A Starling resistor regulates cerebral venous outflow in dogs

This investigation was undertaken to determine whether a Starling resistor or venous waterfall effect exists between the sagittal sinus and the cerebral veins such that increases in sagittal sinus pressure (Pss) do not abolish cerebral venous outflow and to examine two possible contributions of extracranial venous valves in regulating outflow. Anesthetized dogs were subjected to positive end-expiratory pressure (PEEP) before and after intracranial pressure (Pic) was elevated by inflation of an epidural balloon. PEEP raised Pss equally in all animals, but Pic and cerebral venous pressure (Pcv) increased less in the presence of intracranial hypertension. When Pss was low, passage of a catheter in the cerebral vein in and out of the sagittal sinus demonstrated an abrupt drop in pressure as the sinus was entered. When Pss was raised and lowered independently of superior vena caval pressure (Psvc) the changes in Pic and Pcv were less when Pss was decreased than when it was increased. Sustained increases and decreases in Psvc caused increases and decreases in Pcv, Pic, Pss, and external jugular venous pressure (Pejv) regardless of whether external jugular venous valves were present or absent. We conclude that a Starling resistor between the sagittal sinus and the cerebral veins regulates cerebral venous outflow when Pss is increased by PEEP and other maneuvers that raise Psvc. The waterfall maintains Pcv and Pic at normal levels when Psvc and Pss are reduced. Extracranial venous valves are not essential to this mechanism.     

Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users who are carriers of hereditary prothrombotic conditions

Objective: To investigate whether users of oral contraceptives who are carriers of a hereditary prothrombotic condition (factor V Leiden mutation, protein C, S, or antithrombin deficiency) have an increased risk of cerebral sinus thrombosis. Design: Comparison of a prospective series of cases of cerebral sinus thrombosis with population data. Setting: Neurological teaching hospitals from different regions in the Netherlands (cases) and a representative sample of the non-institutionalised Dutch population (controls). Subjects: 40 women aged 18-54 years with cerebral sinus thrombosis (cases) and 2248 women aged 18-49 years (controls). Main outcome measure: Current use of oral contraceptives at the time of the thrombosis (cases) or at the time of the questionnaire (controls). Prevalences of a hereditary prothrombotic condition in patients and in the population with odds ratios. Results: 34 of 40 (85%) women with cerebral sinus thrombosis used oral contraceptives, versus 1007 of 2248 (45%) of the control women; the age adjusted odds ratio was 13 (95% confidence interval 5 to 37). Seven of 36 patients (19%) had a prothrombotic deficiency, versus 7% expected in the population; this corresponds to a threefold to fourfold increase in risk. In women who used oral contraceptives and also carried a prothrombotic defect, the odds ratio for cerebral sinus thrombosis was about 30 relative to women who had neither risk factor. Conclusion: The use of oral contraceptives and being a carrier of a hereditary prothrombotic condition increase the risk of and interact in a multiplicative way in the development of cerebral sinus thrombosis.

Key messages

• The use of oral contraceptives is associated with an increased risk of cerebral venous sinus thrombosis
• This risk of cerebral venous sinus thrombosis in women who use oral contraceptives is larger if there is an additional hereditary prothombotic factor (protein C, S, or antithrombin deficiency, factor V Leiden mutation)
• The association between oral contraceptives, thrombophilia, and deep vein thrombosis is also valid for cerebral sinus thrombosis
• Women do not need to stop using oral contraceptives as the absolute risk of cerebral sinus thrombosis is very small

     

Superior sagittal sinus thrombosis. Still a killer.

Following treating a case of superior sagittal sinus thrombosis, we did an extensive search of the literature, eliciting 795 cases of the disorder. An analysis showed that even after the introduction of antibiotics, the preponderance of these cases have been diagnosed at autopsy. Our findings raise questions about the current methods of diagnosis and management of superior sagittal sinus thrombosis: Can the correct diagnosis be made earlier? Does a distinction between partial and complete thrombosis call for a different management?     

Investigation of Relation between Use of Oral Contraceptives and Thromboembolic Disease. A Further Report

The results of a previous study of the use of oral contraceptives by married women discharged from hospital with a diagnosis of thromboembolic disease in the years 1964–6 were reported by us last year. The present paper adds results relating to patients discharged during 1967 and a few data, that could not be sought previously, for patients discharged with cerebral or coronary thrombosis from three of the hospitals in the earlier period.Of 84 patients with deep-vein thrombosis or pulmonary embolism 42 (50%) had used oral contraceptives during the month preceding the onset of their illness, while only 23 of the 168 controls (14%) had done so. No differences in risk were found either for the types of preparation or for the duration of use. After allowance for age and height, the patients with venous thromboembolism were about 10 lb. (4,535 g.) heavier than the control patients, irrespective of whether they were using oral contraceptives or not. No appreciable difference was found between the smoking habits of patients with and without venous thromboembolism treated during 1967, nor between women who were using oral contraceptives and those who were not. The trend in hospital admissions for venous thromboembolism with time corresponded to the trend in the use of oral contraceptives, and there was no evidence to suggest that the number of admissions was affected by publicity about the risk of using the preparations. Of 19 patients with cerebral thrombosis 11 (58%) had been using oral contraceptives, compared with an expected figure of 3.5 from the experience of the control subjects. All the published data (clinical, angiographic, and post-mortem) show that the thrombosis affects the cerebral arteries rather than the cerebral veins. Of 17 patients with coronary thrombosis 2 (12%) had been using oral contraceptives, compared with an expected figure of 2.1. The patients with coronary thrombosis smoked more than the control patients and were, on average, 8.3 lb. (3,765 g.) heavier than control women of the same age and height.The new evidence strengthens the belief that oral contraceptives are a cause of venous thromboembolism and cerebral thrombosis but does not indicate that they are a cause of coronary thrombosis.     

The superficial cerebral veins

Estimated were the number, the course, and the width of the superficial cerebral veins. The veins on the superolateral surface of the brain are the prefrontal superficial lateral superior, the precentral superficial lateral superior, the central superficial lateral superior, the parietal superficial lateral superior, and the occipital superficial lateral superior veins which drain to the superior sagittal sinus, to bridging veins, and to the falx cerebri. The veins which drain the lateral surface of the brain downwards are the middle superficial cerebral veins, the temporal inferior, occipital inferior, and anastomotic veins. The diameters of these veins were measured at the perforation of the arachnoid membrane and the diameters of the anastomotic veins on their narrowest area. On the medial side of the hemispheres, we divided in precentral superficial superior medial, central superficial medial, parietal superficial medial, occipital superficial medial dorsal veins of the corpus callosum, and internal occipital veins. On the basal surface of the hemispheres, we studied and described the uncal veins and the inferior hemispheric veins. Studied and discussed are also the bridging veins in the course of the inferior cerebral veins, the paracavernous sinuses, and the last course of the veins and their connections with the dura mater or the course inside the dura. Given are besides the numbers of these veins, the area of perforation of the arachnoid membrane, and their width and medical importance.     

Mathematical simulation of gliding contusions

A gliding contusion in the acute phase is characterized by a streaklike hemorrhage of venous origin situated subcortically in a paramedial convolution. In later stages perivascular necrosis may develop. This type of injury is caused by head angular acceleration and is often seen in traffic casualties when the head has hit the steering wheel, the dashboard or the windshield.

The deformation of the brain matter close to the superior sagittal sinus has been simulated by means of a mathematical viscoelastic model in order to clarify the genesis of the gliding contusions. The blood vessels in the brain matter will be strained as a consequence of the brain deformation which results from head angular acceleration. The highest values of the strain occur subcortically where the blood vessels are injured first. The tolerance levels for gliding contusions have been determined. The calculations which were based on experiments regarding the dynamic properties of the superior cerebral veins and on two alternative injury criteria proposed, indicate that a gliding contusion is not likely to arise if the maximal angular acceleration does not exceed 4500 rad/sec² or the change in angular velocity does not exceed 70 rad/sec.     

Veins of the human cerebellum

(1) The veins of the human cerebellum, which may be classified into internal and external venous channels, correspond, in this respect, to the veins of the cerebral hemispheres. (2) The external cerebellar veins are arranged in three groups which, in turn, correspond to the three cerebellar surfaces and which communicate extensively. Accordingly, the terminal segments of the cerebellar veins overlap, which implies that no one-to-one relationship exists between the mouths of the individual veins and their respective distributions. (3) The terminal segments of the cerebellar veins are the superior petrosal sinus, the tentorial venous sinuses, the great vein of Galen and the internal vertebral plexus. (4) The tentorial venous channels may form a collateral venous arrangement. (5) The internal cerebellar veins consist of the nuclear veins and the medullary veins. (6) The medullary veins form a cortex-perforating group and a group located in the basal medullary region. The latter form a venous arborization of blood vessels not described thus far. This group of veins opens chiefly into the vein of the lateral recess of the fourth ventricle.(7) Attention is called to a 'venous watershed' corresponding to the one that exists in the cerebral hemispheres. (8) The veins of the dentate nucleus are composed of several venous channels draining its external surface and one single vein draining its internal surface. The latter has not been described thus far. The external veins of the dentate nucleus open into the venous star and the cortex-perforating veins. The internal nuclear vein, on the other hand, emerging from the hilum of the dentate nucleus, runs along the superior cerebellar peduncle. Thus, the term 'vena centralis nuclei dentati' appears to be appropriate to designate this vessel. It ultimately opens into the precentral cerebellar vein. (9) In certain places, various-colored substances used for injection form mixed pools.     

A simple new method for repeated in vivo cerebral cortex flux measurement in rats.

A new application of an indicator dilution technique, using nonradioactive para-aminohippuric acid, is described for superior sagittal sinus blood flow determination in rats. Superior sagittal sinus blood flow, mainly representing cerebral cortex blood flow, amounted to 541 +/- 49 microliters/min in ketamine-anesthetized, but otherwise normal, rats breathing room air. Increasing arterial pCO2 enhanced superior sagittal sinus blood flow (P less than 0.01), providing evidence that this method correctly measures cerebral blood flow. The respiratory quotient was 1.1 and the cerebral cortex metabolic rate of oxygen consumption was +/- 1.45 mumol/min. Cerebral cortex ammonia uptake was not significantly different from zero and of the amino acid fluxes, only alanine differed from zero (P less than 0.05). Flux measurements are crucial in studies of healthy or altered organ metabolism in both experimental animals and postoperative surgical patients. We devised a simple and economical method of repeated cerebral cortex flux measurement in rats that is a potentially valuable tool in metabolic studies of the cerebral cortex.     

Cerebral haemorrhagic infarction in young patients with hereditary protein C deficiency: evidence for "spontaneous" cerebral venous thrombosis.

Among 53 patients with hereditary protein C deficiency belonging to 20 families three women were encountered who, aged 27, 34, and 38 respectively, had had cerebral haemorrhagic infarction, probably due to intracranial venous thrombosis. All three had also had venous thrombosis of the leg and pulmonary embolism either before or after their cerebral infarction. One patient sustained cerebral infarction while receiving an oral contraceptive, but infarction in the two others occurred "spontaneously." One patient also had an intraventricular and subarachnoid haemorrhage during the induction phase of coumarin treatment, which was assumed to have resulted from haemorrhagic infarction of the chorioid plexus, analogous to coumarin provoked haemorrhagic skin necrosis in protein C deficiency. Hereditary protein C deficiency should be considered in young patients with acute or subacute cerebral symptoms, especially if they have a family or personal history of venous thromboembolism.     

Congenital scalp defect with thrombosis of the sagittal sinus. Case report.

A case report of a congenital scalp defect, associated with thrombosis of the superior sagittal sinus, is presented. A thrombectomy of the sinus, followed by skin grafting, was successful in achieving wound closure and a healthy, normal child. We propose that thrombectomy be considered for future similar situations.     

In vivo detection of venous sinus distension due to intracranial hypotension in small animal using pulsed‐laser‐diode photoacoustic tomography

Intracranial hypotension (IH) is a pathophysiological condition of reduced intracranial pressure caused by low cerebrospinal fluid (CSF) volume due to dural injuries from lumbar puncture, surgery, or trauma. Understanding the prognosis of IH in small animal models is important to gain insights on the complications associated with it such as orthostatic headache, cerebral venous thrombosis, coma, and so forth. Photoacoustic tomography (PAT) offers a novel and cost‐effective way to perceive and detect IH in small animal models. In this study, a pulsed laser diode (PLD)‐based PAT imaging system was used to examine the changes in the venous sinuses of the rat brain due to IH, induced through CSF extraction. After the CSF extraction, an increase in the sagittal sinus area by ~30% and width by 40% ± 5% was observed. These results provide supportive evidence that the PLD‐PAT can be employed for detecting changes in sagittal sinus due to IH in rat model.     

Atresia of the right atrial ostium of the coronary sinus

A case of asymptomatic congenital occlusion of the ostium of the coronary sinus is described. The myocardial venous drainage was maintained via a persistent left superior vena cava as well via ectatic, widened atrial veins of the dorsal wall of the left atrium. The study shows that complete ostial occlusion of the coronary sinus does not reduce cardiac venous drainage. The view of the literature allows a comparison with the comprehensive classification of coronary sinus anomalies.     

Anterior falcate artery in adults: histology of the relation of superior sagittal sinus, dural vein and the arachnoid granulations]

The anterior falcate artery, which is the continuation of the anterior ethmoidal, supplies the dura mater in the region of the superior sagittal sinus as far almost as the coronal suture. Graphic reconstructions show its relationships to the veins, the sinus, and the arachnoid granulations. Histological studies of the artery emphasize its adaptation to longitudinal stretching. The complexity of its relationships suggests a functional significance beyond that of nourishing the dura.     

Cerebral Blood Flow and Oxidative Metabolism in Conscious Fischer-344 Rats of Different Ages

Abstract: The cerebral metabolic rates for O₂ and for glucose were measured in conscious, fasted male Fischer-344 rats at the ages of 3, 12, and 24 months, and cerebral blood flow was determined with ¹⁴C-iodoantipyrine. The metabolic rates for oxygen and glucose were obtained by multiplying blood flow by the O₂ and glucose concentration differences, respectively, between blood in the femoral artery and in the superior sagittal sinus. Mean cerebral blood flow and the metabolic rates for oxygen and glucose did not differ significantly (p > 0.05) between 3 and 12 or between 12 and 24 months. Nor did the arteriovenous differences for O₂ and for glucose change significantly with age. Because the superior sagittal sinus drains blood mainly from the cerebral cortex, the results indicate that average cerebral cortical oxidative metabolism, and the coupling ratios between the cerebral metabolic rate for oxygen and cerebral blood flow and between the cerebral metabolic rate for glucose and cerebral blood flow, do not change significantly with age in the Fischer-344 rat.     

Alternative venous outflow vessels in microvascular breast reconstruction

The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors' experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10-year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful.     

Coexistance of cerebral sinovenous thrombosis and Dandy Walker malformation in newborn

Cerebral sinovenous thrombosis in neonatal period may cause neurological impairment, epilepsy, and lead to stroke. It is caused primarily by coagulopathy of numerous reasons, occasionally perinatal asphyxia, traumatic delivery and hyperhomocysteinemia. Dandy-Walker malformation is characterized by agenesis or hypoplasia of the cerebellar vermis, cystic dilatation of the fourth ventricle, and enlargement of the posterior fossa. Dandy-Walker malformation, variant, and mega cisterna magna represent a spectrum of developmental anomalies. Insults to developing cerebellar hemispheres and the fourth ventricle are believed to be the cause of malformation. Our patient was born from noncomplicated pregnancy, noncomplicated nontraumatic vaginal delivery at term, excellent Apgar scores, without peculiarities in clinical status. She was brest-fed by the 42nd hour of life when she had rightsided seizures during sleep that repeated for five times in next 24 hours. Brain Ultrasound (US) revealed clot in left lateral ventricle, slight dilatation of left ventricle, both sided periventricular echodensity, ischemia, slight enlargement of forth ventricle and a bit smaller cerebellum. There was no visible flow through left transverse, superior sagittal and straight sinus. Magnetic Resonance (MRI) confirmed the finding and showed thrombosis of left and right transverse venous sinuses and confluence of sinuses. Electroencephalogram (EEG) showed leftsided focal changes. The newborn was treated with phenobarbiton for 8 days and had no convulsions during that period. All coagulation parameters, homocistein, lipoproteins (a) and D-dimers were normal. There were no mutations on FV R506Q, PT 20210A, MTHFR 677C/T. No antiphospholipides were found. Heart US showed no structural anomalies. No other patology or risk factors were present at the time. Before discharge, US showed hydrocephalus. Flow in affected sinuses was visible with color Doppler. MRI showed recanalization of affected sinuses, also hydrocephalus and presentation of Dandy Walker On EEG there was borderline finding. Due to progression of hydrocephalus ventriculo-peritoneal shunt was placed. In age of 1 year EEG was slower for age but without focus. Neurological development was normal for age. The question is whether this child had intrauterine insult and inception of Dandy Walker with further postnatal progress of thrombosis and evolution to full picture of Dandy Walker with hydrocephalus OR thrombosis that led to development of hydrocephalus and Dandy Walker malformation in this child were accidental coexistance.     

Effectiveness of long term oral anticoagulation treatment in preventing venous thrombosis in hereditary protein S deficiency.

In eight of 14 patients who were deficient in protein S and who belonged to two unrelated families thrombosis presented as thrombophlebitis in seven and deep vein thrombosis in six, complicated by pulmonary embolism in four and leg ulcers in two. In four patients superficial thrombophlebitis preceded deep vein thrombosis by one to 11 years. Post-thrombotic varicose veins and venous insufficiency had developed in four patients. In three of those and in a fourth patient symptomatic superficial thrombophlebitis, deep vein thrombosis, and pulmonary embolism did not recur while they were taking oral anticoagulant treatment for six to 12 years. The anticoagulation intensity corresponded to international normalised ratio values of over 2.5. It is concluded that the benefits of anticoagulant treatment for patients with congenital thrombotic disease are great, and thus it is necessary to make an early diagnosis and treat patients at risk of developing thrombosis.     

Microsurgical reattachment of totally amputated ears

At a time when microsurgical reattachment of amputated limbs is commonplace, successful reattachment of total ear amputations is rare. Avulsed vessels, small diameters (0.3 to 0.7 mm), and technical difficulties provide primary obstacles. Three clinical cases of ear reattachments are presented which encompass the clinical spectrum of an uncomplicated success, a salvage of an impending failure, and a late failure due to venous thrombosis. In all cases there was difficulty with identification of vessels, with differentiation of arteries from veins, and in the performance of venous anastomoses. Vein grafts were necessary in two of the three patients. Anticoagulation was essential in alleviating venous thrombosis. Medicinal leeches (Hirudo medicinalis) were used to salvage one case with venous thrombosis. Despite the technical difficulties and long operative times, successful microvascular reattachment of an amputated ear is superior to any other means of reattachment or reconstruction.     

Homology and evolution of the orbitotemporal venous sinuses of humans.

The orbitotemporal venous sinuses accompany the intracranial branches of the stapedial artery. These sinuses are large in primitive primates and drain the extensive territories supplied by the stapedial artery as well as the brain. The orbit is drained by a wide cranio-orbital sinus which empties into the postglenoid emissary vein. Also emptying into the postglenoid vein is the petrosquamous sinus. The latter diverts cerebral blood from the transverse sinus and also drains the temporalis muscle. Emptying into both the cranio-orbital and petrosquamous sinuses are meningeal tributaries, which drain the cranial side wall and the dura mater. The relatively small sinus communicans runs in the angle between the petrosal bone and the cranial side wall. It commences at the postglenoid vein and connects the distal end of the petrosquamous sinus to the pterygoid venous plexus. In humans, the orbitotemporal sinus system is greatly modified. Its remnants persist for the most part as "middle meningeal veins." The system no longer drains the orbit, the temporal fossa, or the brain. The petrosquamous sinus becomes attenuated or obliterated along part or all of its length. The postglenoid vein vanishes. The cranio-orbital sinus is reduced in diameter and its connection to the orbit is feeble or absent. During development, the posterior end of the cranio-orbital sinus migrates inferiorly along the sinus communicans. In most individuals, this migration ceases at the foramen spinosum, site of the emissary vein of the sinus communicans. Meningeal tributaries are relatively large in humans, and drain principally into the cranio-orbital sinus or sphenoparietal sinus. The sphenoparietal sinus is an evolutionary novelty restricted to hominoids and is frequently developed in only Homo and Pongo.