NETTER’S CLINICAL ANATOMY8 Head and Neck Feramen cecum iste for Hypegossal anal Supetir otal issue —— Foramen tne oramen spinasum =~ | Carat cana for gla framen — tsar v.10 super sagt sinus -Avierot ebro foramen =~ Aner eh and foramina of eb pate ==——Otactaryn {CNS Posie etd armen ———Porrir email, v, and pte caal = fomien «en [Ophibame catametor nN th Secon 9c fe scima fara ad matacary branches of ophthalmic m (CN Vi) Abdicenem CNV Superor ephtnamic: ~Masllary CNV) Mandibular m CNV) Lesser patrons a a Mille meningeal a and Meningeal branch af mandbula {inal a ae Lesser pets (CNX Grater petrol n(CN WD Facial» (CN vb | Vestsliocactearn (EN vi Libyan Inferior pets sinus Glessopharyngalm (CN =| Vague CN sein Cx Peter maringel a. ypogionsal a CN XID Mes oblonga Meninges Seth and vers ln Spinal tonto seeeeoy nn CN A FIGURE 8.4 Superior Aspect of Cranial Base (Cranial Fossa). (From Atlas of human anatomy, ed 7, Plate 20) space and contains cerebrospinal fluid, which bathes and protects the central nervous system (CNS). © Pia mater: delicate membrane of connective tissue that intimately envelops the brain and spinal cord. ‘The cranial dura mater is distinguished from the dura mater covering the spinal cord by its two layers, An outer periosteal layer is attached to the inner aspect of the cranium and is supplied by the ‘meningeal arteries, which le on its surface between itand the bony skull. Imprints of these meningeal artery branches can be seen as depressions on the inner table of bone. This periosteal dura mater is. continuous with the periosteum on the outer surface of the skull at the foramen magnum and where other intracranial foramina open onto the outer skull surface, The inner dural layer is termed the ‘meningeal layer and is in close contact with the tunderlying arachnoid mater and is continuous with the spinal dura mater at the level of the foramen. magnum. ‘The dura mater is richly innervated by meningeal sensory branches of the trigeminal nerve (fifth44a Chapter 8 Head and Neck (Choo plemuof lateral venti (phantom Superior sail ss ster of corpus callosuny Chroid plows of Sd vente interventricular foramen of Mon) Interpedunclar ci corer {tera sperure ramen of Lunch Choroid pesurof 4th vente Median aperture foramen of Mages) Cental ana of spinal cond FIGURE 8.5 Central Nervous System Meninges, Cerebrospinal Flu Circulation, and Arachnoié Granulations. (From Atlas of human anatomy e@ 7, Plate 120) cranial nerve, CN V); the vagus nerve (CNX), specifically to the posterior cranial fossa: and the upper cervical nerves. A portion of the dura mater in the posterior cranial fossa also may receive some innervation from the glossopharyngeal nerve (CN 1X), acoessary nerve (CN X1), and hypoglossal nerve (CN XID, The arachnoid mater and pia mater lack sensory innervation. The periosteal dura mater and ‘meningeal dura mater separate to form thick con- nective tissue folds or layers that separate various brain regions and lobes (Figs. 85, 86, 8.7, and 8.8): # Falx cerebri: double layer of meningeal dura mater between the two cerebral hemispheres, «© Falx cerebelli:sickle-shaped layer of meningeal dura mater that projects between the two cer- ebellar hemispheres. « Tentorium cerebelli: fold of meningeal dura rater that covers the cerebellum and supports the occipital lobes of the cerebral hemispheres. © Diaphragma sellae: horizontal shelf of men- ingeal dura mater that forms the roof of the sella turcica covering the pituitary gland; the FIGURE 8.6 Ducal Projections.445 Superior opbhaimic Iotrcavernous (tcl sna and pitta hind Intra erated Cavemour sin. Basar venous ples Trochlear EN W) Tigerinal ganglion gase'an selina) Mile meningeal Abducens n (CNV sugar ores ‘Simo sinus contin of taneere ss) Superior an Inferior petrsal sinuses “entorum ceebell Great cerbral. of ale Siraight smu Confvnce of sine: ores cerebral vf Calend Super saga sinus ugar foramen Fala cere Simo sinus Invior sagt sinus 7 BN sight sous ranevere sna Conence of inutes Occipital sews Cavern si pte chissm communicating calomatorn (CN th otra eral Aaducene {CNV segment Ophthalien (CN vy) Hypophyss ‘protry en Masllaey nC V9 phenol sinut coronal section sop Chrowghenemous sna: FIGURE 8.7 Dural Venous Sinuses. (Prom Atlas of human anton e@ 7, Plates 114 and 115)446 infundibulum passes through this dural shelf to connect the hypothalamus with the pituitary gland. Dural Venous Sinuses “The dura mater also separates to form several large cendotheliallined venous channels between its periosteal and meningeal layers; these include the superior and inferior sagittal sinuses, straight sinus, confluence of sinuses, transverse, sigmoid, and ‘cavernous sinuses, and several smaller dural sinuses (Table 82 and Fig. 87). These dural venous sinuses drain blood from the brain, largely posteriorly, and then largely into the internal jugular veins. These sinuses lack valves, however, so the direction of ee sinus ‘CHARACTERISTICS Superior sagital__Midline sinus alog the convex ‘superior border ofthe fax cere -Mialine sinus along the inferior Tee edge ofthe fa creel nd joined by the great cerebral ein (or Galen) uns in the attachment ofthe fx ‘etebi and the tentorium cerebell, and s formed by the inferior ‘ltl sinus and gest cerebral Meeting of superior and inferior sagital sinuses, the straight sinus, and the ocelpial snus Extends from the confience of ‘uses along the lateral edge ofthe teoriam cerebel Continuation of the transverse sinus ‘that pases inferomedially in an ‘S-shaped pathway tothe jugular foramen (becomes internal jugular vain) [ns in the fax cerebll tothe ‘confluence of sinuses [Network of venous channels on ‘ase part af the oelptal hone, swith connections tothe petzoeal Shuses dain into vertebral ‘venous plexus Les between dural layers on each Side of the sll turetea connects tw the superior ophthalmle vein, pterygoid plexus of veins _phenoparietal sinuses, petra sinuses, and baslr snus Rune along the posterior edge ofthe lesser wing ofthe sphenoié bone and drains Into the envernous nat Small veins connect the dita, sinuses with the ple veins Inthe ‘bony skal waich are connected to sealp veine Inferior sagital Straight Conftuence of Transverse Sigmoid Occipital Basie Cavernous Sphenoparietal Emissary veins Chapter 8 Head and Neck blood flow through the sinuses is pressure depen- dent, Of particular importance is the cavernous ‘venous sinus (Fig. §:7), which lies on either side of the sella turcica and has an anatomical relation- ship with the internal carotid artery and several cranial nerves, including CN Ill, CN IV, CN Vi, CNV, and CN VL Injury or inflammation in this region can affect some or all of these important structures. Also, the optic chiasm lies just above this area, so CN Ui may be involved in any superior expansion of the cavernous sinus (eg. pituitary tumor). Subarachnoid Space ‘The subarachnoid space (between the arachnoid rater and pia mater) contains cerebrospinal fluid (CSE), which performs the following functions (Figs 85 and 8.8) © Supports and cushions the spinal cord and brain. «© Fulfill some functions normally provided by the lymphatic system. © Occupies a volume of about 150 mL in the subarachnoid space «© Is produced by choroid plexuses in the brains ventricles. «© Is produced at a rate of about 500 to 700 mL/ aay, «Is reabsorbed largely by the cranial arachnoid granulations and by microscopic arachnoid ¢granulations feeding into venules along the length of the spinal cord. ‘The arachnoid granulations absorb most of the CSP and detiverit to the dural venous sinuses (see Figs. 85 and 8.8), These granulations are composed of convoluted aggregations of arachnoid ‘mater that extend as “tufts into the superior sagittal sinus and function as one-way valves for the clear- ance of CSF; the CSF crosses into the venous sinus, but venous blood cannot enter the subarachnoid space, Smal, microscopic arachnoid cell herniations also occur along the spinal cord, where CSF (which, circulates at a higher pressure than venous blood) is delivered directly into small spinal cord veins ‘The CSF circulating around the brain (and spinal cord) provides a protective cushion and buoyancy for the CNS, thus reducing the pressure ofthe brain. oon the vessels and nerves on its inferior surface. also can serve as a fluid delivery system for certain chemical mediators (eg. interleukins and prostaglandins) and represents an internal paracrine communication system for certain CNS areas that are close to the ventriclesChapter 8 Head and Neck 4a7 3g | Scalp, skull, meningeal, and cerebral blood vessels Cerebral belgng¥) penetrates subdural pues ener ius Arachnid gramation superior sagt sis ‘Dura mate (periosteal and meningeal Arachnoid mater sept Subarachnoid space Geanular tention osaby Sachrod eranaton) pian aponeurosis rem ccavata Meningeal Superior central, FIGURE 8.8 Relationship of Arachnoid Granulatons and Venous Sieus. (From Atlas of human ‘anatomy, ed 7, Plates 111 and 113.)Chapter 8 Head and Neck Hydrocephalus Hydrocephalus is the accumulation of excess CSF within the brain's ventricular system. It is caused by overproduction or decreased absorption of CSF or by blockage of one of the passageways for CSF flow in the subarachnoid space. nicl appearance in advances hydrocehalus secon sraugh bain showing marked ‘station of srl and raves, Potent lesion sites in obstructive hydrocephalus {insert fermina of Mora 2 reba quae Sy StS sper Lune ‘ean tere a agence) ‘Shunt procedure for hydrocephalus drs venile Reservoir a end of annua planted Beneath gle permis varscuureous reel pneu for wthtawal CSF, TiroduGion of anti, o dye test patency of shunt Canals nated in tral vente Onesnay valve a prevent efx of blood ‘nperts! and contol €SF peste Drsmage tube may be inochiced eto nema jal an bance nis gh ‘um a ech cion,o ray be nine subetancol to abdoen, “Type Definition Obtuive ‘Congenital senor of eral aqui (Syn or abraon erste trae by ot ‘Gbsracon ogee versa stem «, arachnoid pace ‘emonhagel ors achnad granule Neral presi ‘lil dione ef propsive dancin gu srden ada ‘Rontnrc compat map) sows verses ionMeningitis is serious condition defined as an inflammation of the arachnoid mater and pia meter. It results ‘most often from bacterial or aseptic causes. Aseptic causes include viral infections, crug reactions, and systernic iseases. Patients with mering’s usualy present with the folowing symotoms: + Headache + Fever + Seiaures: + Painful sti? neck Diagnosis is made by performing a lumbar puncture and examining the CSF Bacterial meningitis, Sources of infection Basal skull factre Premonia Dermal sinuses Gross Anatomy of the Brain ‘The most notable feature of the human brain is its Iarge cerebral hemispheres (Figs. 89 and 8.10), Several circumscribed regions ofthe cerebral cortex are associated with specific functions, and key surface landmarks of the typical human cerebrum. are used to divide the brain into lobes: four or five, depending on classification, with the fifth lobe being either the insula or the limbic lobe. The lobes and their general functions are as follows: © Frontal: mediates precise voluntary motor control, learned motor skills, planned movement, eye movement, expressive speech, personality, working memory, complex problem solving, ‘emotions, judgment, socialization, olfaction, and drive, Cribrifrm plate defect Sinusitis othmoidts) Nasopharyngiis skin uruncles) Infection of laptomeninges usually hematogenot, but maybe deck from paranasl sinuses middle ex, mastoid cll or 1 leak om rif pit defect or vin Shera sie Inflammation and suppurative process on surface of Teptomeninges of brain and spinal cond Parietal: affects sensory input, spatial discrimina- tion, sensory representation and integration, taste, and receptive speech. Occipital: affects visual input and processing, ‘Temporal: mediates auditory input and auditory ‘memory integration, spoken language (dominant side), and body language (nondominant side). Insula: a fifth deep lobe that lies medial to the temporal lobe (sometimes included as part of temporal lobe); influences vestibular function, some language, perception of visceral sensations eg. upset stomach), emotions, and limbic functions. Limbic: also sometimes considered a fifth medial Jobe (cingulate cortex); influences emotions and some autonomic functions.450 Supplemental mets ore Tongue Spinal ed ‘Median sagital MR image FIGURE 8.9 rain and Brainstem. (From Atlas of human anatomy ed 7, Plate 17) Other key areas of the brain include the following components (Fig. 89) ‘© Thalamus: gateway to the cortex; simplistically functions asan “executive secretary’ to the cortex (relay center between cortical and subcortical areas). ‘© Cerebellum: coordinates smooth motor activi- ties, and processes muscle position; possible role in behavior and cognition. © Brainstem: includes the midbrain, pons, and ‘medulla oblongata; conveys motor and sensory information from the body and autonomic and motor information from higher centers to peripheral targets. Internally, the brain contains four ventricles, ‘wo lateral ventricles, and a central third and fourth. ventricle (Fig. 8.11). Cerebrospinal fluid, produced by the choroid plexus (see Fig. 8.5), circulates through. these ventricles and then enters the subarachnoid. ela oblongata infin nasal ech Paramedian sagittal MR image space through two lateral apertures {foramina of Luschka) or a median aperture (foramen of ‘Magendie) in the fourth ventricle Blood Supply to the Brain Arteries supplying the brain arise largely from the following two pairs of arteries (Fig. 8.12 and Table 8.3) © Vertebrals: these two arteries (right and lett) arise from the subclavian artery, ascend through the transverse foramina ofthe C1-Cé vertebrae, and enter the foramen magnum of the skull © Internal carotids: these two arteries (right and left) arise from the common carotid artery in the lower neck, ascend superiorly in the neck, enter the carotid canal, and traverse the foramen Iacerum to terminate as the middle and anterior cerebral arteries, which anastomose with the arterial circle of Willis.Postcentral gyrus Precental sulcus Posteena sulcus Frontal (8 frontoparetal and tempera (7) opercula Superior frontal gyrus Superior parietal lobule Inferior parietal lobule Angular gyrus Paritooccipital sulcus raneverse ‘occipital sulcus Middle frontal gynus Inferior frontal sulcus Calearine fissre LOcpital pole Inferior frontal gyrus Frontal pole Lateral (sylvian fissure Tempont po Soper tempor 8 tte temporal ges Parietal lobe Frontal lobe ‘Occipital lobe Cental suleus of ins Circular sulens of isu: Temporal lobe. 4 oul FIGURE 8.10 Surface Anatomy ofthe Forebrin: Lateral View. pees eed eee Subarachnoid Hemorrhage Font atic ben Cental pat Temporal Ginieron horn Occipital (posterin horn Subarachnoid nemorthage usually occurs from an ‘arial source and resus in the collection of Sood igh tater venticle between the arachnod mater and pia mater. The most common cause of subarachnoid hemorrhage is the rupture of @ saccular, or berry, aneurysm. “Ophthalmic 4% Posterior communicating 18% Left interventricular Cerebral aqueduct ff Sylvia) Lest Iateral aperture Aioramen of Lusch) Median spercure Aioramen of Magencie) 4th ventricle FIGURE 8.11 Ventricular System of the Brain. (From Alas of human anatony, ed 7, Plate 119) posterior cerebral Basar 10%Anterior cree, Invernl cara Arterolerl cena ‘enclostiate a. Superior cerebellar 2 asa Ponti Labyrinine internal seousel 3 Anterior inferior rebel 2 IAICAY COURSE AND ARTERY STRUCTURES SUPPLIED Vertebal From subclavian artery; supplies cerebelism Posterior inferior From vertebral artery: supplles cerebellar the posteroinferior cerebellum Beslan From both vertebral supplies brainstem, cerebellum, and cerebrum Anterior inferior From basil; supplies inferior cerebellar ‘cerebellar Superior cerebellar From basilar; supplies superior ‘cerebellar Posterior cereal From basil; supplies inferior ‘cerebrum and occptal lobe Posterior (Cerebral arterial circle (of Wills) communicating Jnternal carota (1C) From common carotid: supplies ‘cerebral lobes and eye Middle erebeal From IG supplies intra aspect of cerebral hemispheres Anterior (Cerebral arterial cil (of Wills) communicating Anterior cerebral From IC; supplies medial ad superaateral cerebral hemispheres (except occipital lobe) Cerebral atrial ‘Gee (of Wil “brani | ‘The vertebral arteries give rise to the ante- rior and posterior spinal arteries (a portion of the supply to the spinal cord) and the posterior inferior cerebellar arteries, and then join at about the level of the junction between the medulla and pons to form the basilar artery (Fig. 8.12) ‘The internal carotid arteries cack give rise to an ophthalmic artery, a posterior communicating, artery, a middle cerebral artery, and an anterior cerebral artery. lable 8.3 summarizes the brain regions supplied by these vessels and their major branches. Cranial Nerves See Chapter i for an overview of the general “organization of the nervous system, In addition to the 31 pairs of spinal nerves, 12 pairs of cranial nerves arise from the brain and. upper spinal cord (CN XI). As with the spinal nerves, cranial nerves are part of the periph- eral nervous system and are identified both by name and by Roman numerals CN I to CN XiL “ext comined on p. 459,Chapter 8 Head and Neck 453 cs Epidural Hematomas Epidural hematomas result most often from motor vehicle crashes, falls, and spors injures. The bload collects between the periosteal dura mater and bony cranium. The source of the bleeding is usually arterial (85%) common locations include the frontal, temporal fiddle meningeal artery is very susceptible, especially where it les deeo to the pterion), ana occipital regions. “Temporal fot hematoma Medial doplacerent oh rile cerebral vrei Stl fracute casing sale meningeal Herat of tempor abe eed eater ia Shi of brainstem o oppose side may reverse Intralzaion of sigs By tal presture on nist! pats Compression of ortcospinal and associated puta, resulting conalateralhemipaes Compresion of oealmetr it Seep tenon hypereli, sd Babins Tending psa ppl cite " " rd rd cramiain mele aly Posterior fossa hematoms ‘Occipital vaumsa andor fracture: headache, Inesingisns,cerebellorand canis Sgn shins ad Sablon hematoma Frontal auma headache, poor (rcbation,nteraitent, orentston snisocoea Epil herators arrowhead) a seen nan ail CT rot the mass eect fhe hematoma andthe misine {Riel te bran with dled venice rom yor [Nusa practea!ypproachto rdoegy, Pade, Saunders, 2006,Subdural Hematomas Subdural hematomas are usualy caused by an acute venous hemorthage ofthe cortical bridging veins cain ing cortical blood into the superior sagittal sinus. Half are associated with skull fractures, Ina suodutalhematoma the blood collects between the meningeal dura mater and the arachnoid mater (a potertial space). Cinical signs include a decreasing level of consciousness, ipsilateral pupillary dilation, headache, and contralateral hemipares's. These hematomas may develop within 1 ‘week atter injury but often present with clnical signs within hours. Chronic subdural hematomas are most common in elderly persons and alcoholic patients who have some brain atrophy, which increases the 9808 traversed by the bridging veins anc renders the stretched vein susceptible to tearing. Section showing aut subdural hematoma a ight side Ah atbdural hemor ausoced wih tee! abe inrscerebral Retna (ur temporal labs an fel Transient Ischemic Attack Atransient ischemic stack is temporary interruption of focal brain circulation that resuks in a neurologic tii that lasts lass than 24 hours, usually 15 minutes 0 1 hour. The most common eause of TIA is embole tlisease from the heart, carotid, or cerebral vessels, which may temporary block a vessel. The onset of tho doficit is abrupt, and rocovory is gradual. Tho ‘most common defets include the following: Hemiparesis Hemisensory loss ‘Aphasia Confusion Hemianopia Ataxia Ver'go _Aheroma with or without lot {Nsfureton of ermal carotid hey ino antnrand mie Cocke ates {Atsionon within ‘avemous sous. Diseton of internal ‘ais arery “Aheroma with or without ‘dotat best of ‘Gantnon rel sey {ro common! ign of common ‘avoid atey (creamer! we Potential sites for emboli in TIAChapter 8 Head and Neck 455 is Teco Stroke Cerebrovascular accident (CVA) or stroke is @ localzed brain injury caused by # vascular episode thet lasts rmore than 24 hours, whereas a transient ischemic attack (TIA) is a focal ischemic episode lasting less than 24 hours, Stroke is chssified inta the folowing “wo types: + Ischemic (70-80%. infarction, thrombotic or embolic, resulting {rom atherosclerosis of the extracrarial {usually carotid) and intracranial arteries of from underlying heart d'sease + Hemerrhagie: occu's when a cerebral vessel weakers and ruptures (subarachnoid or intracerebral hemorrhage), wnich causes intracranial bleeding, usually affecting a larger brain area. Ischemic Stroke moi Irae Hyporia Throats "a nla Clot iragment cae rom hee, i ees cendia lotn care a. xen direcy 6 ypoersion a por cerebral rile cerebral peso borer fone iste 20 Hemorrhagic Stroke