Dissector Answers - Scalp, Cranial Cavity, Meninges & Brain

Learning Objectives:

Upon completion of this session, the student will be able to:

1. Define the scalp, its structural layers, muscles, nerves, and vessels.

2. Identify the prominent landmarks on the internal surface of the skull base.

3. Identify the major blood vessels of the brain, the specializations of cranial meninges, and cranial dural modifications.

4. Identify the cranial nerves on the brain and their courses through the skull base.

5. Identify the parts of the ventricular system and trace the flow of cerebrospinal fluid from production to reabsorption.

Learning Objectives and Explanations:

1. Define the scalp, its layers, muscles, nerves, and vessels. (N98, N99A, N99B, N101, N102, TG7-30)
The scalp consists of five layers of tissue. The first three (scalp proper) are connected intimately and move as a unit in wrinkling the
scalp.

Skin - thin except in the occipital region where it is thick. It has an abundant arterial supply, good lymphatic and venous
drainage, as well as numerous sweat and sebaceous glands.

Connective tissue - thick, richly vascularized subcutaneous layer that is well supplied with cutaneous (sensory) nerves.
This second layer contains the arteries, veins, and cutaneous nerves, which are held tightly in place by collagenous
bundles.
 Aponeurosis (galea aponeurotica) - a strong tendinous sheath that covers the calvaria as well as the frontalis and
occipitalis portions of the epicranius muscle. Laterally, the anterior and superior auricular muscles (moving the ear) also
attach to this aponeurosis.

Loose connective tissue - layer over the calvaria that allows for movement of the first three layers of the scalp.

Pericranium (also called Periosteum) - the external bone of the calvaria. (WB 254).

For a detailed view of the distribution of the nerves and vessels of the scalp please see 255 WB.
2. Identify the prominent landmarks on the internal surface of the skull base. (N6, N7A, N7B, N9, N11, TG7-07, TG7-08)
The internal surface of the skull is divided into three fossae (depressions):

Anterior cranial fossa - This fossa is shallow and the crista galli projects upward from its surface. The cribriform plate
contains multiple foramen through which branches of the olfactory nerve pass. The lesser wing of the sphenoid marks the
posterior border of the anterior cranial fossa.

Middle cranial fossa - This fossa is of intermediate depth and is notable for containing the sella turcica, which holds the
pituitary. The bulk of the middle cranial fossa is composed of the greater wings of the sphenoid and the squamous portion
of the temporal bones, upon which rest the temporal lobes. The posterior border of the middle cranial fossa is a ridge of
bone called the petrous portion of the temporal bone. The middle cranial fossa contains the optic canal, superior orbital
fissure, foramen rotundum, foramen ovale, foramen spinosum, and foramen lacerum.

Posterior cranial fossa - This fossa is relatively deep and contains the cerebellum. Projecting posterior to the foramen
magnum is the internal occipital protuberance. The internal acoustic meatus is located on the petrous portion of the
temporal bone. The jugular foramen is anterolateral to the hypoglossal canal.

3. Identify the major blood vessels of the brain, the specializations of cranial meninges, and cranial dural modifications.
(N98A, N99B, N101, N102, N103, N104A, N104B, N137,N138, N139, TG7-46, TG7-48, TG7-49, TG7-56A, TG7-56B, TG7-72, TG7-73)
Arterial supply

Internal carotid artery - gives rise to ophthalmic (which you will be responsible for in a later lab), posterior communicating,
anterior cerebral, and middle cerebral arteries.
 Vertebral arteries

1. Anterior spinal arteries - paired branches that unite in the midline.

2. Posterior inferior cerebellar arteries, from which arise the two posterior spinal arteries

Basilar artery - formed by union of the vertebral arteries, it gives rise to anterior inferior cerebellar, superior cerebellar
arteries, and bifurcates into the posterior cerebral arteries.

Circle of Willis or Cerebral arterial circle - forms an important means of collateral circulation in case of obstruction. The
circle itself has good collateral circulation, but branches of the circle are end arteries and there is little collateral circulation
in the brain itself. Formed by the union of the anterior cerebral, anterior communicating, posterior communicating, and
posterior cerebral arteries.

Venous Return

Here is a diagram of the direction of venous return in the brain.

Meninges of the brain

I. Pia mater ("delicate mother")

o is a delicate investment that is closely applied to the brain and dips into fissures and sulci.

o enmeshes blood vessels on the surface of the brain.

II. Arachnoid mater ("spidery mother")

 o is a filmy, transparent, spidery layer that is connected to the pia mater by trabeculation.

o is separated from the pia mater by the subarachnoid space, which is filled with cerebrospinal fluid (CSF). It may
contain blood after hemorrhage of a cerebral artery (site of formation of subarachnoid hematoma).

o projects into the superior sagittal sinus to form arachnoid villi, which serve as sites where CSF diffuses into the
blood.

Cerebrospinal fluid

is formed by vascular choroid plexuses in the ventricles of the brain and is contained in the
subarachnoid space.

circulates through the ventricles, enters the subarachnoid space, and eventually is returned to the
venous system through the arachnoid granulations.

Arachnoid granulations

are tuft-like collections of highly folded arachnoid that project into the superior sagittal sinus and its
lateral lacunae (lateral extensions of the superior sagittal sinus).

release CSF into the superior sagittal sinus and often produce erosion or pitting of the inner surface
of the calvaria (granular foveolae).

III. Dura mater ("tough mother")

o outermost covering

o two layers

periosteal dura - lines the cranial bones

 meningeal layer - inner layer that is sometimes separated from the periosteal layer, forming dural venous
sinuses and partitions

o Projections of the dura mater

Falx cerebri is the sickle-shaped double layer of the dura mater, lying between the cerebral hemispheres. It
is attached anteriorly to the crista galli and posteriorly to the tentorium cerebelli. Its inferior concave border is
free and contains the inferior sagittal sinus, and its attachment to the frontal and parietal bones at the sagittal
suture encloses the superior sagittal sinus.

Falx cerebelli is a small sickle-shaped projection between the cerebellar hemispheres. It is attached to the
posterior and inferior parts of the tentorium and contains the occipital sinus in its attachment to the occipital
bone.

Tentorium cerebelli is a crescentic fold of dura mater that supports the occipital lobes of the cerebral
hemispheres and covers the cerebellum. Its internal concave border is free and defines the tentorial notch,
whereas its attachment to the occipital and temporal bones encloses the transverse sinus posteriorly and the
superior petrosal sinus anteriorly.

Diaphragma sellae is a circular, horizontal fold of dura that forms the roof of the sella turcica, covering the
pituitary gland. It has a central aperture for the hypophyseal stalk or infundibulum.

4. Identify the cranial nerves on the brain and their courses through the skull base. (N11, N104, N114, TG7-07, TG7-51, TG7-52)
Nerve Cranial Exit
I Olfactory Cribriform plate
II Optic Optic canal
III Oculomotor Superior orbital fissure
IV Trochlear Superior orbital fissure
V Trigeminal Superior orbital fissure (V1); f. rotundum (V2); f. ovale (V3)
VI Abducens Superior orbital fissure
VII Facial Enters internal auditory meatus, travels through petrous temporal bone, leaves via stylomastoid f.
VIII Vestibulocochlear Enters internal auditory meatus, remains within petrous temporal bone
IX Glossopharyngeal Jugular f.
X Vagus Jugular f.
XI Accessory Jugular f.
XII Hypoglossal Hypoglossal canal

5. Identify the parts of the ventricular system and trace the flow of cerebrospinal fluid from production to reabsorption. (N108, TG7-
46, TG7-49, TG7-50A, TG7-50B)

A. Parts of the ventricular system

o The cerebral hemispheres are hollow, each containing a lateral ventricle. The ventricles contain a tuft of blood
vessels called the choroid plexus, which secretes CSF. The lateral ventricles communicate with the midline third
ventricle by way of the interventricular foramina. A thin membrane and attached choroid plexus roofs the third
ventricle. In the midbrain, the narrow cerebral aqueduct connects the third and fourth ventricles.

o The fourth ventricle lies between the pons, cerebellum, and the medulla. It communicates with the cerebral
aqueduct, the central canal of the spinal cord, and the subarachnoid space. The roof of the fourth ventricle caudal
to the cerebellum, the tela choroidea, is thin like that of the third ventricle and has a choroid plexus. It is perforated
by a small median aperture and two lateral apertures that allow cerebrospinal fluid to exit the ventricular system
and bathe the brain and spinal cord. (WB 29)

B. The flow of CSF from production to reabsorption

o CSF is secreted (produced) by the choroidal epithelial cells of the choroid plexuses in the lateral, third, and fourth
ventricles.

o CSF leaves the lateral ventricles through the interventricular foramina and enters the third ventricle. From there
CSF passes through the cerebral aqueduct into the fourth ventricle. It leaves this ventricle through its median and
lateral apertures and enters the subarachnoid space, which is continuous around the spinal cord and brain. The
 arachnoid forms various spaces around the brain called cisterns, filled with CSF, such as the interpeduncular and
quadrigeminal cisterns. CSF passes into the extensions of the subarachnoid space around the optic nerves.

C. Reabsorption of CSF (reabsorption into the venous system) - the main site of CSF absorption (reabsorption) into the
venous system is through arachnoid granulations. The subarachnoid space containing CSF extends into the arachnoid
granulations, which in turn project upward through the dura into the superior sagittal sinus and lateral projections from it
called lateral lacunae.

Summary: CSF is formed in the brain in the choroid plexus of ventricles, and drains via arachnoid granulations projecting into the
superior sagittal sinus.

Questions and Answers:

1. Note the choroid plexus; where is it found and what is its function? (TG7-50A, TG7-50B)
Choroid plexuses are relatively large, tuft-like carpets of capillaries. They lie in the floors of the lateral ventricles and the roofs of the
third and fourth ventricles. They give off cerebrospinal fluid, filling the ventricles.
2. The spread of infection is mainly facilitated through what layer of the scalp? (N98A, N101, N102, TG7-46, TG7-49)
The subaponeurotic connective tissue layer (areolar tissue) of the scalp facilitates the spread of infection because of its loose character.
3. Note dural attachment to the calvaria and the base of the skull. Is there any difference? (N98A, N101, N102, TG7-46, TG7-47, TG7-
48, TG7-49)
The spinal dura consists of one layer and is a tube with lateral extensions covering nerve rootlets. The cranial dura, on the other hand,
splits to form two layers.

1. An external periosteal layer is the periosteum covering the internal surface of the calvaria.

2. An internal meningeal layer, a strong fibrous membrane that is continuous at the foramen magnum with the spinal dura
mater covering the spinal cord.

The periosteal layer adheres to the internal surface of the skull, and its attachment is tenacious along the suture lines and in the cranial
base. The external periosteal layer is continuous at the cranial foramina with the periosteum on the external surface of the calvaria; it is
NOT continuous with the dura mater of the spinal cord. In most areas, the meningeal layer is intimately fused with the periosteal layer
and cannot be separated from it. The fused external and internal layers of dura over the calvaria can be easily stripped from the cranial
bones. A blow to the head can detach the periosteal layer from the calvaria without fracturing the cranial bones. In the cranial base the
two dural layers are firmly attached and difficult to separate from the bones. Consequently, a fracture of the cranial base tears the dura
and results in leakage of CSF.
4. Examine falx cerebri, falx cerebelli, tentorium cerebelli, and diaphragma sellae. Are these infoldings periosteal or meningeal? Define
attachments and relationship of each and the compartmentalization of the cranial cavity produced by these infoldings.
(N103, N104A, N104B, TG7-47, TG7-48, TG7-49A, TG7-49B)
The internal meningeal layer of dura draws away from the external periosteal layer of dura to form dural infoldings, which separate the
regions of the brain from each other and form dural venous sinuses. These separations in the dural layers form the dural venous
sinuses (compartments). See the objective question above for attachments and relationships of these dural infoldings.
5. What does each compartment contain? (N103, N104A, N104B, TG7-47, TG7-49)
The falx cerebri helps form the superior and inferior sagittal sinuses. The tentorium cerebelli separates the cerebellum from the cerebral
hemispheres. In the line of the junction between the falx cerebri and the tentorium cerebelli lies the straight sinus. The diaphragma
sellae is a horizontal duplication of the meningeal dura that roofs the sella turcica. The falx cerebelli is a partitioning of the dura which
separates the cerebellar hemispheres. It contains the occipital sinus. (WB 323-4)
6. What is the tentorial notch? (N104A, N104B, TG7-47)
The tentorial notch is the opening in the tentorium cerebelli for the brainstem (specifically the midbrain).
7. Observe meningeal arteries in all cranial fossae. Which is the largest? How is it held within the dura? Relation to greater wing of
sphenoid? (Significance?) (N99B, N104A,N104B, TG7-51)
The largest of the meningeal arteries is the middle meningeal artery. It is a branch of the maxillary artery. It goes through the foramen
spinosum and supplies most of the dura mater except for the floors of the anterior and posterior cranial fossae. It runs forward for a
short distance in a groove on the greater wing of the sphenoid bone, lying between bone and dura, and then divides into anterior and
posterior branches. (WB 326, 269) Significance: The dura is sensitive to pain, especially where it is related to the dural venous sinuses
and meningeal arteries. Consequently, piercing the dura where the meningeal arteries enter the base of the skull or near the vertex
causes pain and is a major source of headaches. In addition, the rupture of the middle meningeal artery by fracture of the greater wing
of the sphenoid bone causes an epidural hematoma.
8. What is the innervation of dura? (N104A, N104B, TG7-51)
The dura is innervated by all three divisions of the trigeminal nerves, the vagus nerves, and the hypoglossal nerves.

A. Anterior and posterior ethmoidal branches of the ophthalmic division of the trigeminal nerve in the anterior cranial fossa.
 B. Meningeal branches of the maxillary and mandibular divisions of the trigeminal nerve in the middle cranial fossa.

C. Meningeal branches of the vagus and hypoglossal nerves in the posterior cranial fossa.

9. What cranial nerves exit through the jugular foramen? (N11, N104A, N104B, TG7-07, TG7-51)

Cranial nerves IX, X, and XI.

10. Sinus rectus (is a portion of the great cerebral vein attached to it?) (N103, N104A, N104B, TG7-47, TG7-49)
The sinus rectus, a.k.a. the straight sinus, is formed by the union of the inferior sagittal sinus with the great cerebral vein.
11. Confluens of sinuses (significance, location, pattern, and variations). (N103, N104A, N104B, TG7-47, TG7-49)
The confluens of sinuses is a meeting place of the superior sagittal, straight, occipital, and the right and left transverse sinuses. This
junction is a dilitation at one side of the internal occipital protuberance. Sometimes it is a region of actual confluence, and sometimes
the superior sagittal and straight sinuses (either or both) bifurcate here to form the right and the left transverse sinuses. (WB 325).
12. Superior petrosal sinus (connects what?) (N103, N104A, N104B, TG7-47)
The superior petrosal sinus connects the posterior end of the cavernous sinus to the bend marking the transition between the
transverse and sigmoid sinuses. It receives cerebellar and inferior cerebral veins and veins from the tympanic cavity. (WB 326) .
13. Define emissary veins and the mastoid, condyloid, parietal, and ophthalmic emissary veins. (N98A, N101, N102, TG7-73)
The emissary veins are small veins connecting the dural venous sinuses with the veins of the scalp. They are valveless and, as a result,
may conduct blood inward or outward in accordance with the pressure existing in the sinuses and in the external veins. Some are
constant; others occur occasionally. The superior ophthalmic vein is the largest vein of this type. It connects the angular vein of the face
with the cavernous sinus. The mastoid emissary vein unites the posterior auricular vein with the sigmoid sinus. The parietal emissary
vein occupies the parietal foramen and connects the veins of the scalp with the superior sagittal sinus. The emissary vein of the
foramen cecum connects the veins of the nasal cavity with the superior sagittal sinus. The condyloid canal, when present, transmits an
emissary vein which passes between the lower end of the sigmoid sinus and veins of the suboccipital triangle of the neck. (WB 326)
14. Remove the blood from the cavernous sinus and note trabeculae. Do the two sides communicate? (N104A, N104B, TG7-47, TG7-
60)
The cavernous sinuses usually communicate (WB 325). They are found on each side of the sella turcica and the body of the sphenoid
bone and lie between the meningeal and periosteal layers of the dura mater.
15. Expose the internal carotid artery (course?) (N104A, N104B, N138, N139, TG7-47, TG7-60, TG7-72)
The internal carotid artery:
 has no branches in the neck

ascends within the carotid sheath in company with the vagus nerve and the internal jugular vein.

enters the cranium through the carotid canal in the petrous part of the temporal bone.

in the middle cranial fossa, gives rise to the ophthalmic artery and the anterior and middle cerebral arteries and the
posterior communicating artery.

16. Look for arachnoid granulations (villi). What is their function? (N98A, N101, N102, N108, TG7-46, TG7-49, TG7-50)
The arachnoid granulations are tuftlike collections of highly folded arachnoid that project through the dura mater into lateral lacunae of
the superior sagittal sinus and into other dural sinuses. Through their thin membranes, the cerebrospinal fluid is passed into the blood
stream. (WB 323)
17. Examine the pia mater on the brain. How does it differ from the arachnoid mater in covering the brain? (N98A, N101, N102, TG7-
46, TG7-49)
The pia mater on the brain is a delicate, intimate, areolar investment of brain and spinal cord that enmeshes the blood vessels on their
surfaces. It is a vascular membrane. On the other hand, the arachnoid is a delicate transparent membrane composed of a blend of
collagenous and elastic fibers and squamous mesenchymal epithelial cells. It is NOT vascular and is NOT attached directly to the
surface of the brain or spinal cord. Arachnoid trabeculae are thin strands that conect the arachnoid to the pia mater. (WB 322-23)
18. What is the arterial circle of Willis? (N139, TG7-56A, TG7-56B)
The circle of Willis, a.k.a. cerebral arterial circle, is an important anastomosis at the base of the brain between the following arteries:

Anterior cerebral arteries

Anterior communicating arteries

Internal carotid arteries

Posterior communicating arteries

Posterior cerebral arteries

The various components of the cerebral arterial circle give many small branches to the brain.
Clinical Case - Scalp, Cranial Cavity, Meninges & Brain
A 20-year-old student fell off his bike directly on his head on the way to school. He was not wearing a helmet and was seen unconscious
when paramedics arrived. At the emergency room his pulse and blood pressure were weak, and there was no sign of scalp laceration.
The doctor examined his pupils and found that the right was fixed and dilated and would not react to light. A CT scan was ordered
immediately, and a right-sided epidural hematoma was revealed. The patient was moved to the intensive care unit, and an emergency
evacuation of the hematoma was planned.

Questions to consider:

1. What is the source of the epidural hematoma ?

It is usually the middle meningeal artery or vein.

2. Why was there a dilated pupil on the hematoma side ?

The pupil dilates due to paralysis of the sphincter pupillae muscle due to loss of parasympathetic fibers carried by
the oculomotor nerve and the resultant unopposed action of the intact dilator pupillae muscle (sympathetic innervation).
This muscle gets paralyzed when the oculomotor nerve (CN III) is injured by pressure from a hematoma, usually epidural.

3. What are the structures that lie in the lateral wall of the cavernous sinus?

These are the oculomotor (III), trochlear(IV), and ophthalmic and maxillary divisions of the trigeminal (V).
Practice Quiz - Scalp, Cranial Cavity, Meninges & Brain

Below are written questions from previous quizzes and exams. Click here for a Practical Quiz - old format or Practical Quiz - new
format.

1. During an intramural baseball game a player is hit in the side of the head, between the eye and the ear. He immediately loses
consciousness, wakes up momentarily and then becomes comatose. He is rushed to the ER and is immediately given a CT
scan. The scan shows a skull fracture and an accumulation of blood between the dura and the cranial bone on the side of his
head, compressing his cerebrum. He is rushed to surgery where a hole is bored into his skull to relieve the pressure. After a few
tense hours, he regains consciousness and has an uneventful recovery. The hemorrhage from the fracture would be described
as:

Epidural

Intracerebral

Subaponeurotic

Subarachnoid

Subdural

The correct answer is: Epidural

An epidural hemorrhage is a hemorrhage of blood into the space between the dura and the skull. These hemorrhages are
usually caused by rupturing the middle meningeal artery, which supplies blood to the dura and the bones of the cranial vault. This
hemorrhage results in compression of the dura mater and the brain; if it is not drained, it may result in the brain herniating
 through the tentorium and death. An intracerebral hemorrhage is a hemorrhage within the cerebral hemispheres. A
subaponeurotic hemorrhage could be a collection of blood under the aponeurosis of the scalp, but this is not really a brain
hemorrhage and is not as clinically significant as the other answer choices. A subarachnoid hemorrhage is an acute condition
where blood collects in the area between the pia mater and arachnoid mater. This is often secondary to a head injury or a
ruptured aneurysm. A subdural hemorrhage is characterised by a collection of blood beneath the dura, often caused by a head
injury.

2. An infant was diagnosed as having hydrocephalus. It was determined that there was a blockage in the ventricular system of the
baby's brain between the third and fourth ventricles. The blockage therefore must have involved the:

Central canal

Cerebral aqueduct

Foramen of Luschka (lateral foramen)

Foramen of Magendie (medial foramen)

Interventricular foramen

The correct answer is: cerebral aqueduct

The cerebral aqueduct is the part of the ventricular system that carries cerebrospinal fluid from the third ventricle to the fourth
ventricle. So, this must be the part of the ventricular system that was blocked. The central canal is the space where CSF flows through
the spinal cord. It is continuous with the 4th ventricle. The foramina of Luschka (lateral aperatures) and foramen of Magendie (median
aperature) are small foramina in the 4th ventricle that allow the CSF to leave the ventricular system and enter the subarachnoid space.
The interventricular foramina are passages from the lateral ventricles that allow the CSF to enter the 3rd ventricle.

3. An 84-year old woman suffers a stroke, with paralysis on the right side of her body. Neurological tests show that the intracerebral
hemorrhage has interrupted the blood supply to the posterior part of the frontal, the parietal and medial portions of the temporal
lobes of the left cerebral hemisphere. Which vessel was involved?
 Anterior cerebral artery

Great cerebral vein

Middle cerebral artery

Middle meningeal artery

Posterior cerebral artery

The correct answer is: middle cerebral artery

The middle cerebral artery supplies blood to most of the lateral surface of cerebral hemispheres, and the temporal pole, including
the frontal, parietal, and medial portions of the temporal lobes. So, the specific damage to the temporal lobe suggests that the middle
cerebral artery was disrupted. The other arteries listed do not distribute to the same territory. The anterior cerebral artery supplies the
medial and superior surfaces of the brain, including the frontal pole. The posterior cerebral artery supplies the inferior surface of the
brain and the occipital pole.

Strokes occur in arteries, not veins, so that's one reason why the great cerebral vein is not correct. Veins also drain regions of
blood--they don't supply blood to areas. The middle meningeal artery supplies blood to the dura mater and the cranial vault bones--it
does not supply blood to the brain.

4. A sixty-four-year old man was diagnosed with an acoustic neuroma (tumor of the VIIIth cranial nerve) where it entered the
temporal bone. What other cranial nerve might also be affected since this nerve uses the same foramen as the VIIIth in its
course?

Abducens

Facial

Glossopharyngeal
 Trigeminal

Vagus

The correct answer is: facial

The facial nerve enters the temporal bone with the vestibulocochlear nerve--both cross into the internal acoustic meatus.
Abducens (CN VI) crosses through the superior orbital fissure, along with the oculomotor nerve (CN III), the trochlear nerve (CN IV) and
the ophthalmic division of the trigeminal nerve (CN V1). The glossopharyngeal (CN IX), vagus (CN X), and spinal accessory nerve (CN
XI) all leave through the jugular foramen. Finally, the three divisions of the trigeminal nerve all leave through different foramina: V 1, the
ophthalmic division, exits through the superior orbital fissure; V 2, the maxillary division, leaves through foramen rotundum; V 3, the
mandibular division, leaves through foramen ovale.

5. Infections may spread from the nasal cavity to the meninges along the olfactory nerves, as its fibers pass from the mucosa of the
nasal cavity to the olfactory bulb via the:

Cribriform plate of the ethmoid

Crista galli

Foramen caecum

Superior orbital fissure

The correct answer is: cribriform plate of the ethmoid.

 The olfactory nerve exits the skull through the cribriform plate of the ethmoid bone--an infection in the nasal cavity may be carried
to the olfactory bulb by the nerves that are passing through the cribriform plate. The crista galli is a ridge on the ethmoid bone between
the two sides of the cribriform plate; it provides an anchor for the falx cerebri. Foramen cecum is a small hole in the frontal bone near
the anterior end of the crista galli--it transmits an emissary vein. Finally, the superior orbital fissure is a hole in the sphenoid bone that
transmits many cranial nerves: the oculomotor nerve (CN III), the trochlear nerve (CN IV), the ophthalmic division of the trigeminal
nerve (CN V1) and the abducens nerve (CN VI) all pass through the superior orbital fissure.

6. The "danger zone" of the scalp is recognized as which of the following layers?

Galea aponeurotica

Loose connective tissue

Pericranium

Skin

Subcutaneous connective tissue

The correct answer is: loose connective tissue

The scalp is comprised of the following layers, from superficial to deep: Skin, Connective tissue, Aponeurosis, Loose connective
tissue, and Pericranium. If you take the first letter of each, it spells SCALP. So, now that you know the order of the layers, you need to
figure out which one is the danger zone--the place where infections can spread very quickly. And that layer is layer 4, the loose
connective tissue. Pus or blood can spread easily in this layer, and infections in this layer can pass into the cranial cavity through
emissary veins. So, infections in the loose connective tissue can pass into intracranial structures such as the brain and meninges.
Although layer 2 is a connective tissue layer, too, this layer is a bit thicker and is not a place where infections can easily spread.

7. The presence of blood in a spinal tap taken from an individual with a closed head injury signals arterial bleeding into the:

Cavernous sinus

Epidural space
 Subarachnoid space

Subdural space

The correct answer is: subarachnoid space

Remember back to the spinal cord - when taking cerebrospinal fluid for a spinal tap, you are removing fluid from the subarachnoid
space. The subarachnoid space of the spinal cord is continuous with the subarachnoid space around the brain, so you know that the
patient must have had a subarachnoid hemorrhage. Subarachnoid hemorrhages are acute events, often caused by an aneurysm or a
closed head injury.

In the spinal cord, the epidural space is filled with fat, and the subdural space is really a potential space only - there is no fluid in
this area. The cavernous sinus is a venous sinus of the brain, on the lateral surface of the body of the sphenoid bone.

8. An infection in which scalp layer is likely to spread most readily?

Skin

Connective tissue layer

Aponeurotic layer

Loose areolar tissue

Pericranium

The correct answer is: loose areolar tissue

Loose areolar tissue is another name for the loose connective tissue layer of the scalp. Pus or blood can spread easily in this layer,
and infections in this layer can pass into the cranial cavity through emissary veins. So, infections in the loose connective tissue can pass
into intracranial structures such as the brain and meninges. This can also be called the "danger layer" of the scalp.
 Remember--the scalp is comprised of the following layers, from superficial to deep: Skin, Connective tissue, Aponeurosis, Loose
connective tissue, and Pericranium. (SCALP!) Although layer 2 is a connective tissue layer, too, this layer is a bit thicker and is not a
place where infections can easily spread.

9. A patient who has sustained a fracture to the middle cranial fossa following a fall from a height, might have any of these nerves
injured EXCEPT:

Trigeminal

Oculomotor

Abducens

Trochlear

Hypoglossal

The correct answer is: hypoglossal

The middle cranial fossa is the part of the skull that supports the temporal lobes of the brain. It is made of the greater wings of the
sphenoid and squamous part of the temporal bones laterally and the petrous part of the temporal bones posteriorly. See Netter Plate 6
and 7 for a better picture of this.

Several cranial nerves enter foramina in the middle cranial fossa; all of these nerves might have been damaged in the fall. The
trigeminal nerve (CN V) has three divisions that all leave through spaces in the middle cranial fossa. V 1, the ophthalmic division, exits
through the superior orbital fissure; V2, the maxillary division, leaves through foramen rotundum; V 3, the mandibular division, leaves
through foramen ovale. The oculomotor nerve (CN III) crosses through the superior orbital fissure, along with abducens (CN VI), the
trochlear nerve (CN IV) and the ophthalmic division of the trigeminal nerve (CN V 1). So, all of these nerves might have been damaged
in the fall.

The hypoglossal nerve, however, leaves the base of the skull by passing through the hypoglossal canal, which is in the occipital
bone and the posterior cranial fossa. It is not likely that this nerve was injured in the fall.
 10. The most likely source of blood in a patient with an epidural hemorrhage is:

Vertebral artery

Middle meningeal artery

Superior cerebral veins

Anterior cerebral artery

Circle of Willis

The correct answer is: middle meningeal artery

The middle meningeal artery supplies most of the dura mater and the bones of the cranial vault. It is this artery or vein that is
usually ruptured in an epidural hemorrhage. The vertebral artery carries blood to the deep neck, cervical spinal cord, and hindbrain. It
does not supply blood to the dura. Superior cerebral veins drain blood into the superior sagittal sinus. When injured, they bleed into the
subdural space and cause a subdural hematoma. The anterior cerebral artery supplies blood to the frontal pole of the brain. It is not
found near the epidural space. Finally, the circle of Willis is an important anastomosis at the base of the brain between the following
arteries: posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, anterior cerebral arteries, and anterior
communicating arteries.

11. In a fall from a horse, a rider sustains a severe neck injury at the C6 level. In addition to crushing the spinal cord, the left
transverse process of the C6 vertebra is fractured. What artery is endangered?

Common carotid

Costocervical

Inferior thyroid

Internal carotid

Vertebral
The correct answer is: Vertebral

The paired vertebral arteries travel through the transverse foramina of the C1-C6 vertebrae. So, since the C6 vertebra was
damaged, the vertebral artery could also be ruptured. The other arteries are not closely related with the vertebrae. The common carotid
arteries come off the brachiocephalic trunk on the right side and the aortic arch on the left side, giving off many arteries that supply the
head and neck. The costocervical trunk is a branch of the subclavian artery that supplies the deep neck and the first 2 intercostal
spaces. The inferior thyroid artery is a branch of the thyrocervical trunk that supplies the thyroid. Finally, the internal carotid artery is a
branch of the common carotid that joins the circle of Willis and supplies the brain.

12. A 35-year-old man was admitted to the hospital complaining of double vision (diplopia), inability to see close objects, and blurred
vision in the right eye. A vertebrobasilar angiogram revealed an aneurysm of the superior cerebellar artery close to its origin on
the right side. The doctor attributed the symptoms to the compression of an adjacent cranial nerve by the aneurysm. The
compressed nerve is the:

Abducens (CN VI)

Oculomotor (CN III)

Optic (CN II)

Trigeminal (CN V)

Trochlear (CN IV)

The correct answer is: Oculomotor (CN III)

Given the patient's symptoms, it seems that some nerve involving vision and the ability to control the eye has been injured. Now,
you need to think about which nerve might be damaged by an aneurysm of the superior cerebellar artery. The oculomotor nerve, which
innervates the superior rectus, medial rectus, inferior rectus, and inferior oblique muscles, passes between the posterior cerebral artery
and the superior cerebellar artery. It could be injured if there was enlargement of or damage to either of these vessels. None of the
other cranial nerves are in the right position to be injured from an aneurysm of the superior cerebellar artery.
 13. An elderly patient developed fever and worsening headache a few days after sustaining a scalp laceration and subsequent
infection due to a car accident. At the hospital the case was diagnosed as meningitis and superior sagittal sinus thrombosis. The
attending physician suggested that infection to the sinus initially spread through one of the scalp layers. The scalp layer involved
is:

Areolar tissue

Connective tissue

Epicranial aponeurosis

Periosteum

Skin

The correct answer is: Areolar tissue

Areolar tissue is another name for the loose connective tissue layer of the scalp. Pus or blood can spread easily in this layer, and
infections in this layer can pass into the cranial cavity through emissary veins. So, infections in the loose connective tissue can pass into
intracranial structures such as the superior sagittal sinus, causing conditions like the superior sinus thrombosis.

Remember--the scalp is comprised of the following layers, from superficial to deep: Skin, Connective tissue, Aponeurosis, Loose
connective tissue, and Pericranium. (SCALP!) Although layer 2 is a connective tissue layer, too, this layer is thicker and it's not where
infections can easily spread.

14. While riding her bicycle on campus without a helmet a student is hit by a car and falls, hitting her head on the pavement. She is
brought to the Emergency Room in an unconscious state with signs of a closed head injury. Tests reveal blood in her
cerebrospinal fluid taken from a spinal tap. Diagnosis is of torn cerebral veins as they pass from the brain to the superior sagittal
 sinus. From which of the following was the bloody fluid taken?

Cavernous sinus

Epidural space

Subarachnoid space

Subdural space

Verterbal venous plexus

The correct answer is: Subarachnoid space

Remember back to the spinal cord - when taking cerebrospinal fluid for a spinal tap, you are removing fluid from the subarachnoid
space. The subarachnoid space of the spinal cord is continuous with the subarachnoid space around the brain, so you know that the
patient must have had a subarachnoid hemorrhage. Subarachnoid hemorrhages are acute events, often caused by an aneurysm or a
closed head injury.

In the spinal cord, the epidural space is filled with fat, and the subdural space is really a potential space only - there is no fluid in
this area. The cavernous sinus is a venous sinus of the brain, lateral to the body of the sphenoid bone. The vertebral venous plexus are
the veins that drain the spinal cord - they are valveless veins, so they are an important route that cancer cells can use to metastasize.

15. You have been asked to assess the neurological deficit that might exist in a patient diagnosed with cavernous sinus thrombosis.
You will focus your examination on cranial nerves related to the sinus that includes all the following EXCEPT:

Abducens (CN VI)

Facial (CN VII)

Oculomotor (CN III)

Ophthalmic division of the trigeminal nerve (CN V1)

Trochlear (CN IV)

The correct answer is: Facial (CN VII)

The cavernous sinus is a venous sinus of the brain, lateral to the body of the sphenoid bone. All of the cranial nerves and vessels
that pass out of the skull at the superior orbital fissure pass through the cavernous sinus. This includes the oculomotor nerve, the
trochlear nerve, the ophthalmic division of the trigeminal nerve, and the abducens nerve. The internal carotid artery also passes through
the cavernous sinus. Since three of the nerves in the cavernous sinus control the motions of the extraocular muscles, testing eye
movements would be a good way to see if nerves in the cavernous sinus were disrupted. The ophthamic division of the trigeminal
nerve, which supplies cutaneous sensation to the skin of the upper face, could be tested by evaluating the sensations on the forehead.

The facial nerve is not associated with the cavernous sinus. It passes through the internal acoustic meatus and exits the skull
through the stylomastoid foramen. So, you would not need to test to see if the facial nerve was intact.

16. The glossopharyngeal nerve exits the skull via what opening?

Foramen ovale

Carotid canal

Jugular foramen

Hypoglossal canal

Stylomastoid foramen

The correct answer is: Jugular foramen

The glossopharyngeal nerve (CN IX), vagus (CN X) and accessory nerve (CN XI) exit the skull at the jugular foramen. The
posterior meningeal artery enters the skull through this space. The mandibular division of the trigeminal nerve (V 3) exits the skull
through foramen ovale. The carotid canal is the place where the internal carotid artery and the internal carotid nerve plexus enter the
skull. The hypoglossal canal is where the hypoglossal nerve (CN XII) leaves the skull. The stylomastoid foramen is the hole that the
facial nerve (CN VII) uses to exit the skull.
 17. An infant was found to have hydrocephalus. Studies revealed that the hydrocephalus was caused because CSF could not get out
of the third ventricle. The passage blocked was the:

Central canal

Cerebral aqueduct

Interventricular foramen

Lateral foramen (of Luschka)

Medial foramen (of Magendie)

The correct answer is: Cerebral aqueduct

For CSF to travel from the third ventricle to the 4th ventricle and the central canal of the spinal cord, it must pass through the
cerebral aqueduct. So, this is the passageway that must be blocked. The central canal is the space where CSF flows through the spinal
cord. It is continuous with the 4th ventricle. The foramen of Luschka and foramen of Magendie are small foramina in the 4th ventricle
that allow the CSF to leave the ventricular system and enter the subarachnoid space. The interventricular foramina are passages in the
lateral ventricles that allow the CSF to leave the lateral ventricles and enter the 3rd ventricles. See Netter Plate 102 for a diagram of the
ventricles of the brain.

18. A person develops a cavernous sinus thrombosis. Because of its relationship to the sinus, which cranial nerve might be
affected?

Abducens

Facial

Mandibular V3

Olfactory

Optic
The correct answer is: Abducens (CN VI)

The cavernous sinus is a venous sinus of the brain, lateral to the body of the sphenoid bone. All of the cranial nerves and vessels
that pass out of the skull at the superior orbital fissure pass through the cavernous sinus. This includes the abducens nerve, the
oculomotor nerve, the trochlear nerve, and the ophthalmic division of the trigeminal nerve. Any of these nerves might be affected by a
cavernous venous sinus thrombosis.

The facial nerve is not associated with the cavernous sinus. It passes through the internal acoustic meatus and exits the skull
through the stylomastoid foramen. The mandibular division of the trigeminal nerve (V 3) exits the skull through foramen ovale. The
olfactory nerves enter the skull through the cribriform plate of the ethmoid bone. The optic nerve exits the skull through the optic canal.
None of these nerves are associated with the cavernous sinus.

19. Blockage of the flow of cerebrospinal fluid (CSF) within the cerebral aqueduct (of Sylvius) normally would result in the
enlargement of all of the following ventricular spaces except the:

Fourth ventricle

Interventricular foramen (of Monro)

Lateral ventricle

Third ventricle

The correct answer is: Fourth ventricle

 If the cerebral aqueduct was blocked, CSF would not flow from the third ventricle into the fourth ventricle and the central canal. So,
all the spaces proximal to the blockage would enlarge, while all the spaces distal to the blockage would be normal. The third ventricle,
lateral ventricle, and interventricular foramen are proximal to the blockage of CSF; fluid circulates from the lateral ventricles, through the
interventricular foramen, to the third ventricle before reaching the cerebral aqueduct. This means that all of these spaces should be
enlarged with fluid. The fourth ventricle, however, needs the cerebral aqueduct to be open so that it can receive fluid--it would not
become distended from the blockage in the aqueduct.

20. All of the following nerves exit the cranial cavity by way of bony openings located in the middle cranial fossa EXCEPT:

Abducens

Trochlear

Oculomotor

Trigeminal

Facial

The correct answer is: facial

The middle cranial fossa is the part of the skull that supports the temporal lobes of the brain. It is made of the greater wings of the
sphenoid and squamous parts of the temporal bones laterally and the petrous parts of the temporal bones posteriorly. See Netter Plate
6 and 7 for a better picture of this.

Several cranial nerves enter foramina in the middle cranial fossa. The abducens (CN VI) crosses through the superior orbital
fissure, along with the oculomotor nerve (CN III), trochlear nerve (CN IV) and ophthalmic division of the trigeminal nerve (CN V 1). The
trigeminal nerve (CN V) has three divisions that all leave through spaces in the middle cranial fossa. V 1, the ophthalmic division, exits
through the superior orbital fissure; V2, the maxillary division, leaves through foramen rotundum; V 3, the mandibular division, leaves
through foramen ovale.

The facial nerve, however, leaves the base of the skull by passing through the internal acoustic meatus, which is in the part of the
temporal bone that is in the posterior cranial fossa.
 21. During childbirth, an excessive anteroposterior compression of the head may tear the anterior attachment of the falx cerebri from
the tentorium cerebelli. The bleeding that follows is likely to be from which of the following venous sinuses?

Occipital sinus

Sigmoid sinus

Straight sinus

Superior sagittal sinus

Transverse sinus

The correct answer is: Straight sinus

The straight sinus drains the deep cerebrum--it lies within the junction of the falx cerebri and tentorium cerebelli. This is exactly the
location that was damaged in birth, so this is the correct answer. The occipital sinus drains the cerebellum--it lies within the dura mater
at base of falx cerebelli. It is inferior to the straight sinus. The sigmoid sinus drains the blood from the brain into the internal jugular
vein--it lies within sigmoid groove, covered by dura mater. The superior sagittal sinus drains the cerebral hemispheres--it lies superiorly
within falx cerebri, near the superior border of the skull. The transverse sinus lies within the attachment of tentorium cerebelli to the
inner surface of the calvaria. When trying to understand these sinuses, a picture is really worth a thousand words, so take a look at
Netter 97 and 98!

22. The inferior sagittal sinus is found in the free edge of what structure?

Diaphragma sellae

Falx cerebelli

Falx cerebri

Filum terminale

Tentorium cerebella
The correct answer is: falx cerebri

The falx cerebri is a crescent-shaped, sagittally-oriented fold of dura mater lying between cerebral hemispheres. The inferior
sagittal sinus runs in the inferior margin of the falx cerebri. The falx cerebelli is a small fold of dura mater lying between cerebellar
hemispheres--it is the location of the occipital sinus. The diaphragma sellae is a piece of dura mater which forms the roof of the
hypophyseal fossa; it is pierced by the stalk of the hypophysis. The tentorium cerebelli is a tent-like sheet of dura mater covering of
cerebellum, oriented somewhat transversely. The straight sinus is found in the junction of the falx cerebri and tentorium cerebelli. The
filum terminale is an extension of the pia mater below the end of the spinal cord at L2. It is a structure of the spinal cord, not the brain.