See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/323614978

Evaluation of dural venous sinuses and confluence of sinuses via MRI

venography: anatomy, anatomic variations, and the classification of
variations

Article in Child's Nervous System · June 2018

DOI: 10.1007/s00381-018-3763-4

CITATIONS READS

18 1,528

3 authors, including:

Gülen Burakgazi Taskin Duman

Mustafa Kemal University Mustafa Kemal University
20 PUBLICATIONS 85 CITATIONS 122 PUBLICATIONS 920 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Search for Novel High-Risk Variants in Familial Multiple Sclerosis View project

just academic paper View project

All content following this page was uploaded by Taskin Duman on 20 January 2023.

The user has requested enhancement of the downloaded file.

Child's Nervous System (2018) 34:1183–1188
https://doi.org/10.1007/s00381-018-3763-4

ORIGINAL PAPER

Evaluation of dural venous sinuses and confluence of sinuses via MRI

venography: anatomy, anatomic variations,
and the classification of variations
Hanifi Bayaroğulları 1 & Gülen Burakgazi 1 & Taşkın Duman 2

Received: 1 February 2018 / Accepted: 19 February 2018 / Published online: 7 March 2018
# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose We aimed to determine the anatomical variations more comprehensively particularly at the level of superior sagittal
sinus (SSS), confluence of sinuses (CS), transverse sinuses (TS), straight sinuses (SS) and occipital sinuses (OS) with the help of
the images obtained via MRI venography, and to contribute to the classification efforts.
Methods In our retrospective study, we evaluated 211 patients who admitted to our hospital with various complaints and cerebral
MRI venography has been performed. All investigations were performed by using 1.5-T MRIscanner (Achiva, Philips) with a
VEN-3D –PCA MR venous angiography technique. Section thickness was 0.8 mm and axial plane was used. Other parameters
were as follows: 17/7.1 (TR/TE), flip angle, 10.00, FOV, 220-mm, and matrix 244x140.
Results We divided our cases into 3 types but we increased the number of subgroups. Type I was divided into 4 subgroups (Type
IA, IB, IC, ID), Type II into 9 (Type IIA1, IIA2, IIB1, IIB2, IIC, IID1, IID2, IIE1, IIE2) and Type III into 2 (Type IIIA, IIIB). Type
I constitutes a 26.06% of whole cases, and Type II 59.71%, Type III 14.21%. In our cases R-TS wasn’t revealed in 10 cases
(4.73%) whereas in 37 cases (17.53%) it was hypoplastic. L-TSwasn’t shown in 26 cases (12.32%) and in 85 cases (49.09%) it
was hypoplastic. R-Sig S wasn’t revealed in 7 (3,31%) and was hypoplastic in 34 (16.11%) whereas L-Sig S wasn’t present in 2
(0.94%) and hypoplastic in 72 (34.12%). Among these cases 14 had bilateral hypoplastic TS (6.63%). In cases with hypoplastic
TS or Sig S, as an alternative pathway 30 patients had OS (14.21%). Two of these patients had double OS.
Conclusion Our wish is to contribute to the efforts of clarifying and classifying the intracranial venous structures and their
anatomical variations. We hope our study enlightens a path in this field for future studies.

Keywords Classification . Confluens sinuum . Dural venous sinus . Variation . MRI venous angiography

Introduction possible only for selective patients to obtain very scarce data
on dural sinuses by using conventional venous angiography;
The anatomy, variations, and the interaction with surrounding today, by the help of magnetic resonance imaging (MRI) ve-
structures of dural venous sinuses differ widely. It is particu- nography or multidetector computed tomography (MDCT)
larly important in neuro-surgery, ear-nose-throat, or neurology venography, adequate data is attained non-invasively for a
practice to have a satisfactory knowledge in dural sinus anat- larger number of patients in a short time [1–4]. Following
omy in order to avoid possible complications. Once, it was the advances in the non-invasive techniques, it was better
understood that the structures of dural sinuses vary widely. It
is the confluence of sinuses that shows the most abundant
number of variations. Although many studies and classifica-
* Gülen Burakgazi tions were made regarding the variations of this region so far,
burakgazigulen@gmail.com there is a lack of a comprehensive classification including all
variations [1, 5, 6].
1 In our study, it is aimed to determine the anatomical vari-
Department of Radiology, Medical Faculty of the Mustafa Kemal
University, Serinyol, 31100 Antakya, Hatay, Turkey ations more comprehensively particularly at the level of supe-
2 rior sagittal sinus (SSS), confluence of sinuses (CS), trans-
Department of Neurology, Mustafa Kemal University,
Antakya, Hatay, Turkey verse sinuses (TS), straight sinuses (SS), and occipital sinuses
1184 Childs Nerv Syst (2018) 34:1183–1188

Table 1 Abbreviations used in the study and their descriptions 1.5-T MRI scanner (Achiva, Philips) with a VEN-3D–PCA
Abbreviations Descriptions MR venous angiography technique. Section thickness was
0.8 mm and axial plane was used. Other parameters were as
CS Confluens sinuum follows: 17/7.1 (TR/TE), flip angle, 10.00, FOV, 220-mm, and
SSS Superior sagittal sinus matrix 244 × 140.
SS Straight sinus Our retrospective study was approved by the institutional
TS Transverse sinus review board. Informed consent was waived because of the
Sig S Sigmoid sinus retrospective nature of the study.
OS Occipital sinus
JV Jugular vein
VG Vein of Galen Results
VL Vein of Labbe
VT Vein of Trolard The mean age of the 211 patients recruited in this study
R Right was 38.00 (ranging between 1 and 81). Eighty-one of
L Left the patients were male, whereas 130 were female.
Ac. Accesuar Posterosuperior structures namely SSS, SS, TS, Sig S,
RP Right part and OS were primarily evaluated and ISS, internal cere-
LP Left part bral vein (ICV), veins of Rosenthal (VR), vein of Galen
Ag. Agenetic (VG), vein of Trolard (VT), and vein of Labbe (VL) were
Hypo. Hypoplasia also included into investigations. Abbreviations used in
this paper were included in Table 1.
This study is grounded on a previously published study by
(OS) with the help of the images obtained via MRI venogra- Gökçe et al. on the classification of variations regarding ve-
phy and to contribute to the classification efforts. nous sinuses. Authors of this study classified the variations at
the level of CS as Type 1, Type 2 (Type 2A1, Type 2A2, Type
2B, Type 2C, Type 2D, Type 3E), and Type 3 (Fig. 1).
Material and methods Although this study was generally in line with this prior clas-
sification, we speculated that this might be inadequate in some
We evaluated 211 patients who admitted to our hospital with cases and therefore decided to extend it. Especially, in cases
various complaints and cerebral MRI venography has been with TSs being hypoplastic or agenetic and OS is observed,
performed. Patients with congenital abnormalities, venous this classification was particularly unsatisfactory. We also di-
thrombosis, intracranial tumor, or a history of craniotomy vided our cases into three types but we increased the number
were excluded. All investigations were performed by using of subgroups. Type I was divided into four subgroups (Types

Fig. 1 Schematic drawing of Gökçe E. et al.’s study, Torcular Herophili classification as Type I, Type II (Type IIA1, Type IIA2, Type IIB, Type IIC, Type
IID, Type IIE), and Type III
Childs Nerv Syst (2018) 34:1183–1188 1185

Fig. 2 Subgroup of Tip I CS, schematic drawing (a–d) and 3D SPGR MRI MIP İMAGE (a’–d’). a, a’ Type IA (SSS + SS + R-TS + L-TS). b, b’ Type
1B (SSS + SS + R-TS + Hypo. L-TS) ± OS. c, c’ Type IC (SSS + SS + Hypo. R-TS + L-TS) ± OS. d, d’ Type ID (SSS + SS + Bil. Hypo TS) ± OS

IA, IB, IC, ID) (Fig. 2), Type II into nine (Types IIA1, IIA2,
IIB1, IIB2, IIC, IID1, IID2, IIE1, IIE2) (Fig. 3, Fig. 4, Fig. 5),
and Type III into two (Types IIIA, IIIB) (Fig. 6). A detailed
explanation of types and subgroups is provided in Table 2.
Type I constitutes a 26.06% of whole cases, Type II 59.71%,
and Type III 14.21%. Table 3 shows the distribution of cases.
In our cases, R-TS was not revealed in 10 cases (4.73%)
whereas in 37 cases (17.53%), it was hypoplastic. L-TS was
not shown in 26 cases (12.32%) and in 85 cases (49.09%), it
was hypoplastic. R-Sig S was not revealed in 7 (3.31%) and
was hypoplastic in 34 (16.11%) whereas L-Sig S was not
present in 2 (0.94%) and hypoplastic in 72 (34.12%).
Among these cases, 14 had bilateral hypoplastic TS
(6.63%). In cases with hypoplastic TS or Sig S, as an alterna-
tive pathway, 30 patients had OS (14.21%). Two of these
patients had double OS.
ISVand GV were reported for all cases. Rosenthal vein was
observed in 183 (86.72%), whereas in 28 (13.27%) was not.
ISS was seen in 91 (43.12%) and was not in 120 (56.87%). VT
and VLs were also evaluated in this study. VT was observed in
198 patients (93.83%) on the right, whereas in 13, it was not
observed (6.16%). It was observed on the left in 201 (90.74%)
and was not in 10 (4.73%). VL was observed in 172 of the
patients on the right (81.51%) whereas it was not seen in 39

Fig. 3 Subgroup of Type 2 CS, schematic drawing (a–d) and 3D SPGR MRI MIP İMAGE (a’–d’). a, a’ Type IIA1 (SSS + SS + R-TS/SSS + L-TS). b,
b’ Type IIA2 (SSS + R-TS/SSS + SS + L-TS). c, c’ Type IIB1 (SSS + SS + R-TS/Ag. L-TS) ± 0S. d, d’ Type IIB2 (SSS + SS + L-TS/Ag. R-TS) ± OS
1186
Fig. 4 Schematic drawing (a) and
3D SPGR MRI MIP İMAGE (a’).
Type IIC (SSS/2 + SS/2 + R-TS +
SSS/2 + SS/2 + L-TS)
(18.48%); it was present in 183 (86.72%) and was not seen in
28 (13.27%) on the left.
Discussion
Dural sinuses and cerebral veins are in charge of the intracra-
nial venous drainage. In the posterosuperior group, SS, infe-
rior sagittal sinus (ISS), SS, CS, TS, and SSs are located.
Cavernous sinuses, superior and inferior petrosal sinuses,
sphenoparietal sinuses, and clival venous plexus are
anteroinferior [1, 7–10].
As the largest of venous sinuses, SSS emerges from the
level of frontal bone, runs through the anterior portion of falx
cerebri at sagittal plane posteriorly, and ends at the internal
occipital protuberance of the occipital bone. Following the
pathway of SSS lies the cortical superficial veins. The largest
of these is VT. It merges with SS and TS where it ends and
together they form CS. Dural structures vary widely especially
Fig. 5 Subgroup of Type 2 CS, schematic drawing (a–d) and 3D SPGR
MRI MIP İMAGE (a’–d’). a, a’ Type IID1 (SSS + SS + R-TS/SS +
Hypo. L-TS) ± OS. b, b’ Type IID2 (SSS + SS + L-TS/SS + Hypo.R-
Childs Nerv Syst (2018) 34:1183–1188
at CS and this region shows many anatomical variations.
Blood runs through the TSs, SS, and jugular bulbi from the
level of CS. At the level of TS drains a large cortical vein
called VL. OS is the smallest dural venous sinus and generally
is reported in cases of TS hypoplasia or agenesis in order to
contribute the venous drainage. Since the dural venous sinuses
widely vary anatomically, it is especially important for neuro-
surgeons, neurologists, ETT specialists, or radiologists to be
aware of the anatomy of this region in order to avoid compli-
cations [1, 9, 11]. A number of studies were held to investigate
these variations. The latest of these previous studies was per-
formed by Gökçe et al. This particular study established an
anatomical classification including SSS, SS, and bilateral TSs
in order to group the variations at the level of confluence of
sinuses [1]. In this classification, three types were named with
regard to merging of sinuses: true confluence (four of the
sinuses join and form the confluence), partial confluence also
called as Type 2 (three of the sinuses form the confluence),
non-confluence in other words Type 3. There are also
TS) ± OS. c, c’ Type IIE1 (SSS + SS + R-TS/SSS + L-TS). d, d’ Type
IIE2 (SSS + SS + L-TS/SSS + R-TS)
Childs Nerv Syst (2018) 34:1183–1188 1187

Fig. 6 Subgroup of Tip III CS,

schematic drawing (a, b) and 3D
SPGR MRI MIP İMAGE (b, b’).
a, a’ Type IIIA (SSS + SS + L-
TS/SSS + R-TS) ± OS. b, b’ Type
IIIB (SSS + L-TS/SS + R-TS) ±
OS

subgroups defined for Types 2 and 3. This classification is not
efficient when used to group the cases in which TS sinuses are
hypoplastic or agenetic and therefore OS is formed. In order to
contribute to this prior classification and to better define the
varying anatomy of this region, we established a new classi-
fication (Table 2). In this classification, we divided Type 1 into
four, Type 2 into nine, and Type 3 into two subgroups. In our
classification, the left or right predominance of hypoplastic or
agenetic TSs, OS formation as an alternative pathway, and the
drainage pattern of SS sinus into SSS or TSs were taken into
consideration.
Transverse sinuses which contribute to the formation of
confluence of sinuses differ in their structural properties.
Hypoplasia or agenesis of L-TS is more commonly reported.
As a reason to this, the increased capacity of the right jugular
system as a result of the pulsation of right atrium was sug-
gested. In our study, we reported higher rates of hypoplastic or
agenetic right and left TSs and Sig Ss, although the rates were
comparable with the previous studies. We reported signifi-
cantly higher rates of hypoplasia or agenesis of L-TS in com-
parison with the R-TS. To compensate the lack or inadequacy
of TSs in cases of agenesis or hypoplasia, OS comes to help.
OS was previously reported in varying proportions of popu-
lations, ranging between 4 and 35.5% in numerous studies [3,
12]. In our study, we reported OSs in 28 of our cases and this
constitutes 13.74% of the study population which is compa-
rable with the previously reported rates. As it is reported in our
study, when they gain the role of alternative drainage, OSs

Table 2 Classifications of anatomic variations of dural sinus in confluens sinuum

Type I Type II Type III

Type IA (SSS + SS + R-TS + L-TS)
Type IB (SSS + SS + R-TS + Hypo.
L-TS) ± OS
Type IC (SSS + SS + Hypo.
R-TS + L-TS) ± OS
Type ID (SSS + SS + Bil. Hypo TS) ± OS
Type IIA1 (SSS + SS + R-TS/SSS + L-TS) Type IIIA
(SSS + SS + L-TS/SSS + R-TS) ± OS
Type IIA2 (SSS + R-TS/SSS + SS + L-TS) Type IIIB (SSS + L-TS/SS + R-TS) ± OS
Type IIB1 (SSS + SS + R-TS/Ag. L-TS) ± 0S
Type IIB2 (SSS + SS + L-TS/Ag. R-TS) ± OS
Type IIC (SSS + SS + R-TS + L-TS)
Type IID1 (SSS + SS + R-TS/SS + Hypo.
L-TS) ± OS
Type IID2
(SSS + SS + L-TS/SS + Hypo.R-TS)) ± OS
Type IIE1 (SSS + SS + R-TS/SSS + L-TS)
Type IIE2 (SSS + SS + L-TS/SSS + R-TS)
1188 Childs Nerv Syst (2018) 34:1183–1188

Table 3 Distribution of our cases by types, subgroups, numbers, and anatomical variations. We hope our study enlightens a path
percentages
in this field for future studies.
Types and subgroups of CS Number of patients Percent (%)
Compliance with ethical standards
Type I 55 26.06
Type IA 21 9.95 Our retrospective study was approved by the institutional review board.
Type IB 17 8.05 Informed consent was waived because of the retrospective nature of the
study.
Type IC 11 5.2
Type ID 6 2.8
Conflict of interest The authors declare that they have no conflicts of
Type II 127 59.71 interest.
Type IIA1 4 1.89
Type IIA2 6 2.84
Type IIB1 32 15.16 References
Type IIB2 9 4.26
Type IIC 20 9.47 1. Gökçe E, Pınarbaşılı T, Acu B, Fırat MM, Erkorkmaz Ü (2014)
Type IID1 35 16.58 Torcular Herophili classification and evaluation of dural venous
Type IID2 8 3.79 sinus variations using digital subtraction angiography and magnetic
resonance venographies. Surg Radiol Anat 36:527–536
Type IIE1 8 3.79
2. Widjaja E, Griffiths PD. Intracranial MR venography in children:
Type IIE2 4 1.89 normal anatomy and variations. AJNR Am J Neuroradiol
Type III 30 14.21 2004;25(9):1557–1562
Type IIIA 21 9.95 3. Goyal G, Singh R, Bansal N, Paliwal VK (2016) Anatomical var-
iations of cerebral MR venography: is gender matter?
Type IIIB 9 4.26
Neurointervention 11:92–98
Total 211 100 4. Rollins N, Ison C, Reyes T, Chia J (2005) Cerebral MR venography
in children: comparison of 2D time-of-flight and gadolinium-
enhanced 3D gradient-echo techniques. Radiology 235(3):1011–
show enlarged diameter and they drain into jugular veins ei- 1017
ther unilateral or bilaterally. 5. Fukusumi A, Okudera T, Takahashi S, Taoka T, Sakamoto M,
Nakagawa H, Takayama K, Kichikawa K, Iwasaki S (2010)
In this study, it is reported that the SSS sinus predominantly Anatomical evaluation of the dural sinuses in the region of the
drains into R-TS, whereas SS drains into L-TS. Another com- torcular herophili using three dimensional CT venography. Acad
mon variation we observed at SSS was the bifurcation of the Radiol 17:1103–1111
distal portion into two. In our study, only the bifurcations 6. Singh M, Nagashima M, Inoue Y (2004) Anatomical variations of
larger than 30 mm were taken into consideration, and there occipital bone impressions for dural venous sinuses around the
torcular Herophili, with special reference to the consideration of
were 20 cases in which these bifurcations were evident. In clinical significance. Surg Radiol Anat 26:480–448
cases with bifurcations, the longest one was 60 mm and the 7. Rodallec MH, Krainik A, Feydy A, Hélias A, Colombani JM, Jullès
parts of the SSS were being drained into TS sinuses on the side MC, Marteau V, Zins M (2006) Cerebral venous thrombosis and
where they were located. The most common bifurcation was multidetector CT angiography: tips and tricks. Radiographics 26:
S5–18
observed in Type IIC and second most common was in Type
8. Manara R, Mardari R, Ermani M, Severino MS, Santelli L, Carollo
IIE. In one of our cases, two parts of the bifurcations were C (2010) Transverse dural sinuses: incidence of anatomical variants
joining with each other later on their path. This case was and flow artefacts with 2D time-of-flight MR venography at 1
classified into Type IB1 group. In two cases which were clas- Tesla. Radiol Med 115(2):326–338
sified into Type IB1 and IIC groups, SSs were draining into 9. Ayanzen RH, Bird CR, Keller PJ et al (2000) Cerebral MR venog-
raphy: normal anatomy and potential diagnostic pitfalls. AJNR Am
distal R-TS and were forming accessory TSs. J Neuroradiol 21:74–78
Our study was conducted retrospectively and could not be 10. Scott J.N, Farb R.I. Imaging and anatomy of the normal intracranial
compared with any other modality. A prospective study in- venous system. Neuroimaging Clin N Am 2003;13: 1–12
creasing the number of cases and working with multiple cen- 11. Alper F, Kantarci M, Dane S, Gumustekin K, Onbas O, Durur I
ters would be more useful in classifying dural venous sinus (2004) Importance of anatomical asymmetries of transverse sinuses:
an MR Venographic study. Cerebrovasc Dis 18:236–239
variations. 12. Kobayashi K, Suzuki M, Ueda F, Matsui O (2006) Anatomical
Our wish is to contribute to the efforts of clarifying and study of the occipital sinus using contrast-enhanced magnetic res-
classifying the intracranial venous structures and their onance venography. Neuroradiology 48:373–379

View publication stats