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Eastern Virginia Medical School

Cranial Vault & Dura


Paul F. Aravich, Ph.D.
Medical Gross Anatomy & Embryology 2012
Department of Pathology & Anatomy
Glennan Center for Geriatrics & Gerontology &
Department of Physical Medicine & Rehabilitation
Eastern Virginia Medical School
Norfolk, VA
aravicpf@evms.edu

Cranial Vault & Dura

Objectives: Concept map:


The organization of the scalp and its danger zone.
Blood supply to the scalp
Openings for the cranial nerves
Dura mater & its reflections in the cranial vault
Dural sinuses & the venous drainage of the brain
Internal carotid, vertebral & middle meningeal aa

Clinical correlates

Clinical correlates

Scalp infections & lacerations


Periorbital Ecchymosis: Black eye vs. Raccoon eyes
CSF rhinorrhea & CSF otorrhea
Basilar venous plexus & metastatic/infection spread
Internal carotid artery aneurysm & CN II optic nerve
Fracture of the pterion and type of hemorrhage
Cavernous sinus thrombus

Outline: Cranial Vault & Dura


Scalp
Cranial nerve openings
Dura mater
Dural sinuses
Internal carotid, vertebral & middle meningeal aa

Skin
Connective tissue (sub. cut. tissue): vessels/nn
Aponeurosis, epicranial see next slide
Loose connective tissue to allow movement of 1st 3 layers
Pericranium (periostium) tissue lining bone
Clinical correlate

Factory/machine accidents entangling hair: Often


pull-off scalp proper, causing a scalping injury

Scalp: Soft tissue covering


cranial vault. Usually has hair.

Fig. 7.18 A, p. 539, Grant's Atlas 1999

Scalp proper

Scalp & its layers spell S.C.A.L.P.

Epicranial aponeurosis: for occipitofrontalis m


FYI. AKA galea aponeurosis

Aponeurosis = broad flat t.


Connects 2 bellies of the:

Epicranial aponeurosis

Occipitofrontalis m
A m of facial expression, e.g.
frontal belly wrinkles forehead &
-elevates eyelids I cant believe that
Occipital belly smoothes
Occipital belly
Frontal belly
forehead skin
Occipitofrontalis m
CN VII facial n
FYI: other mm attach to the
-innervates both bellies
epicranial aponeurosis, e.g.,
superior auricular m, which
elevates the auricle (external ear)

Fig. 7.12 A, p. 535, Grant's Atlas 1999

Scalp Arteries, e.g.

Supraorbital a.

Internal carotid a: 2 brr of


ophthalmic a

Supraorbital a.
Supratrochlear a.

Superficial temporal a.

Supratrochlear a.

See Orbit lecture

External carotid a. brr e.g.,

Occipital a.
Superficial temporal a.

FYI post. auricular a. etc.

Note multiple anastomoses


between internal carotid (sup orb/sup
trochlear aa) & external carotid aa

Occipital a.

(superficial temp/occ. etc. aa)


Fig. 7.14 B, p. 537, Grant's Atlas 1999

Laceration of scalp aa:

Bleed like crazy

Clinical correlate

Bleed from both ends of laceration


Due to lots of anastomoses

FYI. Also, held open by subcutaneous collagen fibers


FYI. Good news: washes away infections better than other sites

Scalp lacerations
Most common head laceration requiring surgery
FYI. Hair apposition
technique w/ tissue
glue for superficial,
non-bleeding wound

http://www.aafp.org/afp/2008/1015/p945.html

FYI. For hemostasis (stoppage of


bleeding): provide local anesthetic w/
epinephrine & manual pressure;
clip/clamp larger aa

They are in the diploe Di-Plo-E (AKA spongy


layer or cancellous bone) of the calvaria
(skullcap). Bone marrow is also in the diploe
By contrast, the external & internal surfaces of the
calvaria are made of compact (cortical) bone.

Fig. 7.16, p. 538, Grant's Atlas 1999

Diploic veins of skull:

Emissary veins: connect the skull


surface w/ cranial vault
Superficial v

Emissary v.
They drain into Dural sinus: part
of the venous drainage system
of brain; discussed later

Plate 102 upper, Netter

Diploic v.

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Calvaria has foramina for emissary vv.


anterior

Emissary v. foramina
(present in various
skull bones)

Fig. 7.4 B, p. 841, Moore 1999

FYI. Indentations for


arachnoid granulations
are bigger: Granulations
shunt CSF into dural
sinuses

posterior

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Epicranial aponeurosis:
scalp danger zone

Clinical correlates

Infections deep to epicranial aponeurosis


Can gain access to cranial vault
Via Emissary veins
Scalp infection then becomes intracranial infection

Infections superficial to epicranial aponeurosis

Much less likely to cause intracranial infection

Q. Name another danger space? Ans.


Retropharyngeal danger space. A fascial plane
behind the visceral compartment of the neck
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Scalp
epicranial
aponeurosis

Superficial v
Diploic v

Emissary v

Emissary v

Dural sinus

The Scalp danger space: deep to


epicranial aponeurosis

Modified from eMedicines copy of a Snells 5th Ed. Anatomy diagram


http://emedicine.medscape.com/article/834808-overview

Boxes: scalp proper. Most of vv. are deep to epicran aponeurosis

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Periorbital Ecchymosis ec-key-mosis


Peri: around eyes. Ecchymosis: subcutaneous hematoma

Occipitofrontalis muscle: attachments:

Posterior attachment: mostly occipital bone & part of temporal bone


-prevents scalp bleeding/infection from going into neck
Lateral attachment: mostly zygomatic arches
-prevents scalp bleeding/infection from going laterally

Anterior attachment: skin of forehead/eyelids, not bone

Clinical correlate

Scalp blood can drain into loose connective tissue of eyelids/root nose

Black eye: local periorbital bleed; occurs w/in hrs post trauma
Raccoon eyes:

Occurs 2-3 days post trauma


Always Bilateral
One cause: bleed from anterior basilar skull Fx can drain into lids
(i.e., fracture to cribriform plate in floor of anterior cranial fossa)

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Black eye vs Raccoon eyes

http://en.wikipedia.org/wiki/Black_eye

Local periorbital
subcutaneous
hematoma due to bleed
from facial trauma

Bilateral subcutaneous
hematoma due to
bleed from basilar
skull fracture
http://hgimg.com/bookimages/5/2461.1.jpg

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Scalp lacerations

Lacerations superficial to epicranial aponeurosis

Clinical correlates

Do not gape (aponeurosis holds edges close)

Lacerations deep to epicranial aponeurosis

Gape widely; much more bleeding


FYI: especially in coronal plane due to opposite pulls of 2 bellies of occipitofront m

Suture to adjacent epicranial aponeurosis

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Outline: Cranial Vault & Dura


Scalp
Cranial nerve openings
Dura mater
Dural sinuses
Internal carotid, vertebral & middle meningeal aa

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Review. Cranial vault Openings: CN I VI


CN I olfactorycribriform plate
ethmoid bone
foramina
CN II optic-optic canal; w/ ophthalmic a.

Lesser
wing

V2 trigeminal n. maxillary br.-foramen rotundum

CN III/IV/V1/VI:*
superior orbital
fissure count
Greater wing

Fig. 7. 4B, p. 527,


Grants Atlas 1999

V3 trigeminal n. mandibular br.-foramen ovale


middle meningeal a.:
foramen spinosum

*CN III-oculomotor, IV-trochlear, V1


trigeminal-ophthalmic br, VI-abducens

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CN VII/VIII-facial/vestibulocochlear: internal auditory meatus


on upper posterior face of petrous part of temporal bone

CN IX/X/XI:* jugular
foramen on post. lower
face of petrous; count

*CNs: IX-glossopharyngeal, X-vagus,


XI-spinal accessory

CN XII hypoglossal:
hypoglossal canal in
occipital bone

Fig. 7. 4B, p. 527, Grants Atlas 1999

Review. Openings: CN VII - XII

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IX/X/XI

III

IV hard
Hypophyseal to see
fossa

VI
VII/VIII

Superior view of cranial vault w/


dura; orbital portion of frontal bone
removed to show eye

II

III

XII

VI
VII/VIII

XII

cord

EVMS Division of Anatomy photo

II

clivus

Middle
cranial
fossa
IV hard
to see

eye

IX/X/XI

CNs: cranial vault

Crista galli

eye

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Aneurysm here

Can affect vision

Internal
carotid a
cerebral
segment

Clinical correlate

IX/X/XI

Superior view of cranial vault w/


dura; orbital portion of frontal
bone removed to show eye

eye
CN II

III
III
Hypophyseal
fossa
V
VI
VII/VIII
XII

Internal
carotid a

EVMS Division of Anatomy photo

CN II

Crista galli

CN II optic n: near
cerebral part of internal
carotid a

eye

cord

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Clivus:
mostly
made from
basilar part
of occipital
bone*
*AKA
basiocciput

brain
stem

Div. Anatomy EVMS

Hemisected head

Squamous (plate-like)
part of Occipital bone

10 CNs
connect
w/
Allbrainstem
but CNs
CN I olfactory,
& XI spinal
acc

Dotted line:
foramen
magnum
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Outline: Cranial Vault & Dura


Scalp
Cranial nerve openings
Dura mater
Dural sinuses
Internal carotid, vertebral & middle meningeal aa

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Review. Meninges: 3 mothers or


coverings for the central nervous system

Tuff mother:

Dura mater

Superficial/outer layer
Adheres directly to inside surface of cranial vault

Spider mother:

Arachnoid mater

Intermediate

Tender mother:

Pia mater

Deepest
Adheres directly to brain/cord

Leptomeninges: arachnoid mater + pia mater


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Superior view of cranial vault w/


orbital portion of frontal bone
removed to show eye

eye

EVMS Division of Anatomy photo

Crista galli

Middle
cranial
fossa e.g., dura
lining basal
Hypophyseal
surface
of
fossa
posterior
cranial fossa
clivus

Dura: adheres to
the inside surface
of the cranial vault

eye

cord

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Base of cranial vault w/o dural lining


Anterior

Div. Anatomy, EVMS

Basilar skull

Posterior

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Review. Cranial vault Meninges:


3 spaces superficial to deep
bone
Epidural: a potential space (dura normally adheres to inside of cranial vault)
Contents. Middle meningeal a (br external carotid a)*
dura
Subdural: a potential space (fluid-filled subarachnoid abuts against it)
arachnoid
FYI: arachnoid
trabecula

pia

Subarachnoid space (actual space)


Contents 1, e.g., cerebrospinal fluid (CSF)
Contents 2: most of the extent of major brain aa
Contents 3: most of the extent of major brain vv
Brain (also spinal cord, optic n & olfactory n)
*Rupture of middle meningeal a: epidural hematoma
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Division of Anatomy EVMS

Epidural & Subdural potential spaces


Epidural space
superficial to dura
mater

Brr of middle
meningeal a

Anterior

Lateral view
of brain w/
part of dura
removed

Posterior
Arachnoid mater (clear
shinny membrane)
over vessels/CSF,
which are deep
Wooden applicator in subdural space
between dura & arachnoid

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Suture/seal after cranial surgery


Fascia lata from pts own thigh

Fascia lata is deep fascia on lateral thigh

Sutures + Dura Seal


Synthetic dura
Bovine pericardial sac
2011 FDA advisory1 cautioning against certain

Cadaveric dura transplants


b/c of risk of fatal prion infection Creutzfeldt-Jakob Disease

1
http://www.fda.gov/MedicalDevices/Safety/AlertsandNo

http://medgadget.com/2005/04/duraseal.htm l

Dural repair

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jumps over sulci (valleys), unlike


deeper pia mater, which adheres to
brain and penetrates sulci

FYI gyri

Division of Anatomy. EVMS

FY
I

Po
st ce
ntr
al
gy
rus

FYI Pre
-

central
g

yrus

Blue pin through arachnoid


mater. Note how the arachnoid

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Meninges: 3 Differences between Cord/Brain


vertebrae
1. Unlike Brain: Actual epidural space exists with cord
2. Unlike Brain: Contains fat & internal vertebral venous plexus
dura
arachnoid
Subarachnoid space (actual space)
FYI: arachnoid
trabecula

pia

Spinal Cord

3. Unlike Brain: Subdural space is NOT clinically relevant in cord


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Dural tears & basilar skull Fx

Clinical correlates

Trauma- (or surgically) induced torn dura/arachnoid


CSF rhinorrhea

CSF (clear fluid) leaks out of nose


Following Head injury via:
Basal skull Fx of cribriform plate of ethmoid
anterior cranial fossa)

(i.e., Fx of base of

CSF otorrhea
CSF leaks out of ear
Following head injury via
Basal skull Fx of petrous part temporal bone
Ruptured ear drum also needed for CSF to leak out of ear

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3 Dural reflections
#1. Falx cerebri: R/L cerebral
hemispheres drops down from
cranial dura like a curtain

Anterior attachment of
falx cerebri: crista galli
of ethmoid bone not seen

In addition to lining the


bones of the cranial
vault, there are sheets
of dura that reflect
away from the bone &
follow contours of brain
FYI. Falx cerebelli:
vertically oriented fold
R/L lobes of cerebellum

Plate 97, Netter

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From, e.g., top of


petrous portion of
temporal bone and
A/P clinoid processes

Superior view
of cranial
vault
#3. Diaphragma
sellae: separates
pituitary from brain

Modified from Plate 98, Netter 1997

3 Folds of dura, cont.

#2. Tentorium cerebelli:


makes a tent above
cerebellum to separate it
from cortex
To falx cerebri, cut here

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clivus

pituitary

Superior view of cranial vault w/


orbital portion of frontal bone
removed to show eye

EVMS Division of Anatomy photo

diaphragm of the saddle

Crista galli

Diaphragma sellae

eye line:
Dotted
eye
Diaphragma sellae
separating pituitary
Middlefrom brain
cranial
fossa

cord

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Div. Anatomy EVMS

Other views

Falx cerebri

cerebellum

Tentorium
cerebelli

Hemisected head

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Falx cerebri and tentorium cerebelli

Falx cerebri
Tentorium cerebelli running
down hill

Division of Anatomy EVMS

Brain cut away


at brainstem

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Outline: Cranial Vault & Dura


Scalp
Cranial nerve openings
Dura mater
Dural sinuses
Internal carotid, vertebral & middle meningeal aa

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Dural sinuses

There are 2 layers of dura


Periosteal layer (superficial; against bone)
Meningeal layer (deeper)

Dural sinus

Layers split to form dural sinuses


A dural sinus is, therefore, a tube of dura

2 Functions of Dural sinuses:


Drain venous blood from brain
-To internal jugular vv FYI: R is bigger than L
Drain cerebral spinal fluid from brain

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6 Selected dural sinuses


Superior sagittal sinus
Inferior sagittal sinus
Straight sinus
Transverse sinus
Sigmoid sinus
Cavernous sinus

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Dural sinuses
Superior sagittal sinus; in
upper part of falx cerebri

Falx cerebri

Straight sinus; in medial part


of tentorium cerebelli
Confluence
of sinuses

Plate 97, Netter

Inferior sagittal sinus; in


lower part of falx cerebri

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Dural sinuses, cont.

Cavernous sinus
-near pituitary gland
FYI: superior petrosal
sinus: top of petrous ridge

FYI: inferior petrosal


sinus: bottom posterior
face petrous ridge

Straight
sinus in
tentorium
cerebelli

Sigmoid sinus: find


indentation in occipital
bone of dry skull
Transverse
sinus: find
indentation in
occipital bone of
Confluence dry skull; in
of sinuses tentor. cerebelli

Modified from Plate 98, Netter

pituitary

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Orange arrow: jugular


foramen for IJV

Div. Of anatomy. EVMS

Indentations: transverse & sigmoid sinuses

Black arrow: sigmoid sinus

Blue arrow: transverse sinus


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Division of Anatomy EVMS

Posterior
view of brain
Green wire traveling in
opened superior
sagittal sinus on top of
falx cerebri

General area of the


confluence of sinuses

Occipital sinus deep

Green wire continuing


into opened transverse
sinus within tentorium
cerebelli
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Dural sinuses & internal jugular v posterior view

Div. of Anatomy, EVMS

Superior sagittal sinus

Confluence of sinuses

Transverse Sinus

Sigmoid Sinus

angiogram
Internal jugular v
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Cavernous sinus
-near pituitary gland

In the wall of the


C 51 52 sinus: CN III, IV,
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V1 & V2 O TOM
6

Within the sinus


itself; the int.
carotid artery and
CN VI. CA plus
sympathetics on
the ICA S.

The unusual
instance of an
artery inside a
venous
system

Modified from Plate 98, Netter

Cavernous sinus: 3, 4, 51,52,6, int carotid a., &


post. ganglionic. SNS on ICA count or say O TOM CAS

O TOM CAS
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Cavernous sinus:
Internal carotid a & CNs 3,4,51,52,6 count
Superior view of the middle cranial fossa

Orange: V2 heading
for foramen rotundum

Sella turcica

Q: A cavernous sinus thrombus would


have what affect on eye movement?
A: Paralyze all eye movement: III, IV & VI

clivus

Box: Carotid sinus

Cavernous
sinus also has
ophthalmic vv
draining into it
from orbit

Division of Anatomy EVMS

Stick: sup orbital


fissure w/ III, IV, V1, VI

Pipe cleaner: internal


carotid a w/ post. gang. SNS
fibers from sup cerv gang

Clinical correlate
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ICA*

ICA*

white box

III

III
not seen-IV
V1/2 VI

VI

Green wires entering


sinus w/ CN III
Superior view of
the base of the
cranial vault

*ICA exiting sinus


w/ SNS fibers
cord
Posterior
fossa

Black circle:
hypophyseal fossa

Div. Of anatomy. EVMS

Middle
fossa

clivus

Cavernous
sinus

II

II

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Basilar venous plexus

Interconnects various
sinuses
Also interconnects w/
internal vertebral
venous plexus of spine

Clinical correlates

Allows spread of
metastases &
infections between
brain/spine/trunk

Modified from Plate 98, Netter

Sits on clivus

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Epidural fat
posterior

Plate 173 bottom left. Netter 2006

Internal vertebral
venous plexus
allows malignancy/
infection spread
between
trunk/spine/brain

Dura mater

anterior
Internal vertebral venous plexus (of Batson):
in cord
epidural
Epidural fat
space

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Outline: Cranial Vault & Dura


Scalp
Cranial nerve openings
Dura mater
Dural sinuses
Internal carotid, vertebral & middle meningeal aa

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Brain: Blood Supply

Internal carotid a
Br common carotid a
Most strokes

1st ascending br subclavian a


Travel through:
-transverse foramina of 1st 6 cerv
vert & through
FYI External carotid a
-foramen magnum
FYI Common carotid aa
-make basilar a

Fig. 10.2, p. 369, Blumenfeld. Neuroanatomy


Through Clinical Cases. Sinauer, 2002

FYI Arch of aorta

FYI L. subclavian a

Vertebral aa

Vertebral-basilar system

Internal carotid a

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Internal carotid artery (red): segments

Cerebral seg
Cavernous seg.
Petrous seg. That part inside carotid
canal, which is in petrous part of temp bone

That part inside


cavernous sinus

Cervical seg. That part in


the neck. NO brr in neck
Grants Atlas 2005 Fig. 7.23B p. 621

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Slide 4

Internal carotid
artery
segments. AP
MRA (magnetic
resonance
angiogram).

Cerebral
seg.
Cavernous
seg.
Petrous
seg.
Cervical seg.

Does not capture


stationary tissue
Klioze SD. The Brain.
Dept. of Anatomy &
Neurobiology & Dept.
Radiology, EVMS
54

Vertebral aa
III

III
V

VII VI
VIII
IX
X
XI

clivus

Posterior view
of clivus

VI

XII

Div. Of anatomy. EVMS

dotted lines

Vertebral aa (reflected inferiorly) as they enter foramen magnum

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Slide 4

ICA

ICA

Basilar a

Vertebral aa

Vertebral artery.
AP MRA
(magnetic
resonance
angiogram)
Does not capture
stationary tissue
Klioze SD. The
Brain. Dept. of
Anatomy &
Neurobiology &
Dept. Radiology,
EVMS

56

Middle
meningeal a
Clinical correlate

Q: A Fx of the
pterion will
rupture what a.
& cause what
kind of bleed?
A: ant. br
middle
meningeal a;
epidural bleed

Medial view
Anterior br of middle
meningeal artery is
deep to Pterion
H encircled in black

Posterior br
of middle
meningeal a

Middle
meningeal a
Maxillary a
External
carotid a

FYI. A/P brr


sometimes called
Grants Atlas 2005 Fig. 7.12A p. 609 Frontal/Parietal brr57

Craniotomy & Cranioplasty

Craniotomy: temporary removal of a bone flap


Epidural Video http://www.youtube.com/watch?v=dLMCwGmWvrw&feature=related
Store bone flap in abdominal subcutaneous space or
Store under the epicranial aponeurosis see next slide or
Freeze & store at a bone bank

Cranioplasty: repair of damaged skull


Replace bone flap or use
Plastic implant

http://www.unifesp.br/dneuro/neu
rociencias/229_revisao.pdf

http://www.medscape.com/viewarticle/472974_458

Middle meningeal a
Enters cranial vault via
foramen spinosum in
greater wing of sphenoid

Foramen ovale

Pe
tem trou
p b s pa
on rt
Foramen
e

Indentation
made by post br
of middle
meningeal a

magnum

Basilar skull

Posterior

Div. Anatomy, EVMS

Anterior

59

Cranial Vault & Dura

Objectives: Concept map:


The organization of the scalp and its danger zone.
Blood supply to the scalp
Openings for the cranial nerves
Dura mater & its reflections in the cranial vault
Dural sinuses & the venous drainage of the brain
Internal carotid, vertebral & middle meningeal aa

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