venous drainage of head and neck and applied anatomy

1. VENOUS DRAINAGE
OF HEAD AND
NECK
By:
Avneet K Soni
OMFS
1

2. •The venous system is a network of conduits
i.e. veins which transport deoxygenated blood
from tissues to the heart. Exceptions are
the pulmonary and umbilical veins, both of
which carry oxygenated blood to the
heart. Equally important ,they serve as major
reservoirs of blood.
• About 84% of entire blood volume of body is
in systemic circulation and 16% in heart and
lungs.
• Of the 84 % in systemic circulation,64%is in
veins,13%in arteries and 7% in systemic
arterioles and capillaries
Introduction
2

3. Veins are classified as:
Superficial veins are those whose course is close to the
surface of the body, and have no corresponding arteries.
Deep veins
Deep veins are deeper in the body and have corresponding
arteries.
Communicating veins
Communicating veins (or perforator veins) are veins that
directly connect superficial veins to deep veins.
Pulmonary veins
The pulmonary veins are a set of veins that deliver oxygenated
blood from the lungs to the heart.
Systemic veins
Systemic veins drain the tissues of the body and deliver
deoxygenated blood to the heart.
3

4. The walls and valves of veins
The walls of veins have the same three layers as the arteries.
Although all the layers are present, there is less smooth muscle and
connective tissue. This makes the walls of veins thinner than those of
arteries, which is related to the fact that blood in the veins has less
pressure than in the arteries. Because the walls of the veins are
thinner and less rigid than arteries, veins can hold more blood..
Medium and large veins have venous valves, similar to the semilunar
valves associated with the heart, that help keep the blood flowing
toward the heart. Venous valves are especially important in the arms
and legs, where they prevent the backflow of blood in response to the
pull of gravity
4

5. Artery vs Vein
5

6. 6

7. VENOUS SYSTEM ,HOW DOES IT WORK?
The venous system in the
body returns deoxygenated
blood from all parts of the body,
including the organs, to the right
side of the heart, and then on to
the lungs, to be oxygenated.
From the lungs, the oxygenated
blood passes to the left part of
the heart, to be pumped to all
the tissues and organs of the
body.
7

8. • The venous system consists of large and small veins; the large veins tend to lie
alongside arteries. Veins are more thin-walled than arteries, they act as a reservoir
for blood, and about 60-70% of the body’s blood is in the venous system.
• Many veins have one-way valves to facilitate the flow of blood back to the heart
against the force of gravity. This is especially applicable to the veins in the legs, and
to a lesser extent, in the arms. The valves work in the same way as one- way swing
doors, the blood pushing the valves open as it travels toward the heart; the valves
close as blood fills that part of the vein, and prevents backward flow.
• Though the legs have superficial veins (under the skin) and deep veins (in the
muscles) which carry blood back to the heart, as well as connecting veins known
as “perforating veins” (which connect the superficial and deep veins), most of the
blood is propelled back to the heart by the deep veins. Blood from the superficial
veins mostly travels through the connecting veins to the deep veins and is
returned to the heart this way, this is also a one-way system, as the connecting
veins have valves as well.
• The deep veins are surrounded by muscles enclosed in a fascial sheath. Walking
compresses the veins and thrusts the blood back towards the heart.
• This is why exercise, especially walking, is so useful in preventing stasis of the
blood in the legs, and consequently venous thrombosis.
• The one-way valves also help in this process of return of blood, as well as allowing
the deep veins to refill from the superficial veins.
8

9. The embryo's vein system develops out of a very
irregular network of capillaries, from which finally
individual ones transform themselves definitively into
veins while others disappear again. The result of this is
that the venous system is not very uniform, and in the
adult far more variants of venous outflows than on the
arterial side exist. One can nevertheless distinguish
among three basic systems: cardinal, umbilical and
omphalomesenteric. The pulmonary veins cannot be
counted as belonging to these three systems and are
treated separately.
The cardinal veins form as the basis for the intraembryonic venous part of the circulatory
system. Various venous systems appear in various stages of the embryogenesis and partially
disappear again. Very early in the development two paired systems appear:
The anterior cardinal veins bring the blood from the head region via the left and right common
cardinal vein
The posterior cardinal veins drain the blood from the lower half of the body into the two
common cardinal veins
From here, the blood is emptied into the sinus venosus and into the atrium via the sinus horns.
EMBYROLOGY
9

10. Fate of anterior and common cardinal veins
The anterior cardinal veins are joined by subclavian veins that drain forelimbs. Soon there
after anterior cardinal veins become inter connected by transverse anastomosis,proximal
to their junction with subclavian veins. The part of the left anterior cardinal vein caudal to
this anasomosis retrogresses, and so does the left cardinal vein.
10

11. Superior vena cava is derived from, right anterior cardinal vein,caudal
to transverse anastomosis with left ant cardinal & right common
cardinal vein. The Superior Vena Cava (E)
The left brachiocephalic vein(G) , is derived from part of left anterior
cardinal vein corresponding to the right bracheocephalic vein(1) &
Transverse intercardinal anastomosis(2)
The right bracheocepahlic vein(F) is derived from the right anterior
cardinal vein,between the point of its junction with the subclavian vein
& point of its junction with transverse anastomosis.
11

12. The internal jugular veins (H) develop from the parts of
the anterior cardinal veins cranial to their junction with
subclavian veins
The external jugular veins arise as secondary
channels and are not derived from anterior
cardinal veins.
The caudal part of the anterior cardinal vein, and the whole of the common cardinal vein, for the
left side undergo retrogression. The greater part of the posterior cardinal vein of this side
disappears, but a small part adjoining the common cardinal vein persists as a small vein. Tthe
left horn of the sinus venosus undergoes considerable retrogression and is reduced to a
tributary of the right horn. These retrogressing veins of the left side persist into adult life as the
left superior intercostals vein and the coronary sinus.
12

13. Arteriovenous anastomoses are direct connections between smaller arteries and veins.
Connecting vessels may be straight or coiled & often possses a thick muscular tunic. Simple
arteriovenous anastomoses are widespread & occur notably in the skin of nose,lips
,ears,nasal& alimentary mucosae,tongue,thyroid gland & sympathetic ganglia. In old age they
atrophy ,sclerose and diminish in number & may contribute to less efficient temp. regulation.
13

14. Veins of head, face, neck and brain
Exterior of head Neck Brain
and face
• Supratrochlear *External Jugular *Diploic veins
• Supraorbital *Cerebral
vein
• Facial vein
• Superficial temporal *Anterior Jugular *DuralVenous
• Maxillary vein *Internal Jugular Sinuses
• Pterygoid Venous *Subclavian
plexus *Brachiocephalic
• Retromandibular
• Posterior auricular
• Occipital vein
14

15. Supra trochlear vein
Starts on the forehead from
venous network which
connects to the frontal
tributaries of superficial
temporal vein.
Joins supra-orbital vein to
form facial vein near medial
canthus.
15

16. Supraorbital vein
• begins on the forehead where it communicates with the frontal branch of
the superficial temporal vein. It runs downward superficial to the Frontalis
muscle, and joins the frontal vein at the medial angle of the orbit to form
the angular vein.Passes under orbicularis oculi. A branch passes through
supraorbital notch to join superior ophthalmic vein .In notch it receives
veins from frontal sinus & frontal diploe.
16

17. Facial vein
• Coursing parallel to facial arteries are
valveless veins that provide the
primary superficial drainage of the
face.
• Commences at the side on the root of
the nose and
• Lies behind facial artery and is less
tortuous
• formed by the union of the
supraorbital and supratrochlear veins
at the medial canthus to form the
angular vein
• Communicate with the cavernous
sinus through the ophthalmic vein or
via the supraorbital vein.
17

18. Facial vein
9 levator labii superioris alaeque
nasii
10 levator labii superioris
11zygomaticus minor
17marginal mandibular
18facial artery
19facial vein
20buccinator
21zygomaticus major
22acessory parotid gland
23masseter
27parotid gland
29 sternocleidomastoid
18

19. Facial vein, tributaries
• superior ophthalmic vein
• Veins of ala of nose
• Deep facial vein, from pterygoid plexus
• Inferior palpebral
• Superior and inferior labial (drains area
of upper and lower lip)
• Buccinators (drains area of cheek)
• Parotid and messeteric veins (drains area
from parotid and masseter)
• Below mandible it receives submental ,
tonsillar , external palatine and
submandibular vein
• Applied Importance:
• Facial veins have no valves and it
connects to cavernous sinus by 2 routes.
• 1.) via ophthalmic vein or supraorbital
vein.
• 2)Via deep facial vein to pterygoid plexus
and hence to cavernous sinus.
• Thus infective thrombosis of facial vein
may extend to intracranial venous
sinuses. 19

20. Superficial temporal
•Begins in a widespread network joined across scalp to contra-lateral vein and with
supratrochlear, supraorbital, posterior auricular and occipital veins, all draining same network
•cross posterior root of zygoma & enters parotid gland to unite with maxillary vein to form
retromandibular vein.
20

21. Maxillary vein
A short trunk accompanies
the first part of maxillary
artery;
It is confluence of vein from
pterygoid plexus,passes back
between sphenomandibular
ligament and neck of
mandible,to enter the
parotid gland and
Here it unites with superficial
temporal to form
retromandibular vein.
21

22. Retromandibular vein
Runs posterior to ramus of the mandible within the
substance of parotid gland
Superficial to external carotid artery and deep to
facial nerve
Divides into an anterior branch going forwards to join
with facial vein and
Posterior branch which joins posterior auricular to
form external jugular vein
Knowledge of the normal anatomy of the extra-
cranial FN and its relationship with the RMV is
essential for surgeons dealing with parotid glands.
Formation of the RMV by union of the superficial
temporal vein and maxillary vein mostly occurs at
a level higher than the passage of the main trunk
and branches of the FN, where they laterally pass
to the vein. In normal anatomical variation, the
risk of bleeding from the RMV as a result of its
injury is not high during parotid surgery. In
contrast, in cases of abnormal anatomical
variation where RMV passes laterally to the FN or
its branches, the risk of bleeding and nerve injury
during parotid surgery is much higher.
22

23. Lateral view of right facial nerve (FN) giving
superior division (SD) and inferior division
(ID); each of them pass through a separate
ring in the retro-mandibular vein (RMV).
FN, facial nerve; RMV, ret-
romandibular vein; STV, superfacial
temporal vein; MV, maxillary vein;
SD, superior division; ID, inferior
division.
Maxillofacial surgeons should be also familiar with different FN variations. In open surgical
reduction of mandibular condyle fractures, the FN and its branches can be localized by using
the superficial temporal veins and the RMVs as a guide, even in abnormal course of the nerve.
23

24. Posterior auricular
• Begins upon the side of neck,in a plexus which
communicates with tributaries of occipital vein
and temporal veins.
• Descends behind the auricula and joins the
posterior division of retromandibular vein to form
external jugular vein.
• Applied: receives mastoid emissary veins from
sigmoid sinus. Infection here can be dangerous or
fatal from retrograde thrombosis of cerebellar
and medullary veins.
24

25. Occipital vein
• Begins in posterior network in scalp, pierce
the cranial attachment of trapezius, turns into
suboccipital triangle and becomes deep.
• May follow occipital artery to end in internal
jugular vein vein;
• Or join posterior auricular & hence external
jugular vein.
25

26. 26

27. Pterygoid venous plexus
Placed partly between temporalis and lateral pterygoid and partly
between two pterygoids.
Anteriorly reaches from the maxillary tuberosity and superiorly to
the base of skull
Sphenopalatine,deep temporal, pterygoid, massetric, buccal,
dental, greater palatine and middle meningeal veins and branches
from inferior opthalmic veins are all tributaries.
Connects with facial veins facial veins through deep facial veins &
With cavernous sinus through veins that pass through sphenoidal
emissary foramen, foramen ovale and lacerum
Its deep tributaries are connected with middle meningeal vein.
Applied : needle track communications can also result in infection
to pterygoid plexus. PSA Block  hematoma, black eye
 serves as a media for spread of external infection to eye.
27

28. Pathway of spread of infection to cavernous sinus
28

29. Veins of the neck
The word "jugular" refers to the throat or neck. It derives fromthe
Latin "jugulum" meaning throat or collarbone and the Latin
"jugum" meaningyoke. To go for the jugular is to attack a vital
part that is particularly vulnerable.
29

30. 30

31. External jugular vein largely drains
scalp and face, but also some deeper
parts.
Formed by union of post divisiion of
retromandibular vein & post auricular
vein.
Begins near the angle of mandible,just
below the parotid gland and drains into
subclavian vein.
Covered with platysma and superficial
fascia and separated from
sternocleidomastoid by deep cervical
fascia.
Between the entrance into subclavian
vein, abt 4cm above clavicle, it is often
dilated as so called sinus.
Surface anatomy: usualy visible as it
crosses sternocleidomastoid obliquely.
Can be seen by effort blowing of
mouth closed
31

32. Tributries of external jugular vein
• Posterior external jugular vein
• Transverse cervical vein
• Suprascapular vein
• Anterior jugular vein
• A branch from internal jugular in the parotid
• Occasionally joined by occipital
32

33. Visualization (LEWIS METHOD)
The veins of the neck, viewed from in front.
The patient is positioned under 45°, and the filling
level of the jugular vein determined. Visualize
the internal jugular vein when looking for the
pulsation. In healthy people, the filling level of the
jugular vein should be less than
3 centimetres vertical height above the sternal angle.
The JVP is easiest to observe if one looks along the
surface of the sternocleidomastoid muscle, as it is
easier to appreciate the movement relative to the
neck when looking from the side (as opposed to
looking at the surface at a 90 degree angle). Like
judging the movement of an automobile from a
distance, it is easier to see the movement of an
automobile when it is crossing one's path at 90
degrees (i.e. moving left to right or right to left), as
opposed to coming toward one.
JVP
33

34. • The JVP and carotid pulse can be differentiated several ways
• multiphasic - the JVP "beats" twice (in quick succession) in the cardiac cycle. In other words,
there are two waves in the JVP for each contraction-relaxation cycle by the heart. The first beat
represents that atrial contraction (termed a) and second beat represents venous filling of the
right atrium against a closed tricuspid valve (termed v) and not the commonly mistaken
'ventricular contraction'. These wave forms may be altered by certain medical conditions;
therefore, this is not always an accurate way to differentiate the JVP from the carotid pulse. The
carotid artery only has one beat in the cardiac cycle.
• non-palpable - the JVP cannot be palpated. If one feels a pulse in the neck, it is generally
the common carotid artery.
• occludable - the JVP can be stopped by occluding the internal jugular vein by lightly pressing
against the neck. It will fill from above.
• varies with head-up-tilt (HUT) - the JVP varies with the angle of neck. If a person is standing, his
JVP appears to be lower on the neck (or may not be seen at all because it is below the sternal
angle). The carotid pulse's location does not vary with HUT.
• varies with respiration - the JVP usually decreases with deep inspiration.
Differentiation from the carotid pulse
34

35. Jugular vein
No pulsations palpable
Pulsations are obliterated by
pressure above the clavicle
Levels of pulse wave decrease on
inspiration; increased on expiration
Usually two pulsations per systole
Pulsations sometimes are prominent
without abdominal pressure
Carotid artery
pulsations palpable
Pulsations are not obliterated by
pressure above the clavicle
No effects of respiration on pulse
One pulsation per systole
No effect of abdominal pressure on
pulsations
35

36. A man with severe
congestive cardiac failure
with marked jugular
venous distension.
External jugular vein
marked by arrow.
36

37. Anterior jugular vein
• Starts near the hyoid bone
by confluence of
superficial submandibular
vein.
• Descends between midline
and ant border of
sternocleidomastoid
turning lateraly, low in
neck,posterior to this
muscle but superficial to
depressor of hyoid bone
• Joins external jugular vein
or subclavian vein directly.
• There are usualy two
anterior jugular veins, just
above the sternum,
communicate by large
transverse trunk, the
venous jugular arch
• Have no valves
37

38. • 1parotid gland
• 2sternocliedomastoid
• 3external jugular vein
• 4great auricular nerve
• 8trapezius
• 9Acessory nerve
• 11superficial cervical vein
• 14anterior jugular vein
• 17transverse
cervicalnerve
• 18submandibular gland
• 19lower border of
mandible
38

39. Internal jugular vein
• 1Body of hyoid bone
• 2sternohyoid
• 3superior belly of
omohyoid
• 4Thyrohyoid
• 5superior thyroid artery
• 7common carotid artery
• 8Internal jugular vein
• 9tendon of omohyoid
• 12cricothyroid
• 13isthmus thyroid
• 14lateral lobr thyroid
• 16inferior thyroid veins
39

40. Internal jugular vein
Begins at the base of the skull in the
posterior compartment of jugular foramen
 collects blood from brain
Immediately below the jugular foramen,
it is widened to form superior bulb of
internal jugular v, contained in jugular
fossa
Located post. to internal carotid artery
At its lower end, at the junction with
subclavian vein v , IJV is again widened to
form inferior bulb
Posterior to sternal end of clavicle,IJV
combines with subclavian vein to form
bracheocephalic vein .
Surface anatomy :IJV is represented in
surface projection by broad band drawn
from lobule of ear to median end of
clavicle.
Applied: infection from middle ear
spreads to IJV
Surgical removal of deep cervical nodes
can puncture IJV 40

41. Deep cervical lymph nodes are found
along the internal jugular vein within
the carotid sheath. In block
dissection,the the subclavian vein,JV
is removed to facilitate the removal of
nodes.
In the root of neck,IJV lies behind the
gap between sternal and clavicular
heads of SCM and ends by joining the
subclavian vein to form
bracheocephalic vein.
Pharyngeal vein. Common facial vein&
superior and middle thyroid veins also
drain into IJV. Undue traction during
thyroid surgery can result in avulsion
of these veins from IJV. Gentle
traction , double ligation of these
veins are important steps in
mobilization of thyroid lobes
41

42. Bilateral internal, external, posterior external and anterior
jugular vein ligations and excisions performed in the neck due
to larynx tumors . Radical neck dissection is a standard
procedure in the management of head and neck cancer
patients with bilateral lymph node metastasis to the neck.
Sacrifice of both internal and external jugular veins bilaterally
has been recognized as a dangerous approach leading to
intracranial hypertension with subsequent neurological sequela
and death.. After bilateral jugular vein ligations, digital
subtraction angiography (DSA) showed that the venous
drainage route of the brain had been diverted from the jugular
veins to the vertebral venous plexus.
42

43. Tributaries of internal jugular vein
•Into superior bulb
•Inferior petrosal sinus
•Veins of pharynx
•Root of tongue & sublingual
area
•Superior thyroid vein
•Middle thyroid vein
:
43

44. At the root of the neck, the right internal jugular vein is a little distance from
the common carotid artery, and crosses the first part of the subclavian artery, while
the left internal jugular vein usually overlaps the common carotid artery.
The left vein is generally smaller than the right, and each contains a pair of valves,
which are placed about 2.5 cm above the termination of the vessel.
44

45. • Thrombosis of the internal jugular (IJ) vein is an underdiagnosed condition that may occur as a
complication of head and neck infections, surgery, central venous access, local malignancy,polycythemia,
hyperhomocysteinemia, neck massage, and intravenous drug abuse.
• thrombosis may become secondarily infected, producing a septic thrombophlebitis. An infected IJ
thrombus caused by extension of an oropharyngeal infection is referred to as Lemierre syndrome. The
incidence of Lemierre syndrome has fallen dramatically since the use of antibiotics began in the late 1950s.
However, it still occurs, particularly in underserved populations.
• The frequency of IJ vein thrombosis in individuals who abuse intravenous drugs is not known, but it usually
occurs in people who have been using injectable drugs for years and have exhausted all peripheral access
sites.
• The symptoms and signs of IJ thrombosis can often be very subtle, making it easy to overlook the diagnosis.
Pain and swelling at the angle of the jaw and a palpable cord beneath the sternocleidomastoid muscle both
may be absent in a significant minority of patients. Once infection has set in, other objective findings may
be found. Tovi et al described the following clinical manifestations in their 1991 series of patients with
septic IJ thrombosis as follows:
• Clinical manifestations of IJ thrombosis occur in the following percentages of patients:
• Fever - 83% of patients
• Leukocytosis - 78% of patients
• Cervical pain - 66% of patients
• Mass or neck swelling - 72% of patients
• Sepsis syndrome - 39% of patients
• Pleuropulmonary complications - 28% of patients
• Superior vena cava syndrome - 11% of patients
• Chylothorax - 5% of patients
• Jugular foramen syndrome - 6% of patients
• Increased intracranial pressure with symptoms that include headache, visual disturbances, and altered
sensorium - rare
A
P
P
L
I
E
D
A
S
P
E
C
T
IJV
45

46. Jugular phlebectasia in children
• Jugular phlebectasia is a congenital dilatation of jugular vein which appears as a
soft, compressible mass in the neck only during straining or crying. It should be
differentiated from laryngocele, cysts and tumors of neck which may also appear
during straining. Ultrasonography (US) and computerized tomography (CT) are
diagnostic methods to distinguish the pathology
• More common in internal jugular vein.
• The Valsalva maneuver is most important for establishing the diagnosis.
Ultrasound or CDFI, or in combination with the Valsalva's breathing test, was the
diagnostic procedure of choice to confirm the diagnosis of JVP because of its
clarity, safety, and low cost. Surgical intervention is recommended for cosmetic
and psychologic purposes. Ligation or excision of the involved jugular vein is very
safe, simple, and effective for most patients. However, in cases of lesions of the
right and bilateral internal jugular veins, longitudinal constriction suture
venoplasty plus encapsulation might be more preferable and safer, and should be
recommended. Otherwise, treatment should be conservative (follow-up
evaluation).
46

47. • The jugular veins are relatively superficial and not
protected by tissues such as bone or cartilage. This
makes them susceptible to damage. Due to the large
volumes of blood that flow though the jugular veins,
damage to the jugulars can quickly cause significant
blood loss, which can lead to hypovolemic shock and
then death if not treated.
• It should also be noted that cuts or abrasions in the
skin near the jugular vein will bleed longer and more
profusely (i.e. from chewing tobacco or shaving
accidents). Since 95% of the body's blood passes
through this vein, it takes on average about 30
minutes to fully stop a shaving abrasion on the face.
47

48. Lingual vein: drains tongue & sublingual region
3 branches: dorsal lingual v
deep lingual v
sublingual v
IJV
48

49. Abnormaly dilated, tortuous veins produced by prolonged, increase
intraluminal pressure. Small purplish or blue-black round swellings under the
tongue with age and are known as “caviar lesions”
Lingual varicosity
Veins are supposed to act as one-way valves and shouldn't allow back flow of blood.
But if a vein becomes weak, blood may flow backwards and collect in your vein causing
inflammation and swelling. These swollen veins are varicose veins.
 Varicose veins are normally found on the backs of your calves or on the inside of your
leg.
 No treatment is indicated for lingual varices.. Care needs to be exercised when
performing surgery in this region due to the high vascularity of the area.
49

50. Subclavian vein
• Each subclavian vein is a continuation of the axillary vein and runs from the outer border of
the first rib to the medial border of anterior scalene muscle. From here it joins with
the internal jugular vein to form the brachiocephalic vein (also known as "innominate vein").
The angle of union is termed the venous angle.The thoracic duct drains into the left
subclavian vein, near its junction with the left internal jugular vein. It carries lymph (water
and solutes) from the lymphatic system, as well as chylomicrons or chyle, formed in
the intestines from dietary fat and lipids.
• The right lymphatic duct drains its lymph into the junction of the right internal jugular vein,
and the right subclavian vein. 50

51. 51

52. 1 post external jugular vein
2 occipital vessels
3 ext vertebral venous plexus
4 Post auricular vessels
5Retromandibular vein
7 pterygoid venous plexus
8 facial vein
9 facial artery
11 ant jugular vein
13 int jugular vein
14 ext jugular vein
15 subclavian vein
16 brachiocephalic vein
Cast of blood vessels showing volume of blood which can
accumulate in venous network of neck
52

53. Diploic veins
• Frontal diploic vein
• An anterior temporal
diploic vein
• A posterior temporal
diploic vein
• An occipital diploic vein
These veins occupy channels in diploe of some cranial bones and are
devoid of valves. They are large with dilation at regular interval;their
thin wall is merely endothelium. Absent at birth,begin to develop at
about 2yrs. They communicate with meningeal veins,dural sinuses
&pericranial veins.
53

54. Cerebral veins
• They are divided into
external & internal
groups according to the
outer surface or inner
parts of hemispheres
they drain into.
• External cerebral vein
Superior cerebral vein
• middle cerebral vein
• Inferior cerebral veins
• Basal vein .
• Internal cerebral veins
External cerebral veins drain into superior saggital sinus
Internal cerebral veins drain into great cerebral veins of Galen 54

55. CRANIAL VENOUS SINUSES
These are spaces between endosteal & meningeal layers
of duramater.
General features:
Their walls are formed by duramater lined by
epithelium, muscular coat is absent
They have no valves
Receive 1) venous blood from brain, meninges and
bone
2) the CSF
 major draining pathways from the brain,predominantly
to internal jugular veins.
They communicate with veins outside the skull through
emissary veins. These connections help to keep pressure
of blood in sinus constant.
55

56. Paired
Cavernous sinus
Superior petrosal sinus
Inferior petrosal sinus
Transverse sinus
Sigmoid sinus
Sphenoparietal sinus
Middle meningeal veins
• Unpaired
• Superior saggital sinus
• Inferior saggital sinus
• Straight sinus
• Occipital sinus
• Ant. intercavernous S
• Post. intercavernous S
• Basilar plexus of veins
Dural venous sinuses
56

57. 57

58. 58

59. Venous sinuses
Name Drains to
Inferior sagittal sinus Straight sinus
Superior sagittal sinus Confluence of sinuses
Straight sinus Confluence of sinuses
Occipital sinus Confluence of sinuses
Confluence of sinuses Transverse sinuses
Cavernous sinuses Superior and inferior petrosal sinuses
Transverse sinuses Sigmoid sinus
Superior petrosal sinus Sigmoid sinus
Inferior petrosal sinus Internal jugular vein
Sigmoid sinuses Internal jugular vein
59

60. Sup cerebral vein superior saggital sinusright transverse sinussigmoid sinusRt IJV
Deep cerebral vgreat cerebral vstraight sinusleft transverse slft sigmoid slft IJV
60

61. Clinical relevance
Dural sinus thrombosis may lead to haemorrhagic infarction with
serious consequences including epilepsy, neurological deficits
and death.
Common causes of dural venous sinus thrombosis include head
and neck infections, head injury,skull fractures or intracranial
hematomas either by direct compression of the sinus or
endothelial damage within the sinus can cause the activation of
coagulation system resulting in sinus occlusion.Brain cells
contain an abundance of thromboplastin that is released after
injury inducing an hypercoagulable state leading to destruction of
platelets & erythrocytes followed by thrombus formation.
Most common thrombosed sinuses are tranverse,cavernous &
superior saggital sinus
Clinical symptoms
headache,papilloedema,impaired consciousness, vomitting.
61

62. Metastasis oftumour cellsto dural sinuses
Tha basilar and occipital sinuses communicate through the
foramen magnum with the internal venous plexuses. Because
these venous channels are valveless, compression of the
thorax, abdomen, or pelvis as occurs during heavy coughing and
straining may force venous blood from these regions into
vertebral venous system and from it into dural venous sinuses.
As a a result, pus in the abscesses and tumour cells in these
regions may spread to vertebrae and brain.
62

63. Cavernous sinus
are so named because they present a reticulated
structure, due to their being traversed by numerous
interlacing filaments.
 situated in the middle cranial fossa, one on either
side of sphenoid bone
Size : 2cm long , 1cm wide.
Extent : anteriorly extends upto medial end of
superior orbital fissure,
posteriorly: upto apex of petrous temporal
 drains into : a) transverse sinus via superior sinus
petrosal sinus.
 b)int jugular vein via inferior petrosal sinus &
venous plexus around int carotid artery ,
c) pterygoid plexus through emissary veins
passing through foramen ovale,
d)facial vein through superior opthalmic vein.
Right and left communicate with each other
through intercavernous sinus and basilar plexus of
veins.
 all these communications are valveless & blood
can flow in either direction.
63

64. t
1
2
The Superior Ophthalmic Vein begins at the inner angle of the orbit in a vein named the nasofrontal
which communicates anteriorly with the angular vein; it pursues the same course as the ophthalmic
artery, and receives tributaries corresponding to the branches of that vessel. Forming a short single trunk,
it passes between the two heads of the lateral Rectus and through the medial part of the superior orbital
fissure, and ends in the cavernous sinus.
1
3
The Inferior Ophthalmic Vein begins in a venous net-work at the forepart of the floor and medial wall of
the orbit; it receives some veins from the inferior Rectus, inferior Oblique,lacrimal sac and eyelids, runs
backward in the lower part of the orbit and divides into two branches. One of these passes through the
inferior orbital fissure and joins the pterygoid venous plexus, while the other enters the cranium through
the superior orbital fissure and ends in the cavernous sinus, either by a separate opening, or more
frequently in common with the superior ophthalmic vein.
1
4
Opthalmic veins , two in number ;
superior and inferior are devoid of
valves
64

65. Applied anatomy
 Thrombosis caused by sepsis in the danger area of face, nasal
cavity, paranasal sinuses give rise to :
Nervous symptoms:
1) severe pain in the eye and forehead in the area of distribution
of opthalmic nerve.
2) Involvement of 3rd, 4th and 6th nerve resulting in paralysis of
muscle supplied.
Venous symptoms:
1) Marked edema of eyelid, cornea & exopthalmos due to
congestion of orbital vein.
Carotid and cavernous communication: because of peculiar
relationship of cavernous sinus to internal carotid artery a
communication may occur between the two as a result of injury.
When this happens the arterial pressure is communicated
through the sinus to vein of orbit & as a result the eye become
prominent & pulsate with each heart beat( pulsating exopthalmos)
65

66. Cavernous sinus thrombophlebitis results as a complication of a prior orbital
cellulitis or may be a starting point of such an infection. In either event, the
inflammation originates in the neighbourhood. The known avidity for the
orbit to share the troubles of the neighour is due to free venous
communication, anteriorly with the facial vein through angular vein and
posteriorly with the cavernous sinus through the Ophthalmic veins. Thus any
suppuration in the vast area drained by these veins should be eyed
suspiciously and dealt with caution, as the prognosis is mostly fatal, because
of the involvement of the cavernous sinus in the absence of proper therapy.
With modern chemo-therapy the cases are seen rarely and only as a result of
inadequate attention and care of a seemingly harmless inflammation and or a
resistant strain of organism.
66

67. Emissary veins are conduits between the extracranial scalp veins and the diploic
and intracranial venous systems. These veins are valveless and therefore can
transmit infection from the extracranial to the intracranial compartment.
The meningeal veins are epidural veins that lie within the dura draining the falx
cerebri, the tentorium, and the cranial dura. They run in shallow grooves on the
inner table of the skull to communicate with the dural sinuses or traverse
extracranially to the pterygoid plexus in the deep face or vertebral plexus around
the cervical spine.
The diploic veins are small irregular endothelial-lined channels coursing between
the inner and outer tables of the skull. These communicate with the extracranial
venous system, the meningeal veins, and the dural sinuses. They are rarely seen
using angiography unless enlarged, as in the case of an arterial-venous
malformation.
Communication between extracranial and intracranial veins
67

68. • Sinus pericranii (SP) is a rare disorder characterized by a congenital (or
occasionally, acquired) epicranial venous malformation of the scalp. Sinus
pericranii is an abnormal communication between the intracranial and
extracranial venous drainage pathways. Treatment of this condition has
mainly been recommended for aesthetic reasons and prevention of
hemorrhage. Sinus pericranii is a venous anomaly where a communication
between the intracranial dural sinuses and dilated epicranial venous
structures exists. That venous anomaly is a collection of nonmuscular
venous blood vessels adhering tightly to the outer surface of the skull and
directly communicating with intracranial venous sinuses through diploic
veins. The venous collections receive blood from and drain into the
intracranial venous sinuses. The varicosities are intimately associated with
the periostium, are distensible, and vary in size when changes in
intracranial pressure occur.
• the nature of this malformation remains unclear. Congenital, spontaneous,
and acquired origins are accepted.The surgical treatment involves the
resection of the extracranial venous package and ligation of the emissary
communicating vein. In some cases of SP, surgical excision is performed for
cosmetic reasons.
Sinus pericranii
68

69. Vascular malformations
Described as abnormalities of blood
and lymphatic vessels, vascular
malformations, like many
hemangiomas, are present at birth
but do not undergo proliferation
and do not spontaneously involute.
• Donot regress with age and may be
associated with severe or life
threatening haemorrhage.
• A large venous malformation
appears as bluish , soft,
compressible lesion,no bruit or
pulsation is present.
• Fail to show characterstic picture on
radiograph. MRI can indicate the
pesence and extent of vascular
malformation.
• TREATMENT: May be treated with
sclerotherapy as well as direct
injections of sodium morrhuate,
boiling water, alcohol & ethibloc.
• Combined application of sodium
tetradecyl sulfate sclerothearpy &
conservative ablative surgery when69

70. Telangiectasias on the face are often treated with a laser. Laser therapy uses a light beam
that is pulsed onto the veins in order to seal them off, causing them to dissolve. These light-
based treatments require adequate heating of the veins. These treatments can result in the
destruction of sweat glands, and the risk increases with the number of treatments.
Telangiectasias or angioectasias are small dilated blood
vessels near the surface of the skin or mucous membranes,
measuring between 0.5 and 1 millimeter in diameter.They
can develop anywhere on the body but are commonly seen
on the face around the nose, cheeks, and chin. They can
also develop on the legs, specifically on the upper thigh,
below the knee joint, and around the ankles. Many patients
who suffer with spider veins seek the assistance of
physicians who specialize in vein care or peripheral vascular
disease. These physicians are called phlebologists or
interventional radiologists.
Some telangiectasia are due to developmental abnormalities
that can closely mimic the behaviour of benign vascular
neoplasms. They may be composed of abnormal
aggregations of arterioles, capillaries, or venules.
Telangiectasia
70

71. Usual sites:
Saphenous vein (near
medial malleolus of ankle)
Anti cubical vein at the
elbow (Basilic vein)
Procedure
The skin is cleaned, draped, and anesthetized if time allows. The greater saphenous vein is
identified on the surface, a full-thickness transverse skin incision is made, and 2 cm of the vein is
freed from the surrounding structures. The vessel is tied closed distally, the proximal portion is
transected (venotomy) and gently dilated, and a cannula is introduced through the venotomy
and secured in place with a more proximal ligature around the vein and cannula. An intravenous
line is connected to the cannula to complete the procedure.
Venous cutdown is an emergency procedure in which the vein is exposed surgically and then
a cannula is inserted into the vein under direct vision. It is used to get vascular access in trauma
and hypovolemic shock patients when peripheral cannulation is difficult or impossible.
The saphenous vein is most commonly used. Emergent venous access when attempts to gain
access by the peripheral or percutaneous routes have failed.
71

72. 72

73. Complications of venous cutdown include cellulitis, hematoma, phlebitis, perforation of the
posterior wall of the vein, venous thrombosis and nerve and arterial transection. This
procedure can result in damage to the saphenous nerve due to its intimate path with the
great saphenous vein, resulting in loss of cutaneous sensation in the medial leg. Over the
years the venous cutdown procedure has become outdated by the introduction and recent
pre hospital developments of intraosseous infusion in trauma/hypovolemic shock patients.
complications
73

74. In medicine, a central venous catheter ("central line", "CVC", "central venous line" or "central
venous access catheter") is a catheterplaced into a large vein in the neck (internal jugular
vein), chest (subclavian vein or axillary vein) or groin (femoral vein). It is used to administer
medication or fluids, obtain blood tests (specifically the "mixed venous oxygen saturation"), and
directly obtain cardiovascular measurements such as the central venous pressure.
Indications and uses
Indications for the use of central lines include:
Monitoring of the central venous pressure (CVP) in acutely ill
patients to quantify fluid balance
Long-term Intravenous antibiotics
Long-term Parenteral nutrition especially in chronically ill
patients
Long-term pain medications
Chemotherapy
Central venous catheters usually remain in place for a longer period of time than other venous
access devices, especially when the reason for their use is longstanding (such as total parenteral
nutrition in a chronically ill patient). The line is then inserted using the Seldinger technique: a
blunt guidewire is passed through the needle, then the needle is removed. A dilating device may
be passed over the guidewire to slightly enlarge the tract. Finally, the central line itself is then
passed over the guidewire, which is then removed. All the lumens of the line are aspirated (to
ensure that they are all positioned inside the vein) and flushed. A chest X-ray is typically
performed afterwards to confirm that the line is positioned inside the superior vena cava and, in
the case of insertion through the subclavian vein, that no pneumothorax was caused as a side
effect.
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75. 75

76. Free flap transplantation is an important method for the surgical resurfacing of soft tissue
defects in all parts of the body. The arterialized venous flap technique depends on the use of
two veins in the skin flap that are used respectively for arterial flow and venous drainage. The
blood in the arterialized venous flap disperses faster and over a larger area than in flow-through
venous island flaps. Survival depends on the size of the flap, arterial inflow, and venous outflow.
For good results, an arterialized venous flap should be designed to contain most of the venous
network in the centre, the arterial inflow should be anastomosed to one afferent vein, and two
or more efferent veins should drain the arterialized venous flap.
The arterialized venous flap technique involves the use of two veins in the skin flap, one for
arterial flow and one for venous drainage.
Historically, an early technique for the rescue of an ischaemic extremity consisted of the
creation of an arteriovenous fistula between the venous and arterial systems of the extremity,
following which the venous system served as a route of arterial inflow. Ozek et al.' studied the
changes occurring in the venous system after its arterialization and showed that the thickening
and hypertrophy of the vessel walls indicated adaptive changes to withstand the increased
stress experienced in their new roles as arterial conduits. In experimental rat models,
histological evidence clearly shows that arterialization of the venous system can significantly
counteract ischaemic injury to extremity muscles that have suffered loss of arterial supply.
76

77. nada et al. studied factors affecting the survival of
the arterialized venous flap and found that these
flaps could become necrotic in the presence of a
relative excess of arterial blood inflow and that two
venous exits were more effective than one. They
concluded that survival depended on the size of the
flap, arterial inflow, and venous outflow.
Woo et al.
They recommended the following procedures for
complete survival:
an arterialized venous flap should be designed to
contain most of the venous network in the centre
the arterial inflow should be anastomosed to one
afferent vein
two or more efferent veins should drain the
arterialized venous flap
Both the arterial and venous trees are actively involved in the exchange of oxygen and carbon
dioxide.
77

78. Thank you
78