Meninges

Dura Matter :
• Is the outer most layer of the menings . it is tough
fibrous tissue and it's very vascular , supplied by
middle meningeal vessel
• Dura matter is made of 2 layers
1. Outer layer : is attached to the bone and
called periosteal layer.
2. Inner layer : cover the brain with the other
menings and called meningeal layer .
• the two layer of the Dura matter is always fuse
together But they can be separated
1. To accommodate venous sinuses
2. In Extradural hematoma .

Arachnoid Matter :
• Has a lot of veins and vessels .
• Has multiple invaginations in the venous sinuses
for drainage of CSF to the blood.
• These invaginations called the Arachnoid villi and
collectively called Arachnoid granulation.
• Sometimes in the meningitis these Arachnoid
granulation become fibrosed and this stop the
drainage of CSF to the sinus .
• CSF it will accumulate and cause :-
1. In young people hydrocephalus .
2. In adult the bone is strong and can't cause
hydrocephalus and these called Normal tension
hydrocephalus or normal pressure hydrocephalus
• The ventricals may increase in size in this cause
atrophy for the brain and pateint will presented :-
1. Amnesia = loss of memory .
2. Ataxia = inability to co-ordinate the
muscle movement.
• All this occre after Meningitis so it called post
meningitic hydrocephalus .

Pia Matter :-
• Cover the Brain surface and Attach to the gyri
and sulci of the brain .

• Subdural space :between the meningeal

layer of the Dura matter and the Arachnoid
matter . It contains :-
1. Terminal part of the cerebral veins
• Subarachnoid space : between Arachnoid and the
pia matter it contain
1. Cerebral vessel
2. CSF
★ Extradural hematoma :
• Occur between the 2 layer of the Dura matter
• The source of bleeding is the anterior branch
of the middle meningeal artery which directly
behined the PTERION.
• Why extradural heamtoma is top emergency and
life threatening condition ??!
• Answer :‫ اﻟﺰول اﻟﺒﯿﻜﻮن ﻋﻨﺪو‬extradural heamtoma
‫ال‬classical scenario ‫اﻟﺒﺠﯿﻚ ﺑﯿﻬﻮ اﻟﻤﺴﺘﺸﻔﻰ‬
‫ﻳﻘﻮل ﻟﯿﻚ ﻳﺎخ وا‬
. ‫وﻗﻌﺘﺎ ﻋﻠﻰ رأﺳﻲ وﻓﻘﺪﺗﻬﺎ اﻟﻮﻋﻲ وﺑﻌﺪ داك ﺻﺤﯿﺖ‬
‫ﺳﺒﺐ ﻓﻘﺪان اﻟﻮﻋﻲ اﻷول دا ﺷﻨﻮ ؟؟‬
{ brain concussion ‫ﻣﻊ اﻟﻀﺮﺑﺔ ﺑﯿﺘﺤﺼﻞ ﺣﺮﻛﻪ ﻟﻠﻤﺦ } ارﺗﺠﺎج‬
‫اﻟﺤﺮﻛﻪ ﺑﺘﺨﻠﯿﻚ ﺗﻔﻘﺪ اﻟﻮﻋﻲ ﻟﻜﻦ ﻣﻤﻜﻦ ﺗﺼﺤﻰ ﺑﻌﺪﻳﻬﺎ ﻻﻧﻬﺎ ﺣﺎﺟﻪ‬
temporal ‫ ﻣﺆﻗﺘﻪ‬.
‫ ﺣﯿﻜﻮن ﺷﻨﻮ م دام اﻟﺰول دا‬injury‫ ﺑﺘﺎع ال‬effect‫اﮬﺎ ال‬
‫واﻗﻒ ﺑﯿﺘﻜﻠﻢ ﻣﻌﺎك ؟؟‬
• We have bleeding from the middle meningeal
artery and the blood start to accumulate in
cranial cavity and this accumulation form the
extradural heamtoma.
• This hematoma try to push the bone but it fail ;
and therefore it will push the brain and menings
against the base of the brain . -‫ﺗﺤﺖ ﻃﺒﻌﺎ م ف ﻓﺘﺤﻪ‬
‫ﻏﯿﺮ ال‬foramin magnum ‫ﻓﯿﺤﺎول ال‬brain stem‫ﻳﻄﻠﻊ‬
‫ ﺑﯿﻬﺎ ﻛﺪا ﻋﻤﻠﻨﺎ‬compression ‫ﻋﻠﻲ ال‬brain stem‫ﻓﺎﻟﻌﯿﺎن‬
‫ﺗﺎﻧﻲ ﻳﺒﺪأ ﻳﺸﻌﺮ ﺑﻲ‬
 ‫ ﺗﺎﻧﻲ ﻳﺒﺪأ ﻳﺸﻌﺮ ﺑﻲ‬: Confusion , headache, drowsiness
and coma. In the brain stem we have the medulla
which contain the vital centre like respiratory
centre And this compression will affect the
medulla and produce sudden death. ‫ﻳﻌﻨﻲ اﻟﺰول اﻟﻌﻨﺪو‬
extradural heamtoma ‫ >== ﺑﯿﻤﻮت ﻓﺠﺄه‬suddenly .
• The peroid between the lose of consciousness
and death is called LOSED PEROID OR LOSED
INTERVAL . and it Tricky peroid and you have
to be careful about it ‫ﻳﻌﻨﻲ اﻟﻤﺮﻳﺾ وﮬﻮ ﺑﯿﺘﻜﻠﻢ ﻣﻌﺎك‬
‫ ف‬LOSED INTERVAL.
• Any person come to you in the hospital with head
injury you assume it has extradural hematoma
until you prove other wise Treatment :- ‫ﺗﻔﺘﺢ ال‬
bone ‫ وﺗﻌﻤﻞ‬evacuation to the hematoma.
• In the CT SCAN extradural heamtoma appear
convex in shape
• ‫ اﮬﻢ ﺳﺆال ﺗﺴﺄﻟﻮ ﻟﻠﻌﯿﺎن ﮬﻞ ﻓﻘﺪت اﻟﻮﻋﻲ وﻻ ﻻ ؟؟‬.

★ Subdural hematoma :-
• between the meningeal layer of the Dura and
Arachnoid Matter .
• Therefore has ability to expand unlike the
extradural heamtoma not expand because the
periosteal layer of the Dura is strongly attache
to the the bone and it suture each bone has it
own periosteal layer .
• The source of the bleeding the cerebral veins .
• Subdural hematoma appear sickle shaped
in the CT

# difference between the subdural and

extradural hematoma
• Extradural :-
1. Convex in CT scan
2. fresh white in Color in CT scan
3. Not expand but compress on the brain
4. Middle meningeal artery is the source
of bleeding
• Subdural :-
1. Sickle shape in CT scan
2. Black in color in CT because it usually chronic
3. Can expand
4. Cerebral veins is source of bleeding

# blood supply of the menings :

1. Ethmoidal artery .
2. Middle meningeal artery is the main
blood supply
3. Accessory meningeal artery .
4. Occipital artery .
5. Vertebral artery .

# Nerve Supply Of The Menings

• has only sensory innervation :

1. Trigeminal nerve : by it all branch give sensory
innervation to the meanings.
2. Cranial nerves that enter jugular foramin { 9,
10 ,11}also supply it
3. Cervical plexus by :- C1,C2 ,C3 enter Through
the foramin magnum
Q: Why patients with meningitis has neck stiffness ?

• Answer : because the cervical plexus supply both

neck and the meanings.

# Foldings Of The Dura Matter :-

• To stabilize the brain the Dura matter
is has to fold .

‡ 1. Falx Cerebri :
• found in the midline
• It's a Sagital suture and separate the 2 lobes of
the brain from each other .
• it is function to stabilize the brain .
• Upper margin of the falx cerebri contain Superior
Sagital Sinus and Lower margin or the free margin
contain Inferior Sagital Sinus

‡ 2. Tentorium cerebelli :
• transverse folds . Cover the posterior
cranial fossa
• Above it the occipital lobe of the brain and
below it the cerebellum.
• It has opening called Tentorial notch connect the
brain stem with the rest of the brain.
• Tentorial notch attach the anterior and
posterior clinoid process and form roof for
the cavernous sinus .

‡ 3. falx cerebelli :
• separate the 2 lobes if the cerebellum.

‡ 4. Diaphragm sellae :
• cover the sella turcica or the pituitary fossa .
• Has opening for the pitutary stalk to connect the
pituitary gland with the hypothalamus.

•--------------------------------------------------•
 Cerebro Spinal Fluid :-
• Surround the brain and the spinal cord
• Produce by the choroid plexus , and It is
about 150 ml .
• Contiously produced and changed 3 times per day

# Function of the CSF :-

1. Bring the nutrients to the CNS and remove
it's waste products
2. Reduce the weight of the brain from
1500 g to 50 g

•--------------------------------------------------•

Brain Sinuses :-
‡ 1. Superior Sagital Sinus :
• Start from the foramin cecum anteriorly and as
it go posterioly it become big becaus it receives
venous drainage and reach the internal occipital
protuberance where it curve to the right to form
right transverse sinus
• At the base of petrous part of the temporal
bone it convert to segmoidal sinus when
enter the jugular foramin it became right
internal jugular vein .
• Superior sagital sinus drainage
1. Superior cerebral vein : from the brain
2. Diploic vein : from the bone
3. Emissary vein : from the scalp
4. Arachnoid granulation : CSF .

• CSF mainly drain to the SSS.

• Superior sagital sinus is A typical vein , and
bleeding from it is fatal.

‡ 2. Inferior Sagital Sinus :-

• In the junction of the falx cerebri and Tentorium
cerebelli inferior Sagital Sinus receive the
great cerebral vein of Galen and convert
into straight sinus .

‡ 3. Straight sinus :-
• form by the inferior sagital sinus when it join the
great cerebral vein of Galen.
• When it reach the internal occipital protuberance
it curve to the the left to left transverse sinus
• At the base of the petrous part of the temporal
bone it form the left segmoidal sinus which enter
the jugular foramin as left internal jugular vein .
‡ 4. Occipital sinus :-
• from the internal occipital protuberance to the
foramin magnum and then divide to drain to
the segmoidal sinus

‡ 5 Transverse sinus :-
• Right and left .

‡ 6. segmoidal sinus :-
• Right and left .

Note :- " Exam "

• region of the internal occipital protuberance
called the confluence of the sinus because
it contain
1. Superior sagittal sinus
2. Straight sinus
3. Occipital sinus

‡ 7. Cavernus sinus :
• in each side of the pituitary fossa .
• Receive 3 veins
1. Superior ophthalmic vein from the eye.
2. Sphinopareital sinus from the lesser wing of the
sphenoid bone " in OSPE EXAM"
3. Superficial middle cerebral vein from the brain.

• From the Cavernus sinus the blood drained

by 2 sinus which are
1. Superior petrosal sinus : drain to where the
transverse sinus change to segmoidal sinus .
2. inferior petrosal sinus : drain to the internal
jugular vein as the first tributary of the
internal jugular vein and pass through the
jugular foramin.

# Note :-
• all the blood from the brain is drained by great
cerebral vein of Galen except :
1. Superior cerebral vein drain into SSS.
2. Superficial middle cerebral vein drain into
cavernus sinus .

• Sigmoid sinus receive :-

1. Transverse sinus
2. Occipital sinus
3. Superior petrosal sinus

# Content of the Cavernus sinus :-

• in the cavity of the sinus we find :-
1. Intercavernus segment of the internal
carotid artery .
2. sympathetic plexus around the internal
carotid artery
3. Abducen nerve { CN 6}: inferolateral to the
artery . Supplying laterl rectus muscle .

• in the wall of the sinus we fined :

1. maxillary nerve V2
2. Ophthalmic nerve V1
3. Trochlear nerve IV
4. Occlomotor nerve lll

• The Cavernus sinus is directly behined superior

orbital fissure , so any thing enter the eye must
passe through it such as :-
1. Oculomotor nerve III
2. Trochlear nerve IV
3. Ophthalmic nerve V1
4. Superior ophthalmic vein
5. Abducen nerve VI

• Inside the Cavernus sinus we have connections

between the sympathetic plexux around
 the internal carotid artery and Occlomotor
nerve III and also betwen sympathetic plexux
around the Internal carotid artery and the
ophthalmic nerve V1
• The Oculomotor supply III levator palpebrae
superious by the sympathetic fiber from the sym-
pathetic plexux around the internal carotid atery
and by parasympathtic from occulomotor it self
• Ophthalmic nerve V1 supply dilator pupilae
muscle with sympathetic fiber from the
sympathetic plexux around the internal
carotid atery

★ Horner Syndrome :
• Causes :
• 1. Internal carotid artery aneurysm inside the
cavernous sinus. So the connection between the
sympathetic plexus with other nerve is lost so
the patient comw wih partial ptosis
• A) partial ptosia : occur because the
sympathetic innervation to the levator palpebrae
superiors is stoped. It's Partial because the
parasympathtic part of the occulomotor which
supply the levator palpebrae superiors is intact.
• In the levator palpebrae superiors the
parasympathtic is dominant than than the
sympathetic , so if oculomotr is injured this
result in complete ptosis .
• B) Myosis : constriction of the eye pupil ,
because sympathetic fiber which inervate the
dilator pupilae muscle is stoped.
• 2. Lung cancer : because it compress the cervical
symapthetic trunck
• In addition to myosis and ptosis the patient will
have Anhydrosis ( loos of sweating in the face)
• This because sympathetic innervation for
the sweat gland of the face come from the
cervical plexus
• So if the patient have normal sweat →
the internal
carotid artery aneurysm .
• Is the patient have no sweating → lung
cancer or cervical rib

★ Rupture of the internal carotid artery inside

the cavernus sinus :-
• result in reverse flow of the blood . It may passes
through the superior ophthalmic vein to the eye
result in Exo-ophthalmus

★ Danger Area of The Face :-

• bounded by 2 veins angular vein above and
deep facial vein below.
• Any infection in this area can reach the caverns
sinus and can lead to death .
1. angular vein empty in superior ophthalmic vein
which empty in the Cavernus sinus .
2. deep facial vein go to the pterygoid venous
plexus them through the emissary veins to
the cavernus sinus .
• From the Cavernus sinus the infection goes
through the superior petrosal sinus to the sigmoid
sinus then to the medulla . Which contain vital
centre and any infection in it is fatal .

Mastoiditisc :-
• is an infection of the air cells within the mastoid
process of the temporal bone, often caused
by untreated acute otitis media. A known
complication of mastoiditis is infl ammation of
the transverse sinus.
Last modified: Sep 14, 2018