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J Neurosurg 106:900–902, 2007 Surgical anatomy and landmarks for the basal vein of Rosenthal R. SHANE TUBBS, M.S., P.A.-C., PH.D.,1,2 MARIOS LOUKAS, M.D., PH.D.,3,4 ROBERT G. LOUIS JR., M.D.,3 MOHAMMADALI M. SHOJA, M.D.,5 CAMERON S. ASKEW, B.S.,6 APRIL PHANTANA-ANGKOOL, B.S.,6 E. GEORGE SALTER, PH.D.,2 AND W. JERRY OAKES, M.D.1 Section of Pediatric Neurosurgery, 2Department of Cell Biology, and 6School of Medicine, University of Alabama at Birmingham, Alabama; 3Department of Anatomical Sciences, St. George’s University, Grenada, West Indies; 4Department of Education and Development, Harvard Medical School, Boston, Massachusetts; and 5Department of Anatomy and Neurosurgery, Tabriz Medical University, Tabriz, Iran 1 Object. The basal vein of Rosenthal (BV) courses from the premesencephalic cistern, through the ambient cistern, and terminates in the quadrigeminal cistern. The aim of this study was to describe and quantitate the surgical anatomy of this structure and specifically to provide landmarks for identifying this vessel along its course. These data may be of use, for example, to surgeons using subtemporal operative approaches through regions where this vessel is concealed. Methods. The authors examined 15 latex-injected adult cadaveric brains (30 sides) to delineate the morphological characteristics of the BV. Dissections of the BV were then performed and measurements were made between this structure and the tentorial incisura at the anterior, middle, and posterior borders of the lateral midbrain. All specimens were found to have a left and right BV with varying morphological characteristics. The mean distance between the BV and posterior cerebral artery at the midpoint of the lateral midbrain was 16 mm. The BV was always found superomedial to the posterior cerebral artery along the lateral aspect of the midbrain, and the BV ranged in diameter from 1 to 5 mm. The BV drained into the vein of Galen in all but two specimens. The mean distances from the tentorial edge to the BV at the anterior, middle, and posterior borders of the lateral midbrain were 11, 13, and 4 mm, respectively. No statistically significant differences were found when comparing left and right sides or male and female specimens. Conclusions. The authors hope that these data will help the neurosurgeon operating near the BV to avoid injury to this important structure. KEY WORDS • cranium • brain • vasculature • midbrain • anatomy • cadaver deep venous system of the brain is composed of the internal cerebral vein, great vein of Galen, the BV, and their respective tributaries.4 The BV begins just anterior to the midbrain near the anterior perforated substance, travels lateral to this structure, and terminates posteriorly, usually into the great vein of Galen, although it may drain into the straight sinus or the internal cerebral veins (Fig. 1).7,9 The BV was first described by Rosenthal in 1824 and arises from four main vessels: the anterior cerebral vein, formed by the anterior limbic and pericallosal veins; the medial and inferior frontal veins, of which one is the olfactory vein; the deep sylvian vein (deep middle cerebral); and the inferior striate veins (Fig. 2).3,9 Other tributaries to the BV that have been described include the hippocampal vein, the inferior choroidal vein (which may be large),2 and the inferior ventricular, posterior thalamic, peduncular, lateral mesencephalic, pontine, precentral, and quadrigeminal veins. Several important structures accom- T HE Abbreviation used in this paper: BV = basal vein of Rosenthal. 900 pany the BV lateral to the midbrain, including the posterior cerebral and superior cerebellar arteries and the trochlear nerve. Materials and Methods Fifteen formalin-fixed adult cadaveric heads (30 sides) from patients 60 to 88 years of age at death (mean 79 years) were dissected. Seven specimens were obtained from male cadavers and eight specimens from female cadavers. With each cadaver in the supine position, the carotid sheath was identified and the internal jugular vein was isolated bilaterally. Blue latex was injected into both the left and right internal jugular veins. Specimens were allowed to cure for at least 36 hours prior to dissection. The calvaria and brains were next removed using an oscillating bone saw, and the basilar sinus was identified and studied with dissection. Dissections of the BV were performed using a subtemporal approach and quantitation was made of its branching pattern. A surgical microscope (Zeiss) was used for magnification. Measurements were then made between the BV and the tentorial incisura at the anterior, middle, and posterior borders of the midbrain (Fig. 3). Microcalipers were used for all measurements. A statistical analysis of the differences between sides was performed using chi-square tests (Cramer Phi and Cramer V tests). Significance was determined to be a probability value less than 0.05. J. Neurosurg. / Volume 106 / May, 2007 Basal vein of Rosenthal FIG. 1. Artist’s illustration of the BV as it travels around the lateral aspect of the mesencephalon. Results The BV was identified in all specimens and was found to be superior and medial to the posterior cerebral artery in all cases. The distance between the BV and the posterior cerebral artery at the lateral midbrain ranged from 1 to 25 mm (mean 6 standard deviation 16 6 3.5 mm). The BV ranged in diameter from 1 to 5 mm (mean 2 mm). Tributaries contributing directly into the BV generally measured 0.25 to 0.5 mm. The type and number of these tributaries are found in Table 1. The BV drained into the vein of Galen in all but two specimens. On one left side the BV drained into the ipsilateral internal cerebral vein, and in one specimen both the left and right BV drained into the superficial pial vessels along the temporooccipital lobes and thus did not have any connection to the vein of Galen. A left BV in a female cadaver was found to drain into both the vein of TABLE 1 Tributaries to the BV observed in 30 cadaveric sides Tributary No. of Branches (range) lamina terminalis anterior perforated substance infundibulum mammillary body optic tract superficial optic tract deep choroidal (temporal horn) amygdala uncus hippocampus/fornix lateral mesencephalon lateral geniculate body pulvinar pineal tectal superior medullary velum tentorial bridging vein 0–2 0–3 0–5 0–2 1–3 1–3 1–2 0–2 0–2 0–2 2–6 0–3 0–2 0–1 0–3 0–1 1 J. Neurosurg. / Volume 106 / May, 2007 FIG. 2. Upper: Inferior view of the BV after transection of the mesencephalon. The arrowhead indicates the BV. Lower: Artist’s illustration of the view shown in the upper panel demonstrating additional tributaries. Galen and a superior cerebellar vein. This same specimen was found to have a very prominent lateral mesencephalic vein that drained inferiorly into the superior petrosal sinus. The distance ranges from the tentorial edge to the BV at the anterior, middle, and posterior borders of the midbrain were 6 to 15 mm (mean 6 standard deviation 11 6 1.1 mm), 5 to 20 mm (13 6 1.3 mm), and 1 to 10 mm (4 6 1.0 mm), respectively (Fig. 3). No statistically significant differences were found when comparing left and right sides or male and female specimens. No gross intracranial lesions were observed in any cadaver. Discussion Padget demonstrated that the BV is a complicated ves5 901 R. S. Tubbs et al. sigmoid sinus via the BV and its indirect connection to the superior petrosal sinus by the lateral mesencephalic vein.5,6 Additionally, other veins that occasionally drain into the BV include the internal occipital, splenial, precentral cerebellar, superior vermian, and subependymal veins from the atrium, and the superior thalamic veins.3 Topographically, Zajgner11 found that the BV crossed the tentorial notch in three of 23 cases. In a previous study of the cisternal segment of the trochlear nerve, we found that the mean distance between this nerve (cisternal segment) and the BV at a midpoint of the lateral midbrain was 7.5 mm.8 In the present study, we found that the mean distances from the tentorial edge to the BV at the anterior, middle, and posterior borders of the lateral midbrain were 11, 13, and 4 mm, respectively. FIG. 3. Lateral view of the midbrain demonstrating the distances measured in this study from the tentorial edge to the BV at the anterior, middle, and posterior borders of the lateral mesencephalon (arrows). sel formed when the embryo is approximately 70 mm long that arises secondarily as a longitudinal anastomotic channel uniting several regional embryologic veins. These components develop as the telencephalic, diencephalic, and mesencephalic veins when the embryo is between 14 and 18 mm long, and differentiate into the deep telencephalic, ventral diencephalic, dorsal diencephalic, and mesencephalic veins. Posterior drainage is formed by a connection between the dorsal diencephalic vein and the internal cerebral vein or a tributary of the vein of Galen. The deep middle cerebral vein and the anterior cerebral veins develop from the deep telencephalic vein, and the ventral diencephalic vein drains from the primitive tentorial sinus into the transverse sinus at approximately the 40-mm embryo stage. Interestingly, in many animals the BV drains into the transverse sinus.10 The ventral diencephalic vein forms a communication between the superior petrosal sinus via the peduncular vein and the anterior pontomesencephalic vein in addition to the primitive tentorial sinus. The mesencephalic vein forms the lateral mesencephalic vein that connects the ventral diencephalic vein of one side to the mesencephalic vein (this vein becomes the superior petrosal sinus) contralaterally. Suzuki and colleagues7 have proposed that the potential variations of the BV can be classified on the basis of these five drainage pathways and their anastomoses between the primary primitive veins (deep telencephalic vein, ventral diencephalic vein, dorsal diencephalic vein, and mesencephalic vein). Padget5 postulated that the superficial pial veins of the cortex may drain into the BV. In fact, one of our specimens was found to have a bilateral BV that drained not into the galenic system but rather terminated more laterally into the pial veins of the temporal and occipital lobes. Browder and Kaplan1 have reported veins of the medial occipital lobe draining into the caudal part of the BV. In one specimen, a right pineal vein was found to drain into the posterior BV. We found only one other source9 describing pineal veins (which usually drain into the vein of Galen) draining into the BV, as seen in two of our specimens. When the great vein of Galen is occluded, deep drainage can pass into the 902 Conclusions A more accurate knowledge of the anatomy of the BV, including surgical landmarks, could potentially be helpful to clinicians and particularly neurosurgeons who deal with cerebral venous disorders or operate in the vicinity of this vein. References 1. Browder J, Kaplan HA: Cerebral Dural Sinuses and their Tributaries. Springfield, Ill: Charles C Thomas, 1976, p 94 2. Grand W, Hopkins LN: Vasculature of the Brain and Cranial Base: Variations in Clinical Anatomy. New York: Thieme, 1999, p 186 3. Huang YP, Wolf BS: The basal cerebral vein and its tributaries, in Newton TH, Poos DG (eds): Radiology of the Skull and Brain. St. Louis: Mosby, 1974, pp 2111–2154 4. Ono M, Rhoton AL Jr, Peace D, Rodriguez RJ: Microsurgical anatomy of the deep venous system of the brain. Neurosurgery 15:621–657, 1984 5. Padget DH: The cranial venous system in man in reference to development, adult configuration, and relation to the arteries. Am J Anat 98:307–355, 1956 6. San Millán Ruíz D, Gailloud P, Rüfenacht DA, Delavelle J, Henry F, Fasel JH: The craniocervical venous system in relation to cerebral venous drainage. AJNR Am J Neuroradiol 23: 1500–1508, 2002 7. Suzuki Y, Ikeda H, Shimadu M, Ikeda Y, Matsumoto K: Variations of the basal vein: identification using three-dimensional CT angiography. AJNR Am J Neuroradiol 22:670–676, 2001 8. Tubbs RS, Oakes WJ: Relationships of the cisternal segment of the trochlear nerve. J Neurosurg 89:1015–1019, 1998 9. Wackenheim A, Braun JP: The Veins of the Posterior Fossa: Normal and Pathologic Findings. Berlin: Springer-Verlag, 1978, p 9 10. Wolf BS, Huang YP, Newman CM: The lateral anastomotic mesencephalic vein and other variations in drainage of the basal cerebral vein. Am J Roentgenol Radium Ther Nucl Med 89: 411–422, 1963 11. Zajgner J: Normal relationship between basal vein and posterior cerebral artery. Acta Radiol Diagn (Stockh) 9:549–552, 1969 Manuscript submitted June 9, 2006. Accepted December 12, 2006. Address reprint requests to: R. Shane Tubbs, Ph.D., Pediatric Neurosurgery, Children’s Hospital, 1600 7th Avenue South ACC 400, Birmingham, Alabama 35233. email: [email protected]. J. Neurosurg. / Volume 106 / May, 2007