Wolfgang Seeger Microsurgery of Cerebral Veins Springer-Verlag Wien NewY ork Prof. Dr. med. WOLFGANG SEEGER Medical Director of the Department of General Neurosurgery and Chairman of Neurosurgery of the Neurosurgical Clinic, University of Freiburg i. Br., Federal Republic of Germany ISBN-13: 978-3-7091-7020-5 e-ISBN-13: 978-3-7091-7018-2 DOl: 10.1007/978-3-7091-7018-2 With 201 Figures This work is subject to copyright All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcastin'g, reproduction by photocopying machine or similar means, and storage in data banks © 1984 by Spril)ger-VerlaglWien Softcover reprint of the hardcover I st edition 1984 Design: Hans Joachim Boning, Wien Library of Congress Cataloging in Publication Data. Seeger, Wolfgang, 1929 - . Microsurgery of cerebral veins. Includes bibliographies. 1. Cerebral veins-Surgery. 2. Microsurgery. I. Title. [DNLM: 1. Brain-blood supply-atlases. 2. Veins-sut:.gery-atlases. 3. Microsurgery atlases. WL 17 S4S1mb]. RDS94.2.S44 1984. 617' .481. 84-20297. __________________________________________________ PREFACE~I ~IV Preface A description of cerebral veins under operative versely, where there are large arterial vessel stems (at technical aspects is practically a description of opera the base of the brain) the veins somewhat lose their tive approaches and their obstruction by cerebral significance. They become important again in the veins. It is this which constitutes the major difference region of the basal Dura, the Tentorium, and the Falx between arteries and veins. The arteries of the brain but (with the exception of the region of the Sinus originate from only four large vessel stems, which cavernosus) away from the large arterial stems. This bridge the CSF space and then run along the surface justifies writing a microneurosurgical textbook exclu of the brain or inside the brain. Arterial vessels hardly sively under the aspect of the cerebral veins. interfere with operative approaches, even in the deep That we know so much about cerebral veins is due CSF spaces such as the Sylvian fissure, the Tentorium primarily to the work of neuroradiologists. It is not fissure, and the ventricle system. Veins, on the other the objective of the present volume to provide a hand, can appear in almost every location of the brain compreherisive and comparative survey of the large as so-called bridging veins. They are extremely vari number of individual results of attempts at establish able and can bloc~ the approach to deep CSF spaces ing vein types. Such an endeavor might be of some almost anywhere. Today, most sites of the brain are historical and developmental interest, however, it is micro surgically accessible, thanks to the fact that the of little relevance for the surgeon, who is confronted deep CSF spaces are now being used where they were with at times extreme variants in the individual case. once avoided because they were so rich in vessels. It is Theref.ore, some interesting details had to be left out therefore all the more important to know the veins of the book. Instead, the "typical" courses of the and their variants. The last point alone justifies carry veins are contrasted with the extreme deviations in ing out angiography prior to intracranial operations, if order to illustrate the range of variation the surgeon only as an additional safety measure, although an has to reckon with. The veins are represented in giograms do not always reliably show how the veins relation to the surrounding structures; first, in an might block the operative approach. anatomical model, then in the microsurgical topogra In contrastio the Fissura longitudinalis, in the region phy. Typical operations and modifications of ap of the posterior cranial Fossa it is difficult to assess the proaches depending on atypical courses of the veins veins and their blocking potential when the quad are described. As in the preceding volumes of this rigemina or the Fissura horizontalis cerebelli are be series, the same maxim holds true here: problematic ingapproached. Such an evaluation is also problem operations on the brain should first be simulated on a atic at other sites near the midline (e.g., the afferent brain which has been preserved in formalin. A book vessels of the V. magna Galeni and their connections may draw attention to certain structural peculiarities, to-the Sinus petrosus sup.). Fortunately, these veins however, it cannot provide the true spatial dimen have courses which are more regular than those of the sions that only the natural organ can. Furthermore, veins in the convexity of the cerebrum and the cere for this work, too, the drawings were done not by a bellum. Thus in a surgical textbook the veins cannot professional draftsman but by a surgeon, on the basis be depicted in isolation as they are in a neuroradiolog of his operations and those of his coworkers. There ical presentation. Special attention must be paid to are no professional draftsmen who possess the neces the relationships between the veins and other struc sary anatomical and technical surgical knowledge. I tures, particularly the cerebral structures, the ar therefore have to apologize for the shortcomings of teries, the Tentorium, and the Falx. In the areas my drawings, which have to be expected of someone where the largest veins flow (e.g., <l;t the edge of the who has spent most of his life not at the drawing table hemisphere), mostly small arteries are found. Con- but at the operating table. VI~I- -------------------------------------------______~ lpREFACE It remains for me to acknowledge my indebtedness to the Neuropathological Institute of Freiburg Universi those who have assisted me in the preparation of this ty and Prof. Staubesand, Director of the Anatomical book. I should especially like to mention Prof. J. Institute of Freiburg University, who provided the Bonnal, Liege, for his description of the Sinus sagit anatomical preparations. Virginia Sonntag-O'Brien talis sup. and its plastic' reconstruction, and Prof. J. translated the text and Ermy Hilsenbeck-Hotteck Baumgartner, Colmar, for his work on the quad typed the manuscript. rigemina. The present volume - just as the previous In conclusion I should like to particularly thank ones - is based on practical clin~cal work. I want to Springer Verlag Wien-New York for their coopera express my gratitude to my co-workers, Prof. J. M. tion which was excellent as usual. Gilsbach, PD Dr. H. R. Eggert, Dr. W. Hassler, and Dr. A. Harders for many valuable and stimulating Freiburg, October 1984 Wolfgang Seeger discussions. My appreciation goes to Prof. B. Volk of CONTENTS VII L...l_ _______________________- ---Jl Contents Part I General Remarks (Figs.1 to 6) Chapter 1 (Figs. 1 to 6) 2 Part II Special Microsurgical Aspects (Figs. 7 to 201) Chapter 2 Sinus sagittalis sup. (Figs 7 to 84) 16 Sinus sagittalis sup., Venous Collateral Circulation (Figs. 7 to 12) 16 Sinus sagittalis sup., Frontal (Figs. 13 to 21) 28 Sinus sagittalis sup., Parietal (Figs. 22 to 41) 46 Addendum: Reconstruction of the Sinus (Figs. 42 to 48) 86 Sinus sagittalis sup., Parieto-occipital (Figs. 49 to 84) 100 Chapter 3 Galenic Vein System (Figs. 85 to 153) 172 Veins of the Fissura transversa cerebri (Figs. 85 to 114) 172 Veins of the Lateral Ventricle (Figs. 115 to 143) 232 Veins of the Cisterna tecti ("quadrigemina") (Figs. 144 to 153) 290 Chapter 4 Infratentorial Veins (Including Caudal Veins of the Galenic System) (Figs. 154 to 179) 310 Chapter 5 Draining Veins on the Cranial Base and Superficial Veins of the Cortex (Figs. 180 to 201) 362 References 407 Subject Index 417 Part I General Remarks (Figs. 1 to 6) __________________________________________ GENERALREMARKS~I ~12 Chapter 1 General Remarks (Figs. 1 to 6) Fig. 1. Electrocoagulation stretches the venous (and the arterial) vessels. Lumen not completely occluded, as stretching keeps the vessel open A Example of vessel stretched between brain sur face and tumor B Coagulation of the vessel C Vessel lumen not completely occluded strai.n ed vesse \ after shrinki.n g by coagulation CD ________________________________________ GENERALREMARKS~I ~14 Fig. 2 A The vessel is cut B Vessel stumps are retracted after coagulation C After some time, the narrow lumen becomes dilated due to intravasal pressure D Rupture of vessel stumps