1944 CLINICAL NEURO-OPHTHALMOLOGY
inferior oblique and inferior rectus muscles and to the lacri-
mal and dorsal nasal arteries (29,131,136). The infraorbital
artery emerges on the face after passing through the infraor-
VENOUS SYSTEM OF THE BRAIN
The system of vessels that drains venous blood from the
cranium includes cerebral and posterior fossa veins, diploic
veins, meningeal veins, dural sinuses, orbital veins, and the
internal and external jugular veins.
VEINS OF THE BRAIN: CEREBRAL AND
POSTERIOR FOSSA VEINS
The veins of the brain possess no valves, and their walls
are extremely thin because they have no muscularis. These
vessels pierce the arachnoid and the inner or meningeal layer
of the dura mater to drain into the cranial venous sinuses.
The veins of the brain are usually separated into those that
drain the cerebral hemispheres and those that drain the poste-
rior fossa.
Cerebral Veins
The cerebral veins are of two types: superficial and deep.
Superficial cerebral veins collect blood from large and
small pial veins that cover the surface of the cerebral hemi-
spheres, anastomosing extensively with each other (Fig.
39.58). The veins cross arteries on the outside in about 90%
of patients as opposed to the veins lying deep to the arteries
at vein-artery crossings (137). Deep cerebral veins drain the
subcortical structures of the telencephalon and diencephalon
(Fig. 39.58). These vessels vary considerably in number, but
they are more consistent in size, shape, and location than are
bital foramen where it anastomoses with the angular branch
of the external maxillary artery and with terminal branches
of the ophthalmic artery.
the superficial cerebral veins with which they anastomose
extensively (138–141).
Superficial Cerebral Veins
Ten to 20 superior cerebral veins drain the superior re-
gions of the cerebral cortex, including the medial surface
and the convexity of the frontal, parietal, and occipital lobes
(142). These veins run upward to open in the superior sagittal
(longitudinal) sinus (Fig. 39.59). In a study of ten unfixed
human brains, six to seven of these veins drained the anterior
frontal region, three veins drained each posterior frontal re-
gion, four veins drained each parietal region, and one vein
drained each occipital region (143). The majority of these
vessels initially ascend upward and backward. However, as
they reach the superior convexity of the brain, they turn
rostrally and enter the superior sinus against the flow of
blood (139). Only one or two of the superior cerebral veins,
the anterior frontal veins, join the superior sagittal sinus in
the direction of the flow of blood.
Some authors have named individual superior cerebral
veins based on their relative position to underlying cerebral
structures; e.g., precentral vein, postcentral vein, occipital
vein, occipitotemporal vein (139). One of the largest veins
usually travels in or near the central sulcus and is called the
rolandic (or central) vein (139). This vein drains the region
of the primary motor and somesthetic sensory cortex (Fig.
39.59).
Figure 39.58. The deep cerebral veins, basal veins, and
cerebellar veins: 1, anterior caudate vein; 2, terminal vein;
3, internal cerebral vein; 4, anterior cerebral vein; 5, lenti-
culostriate veins; 6, anterior vein of the corpus callosum;
7, prepontine vein; 8, basal vein (of Rosenthal); 9, great
vein of Galen; 10, inferior cerebellar veins; 11, superior
cerebellar veins; 12, pericallosal vein; 13, internal occipital
veins; 14, inferior sagittal sinus; 15, straight sinus; 16,
torcular Herophili; 17, occipital sinus. (From Krayenbuhl
H, Yasargil M. Cerebral Angiography, Ed 2. Philadelphia:
Lippincott, 1968.)
 ANATOMY AND PHYSIOLOGY OF THE CEREBROVASCULAR SYSTEM
Figure 39.59. Schematic illustration of the superficial cerebral veins. (From Capra N, Kapp J. Anatomic and physiologic
aspects of venous system. In: Wood J, ed. Cerebral Blood Flow. Physiologic and Clinical Aspects. New York: McGraw-Hill,
1987⬊37–58.)
At the junction of the veins with the superior sagittal sinus,
their walls contain an increased amount of collagen fascicles
and elastic fibers, compared with the composition of the
walls along the rest of the vein (144). This increased amount
of connective tissue is continuous with that of the sinus itself.
It is believed that this fibrous structure helps to maintain the
structural integrity of these vessels and therefore plays a role
in the regulation of blood flow within them.
Most of the lateral surface of each cerebral hemisphere is
drained by a descending vein, the superficial middle cere-
bral (sylvian) vein (Fig. 39.59). This vessel shows the great-
est variation in size and course of all the superficial cerebral
veins (145,146). The superficial middle cerebral vein (of
which there may be two) originates near the horizontal or
posterior limb of the sylvian fissure. Each vein runs down-
ward and forward within the fissure toward the pterion and
then medially along the sphenoid ridge to end in the spheno-
parietal or cavernous sinuses.
The superficial middle cerebral vein is connected with the
superior sagittal sinus via the vein of Trolard (the greater
anastomotic vein) and with the lateral sinus through the vein
of Labbé (the lesser or inferior anastomotic vein) (Fig.
39.59). There is considerable variation in the size and exact
location of these collateral channels (141).
The inferior cerebral veins drain the undersurface of the
cerebral hemisphere. Those veins under the temporal lobe
anastomose with the middle cerebral and basal veins and
eventually drain into the cavernous, sphenoparietal, and su-
perior petrosal sinuses, whereas those on the orbital surface
of the frontal lobe join the superficial frontal veins and empty
into the superior sagittal sinus.
1945
Deep Cerebral Veins
The principal deep cerebral veins are the insular and striate
veins, the subependymal veins, the medullary veins, the
basal vein (of Rosenthal), and the great cerebral vein (of
Galen) (Fig. 39.58).
Insular and Striate Veins
A variable number of veins over the surface of the insula
have a configuration similar to the branches of the MCA.
These veins usually drain into the deep middle cerebral vein,
which in turn empties into the basal cerebral vein or, occa-
sionally, into the sphenoparietal sinus (see below). In addi-
tion to the insular veins, the deep middle cerebral vein re-
ceives the striate veins and veins from the inferior aspect of
the frontal lobe. An uncal vein runs along the medial aspect
of the temporal lobe and drains either into the sphenoparietal
sinus anterior to the uncus or directly into the cavernous
sinus (147). The insula can be drained by a deep middle
cerebral vein or by a combination of this vein and more
complex deep and superficial veins (148).
Subependymal Veins
As their name implies, these vessels are located just be-
neath the ependymal surface of the ventricles. The main
subependymal veins are the two internal cerebral veins, the
thalamostriate (terminal) veins, and the septal veins, but
there are many others as well.
The internal cerebral veins are paired vessels that are
situated just off the midline. They are adjacent to each other
in the tela choroidea of the roof of the 3rd ventricle for most
1946 CLINICAL NEURO-OPHTHALMOLOGY
of their course. Their configuration is therefore that of the
roof of the 3rd ventricle (Figs. 39.58, 39.60, and 39.61).
These veins begin at the foramen of Monro and leave the
roof of the 3rd ventricle and enter the upper portion of the
quadrigeminal cistern, where they join to form a short trunk,
the great cerebral vein (of Galen), in the posterior incisural
space (Fig. 39.62).
The main tributary of the internal cerebral vein on each
side is the thalamostriate (or terminal) vein. This vein is
formed by tributaries running on the wall of the lateral ven-
tricle, and it also receives the choroid vein, which runs along
the choroid plexus of the lateral ventricle (Fig. 39.60). Near
the posterior edge of the foramen of Monro, the thalamostri-
ate vein turns abruptly and terminates in the internal cerebral
vein (Figs. 39.60 and 39.61). The junction of the internal
cerebral and thalamostriate veins is called the venous angle
(138). Here, the anterior septal vein, extending backward
from the frontal horn of the lateral ventricle on each side,
also usually joins the internal cerebral vein either at the ve-
nous angle or beyond the foramen of Monro (149).
The posterior callosal vein is a small vessel that extends
around the splenium of the corpus callosum and empties into
the anterior portion of the vein of Galen (great cerebral vein)
just behind its junction with the two internal cerebral veins.
Figure 39.60. Schematic illustration of the deep cerebral veins seen from
above. On each side, a septal vein (1) joins with a thalamostriate vein (2)
to form the internal cerebral vein (4). The internal cerebral veins are located
within the velum interpositum (5). They join posteriorly to form the great
vein of Galen (6). In this illustration, the choroid plexus has been removed
on the right side to show the choroid vein (12). 2, anterior horn at its
junction with the body of the lateral ventricle; 7, occipital horn of the
lateral ventricle; 8, tentorium cerebelli; 9, superior and inferior colliculi;
10, choroid plexus; 11, initial segment of the thalamostriate vein; 13, tem-
poral horn of the lateral ventricle; 14, frontal horn of the lateral ventricle.
(From Taveras J, Wood E. Diagnostic Neuroradiology. Baltimore: Wil-
liams & Wilkins, 1976.)
Medullary Veins
There are numerous veins that are distributed radially in
the depths of the cerebral hemispheres. These are the medul-
lary veins. The deeper veins drain into other deep cerebral
veins, whereas the more superficial medullary veins drain
into the superficial cerebral veins. There are, however, anas-
tomoses between the two groups.
Basal Vein (of Rosenthal)
The basal vein (of Rosenthal) (150) originates on the me-
dial aspect of the anterior portion of the temporal lobe, near
the optic chiasm. It is formed from tributaries arising on the
medial surface and temporal horn of the temporal lobe, from
a small anterior cerebral vein that runs adjacent to the ante-
rior cerebral artery, and from the large, deep middle cerebral
vein (141).
The basal vein passes around the mesencephalon beneath
the uncus and hippocampal gyrus. Its course parallels, but
is slightly rostral to, the course of the posterior cerebral ar-
tery. It usually unites with the two internal cerebral veins
and the contralateral basal vein to form the vein of Galen
(Fig. 39.62) (138,150). Variations from this classic conflu-
ence are common, however (147,151). The basal vein may
empty into the vein of Galen after that vein has already
formed but before it enters the straight sinus, or the basal
vein may empty directly into the straight sinus, into the trans-
verse sinus, or via the lateral mesencephalic vein into the
superior petrosal sinus (147). It may also drain through tribu-
taries into the cavernous sinus. Along its course, the basal
vein receives blood from veins coming from the hippocam-
pal gyrus, the interpeduncular fossa, and the mesencephalon
(141). Inferior striate veins, which drain the corpus striatum
and the anterior perforated substance, also empty into the
basal vein as well as occasionally the superficial sylvian
veins (152).
Great Cerebral Vein (of Galen)
As noted earlier, the great cerebral vein of Galen, often
called either the ‘‘great cerebral vein’’ or the ‘‘vein of
Galen,’’ usually arises from the confluence of the two inter-
nal cerebral veins and the two basal veins in the posterior
incisural space just posterior and superior to the pineal gland
(Figs. 39.58 and 39.60–39.63) (138). This short vessel, about
2 cm in length, runs upward and backward around the sple-
nium of the corpus callosum to end in the straight sinus at
the junction of the falx cerebri and the tentorium cerebelli
(Fig. 39.58). Along its course, the vein of Galen receives
blood from a number of supratentorial and infratentorial
veins. These include the pericallosal veins, the internal oc-
cipital veins, the lateral pineal veins (153), and the veins
draining the tentorial surface of the cerebellum, the cerebel-
lomesencephalic fissure, and the superior half of the roof of
the 4th ventricle (138).
Posterior Fossa Veins
The veins of the posterior fossa may be divided into four
groups: (a) superficial, (b) deep, (c) brainstem, and (d) bridg-
 ANATOMY AND PHYSIOLOGY OF THE CEREBROVASCULAR SYSTEM 1947

Figure 39.61. Angiographic appearance of the internal cerebral vein. A, The internal cerebral vein (arrowheads) is formed
from the junction of the thalamostriate vein (1) and the septal vein (5). The internal cerebral vein then drains into the great
vein of Galen (asterisk): 2, posterior caudate vein; 3, medial atrial vein; 4, inferior ventricular vein; 6, anterior caudate veins.
B, The internal cerebral vein (arrowheads) is formed from the junction of the thalamostriate (1) and septal (7) veins. It drains
into the great vein of Galen (asterisk), which also receives blood from the basal vein of Rosenthal (6). 2, anterior caudate vein;
3, posterior caudate vein; 4, medial subependymal vein perforating the roof of the 3rd ventricle to join the internal cerebral
vein; 5, medial atrial vein. ISS, inferior sagittal sinus; ICV, internal cerebral vein; G, vein of Galen; R, basal vein of Rosenthal;
TS, transverse sinus; TH, torcular Herophili; IPS, inferior petrosal sinus; SPS, superior petrosal sinus; JV, jugular vein; SS,
straight sinus; GAV, greater anastomotic vein. Arrowheads denote the inferior anastomotic vein. (From Taveras J, Wood E.
Diagnostic Neuroradiology. Baltimore: Williams & Wilkins, 1976.)

Figure 39.62. Cerebral angiogram, venous phase, lateral view. The SSS
is shown draining into the torcular Herophili. The transverse sinuses move
anteriorly in this view draining into the sigmoid sinuses which drain into the
inferior jugular veins. The internal cerebral veins join with the basal vein of
Rosenthal creating the great vein of Galen. The inferior sagittal sinus is faint
and joins with the great vein of Galen draining into the straight sinus which
drains into the torcular Herophili. The superior petrosal sinus drains into the
proximal sigmoid sinus and the inferior petrosal sinus drains into the proximal
jugular vein. The great anastomotic and inferior anastomotic veins are also
demonstrated.
1948 CLINICAL NEURO-OPHTHALMOLOGY
ing veins (154). The superficial and deep veins of the poste-
rior fossa drain the cerebellum and the brainstem veins
drain the brainstem structures. The bridging veins drain
either into the vein of Galen, the superior and inferior petro-
sal sinus, and the tentorial sinus near the torcula.
DIPLOIC VEINS
Diploic veins occupy channels in the diploë of the cranial
bones. They are large and contain pouch-like dilations at
irregular intervals. These vessels communicate with the me-
ningeal veins, with the sinuses of the dura mater, and with
the veins of the pericranium.
MENINGEAL VEINS
The small venous channels that drain the dura mater cov-
ering the brain are the meningeal veins. They are actually
small sinuses that accompany the meningeal arteries, usually
in pairs (venae comitantes). The largest meningeal veins ac-
company the middle meningeal artery (139). The meningeal
Figure 39.63. Schematic illustration of the origin
and course of the basal vein (of Rosenthal). The tip
of the temporal lobe on the right side has been re-
moved, and a horizontal cross cut through the right
temporal and occipital lobes that exposes the tem-
poral horn, occipital horn, and atrium of the right
lateral ventricle is shown. The right basal vein (7) is
fed by a number of veins, including the anterior cere-
bral vein (1), the olfactory vein (2), and the deep
middle cerebral vein (4). The two basal veins join
with the two internal cerebral veins (shown cut) to
form the vein of Galen (13): 3, superficial middle
vein; 5, mammillary body; 6, temporal horn of the
lateral ventricle; 8, hippocampus; 9, collateral emi-
nence; 10, posterior horn of the lateral ventricle; 11,
superior sagittal sinus; 12, lateral (transverse) sinus;
14, quadrigeminal plate; 15, cerebral aqueduct; 16,
left basal vein; 17, cerebral peduncle; 18, posterior
perforated substance; 19, optic chiasm; 20, anterior
perforated substance; 21, lateral olfactory striae; 22,
anterior tip of left temporal lobe; 23, anterior commu-
nicating vein; 24, olfactory tract; 25, longitudinal (in-
terhemispheric) fissure; 26, olfactory bulb; 27, super-
ficial cerebral vein. (From Taveras J, Wood E.
Diagnostic Neuroradiology. Baltimore: Williams &
Wilkins, 1976.)
veins receive blood from the diploic veins of the calvarium
and from some of the cortical veins. Depending on their
location, the meningeal veins drain into the large dural si-
nuses at the base of the skull or into the superior sagittal
sinus and its venous lacunae (139).
DURAL SINUSES
The sinuses of the dura mater are venous channels that
drain blood from the brain, dura, and diplöe (Figs. 39.64
and 39.65). Situated between the two layers of the dura
mater, they are devoid of valves and are lined by endothelial
cells and by connective tissue that is continuous with that
of the veins that drain into them (144). They are often divided
into two groups: (a) the posterosuperior group, located at
the upper and back parts of the skull; and (b) the anteroin-
ferior group, located at the base of the skull. The postero-
superior group of dural sinuses is composed of the superior
sagittal sinuses (SSS), inferior sagittal, straight, transverse,
sigmoid, tentorial, and occipital sinuses. The SSS, inferior
sagittal, straight, and occipital sinuses are single, unpaired