STEP 1

®
USMLE

Anatomy
Lecture Notes
2017

USMLE Step 1 Anatomy.indb 1 10/25/16 5:03 PM

 Chapter 6 l Head and Neck

Supraorbital foramen (supraorbital VAN)

Optic canal (II and ophthalmic artery)

Superior orbital fissure (III, IV, VI, ophthalmic

nerve and veins)

Inferior orbital fissure

Infraorbital foramen (infraorbital VAN)

Mental foramen (mental VAN)

Figure II-6-10. Foramina: Front of Skull

Figure II-6-10. Foramina: Front of Skull

CRANIAL MENINGES AND DURAL VENOUS SINUSES

Cranial Meninges
The brain is covered by 3 meninges that are continuous through the foramen
magnum with the spinal meninges. There are several similarities and differences
between spinal and cranial meninges.

• Pia mater tightly invests the surfaces of the brain and cannot be dis-
sected away, having the same relationship with the brain as spinal pia
mater.
• Dura mater (thickest) unlike the spinal dura, consists of 2 layers (peri-
osteal and meningeal) that are fused together during most of their
course in the cranial cavity.
–– Periosteal layer: outer layer lines the inner surfaces of the flat bones
and serves as their periosteum; can easily be peeled away from the
bones
–– Meningeal (true dura) layer: innermost layer that is mostly fused
with the periosteal dura mater throughout the cranial cavity. At
certain points in the cranium, the meningeal layer separates from the
periosteal layer and forms the dural venous sinuses and connective
tissue foldings or duplications: falx cerebri, diaphragma sellae and
tentorium cerebelli. These duplications separate and support differ-
ent parts of the CNS.

237

USMLE Step 1 Anatomy.indb 237 10/25/16 5:06 PM

 Section II l Gross Anatomy

Anatomy Immunology
• Arachnoid is the thin, delicate membrane which lines and follows the
inner surface of the meningeal dura. Projections of arachnoid called
arachnoid granulations penetrate through the dura mater and extend
into the superior sagittal dural venous sinus. Arachnoid granulations
Pharmacology Biochemistry
are where CSF returns to the systemic venous circulation.

Deep vein
Physiology Arachnoid
Medical Genetics of scalp Emissary vein
granulations
Diploic vein Skin

Pathology Behavioral Science/Social Sciences

Galea aponeurotica

Pericranium

Skull (diploic bone)

Microbiology

Superior sagittal Periosteal dura mater

sinus
Meningeal dura mater
Falx cerebri Cranial
meninges
Arachnoid
Subarachnoid
space
Pia mater
Inferior sagittal
sinus Bridging veins

Figure II-6-11. Coronal Section of the Dural Sinuses

Figure II-6-11. Coronal Section of the Dural Sinuses

There are several spaces related to the cranial meninges:

• Epidural space is a potential space between the periosteal dura and the
bones of the skull: site of epidural hematomas (described later).
• Subdural space is the potential space between the meningeal dura and
the arachnoid membrane: site of subdural hematomas (described later).
• Subarachnoid space lies between the arachnoid and pia mater contain-
ing CSF: site of subarachnoid hemorrhage (described later).

Dural Venous Sinuses

Dural venous sinuses are formed at different points in the cranial cavity where
the periosteal and meningeal dural layers separate to form endothelial lined
venous channels called dural venous sinuses (Figures II-6-11 and II-6-12). The
sinuses provide the major venous drainage from most structures within the cra-
nial cavity. They drain mostly into the internal jugular vein, which exits the
cranial fl or at the jugular foramen. Most of the dural venous sinuses are located
in the 2 largest duplications of meningeal dura mater (falx cerebri and the ten-
torium cerebelli).

238

USMLE Step 1 Anatomy.indb 238 10/25/16 5:06 PM

 Chapter 6 l Head and Neck

The primary tributaries that fl w into the sinuses are the following:

• Cerebral and cerebelli veins form bridging veins, which pass across
the subdural space to drain into the sinuses.
• Emissary veins are valveless channels that course through the bones
of the skull and allow dural sinuses to communicate with extracranial
veins.
• Diploic veins drain the spongy (diploe) core of the flat bones.
• Arachnoid granulations are where CSF returns to the venous circula-
tion.
• Meningeal veins drain the meninges.

1
A

Names of the Major Dural Sinuses 2

1. Superior sagittal* 6
Orbit (ophthalmic veins)
2. Inferior sagittal 3 7
B
3. Straight* 4
4. Transverse* (2) 4
6
Deep face veins
5. Sigmoid (2)
6. Cavernous (2) 5
Confluence of sinuses
5
7. Superior petrosal (2)
* Drain into the confluence of sinuses
located at the inion.
Jugular foramen

Folds (Duplications) of Dura Mater

A. Falx cerebri Internal jugular vein
B. Tentorium cerebelli

FigureFigure
II-6-12.II-6-12. Dural Venous
Dural Venous Sinuses Sinuses

Major dural venous sinuses

The major dural venous sinuses are the following:

• The superior sagittal sinus is located in the midsagittal plane along

the superior aspect of the falx cerebri. It drains primarily into the con-
fluence of the sinuses.
• The inferior sagittal sinus is located in the midsagittal plane near the
inferior margin of the falx cerebri. It terminates by joining with the
great cerebral vein (of Galen) to form the straight sinus at the junction
of the falx cerebri and tentorium cerebelli.

239

USMLE Step 1 Anatomy.indb 239 10/25/16 5:06 PM

 Section II l Gross Anatomy

Anatomy Immunology
• The straight sinus is formed by the union of the inferior sagittal sinus
and the great cerebral vein. It usually terminates by draining into the
confluens of sinuses (or into the transverse sinus).
Pharmacology Biochemistry • The occipital sinus is a small sinus found in the posterior border of the
tentorium cerebelli. It drains into the confluens of sinuses.
• The confluens of sinuses is formed by the union of the superior sagit-
tal, straight, and occipital sinuses posteriorly at the occipital bone. It
Physiology Medical Genetics drains laterally into the 2 transverse sinuses.
• The transverse sinuses are paired sinuses in the tentorium cerebelli
and attached to the occipital bone that drain venous blood from the
confluens of sinuses into the sigmoid sinuses.
Pathology Behavioral Science/Social Sciences
• The sigmoid sinuses are paired and form a S-shaped channel in the
floor of the posterior cranial fossa. The sigmoid sinus drains into the
internal jugular vein at the jugular foramen.
Microbiology
• The paired cavernous sinuses are located on either side of the body of
the sphenoid bone.
–– Each sinus receives blood primarily from the orbit (ophthalmic
veins) and via emissary veins from the deep face (pterygoid venous
plexus). Superficial veins of the maxillary face drain into the medial
angle of the eye, enter the ophthalmic veins, and drain into the cav-
ernous sinus.
–– Each cavernous sinus 1 via the superior and inferior petrosal sinuses
into the sigmoid sinus and internal jugular vein, respectively.
–– The cavernous sinuses are the most clinically significant dural sinuses
because of their relationship to a number of cranial nerves. CN III
and IV and the ophthalmic and maxillary divisions of the trigemi-
nal nerve are located in lateral wall of the sinus. CN VI and internal
carotid artery are located centrally in the sinus.

Cavernous sinus Optic chiasm

Oculomotor nerve (III)
Internal carotid artery
Trochlear nerve (IV)
Pituitary gland
Abducent nerve (VI)
Ophthalmic nerve (V1) Internal carotid artery
Sphenoidal sinus
Maxillary nerve (V2)

Nasopharynx

Figure
Figure Coronal
II-6-13.
II-6-13. Section
Coronal Through
Section Pituitary
Through PituitaryGland
Glandand
andCavernous Sinuses
Cavernous Sinuses

240

USMLE Step 1 Anatomy.indb 240 10/25/16 5:06 PM

 Chapter 6 l Head and Neck

Clinical Correlate

Cavernous Sinus Thrombosis

Infection can spread from the superficial and deep face into the cavernous sinus,
producing a thrombosis that may result in swelling of sinus and damage the cranial nerves
that are related to the cavernous sinus.
CN III and IV and the ophthalmic and maxillary divisions of CN V will be compressed in
the lateral wall of the sinus.
CN VI and the internal carotid artery with its periarterial plexus of postganglionic
sympathetic fibers will be compressed in the central part of the cavernous sinus. CN VI is
typically affected first in a cavernous sinus thrombosis with the other nerves being affected
later. Initially, patients have an internal strabismus (medially deviated eyeball) (CN VI
lesion). Later, all eye movements are affected, along with altered sensation in the skin of
the upper face and scalp.

INTRACRANIAL HEMORRHAGE

Epidural Hematoma
An epidural hematoma results from trauma to the lateral aspect of the skull
which lacerates the middle meningeal artery. Arterial hemorrhage occurs rap-
idly in the epidural space between the periosteal dura and the skull.
• Epidural hemorrhage forms a lens-shaped (biconvex) hematoma at the
lateral hemisphere.
• Epidural hematoma is associated with a momentary loss of conscious-
ness followed by a lucid (asymptomatic) period of up to 48 hours.
• Patients then develop symptoms of elevated intracranial pressure such
as headache, nausea, and vomiting, combined with neurological signs
such as hemiparesis.
• Herniation of the temporal lobe, coma, and death may occur rapidly if
the arterial blood is not evacuated.

Subdural Hematoma
A subdural hematoma results from head trauma that tears superficial (“bridg-
ing”) cerebral veins at the point where they enter the superior sagittal sinus. A
subdural hemorrhage occurs between the meningeal dura and the arachnoid.
• Subdural hemorrhage forms a crescent-shaped hematoma at the lateral
hemisphere.
• Large subdural hematomas result in signs of elevated intracranial pres-
sure such as headache and nausea.
• Small or chronic hematomas are often seen in elderly or chronic alco-
holic patients.
• Over time, herniation of the temporal lobe, coma, and death may result
if the venous blood is not evacuated.

241

USMLE Step 1 Anatomy.indb 241 10/25/16 5:06 PM

 Section II l Gross Anatomy

Anatomy Immunology

Copyright Mosby, an imprint of Elsevier, Inc. Used with permission.

Copyright Mosby, an imprint of Elsevier, Inc. Used with permission.
Nolte:
Nolte: The Human Brain.
The Human Brain.
Pharmacology Biochemistry

Physiology Medical Genetics

Pathology Behavioral Science/Social Sciences

Microbiology

A. Epidural Hematoma* B. Subdural Hematoma*

Figure II-6-14. Intracranial Hemorrhage
Figure II-6-14. Intracranial Hemorrhage

Subarachnoid Hemorrhage
A subarachnoid hemorrhage results from a rupture of a berry aneurysm in
the circle of Willis. The most common site is in the anterior part of the circle of
Willis at the branch point of the anterior cerebral and anterior communicating
arteries. Other common sites are in the proximal part of the middle cerebral
artery or at the junction of the internal carotid and posterior communicating
arteries. Typical presentation is the onset of a severe headache.

ORBITAL MUSCLES AND THEIR INNERVATION

In the orbit, there are 6 extraocular muscles that move the eyeball. A seventh
muscle, the levator palpebrae superioris, elevates the upper eyelid.
• Four of the 6 extraocular muscles (the superior, inferior, and medial
rectus, and the inferior oblique, plus the levator palpebrae superioris)
are innervated by the oculomotor nerve (CN III).
• The superior oblique muscle is the only muscle innervated by the
trochlear nerve (CN IV).
• The lateral rectus is the only muscle innervated by the abducens nerve
(CN VI).
• The levator palpebrae superioris is composed of skeletal muscle
innervated by the oculomotor nerve (CN III) and smooth muscle (the
superior tarsal muscle) innervated by sympathetic fibers.
• Sympathetic fibers reach the orbit from a plexus on the internal carotid
artery of postganglionic axons that originate from cell bodies in the
superior cervical ganglion.

242

USMLE Step 1 Anatomy.indb 242 10/25/16 5:06 PM