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Anatomical Evaluation of the Dural Sinuses in the Region of the Torcular Herophili Using Three Dimensional CT Venography

Posted Aug 31, 2010 Updated Apr 7, 2023
By Akio Fukusumi MD , Toshio Okudera MD , Shoki Takahashi MD , Toshiaki Taoka MD , Masahiko Sakamoto MD , Hiroyuki Nakagawa MD , Katsutoshi Takayama MD , Kimihiko Kichikawa MD , Satoru Iwasaki MD
11 min read

Rationale and Objectives

The torcular herophili, or “confluence of the sinuses,” shows various configurations with other venous sinuses, as revealed by angiography. The aims of this study were to evaluate anatomic variations of this confluence and to assess their clinical relevance using three-dimensional (3D) computed tomographic (CT) venography.

Materials and Methods

The torcular herophili and its relevant venous sinuses were analyzed using 3D CT venography in 120 adults, consisting of 76 patients who were proven to have aneurysms and 44 patients who were proven to have no vascular malformations or aneurysms after the examinations. Three-dimensional CT venography was performed following the arterial phase of 3D CT angiography without any additional injection of contrast material. Three-dimensional volume-rendered venous images were reconstructed on a workstation and reviewed.

Results

The superior sagittal sinus (SSS) drained into the transverse sinus (TS) in four patterns: the SSS reached the centrally located confluence, where it divided into the bilateral TS (20.0%); the SSS was prematurely duplicated into the right and left limbs and drained into the same side TS (26.7%); the SSS drained exclusively into the right TS (44.2%); or the SSS drained exclusively into the left TS (9.2%). The draining pattern of the straight sinus was also classified into four types. The right TS was larger than the left TS. The right TS were higher compared to the left TS. Persistent occipital sinuses were recognized in 57.5% of the subjects. Finally, persistent falcial sinuses were seen in 2.5% of the subjects. A septum in the SSS and complicated venous channels in the confluence were each seen in only one case.

Conclusion

Three-dimensional CT venography is useful as a noninvasive method to evaluate the confluence and its relevant dural sinuses and can provide useful information for surgical intervention.

The torcular herophili, or the “confluence of the sinuses,” is defined as the dilated posterior end of the superior sagittal sinus (SSS), situated to one side (usually the right) of the internal occipital protuberance, where it turns to become a transverse sinus (TS). In this region, the straight sinus (sinus rectus [RS]) drains into the various points, and the occipital sinus (OS) occasionally joins and/or begins . The confluence and its convergent sinuses show various configurations as revealed by angiography.

Although many anatomic and cadaveric studies have investigated the confluence , its radiologic analysis in clinical cases has been rarely published, because selective cerebral angiography does not give a full picture of its configurations . For example, the medial portion of the TS is filled only on vertebral angiography and not on selective internal carotid angiography.

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Materials and methods

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Results

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Classification of Drainage Pattern of the SSS Into the TS

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Figure 1, Classification of the four types of drainage patterns of the superior sagittal sinus (SSS) into the transverse sinus (TS). (a) The SSS reaching the centrally located confluence, then dividing to the bilateral TS (Sc type): 20.0%. (b) The SSS prematurely duplicating into the right and left channels, then draining into the same side TS (Sd type): 26.7%. (c) The SSS predominantly draining into the right TS (Sr type): 44.2%. (d) The SSS predominantly draining into the left TS (Sl type): 9.2%.

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Classification of Drainage Pattern of the RS Into the TS

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Figure 2, Classification of the four types of drainage pattern of the straight sinus (sinus rectus [RS]) into the transverse sinus (TS). (a) The RS reaching the centrally located confluence, then dividing to the bilateral TS (Rc type): 63.3%. (b) The RS prematurely duplicating into the right and left limbs, then each draining into the same side TS (Rd type): 15.0%. (c) The RS predominantly draining into the right TS (Rr type): 10.0%. (d) The RS predominantly draining into the left TS (Rl type): 11.7%.

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Comparison in Size Between the Bilateral TS

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Figure 3, Persistent occipital sinus (OS). (a) Medium-sized OS. The OS is traceable to the marginal sinus around the edge of the foramen magnum and then draining into the right superior jugular bulb. (b) Large OS. The large OS descends into the midline and bifurcates into two limbs, each circumventing the foramen magnum and finally draining into the superior jugular bulbs. Aplasia of the medial portion of the left transverse sinus (TS) is also seen (arrows). RS, straight sinus; SSS, superior sagittal sinus.

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Comparison in Height Between the Bilateral TS

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Persistence of the OS and Its Configuration

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Other Anatomic Variations of Dural Venous Sinuses Near the Confluence

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Figure 4, Other variations of the dural sinuses. (a) Persistent falcial sinus (FS). (b) A venous network at the confluence (arrow). RS, straight sinus; SSS, superior sagittal sinus; TS, transverse sinus.

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Discussion

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Classification of the Drainage Pattern of the SSS Into the TS

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Table 1

Continuity of the SSS with the TS as Shown in Previous Studies

Study Total Subjects Sc (%) Sd (%) Sr (%) Sl (%) Henrici and Kikuchi (1903) 35 11.4 43 28.6 14.3 Edwards (1931) ∗ 50 12 48 22 14 Woodhall (1936) 100 9 52 30 9 Susa (1950) 120 10.8 25.8 52.6 10.8 Makiura (1953) 40 42.5 27.5 25 5 Browning (1953) 100 36 40 18 6 Kaplan et al (1972) ∗ 215 16 10 33 8 Bisaria (1985) ∗ 110 48 10 18 8 Ishizaka (1985) ∗ 52 37 23 17 15 Fukusumi et al (2002) 200 15 26 49 10 Singh et al (2004) 160 35 14 41 10 Present study 120 20.8 26.6 44.2 9.2

Sc, the SSS reaches the centrally located confluence, then divides into the bilateral TS; Sd, the SSS prematurely duplicates into the right and left channels, then drains into the same side TS; Sr, the SSS predominantly drains into the right TS; Sl, the SSS predominantly drains into the left TS; SSS, superior sagittal sinus; TS, transverse sinus.

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Figure 5, Developing cranial venous system in a fetus at 23-mm CR, stage 6 (40–44 days), viewed from above. The anterior dural plexus, from which the sagittal sinus and straight sinus (RS) are derived, drains to the right side predominantly in all. 1 = primitive transverse sinus; 2 = sagittal plexus, which will join the anterior portion of the SSS in adults; 3 = primitive straight sinus; 4 = tentorial sinus; 5 = primitive marginal sinus, which will join the posterior portion of the SSS in adults. Medial situated plexus-formed venous channels will join the bifurcated limbs and then fuse into the posterior portion of the SSS. Primitive marginal sinus should not be confused with the marginal sinus around the foramen magnum. IJV, internal jugular vein; L, left; P, pineal body; R, right.

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Classification of Drainage Pattern of the RS Into the TS

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Table 2

Continuity of the RS with the TS as Shown in Previous Studies

Study Total Subjects Rc (%) Rd (%) Rr (%) Rl (%) Knott (1882) 44 27 0 14 59 Henrici and Kikuchi (1903) 35 11.4 80 0 8.6 Susa (1950) 120 23.3 33.3 19.2 24.2 Makiura (1953) 40 42.5 25 10 22.5 Takeshige (1969) 168 33 39 5 13 Fukusumi et al (2002) 200 40.5 31 20 8.5 Present study 120 63.3 15 10 11.7

Rc, the RS reaches the centrally located confluence, then divides into the bilateral TS; Rd, the RS prematurely duplicates into the right and left limbs, then each drains into the same side TS; Rr, the RS predominantly drains into the right TS; Rl, the RS predominantly drains into the left TS; RS, straight sinus; TS, transverse sinus.

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Comparison in Size Between the Bilateral TS

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Table 3

Dominance of the Right or Left Transverse Sinus as Shown in Previous Studies

Study Total Subjects R > L R = L R < L Edwards (1931) 50 50.0 8.0 42.0 Gibbs and Gibbs (1934) 25 52.0 20.0 29.0 Woodhall (1936) 100 39.0 48.0 13.0 Susa (1950) 120 68.0 16.0 16.0 Browning (1953) 100 51.0 20.0 29.0 Kaplan et al (1972) 215 62.0 15.0 23.0 Ishizaka (1985) 52 52.0 19.2 28.8 Goto and Koda (2000) 132 67.4 20.5 12.1 Fukusumi et al (2002) 200 68.5 10.0 21.5 Present study 120 63.3 21.7 15.0

R > L, with right dominance; R = L, with no dominance; R < L, with left dominance.

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Figure 6, Radiographs of a 22-week-old aborted fetus with injection of contrast medium via right internal jugular vein. (a) Anterior-posterior view; (b) Lateral view. The occipital sinuses (OS) connect between the transverse sinuses (TS) and marginal sinus (MS) around the foramen magnum. Many of these channels regress, resulting in a single thinner OS at birth in most cases. The posterior portion of the superior sagittal sinus (SSS) is duplicated into the right and left limbs and makes a transition to the right and left TS, respectively (the right TS is much larger than the left, or ballooned). The straight sinus (RS) is located in a high position.

Figure 7, Schematic drawing of the development of the transverse sinus (TS) and occipital sinus (OS). (a) Three-month-old fetus: the TS is small in caliber. The OS have not been developed. (b) Four-month-old to 5-month-old fetus: the TS enlarge or balloon from their lateral end later in the 4th month and gradually extend medially to reach the confluence, becoming relatively even in caliber in the 5th month. Also note the underdeveloped sigmoid sinus (SigS) and superior jugular bulb, whereas the OS channels appear well developed and connect to the medial part of the TS with either the marginal sinus (MS) or the distal end of the SigS (ie, the superior jugular bulb). (c) Six-month-old to7-month-old fetus: despite attenuation of the ballooning, the enlarged configuration of the OS will be sustained until birth. The OS have regressed into a single venous channel along the cerebellar falx. (d) After birth. (d-1) to (d-3) represent various development of the OS: short and rudimentary (d-1), medium sized (d-2), and large sized (d-3). The large-sized TS may be associated with aplastic or hypoplastic TS and/or SigS. Em, emissary veins.

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Comparison in Height Between the Bilateral TS

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Persistent OS and Their Configuration

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Clinical Significance

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Figure 8, A case of arteriovenous malformation with venous drainage into the right lateral portion of the transverse sinus (TS). Three-dimensional computed tomographic venography shows a convergent pattern of venous dural sinuses at the torcular herophili, which might permit sacrifice of the right TS during open or endovascular surgical repair of the right arteriovenous malformation. This case was not included in the population of the current study. OS, occipital sinus; RS, straight sinus; SSS, superior sagittal sinus.

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Limitations

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Conclusion

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References

  • 1. Gabella G.: Cardiovascular system.Williams P.L.Gray’s anatomy.1995.Churchill LivingstoneNew York:pp. 1583.

  • 2. Bisaria K.K.: Anatomic variations of venous sinuses in the region of the torcular herophili. J Neurosurg 1985; 62: pp. 90-95.

  • 3. Browning H.: The confluence of dural venous sinuses. Am J Anat 1953; 93: pp. 307-329.

  • 4. Edwards E.A.: Anatomic variation of cranial venous sinuses. Their relation to the effect of jugular compression in lumbar manimetric test. Arch Neurol Psychiatr 1931; 26: pp. 801-814.

  • 5. Gibbs E.L., Gibbs F.A.: The cross section areas of the vessels that form the torcular and the manner in which flow is distributed to the right and to the left lateral sinus. Ana Rec 1934; 59: pp. 419-426.

  • 6. Goto N., Koda M.: Blood vessels in the central nervous system [in Japanese].Sato T.Akita K.Anatomical variations in Japanese.2000.University of Tokyo PressTokyo, Japan:pp. 401-429.

  • 7. Henrici C., Kikuchi J.: Die Varianten der okzipitalen Sinusverbindungen (Confluence sinuum) und ihre klinische Bedeutung. Z Ohrenh 1903; 42: pp. 351-361.

  • 8. Ishizaka H.: Anatomical study of the torcular herophili [in Japanese]. Neurol Med Chir (Tokyo) 1985; 25: pp. 873-880.

  • 9. Kaplan H.A., Browder J., Knightly J.J., et. al.: Variations of the cerebral dural sinuses at the torcular herophili. Importance in radical neck dissection. Am J Surg 1972; 124: pp. 456-461.

  • 10. Knott J.F.: On the cerebral sinuses and their variations. J Anat Phys 1882; 16: pp. 27-42.

  • 11. Makiura F.: Variations of the confluence [in Japanese]. Acta Anat 1953; 28: pp. 87-88.

  • 12. Singh M., Nagashima M., Inoue Y.: Anatomical variations of occipital bone impression for dural venous sinuses around the torcular Herophili. With special reference to the consideration of clinical significance. Surg Radiol Anat 2004; 26: pp. 480-487.

  • 13. Susa Y.: Patterns of the torcular herophili, measurement of sinus lumen and histology of sinus wall [in Japanese]. J Nippon Medical School 1950; 27: pp. 247-263.

  • 14. Takeshige Y.: Die Bedeutung des Venensystems fur die Hamodynamik des Hirnstammes. Anat Anz Bd 1969; 125: pp. 166-192.

  • 15. Woodhall B.: Variations of cranial venous sinuses in the region of the torcular herophili. Arch Surg 1936; 33: pp. 297-314.

  • 16. Dora F., Zileli T.: Common variations of the lateral and occipital sinuses at the confluens sinuum. Neuroradiology 1980; 20: pp. 23-27.

  • 17. Fukusumi A., TanakaT Koh S, et. al.: Anatomical variations of the torcular herophili evaluated with MR venography [in Japanese]. Jpn J Clin Radiol 2002; 47: pp. 625-631.

  • 18. Kobayashi K., Matsui O., Suzuki M., et. al.: Anatomical study of confluence of the sinuses with contrast-enhanced magnetic resonance venography. Neuroradiology 2006; 48: pp. 307-311.

  • 19. Rollins N., Ison C., Booth T., et. al.: MR venography in the pediatric patient. AJNR Am J Neuroradiol 2005; 26: pp. 50-55.

  • 20. Matsumoto M., Kodama N., Sakuma J., et. al.: 3D-CT arteriography and 3D-CT venography: the separate demonstration of arterial-phase and venous phase on 3D-CT angiography in a single procedure. AJNR Am J Neuroradiol 2005; 26: pp. 635-641.

  • 21. Suzuki Y., Ikeda H., Shimadu M., et. al.: Variations of the basal vein: identification using three-dimensional CT angiography. AJNR Am J Neuroradiol 2001; 22: pp. 670-676.

  • 22. Okudera T., Huang Y.P., Yokota A., et. al.: Development of posterior fossa dural sinuses, emissary veins, and jugular bulb: morphological and radiologic study. AJNR Am J Neuroradiol 1994; 15: pp. 1871-1883.

  • 23. Okudera T., Huang Y.P., Yokota A., et. al.: Developmental radiology of posterior fossa dural sinuses in the human fetus: with special reference to physiological enlargement of transverse and occipital sinuses, formation of emissary veins, and development of superior jugular bulb from jugular sinuses.Hakuba A.Surgery of the intracranial venous system.1996.Springer-VerlagTokyo, Japan:pp. 192-203.

  • 24. Okudera T., Ohta T., Huang Y.P.: Embryology of the cranial venous system with particular reference to the dural venous sinuses related to the torcular.Kapp J.P.Schmidek H.H.The cerebral venous system and its disorders.1998.Grune & StrattonOrlando, FL:pp. 93-107.

  • 25. Padget D.H.: The development of cranial venous system in man. From the view point of comparative anatomy. Contrib Embryol 1957; 247: pp. 81-138.

  • 26. Streeter G.L.: The development of the venous sinuses of the dura mater in the human embryo. Am J Anat 1915; 18: pp. 145-178.

  • 27. Masaki S.: Studies on the development of the dural sinuses of the human fetus [in Japanese]. Fukuoka Acta Medica 1959; 50: pp. 2769-2788.

  • 28. LeMay M.: Left-right dissymmetry, handedness. AJNR Am J Neuroradiol 1992; 13: pp. 493-504.

  • 29. Hochberg F.H., LeMay M.: Angiographic correlates of handedness. Neurology 1975; 25: pp. 218-222.

  • 30. Das A.C., Hasen M.: The occipital sinus. J Neurosurg 1970; 33: pp. 307-311.

  • 31. Kobayashi K., Suzuki M., Ueda F., et. al.: Anatomical study of occipital sinus using contrast-enhanced magnetic resonance venography. Neuroradiology 2006; 48: pp. 373-379.

  • 32. Zouaoui A., Hidden G.: Cerebral venous sinuses: anatomical variants or thrombosis?. Acta Anat 1988; 133: pp. 318-324.

  • 33. Ohata K., Moududul H., Morino M., et. al.: Occlusion of the sigmoid sinus after surgery via the presigmoidal-transpetrosal approach. J Neurosurg 1998; 89: pp. 575-584.

Academic Radiology, Volume 17, Issue 9
Journals General Radiology
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