal and preculminate veins. The small tectal veins originate on or near the superior and
inferior colliculi and course upward in the quadrigeminal cistern
Pontotrigeminal vein to drain into the vein of the cerebellomesencephalic fissure, the
This vein arises on the surface of the middle cerebellar superior vermian or internal cerebral vein, or the vein of Galen.
peduncle near the interpeduncular sulcus located between the These veins often anastomose with the vein of the superior cerebel-
superior and middle peduncles, passes above the trigeminal lar peduncle and the pineal, lateral mesencephalic, and basal veins.
nerve, and drains directly into the superior petrosal sinus or
its tributaries (Figs. 3.10 and 3.11). Its proximal end frequently Cerebellomedullary fissure
anastomoses with the vein of the superior cerebellar peduncle The major veins in the cerebellomedullary fissure are the
and the lateral mesencephalic vein. Some of the superior veins of the cerebellomedullary fissure and the inferior cerebellar

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FIGURE 3.8. Suboccipital surface and the cerebellomedullary fissure. A, the retrotonsillar veins pass upward in the fissure
between the tonsil and biventral lobule and empty into the inferior vermian veins. B, the tonsils have been removed to
expose the veins of the cerebellomedullary fissure, which pass laterally on the inferior medullary velum and across the lateral
recesses to join the veins in the cerebellopontine angles. The medial end of the veins of the cerebellomedullary fissure anasto-
mose with the veins around the tonsil. C, another specimen. The tonsils and part of the biventral lobules have been removed
to expose the paired veins of the cerebellomedullary fissure, which cross the inferior medullary velum to empty into the veins
in the cerebellopontine angles. D, the cerebellar hemispheres, except for the right tonsil, have been removed. The right retro-
tonsillar vein courses along the posterior surface of the tonsil and empties into an inferior vermian vein. The left vein of the
cerebellomedullary fissure passes through the lateral recess to join the vein of the middle cerebellar peduncle, which ascends
to empty into a superior petrosal vein. The paired veins of the superior cerebellar peduncle ascend on the peduncle and join
to form the vein of the cerebellomesencephalic fissure. An interpeduncular vein courses between the superior and middle
cerebellar peduncles. A., artery; Bivent., biventral; Cer., cerebellar; Cer. Med., cerebellomedullary; CN, cranial nerve; Fiss.,
fissure; Inf., inferior; Interped., interpeduncular; Lat., lateral; Med., medullary; Mid., middle; Ped., peduncle; Pet., petrosal;
P.I.C.A., posteroinferior cerebellar artery; Retrotons., retrotonsillar; Sup., superior; Tons., tonsillar; V., vein; Ve., vermian;
Vent., ventricle; Vert., vertebral.

peduncle (Figs. 3.3, 3.7-3.9) (2). Both of these veins drain into the anterior hemispheric veins or in the vein of the cerebellopon-
cerebellopontine angle through the communication between tine fissure. If it courses ventral to the flocculus, it passes
the cerebellomedullary and cerebellopontine fissures. between the flocculus and the foramen of Luschka and joins
the lateral medullary vein or the vein of the inferior cerebellar
Vein of the cerebellomedullary fissure peduncle or the pontomedullary sulcus to form the vein of the
This vein originates on the lateral edge of the nodule and middle cerebellar peduncle. The vein of the cerebellomedul-
uvula, courses laterally near the junction of the inferior med- lary fissure frequently connects with its mate on the opposite
ullary velum and tela choroidea, and passes dorsal or ventral side through a transverse vein crossing the nodule or uvula
to the flocculus to reach the cerebellopontine angle (Figs. and/or with the inferior vermian vein. The medial part of the
3.7-3.9). If it courses dorsal to the flocculus, it terminates in the vein of the cerebellomedullary fissure is sometimes hypoplas-

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Posterior Fossa Veins S83

tic or absent. Its tributaries drain the inferior medullary ve- Vein of the cerebellopontine fissure
lum, tela choroidea and attached choroid plexus, periven-
This is the largest vein draining the petrosal surface. It is
tricular white matter, dentate nuclei, anteroinferior surface of
formed just rostral or caudal to the flocculus by the union of
the biventral lobule, and the inferior vermis.
the stems of the anterior hemispheric veins (Figs. 3.9-3.11). It
Vein of the inferior cerebellar peduncle courses in or near the superior limb of the cerebellopontine
fissure, or on the superior part of the petrosal surface near the
This vein courses on the peduncle parallel and several anterolateral margin. It crosses the subarachnoid space rostral
millimeters caudal to the curved inferolateral margin of the to the facial, vestibulocochlear, and trigeminal nerves, and
fourth ventricle (Figs. 3.3, 3.7, and 3.9). Its caudal part is visible drains into the superior petrosal sinus either directly or after
on the posterior surface of the medulla lateral to Magendie’s forming a common stem with other veins draining into the
foramen, but its superior portion is hidden in the cerebellomed- superior petrosal sinus. The vein of the middle cerebellar
ullary fissure. Inferiorly, the veins from each side join below the peduncle and the pontotrigeminal vein often join the vein of
obex to form a single channel, the median posterior medullary the cerebellopontine fissure to form one of the trunks that
vein. Superiorly, it passes below the lateral recesses and joins drain into the superior petrosal sinus near the trigeminal
the vein of the pontomedullary sulcus, either directly or by nerve. The vein of the cerebellomedullary fissure, if it passes
first connecting with the lateral medullary vein. It often re- dorsal to the flocculus, may drain into the vein of the cerebel-
ceives the vein of the cerebellomedullary fissure near the lopontine fissure.
lateral end of the pontomedullary sulcus. These veins, con-
verging on the lateral end of the pontomedullary sulcus, join
to form the vein of the middle cerebellar peduncle. The vein of Vein of the middle cerebellar peduncle
the inferior cerebellar peduncle drains the posterior and lat-
eral aspects of the medulla, the tela choroidea, choroid plexus, This vein originates in the fossette above the inferior olive
the inferior part of the floor of the fourth ventricle, the lateral by the union of the vein of the pontomedullary sulcus with
recess, and the glossopharyngeal and vagus nerves. This ros- the lateral medullary vein or the vein of the inferior cerebellar
tral part of the vein of the inferior cerebellar peduncle often peduncle (Figs. 3.8-3.11). It ascends on the lateral surface of
anastomoses with the sinuses converging on the jugular fora- the middle cerebellar peduncle near the base of the cerebel-
men through a bridging vein that passes along the nerves that lopontine fissure to reach the area posterior to the origin of the
pass through the jugular foramen. trigeminal nerve. It drains directly into the superior petrosal
sinus or joins other veins to form one of the common trunks
Supratonsillar veins that drain into the superior petrosal sinus. Its initial part
passes either between the flocculus and the origin of the
The supratonsillar veins course in the cerebellomedullary
vestibulocochlear nerve or between the origins of the vestibu-
fissure near the superior pole of the tonsil (Fig. 3.3) (9). The
locochlear and the facial nerves.
name “supratonsillar” suggests that these veins drain the
The vein of the middle cerebellar peduncle receives the
tonsil; however, they course on and drain the opposite side of
drainage of the rostral half of the medulla, the inferior half of
the cerebellomedullary fissure from the tonsil. They originate
the fourth ventricle, and the lateral surface of the pons. It often
in the deep nuclei and white matter of the cerebellum and
receives the drainage of the veins of the cerebellomedullary
drain the inferior half of the roof of the fourth ventricle rather
fissure and inferior cerebellar peduncle, some of the trans-
than the tonsil. They course along the inferior medullary
verse pontine veins, and the veins draining the origins of the
velum and drain into the vein of the cerebellomedullary fis-
facial and the vestibulocochlear nerves. It is large if the vein of
sure or the inferior vermian vein.
the cerebellomedullary fissure courses ventral to the flocculus
Choroidal veins to join it rather than passing dorsal to the flocculus to join the
anterior hemispheric veins or the vein of the cerebellopontine
The choroidal veins drain the tela choroidea and the at- fissure.
tached choroid plexus, and are tributaries of the veins of the
cerebellomedullary fissure and the inferior cerebellar pedun-
cle. The medial half of the vein of the cerebellomedullary
fissure drains the rostral part of the medial segment and the VEINS OF THE BRAINSTEM
medial part of the lateral segment of the choroid plexus. The The veins of the brainstem are divided into two groups
lateral half of the vein of the cerebellomedullary fissure, and based on whether they course longitudinally or transversely
the rostral part of the vein of the inferior cerebellar peduncle (Figs. 3.3 and 3.9-3.11). The longitudinal veins are the median
drain the lateral part of the lateral segment. The caudal part of anterior pontomesencephalic, median anterior medullary, lat-
the vein of the inferior cerebellar peduncle receives the drain- eral anterior pontomesencephalic, lateral anterior medullary
age of the caudal part of the medial segment (Fig. 3.3). (preolivary), lateral mesencephalic, lateral medullary, and
retro-olivary veins. The transverse veins are the veins of the
Cerebellopontine fissure pontomesencephalic and the pontomedullary sulci, and the
The major veins arising in this region are the veins of the transverse pontine, transverse medullary, peduncular, and
cerebellopontine fissure and the middle cerebellar peduncle. posterior communicating veins.

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FIGURE 3.9. Brainstem and petrosal surface. A, the vertebral and basilar arteries and their branches course superficial to the
veins. The veins on the anterior surface of the pons and medulla and the petrosal surface drain predominantly into the superior
petrosal veins, which empty into the superior petrosal sinuses. B, the arteries have been removed. The median anterior pontomes-
encephalic and median anterior medullary veins ascend on the front of the brainstem. The transverse pontine and transverse med-
ullary veins run transversely across the pons and medulla surfaces. The anterior hemispheric veins drain the petrosal surface and
commonly empty into the vein of the cerebellopontine fissure, which ascends to join the superior petrosal veins. The vein of the
pontomedullary sulcus passes across the pontomedullary junction. C, enlarged view of the right petrosal surface. The anterior
hemispheric veins drain the petrosal surface and pass forward to empty into the vein of the cerebellopontine fissure or a superior
petrosal vein. The vein of the cerebellopontine fissure arises at the lateral apex of the cerebellopontine fissure and crosses the mid-
dle cerebellar peduncle, where it is joined by a large transverse pontine vein. D, enlarged view of the left petrosal surface. The vein
of the cerebellopontine fissure arises from the union of the anterior hemispheric veins at the apex of the cerebellopontine fissure

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Posterior Fossa Veins S85

Longitudinal veins and the vein of the pontomedullary sulcus at the pontomed-
ullary junction and inferiorly with the anterior spinal vein. It
Median anterior pontomesencephalic vein may join the lateral anterior pontomesencephalic vein ros-
This vein runs in or near the midline on the anterior surface trally if the inferior part of the median anterior pontomesen-
of the mesencephalon and the pons (Figs. 3.9-3.11). It has a cephalic vein is absent. A bridging vein may connect the
mesencephalic segment that courses in the interpeduncular median anterior medullary vein with the sinuses around the
fossa, and a pontine segment that runs in or adjacent to the jugular foramen.
basilar sulcus. The mesencephalic segment of this vein is
usually composed of the two veins, which are frequently Lateral anterior pontomesencephalic vein
asymmetrical in size and course near the oculomotor nerves This vein on the anterolateral aspect of the brainstem is
on the lateral walls of the interpeduncular fossa. They usually rarely continuous from the midbrain to the lower pons (Fig.
anastomose rostrally with the medial end of the peduncular 3.3). At the mesencephalic level it may anastomose with the
veins and the lateral ends of the posterior communicating basal and peduncular veins and the vein of the pontomesen-
vein. The small veins exiting the posterior perforated sub- cephalic sulcus, and at the pontine level it anastomoses with
stance often join this confluence. A bridging vein may arise in the transverse pontine veins. Caudally, it joins the vein of the
the interpeduncular fossa and pass to the tentorial edge. The pontomedullary sulcus near the abducens nerve. It deviates
paired mesencephalic segments join several millimeters be- medially to connect with the median anterior pontomesence-
low the pontomesencephalic sulcus on the upper surface of phalic or the median anterior medullary veins, if the lower
the pons to form the pontine segment. If the superior part of part of the median anterior pontomesencephalic vein is ab-
the pontine segment is absent, the mesencephalic segment sent. It may give rise to a bridging vein to the inferior petrosal
divides to connect inferiorly with the lateral anterior pon- sinus.
tomesencephalic vein or the vein of the pontomesencephalic
sulcus. Lateral anterior medullary vein (preolivary vein)
The pontine segment, which connects caudally with the This vein courses in the anterolateral sulcus between the
median anterior medullary vein and the vein of the pon- pyramid and the olive, and is partly hidden by the roots of the
tomedullary sulcus, is subdivided into superior, middle, and hypoglossal nerve (Fig. 3.3). A segment along the lateral bor-
inferior parts. One of the three parts is usually absent. If the der of the pyramid may be absent. It connects superiorly with
superior portion is absent, the middle portion anastomoses the vein of the pontomedullary sulcus and inferiorly with the
superiorly with a transverse pontine vein, and the caudal part lateral medullary or transverse medullary vein. The median
is continuous inferiorly with the median anterior medullary and lateral anterior medullary veins are linked together by the
vein. If the middle part is absent, the caudal end of the transverse medullary veins that cross the pyramids at various
superior part and the cranial end of the inferior part anasto- levels.
mose with the transverse pontine or the lateral anterior pon-
tomesencephalic veins. The pontine segment may deviate to Lateral mesencephalic vein
one side away from the basilar sulcus, especially if the trans- This vein runs in or adjacent to the lateral mesencephalic
verse pontine vein gives rise to a large bridging vein to a sulcus and usually drains into the basal vein near the medial
petrosal sinus. geniculate body (Fig. 3.3). It drains the posterolateral aspect of
the midbrain and sometimes receives a branch from the quad-
Median anterior medullary vein rigeminal plate. Its inferior end anastomoses with the ponto-
This vein courses in the median anterior medullary fissure trigeminal vein and the vein of the pontomesencephalic sul-
between the medullary pyramids (Figs. 3.9-3.11). It connects cus. It sometimes receives a superior hemispheric or tectal
superiorly with the median anterior pontomesencephalic vein vein (1, 9, 26).

Š
and ascends to be joined by a superior hemispheric vein from the lateral part of the tentorial surface before emptying into
the superior petrosal sinus. E, the cerebellum has been removed to expose the veins of the superior, inferior, and middle cer-
ebellar peduncles. The vein of the superior cerebellar peduncle ascends to join the vein of the cerebellomesencephalic fis-
sure. The vein of the inferior cerebellar peduncle crosses the peduncle at the inferolateral margin of the fourth ventricle and
passes around the lateral recess to join the veins in the cerebellopontine angle. The veins of the cerebellopontine fissure and
middle cerebellar peduncle and a transverse pontine vein join to form a superior petrosal vein. The vein of the cerebellomed-
ullary fissure empties into the vein of the middle cerebellar peduncle. F, posterior view of the right cerebellopontine angle.
The vein of the cerebellomedullary fissure passes laterally across the lateral recess and empties into the vein of the middle
cerebellar peduncle. The latter vein and the vein of the cerebellopontine fissure join to form a large superior petrosal vein. A
large anterior hemispheric vein ascends along the petrosal surface. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant.,
anterior; Cer., cerebellar, cerebral; Cer. Med., cerebellomedullary; Cer. Pon., cerebellopontine; CN, cranial nerve; Fiss., fis-
sure; Hem., hemispheric; Inf., inferior; Med., median, medullary; Mid., middle; Ped., peduncle; Pet., petrosal; P.I.C.A., pos-
teroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary; Pon. Mes., pontomesencephalic; Pon. Trig., pontotri-
geminal; S.C.A., superior cerebellar artery; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein; Vert., vertebral.

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FIGURE 3.10. Upper brainstem. A, the veins on the anterior surface of the pons and medulla and the veins of the cerebellopontine
fissure and their tributaries empty into the superior petrosal veins. The median anterior medullary vein and median anterior pon-
tomesencephalic veins course in the midline, but often do not extend along the full length of the pons and medulla. The vein of the
pontomesencephalic sulcus and the transverse pontine veins are transversely oriented. The veins of the cerebellomedullary fissure
join the veins of the middle cerebellar peduncle, which ascends to join the veins of the cerebellopontine fissure. B, the veins in the
crural and ambient cistern join the basal vein, which empties into the vein of Galen in the quadrigeminal cistern. The basal vein
also drains the walls of the temporal horn, which has been opened on the right. An internal occipital vein passes from the calcar-
ine sulcus and occipital lobe to the vein of Galen. C, enlarged view of the basal cisterns. The inferior ventricular vein from the
temporal horn and the lateral atrial vein join the basal vein, which also drains the walls of the crural and ambient cisterns. The cer-
ebellomesencephalic fissure, an inferior extension of the quadrigeminal cistern, is drained by tributaries of the vein of Galen. D,
lateral view of the cerebellomesencephalic fissure. The veins in the medial portion of the cerebellomesencephalic fissure empty
into the vein of Galen and those from the lateral part may join the superior petrosal veins. In this case, the vein of the cerebel-
lomesencephalic fissure is small, resulting in most of the fissure’s drainage being directed laterally through a pontotrigeminal vein,
which passes above the trigeminal nerve to empty into a superior petrosal vein formed by a superior hemispheric and transverse pontine
vein and the vein of the cerebellopontine fissure. Ant., anterior; Atr., atrial; Cer., cerebellar; Cer. Med., cerebellomedullary; Cer. Mes.,
cerebellomesencephalic; Cist., cistern; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Int., internal; Lat., lateral; Med., median, med-
ullary; Mes., mesencephalic; Mid., middle; Occip., occipital; Ped., peduncle; Pet., petrosal; Pon., pontine, ponto; Quad., quadrigeminal;
Str., straight; Sulc., sulcus; Sup., superior; Temp., temporal; Trans., transverse; Trig., trigeminal; V., vein; Vent., ventricle.

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Posterior Fossa Veins S87

Lateral medullary and retro-olivary veins may anastomose with the lateral end of this vein near the
confluence of the pontomesencephalic, lateral mesencephalic,
There are usually two longitudinal veins between the lat-
and interpeduncular sulci.
eral border of the olive and the foramen of Luschka (Fig. 3.3):
a smaller ventral vein (the retro-olivary vein), and a larger Transverse pontine veins
dorsal vein (the lateral medullary vein). The lateral medullary
vein courses slightly dorsal to the retro-olivary sulcus along This is a group of veins that cross the anterior surface of the
the rootlets of the accessory, vagus, and glossopharyngeal pons at various levels (Figs. 3.9-3.11). They interconnect the
nerves. It receives the retro-olivary vein from its ventral side median anterior pontomesencephalic vein and the veins on
and the vein of the inferior cerebellar peduncle from its dorsal the lateral surface of the pons. The most prominent transverse
side, and joins the vein of the pontomedullary sulcus to form pontine veins are located at the midpons. Those on the upper
the vein of the middle cerebellar peduncle. This vein and the and lower thirds of the pons are usually small and only
vein of the inferior cerebellar peduncle often give rise to an infrequently transverse the full width of the pons. Those on
inferior petrosal bridging vein near the foramen of Luschka, the midpons are usually present bilaterally and anastomose
which courses along the rootlets of the nerves entering the medially with the median anterior pontomesencephalic vein.
jugular foramen to join the venous sinuses near the jugular They course laterally above or below the trigeminal nerve to
bulb. drain into the superior petrosal sinus, the pontotrigeminal
The retro-olivary vein usually courses along the rostral vein, or the vein of the cerebellopontine fissure or the middle
two-thirds of the retro-olivary sulcus slightly ventral to the cerebellar peduncle. They sometimes give rise to a bridging
lateral medullary vein. Although small, it may rarely replace vein to the inferior petrosal sinus. If the middle third of the
the lateral medullary vein. It often anastomoses near the median anterior pontomesencephalic vein is absent, the ends
lower edge of the olive with the caudal part of the lateral adjoining the absent segments drain into the transverse pon-
medullary vein and above the olive with either the vein of the tine veins.
pontomedullary sulcus or the rostral end of the lateral med-
Vein of the pontomedullary sulcus
ullary vein.
This vein courses in or near the pontomedullary sulcus and
Transversely oriented veins connects with the longitudinally oriented veins on the ante-
rior aspect of the pons and medulla (Figs. 3.3 and 3.9). It joins
Peduncular vein the lateral medullary or retro-olivary veins or the vein of the
This vein arises in the interpeduncular fossa and courses inferior cerebellar peduncle above the olive to form the vein of
laterally around the cerebral peduncle below the optic tract the middle cerebellar peduncle. It may give rise to a bridging
toward the basal vein (Figs. 3.3, 3.9, and 3.10). It anastomoses vein to the sinuses around the jugular foramen.
medially with the posterior communicating vein, which links
the medial ends of the peduncular veins, and with the upper
Transverse medullary veins
end of the median anterior pontomesencephalic vein. Its me- These veins cross the anterior and lateral surfaces of the
dial end is located on the superomedial surface of the origin of medulla at the level of the medullary pyramid or below (Fig.
the oculomotor nerve. The lateral end of the vein drains into 3.9). They interconnect the median anterior medullary vein
the basal vein or one of its tributaries. In a few cases it drains with the veins on the lateral surface of the medulla. They
through a bridging vein into a sinus in the edge of the rarely cross the full distance from the median anterior med-
tentorium. ullary vein to the lateral medullary vein, but usually consist of
one or two shorter veins passing transversely across the med-
Posterior communicating vein ullary pyramid or the olive. The largest transverse medullary
This vein courses transversely across the interpeduncular veins are usually situated at the level of the middle third
fossa on the superomedial surface of the oculomotor nerves, of the pyramid. They sometimes give rise to a bridging vein to
interconnecting the medial ends of the peduncular veins and the sigmoid or marginal sinuses.
the rostral ends of the median anterior pontomesencephalic
veins (Fig. 3.3). It usually courses in the interpeduncular cis- MAJOR DRAINING GROUPS
tern, bridging over rather than coursing on the floor of the The terminal end of the veins draining the brainstem and
interpeduncular fossa. Small veins exiting the interpeduncu- cerebellum form bridging veins that collect into three groups:
lar fossa frequently join the posterior communicating vein. 1) a galenic group that drains into the vein of Galen; 2) a
petrosal group that drains into the petrosal sinuses; and 3)
Vein of the pontomesencephalic sulcus a tentorial group that drains into the sinuses converging on
This vein is usually small, and does not extend the entire the torcula (Fig. 3.3). The galenic group drains the tentorial
length of the pontomesencephalic sulcus from the midline to surface, the cerebellomesencephalic fissure, and the superior
the lateral mesencephalic sulcus (Fig. 3.3 and 3.10). It passes half of the roof of the fourth ventricle; the petrosal group
below the oculomotor nerves and anastomoses with the me- drains the petrosal surface, the cerebellomedullary and cer-
dian and lateral anterior pontomesencephalic veins in most ebellopontine fissures, the inferior half of the roof of the
cases. The lateral mesencephalic and pontotrigeminal veins fourth ventricle and the lateral recesses, and the anterior and

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S88 Rhoton

FIGURE 3.11. Superior petrosal veins. A, the superior petrosal veins drain the anterior and lateral surfaces of the brainstem, the
petrosal surface, and some of the lateral part of the tentorial and suboccipital surfaces. The veins of the middle cerebellar peduncle
ascend on the middle cerebellar peduncles and join the veins of the cerebellopontine fissure and the transverse pontine veins to
form superior petrosal veins that empty into the superior petrosal sinuses. B, lateral view of a large superior petrosal vein formed
by the union of the transverse pontine, pontotrigeminal, and anterior hemispheric veins and the vein of the cerebellopontine fis-
sure. A large branch of the superior cerebellar artery and the trigeminal nerve are enmeshed in the tributaries of this superior

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Posterior Fossa Veins S89

lateral sides of the pons and medulla; and the tentorial group The tentorial sinuses can course directly medially to drain into
drains the suboccipital surface. Other less frequent bridging the midportion of the straight sinus, posteromedially to drain
veins pass to the cavernous, marginal, basilar, and sigmoid into the torcula or the straight or lateral sinus near the torcula,
sinuses and the jugular bulb. immediately posteriorly to drain into the middle third of the
lateral sinus, or posterolaterally to drain into the lateral and
superior petrosal sinuses at or near the confluence of the two
Galenic draining group
sinuses. Some sinuses are formed by the union of veins drain-
This group, formed by the veins converging on the vein of ing the tentorium itself.
Galen, includes the superficial veins that drain the tentorial
surface, the deep veins that drain the superior part of the roof
Petrosal draining group
of the fourth ventricle and the cerebellomesencephalic fissure,
and the brainstem veins that drain the midbrain. Most of these The petrosal draining group includes the veins draining
veins drain through the superior vermian and basal veins to into the petrosal sinuses (Figs. 3.1, 3.11, and 3.12) (9, 26). This
reach the vein of Galen (Figs. 3.2-3.5). The superficial group draining group includes the superficial veins that drain the
includes the superior vermian vein and the anterior group of lateral part of the cerebellar hemisphere; a deep group that
the superior hemispheric veins; the deep group includes the drains the cerebellopontine and cerebellomedullary and the
vein of the cerebellomesencephalic fissure and the paired lateral part of the cerebellomesencephalic fissures, and the
veins of the superior cerebellar peduncle; and the brainstem inferior part of the roof and the lateral wall of the fourth
group includes the peduncular, posterior communicating, ventricle; and a brainstem group that drains much of the
and tectal veins and the rostral portions of the medial and brainstem.
lateral anterior pontomesencephalic and the lateral mesence- The petrosal veins are divided into superior and inferior
phalic veins. All of these brainstem veins, except for the tectal petrosal veins based on whether they enter the superior or
vein, join the basal vein that drains into the vein of Galen. The inferior petrosal sinus. The superior petrosal veins are among
tectal veins join the superior vermian vein or the vein of the the largest and most frequent veins in the posterior fossa. The
cerebellomesencephalic fissure. inferior petrosal veins are represented by a few small bridging
veins. The superior petrosal veins may be formed by the
terminal segment of a single vein or by the common stem
Tentorial draining group formed by the union of several veins. The most common
The tentorial draining group includes the veins that drain tributaries of the superior petrosal veins are the transverse
into the straight and lateral sinuses and the torcula, either pontine and pontotrigeminal veins, the common stem of the
directly or through a tentorial sinus (Figs. 3.2-3.6). It is lateral group of the superior hemispheric veins, and the veins
composed of the superficial veins draining the suboccipital of the cerebellopontine fissure and the middle cerebellar pe-
surface and the posterior part of the tentorial surface. The duncle. The superior petrosal veins are subdivided into a
veins from the suboccipital surface include the inferior lateral, intermediate, and medial group based on the relation-
vermian veins and inferior hemispheric veins. The veins ship of their site of entry into the superior petrosal sinus to the
from the tentorial surface include the posterior groups of internal acoustic meatus. The intermediate group drains into
superior hemispheric and superior vermian veins. The in- the sinus above the internal acoustic meatus, the medial
ferior hemispheric veins and the posterior group of the group drains into the sinus medial to the meatus, and the
superior hemispheric veins often join before entering the lateral group drains into the sinus lateral to the meatus. Of 20
tentorial sinuses, which drain into the torcula or into the superior petrosal sinuses examined in our previous study, 8
straight or lateral sinuses near the torcula. received one superior petrosal vein, 10 received two, and
The tentorial sinuses also receive the inferior cerebral veins, 2 received three (15). Of the 34 superior petrosal veins, 22
the vein of Labbé, and the bridging veins to the tentorial edge. (64.7%) were of the medial type, 3 (8.8%) were of the inter-

Š
petrosal vein. Care is required to avoid occluding the superior cerebellar artery when occluding a multipronged petrosal vein.
C, retrosigmoid view. The right cerebellopontine angle is drained by a superior petrosal vein formed by the pontotrigeminal
and transverse pontine veins and the vein of the cerebellopontine fissure. D, the tributaries of this superior petrosal vein
include the transverse pontine, pontotrigeminal, and anterior hemispheric veins and the vein of the cerebellopontine fissure.
E, superior petrosal vein with multiple tributaries. The vestibulocochlear nerve has been depressed to expose the facial nerve.
F, the segment of the superior petrosal sinus, which crosses above the trigeminal nerve and receives the superior petrosal
veins, has been removed. The posterior trigeminal nerve passes forward below the tentorial edge and the superior petro-
sal sinus to enter Meckel’s cave. The superior petrosal sinus extends medially through the upper edge of the porus of Meck-
el’s cave and above the trigeminal nerve to join the cavernous sinus. Some superior petrosal veins may join the sinus on the
medial side of the trigeminal nerve. A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Cer., cerebellar; Cer. Pon., cer-
ebellopontine; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Med., median, medullary; Mid., middle; P.C.A., posterior
cerebral artery; Ped., peduncle; Pet., petrosal; Pon., pontine; Pon. Mes., pontomesencephalic; Pon. Trig., pontotrigeminal;
S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial; Trans., transverse; V., vein.

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S90 Rhoton

FIGURE 3.12. Inferior petrosal sinus and veins. A, posterior view of the anterior portion of the posterior fossa with the
brainstem and cerebellum removed. The inferior petrosal and sigmoid sinuses can be seen through the dura. B, the dural roof
of the basilar, inferior petrosal, and sigmoid sinuses have been removed. The inferior petrosal sinuses extend from the basilar
sinus above to the jugular bulbs below. The inferior petrosal veins arise on the brainstem and empty into the lower part of
the inferior petrosal sinus, jugular bulb, or distal sigmoid sinus. C–E, posterior views into cerebellopontine angle. C, an infe-
rior petrosal vein passes from the medulla between the glossopharyngeal and vagus nerves to the jugular bulb. It receives the
drainage of the vein of the inferior cerebellar peduncle, which crosses the peduncle just below the lateral recess. D, an infe-
rior petrosal nerve passes behind the glossopharyngeal and vagus nerves to empty into the terminal part of the sigmoid sinus.
E, an inferior petrosal vein crosses behind the nerves entering the jugular foramen to reach the sigmoid sinus. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Cer., cerebellar; Cer. Med., cerebellomedullary; CN, cranial nerve;
Fiss., fissure; Inf., inferior; Jug., jugular; Lat., lateral; Med., median, medullary; Ped., peduncle; Pet., petrosal; P.I.C.A., pos-
teroinferior cerebellar artery; Post., posterior; Sig., sigmoid; V., vein; Vert., vertebral.

mediate type, and 9 (26.5%) were of the lateral type. Nineteen Other bridging veins
of 20 (95%) sinuses examined had veins of the medial type, 3
(15%) had veins of the intermediate type, and 9 (45%) had The major bridging veins have been discussed above. Other
veins of the lateral type. The medial group of superior petro- less frequent bridging veins run from the basal vein to a sinus
sal veins is usually a common trunk formed by the union of coursing in the tentorial edge; from the peduncular vein to a
two or three of the following veins: transverse pontine veins, sinus in the tentorial edge or the cavernous sinus; from the
pontotrigeminal veins, and the veins of the cerebellopontine lateral or medial anterior pontomesencephalic or a transverse
fissure and the middle cerebellar peduncle. The latter veins pontine vein to the posterior portion of the cavernous or the
may also enter the sinus without joining another vein. Two of adjoining part of the inferior petrosal sinuses just below
the three intermediate superior petrosal veins were formed by Meckel’s cave; from the veins of the pontomedullary sulcus
a single vein, the vein of the cerebellopontine fissure. The and the inferior cerebellar peduncle or the lateral medullary
most common veins in the lateral group are the common stem vein to the sigmoid and inferior petrosal sinuses near the
formed by the union of superior and inferior hemispheric jugular foramen or jugular bulb; from the vein of the pon-
veins and the vein of the cerebellopontine fissure. tomedullary sulcus, and the lateral anterior, lateral, and trans-

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Posterior Fossa Veins S91

verse medullary veins to a marginal sinus at the level of the the tumor during the later stages of the removal of a large
foramen magnum or to the veins in the hypoglossal canal, which tumor. Smaller tumors can often be removed without sacri-
communicates with the marginal sinuses (Fig. 3.12) (13, 15). ficing a petrosal vein. The large vein encountered around the
superior pole of an acoustic neuroma is the vein of the cer-
ebellopontine fissure, which passes from the petrosal surface
DISCUSSION and cerebellopontine fissure above the facial and vestibuloco-
The infrequent reports of adverse sequelae after the intra- chlear nerves to the area above the trigeminal nerve. This vein
operative occlusion of veins in the posterior fossa is caused by has been occluded during acoustic neuroma removal without
the diffuse anastomosis between the veins. It is not surprising causing a deficit (14).
that more severe sequelae have occurred after occlusion of Compression of the trigeminal nerve by the surrounding veins
bridging veins than after occlusion of veins on the surface of is postulated to be a cause of trigeminal neuralgia (8, 11). In 411
the cerebellum, since the bridging veins are formed by the operations for trigeminal neuralgia, Jannetta found veins com-
terminal end of numerous surface veins. The veins crossing pressing the nerve in 153; however, none of these veins involved
the cerebellopontine angle to reach the petrosal sinuses are the in this compression was listed by name (11). Compression of the
ones most frequently occluded in the course of operations in facial and glossopharyngeal nerves by veins has also been pos-
the posterior fossa. Bridging veins are more frequently ex- tulated to be a cause of hemifacial spasm and glossopharyngeal
posed and sacrificed in the rostral part of the cerebellopontine neuralgia (12). The venous relationships of the trigeminal nerve
angle during operations near the trigeminal nerve than dur- where numerous bridging veins converge on and cross the sub-
ing operations in the central or caudal part near the nerves arachnoid space near the posterior root is distinctly different
entering the internal acoustic meatus and the jugular foramen. from those in the region of the facial and vestibulocochlear
Exposure of the trigeminal nerve through a suboccipital crani- nerves, where the predominant veins are on the side of the
ectomy commonly requires the sacrifice of one or more bridg- brainstem and in contact with the nerves at their junction with
ing veins, while exposure of the nerves entering the internal the brainstem. The veins coursing on or near the junction of the
acoustic meatus infrequently requires sacrifice of even a sin- facial and vestibulocochlear nerves with the brainstem are
gle bridging vein. the veins of the middle cerebellar peduncle, the cerebellomed-
In 1929, Dandy pointed out that the petrosal vein should ullary fissure, and the pontomedullary sulcus. There are no large
receive special attention during posterior fossa operations on the veins intermingling with the nerves at or within the acoustic
trigeminal nerve (4). His illustration showed a vein that coursed meatus, as occurs with the arteries. The major veins near the
in the cerebellopontine angle near the rostral aspect of the tri- glossopharyngeal and vagus nerves also course near the origin
geminal nerve to drain into the superior petrosal sinus. Later, of the nerves on the surface of the brainstem, although there are
this common stem came to be known either as the superior small bridging veins that course along these nerves to the ve-
petrosal vein or simply as the petrosal vein (4, 5, 23). No con- nous sinuses near the jugular bulb. The lateral medullary, retro-
sideration has been given in the surgical literature to the identi- olivary, and transverse medullary veins and the vein of the
fication of the trunks that unite to form the petrosal veins, and to inferior cerebellar peduncle course near the origin of the rootlets
the size of the area drained by their tributaries. The veins con- of the glossopharyngeal and vagus nerves.
verging on the trigeminal nerve to form the superior petrosal Bridging veins are more frequently encountered in expos-
veins are the transverse pontine and the pontotrigeminal veins, ing the tentorial surface of the cerebellum than in exposing the
and the veins of the cerebellopontine fissure and the middle suboccipital or petrosal surfaces of the cerebellum. The bridg-
cerebellar peduncle. The largest vein contributing to the forma- ing veins from the suboccipital surface are often encountered
tion of the petrosal vein near the trigeminal nerve is the vein of on the posterior part of the tentorial surface because the
the cerebellopontine fissure, which drains most of the petrosal hemispheric veins from the suboccipital surface uniformly
surface of the cerebellum and much of the lower brainstem ascend to the tentorial surface before forming bridging veins
and the cerebellopontine and cerebellomedullary fissures. Al- that pass to the venous sinuses in the tentorium. Most of the
though superior petrosal veins can be located at any point along veins from the petrosal surface pass to the vein of the cerebel-
the superior petrosal sinus, most are located just lateral to the lopontine fissure and not directly to a venous sinus. The veins
trigeminal nerve. Adverse sequelae only infrequently follow from the tentorial and suboccipital surface that enter the
occlusion of this medial group of superior petrosal veins; how- sinuses in the tentorium are obstacles in the supracerebellar
ever, we have seen two patients with a transient cerebellar approaches. In the infratentorial supracerebellar approach to
disturbance caused by a venous infarction with hemorrhagic the pineal region, it may be necessary to divide numerous
edema after the intraoperative occlusion of these veins lateral to bridging veins entering the torcula and the tentorial sinuses,
the trigeminal nerve. including some of the superior and inferior hemispheric and
The exposure of lesions such as acoustic neuromas in the vermian veins, and the vein of the cerebellomesencephalic
central part of the cerebellopontine angle near the lateral fissure. These veins have commonly been sacrificed without
recess, by retracting the petrosal surface of the hemisphere adverse effect to open the quadrigeminal region and the in-
away from the sigmoid sinus, can usually be completed with- cisura (18, 22, 27). However cerebellar swelling followed tran-
out sacrificing a single bridging vein. If a vein is obliterated section of one of the bridging veins by Page (17).
during acoustic tumor removal, it is usually one of the supe- Bridging veins infrequently cross from the suboccipital sur-
rior petrosal veins that is sacrificed near the superior pole of face, tonsils, and medulla to the venous sinuses in the dura

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S92 Rhoton

overlying the suboccipital surface. In a few cases, an inferior 2. Braun JP, Tournade A: The veins of the lateral recess of the 4th
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