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Purpose The superficial middle cerebral vein (SMCV) typically drains into the cavernous sinus, which, in turn, connects to the pterygoid venous plexus via a sphenoidal emissary vein. The latter may course through the foramen ovale. The pterygoid plexus drains in most cases into the retromandibular and facial veins. A peculiar SMCV drainage pathway to the internal jugular vein (IJV) via a parapharyngeal vein was found here. Method The anatomic variant reported here was identified by carefully reviewing the archived CT angiogram in a 68-year-old male case. Results A double SMCV was found on the right side. The resulting common SMCV trunk passed laterally to the foramen rotundum to empty into the cavernous sinus. A sphenoidal emissary vein joined it, which continued inferiorly through the foramen ovale to the pterygoid plexus. This plexus was connected to a reservoir on the inner side of the lateral pterygoid plate from which a fenestrated parapharyngeal vein left. It had two primary fenestrations, and the proximal one had a fenestrated arm. It reached inferiorly and turned around the external carotid artery. At that level, it received two tributaries: first, the superior thyroid vein and then, the facial vein. The resulting facial-parapharyngeal trunk ended in the IJV. These veins and the carotid arteries, deep to them, were hidden beneath the submandibular gland. The right maxillary vein and the anterior branch of the retromandibular vein were absent. Conclusion The parapharyngeal vein may be a direct drainage pathway for the SMCV and the pterygoid plexus. It should therefore be acknowledged and spared during various surgical approaches.

Purpose The intracranial venous system is characterized by a great variability both in anatomic and functional issues. In particular, the supratentorial venous system is distinguished in the adult configuration in a deep and superficial pathway. The communication between these two compartments is provided by the so-called transcerebral veins, tiny venous channels connecting the deep medullary veins with the superficial medullary veins. No further connection between the two systems has been described in the literature. Methods We are presenting an incidental finding in a patient undergoing brain Magnetic Resonance Imaging (MRI) in the diagnostic work-up of headache of migraine type. In fact, a hyperintense linear signal change in the white matter of the right hemisphere was identified, connecting the subependymal periventricular region with the pial surface and associated with a Susceptibility Weighted Imaging (SWI) appearance of a long venous channel continuing the course of the lateral thalamostriate vein. No further changes were identified and neuronal migration anomalies were absent. Conclusions We described a new type of connection between deep and superficial venous system, different from the transcerebral veins, and we called it transmantle vein, detailing anatomic and embryologic remarks.

Background The internal venous system of the brain is a crucial anatomical landmark during accesses to the third ventricle through the foramen of Monro. Many classifications based on radiological assessment of the system have been developed, but they tend to be descriptive and do not highlight favorable anatomical variants. The aim of our study was to create a system based on morphometric measurements to facilitate preoperative decision-making regarding access to third ventricle tumors. Methods We conducted an analysis of 119 MRI scans with SWI sequence using BrainLab software to create a model of the ventricular system, which allowed us to perform radiological measurements. We then validated these findings anatomically using 32 human brain specimens. The analyzed structures included the foramen of Monro (FM), the anterior septal vein (ASV), the thalamostriate vein (TSV), the venous angle (VA), the internal cerebral vein (ICV), and the distance between the FM and VA. Results Based on the radiological analysis, we identified 9 internal venous systems, accounting for variations in each analyzed structure. The statistical analysis revealed no differences in the frequency of subtypes between radiological and anatomical studies ( p  = 0.097), nor in the occurrence of false venous angles ( p  = 0.520). We identified venous configurations that, in our assessment, are unfavorable in the context of accessing the third ventricle. Conclusion The resulting classification accounts for significant clinical anatomical variations and, for the first time, provides specific morphometric values for each anatomical subtype. Consequently, it serves as a reproducible reference framework for preoperative planning of access to the third ventricle.

The vein of Rolando, also known as the central sulcal vein, is a critical superficial cerebral vein located in the central sulcus, playing a pivotal role in the venous drainage of the motor and sensory cortices. Named after the Italian anatomist Luigi Rolando, this vein serves as a crucial anatomical landmark in neurosurgery, guiding surgeons to approach critical brain structures with minimal damage. This article explores the anatomy and clinical significance of the vein of Rolando, emphasizing its role in neurosurgery and neuroimaging. Advanced imaging techniques such as functional MRI (fMRI), Magnetic Resonance Venography (MRV), and CT Angiography have enhanced the ability to diagnose and preserve this vein, reducing surgical risks. The article also discusses the interconnectedness of the vein of Rolando with other cerebral veins like the vein of Trolard and underscores the importance of understanding venous variations and drainage patterns for successful surgical outcomes. Preventive measures to protect the vein during neurosurgery are essential to prevent complications such as venous congestion and intracranial pressure. This overview highlights the necessity for precise anatomical knowledge and advanced diagnostic tools in optimizing neurosurgical procedures and patient care.

A single, arterial-optimized 4D-flow MRI acquisition may enable fast assessment of both cerebral arterial and venous flow. However, arteries and veins require different velocity encoding (VENC) settings for optimal velocity-to-noise ratio (VNR). Consequently, venous measurements using arterial-optimized VENC settings are subject to reduced VNR and require further evaluation. This study compared cerebral venous flow and pulsatility assessments using a high-VENC (110 cm/s, adapted to the arterial system) and a low-VENC (40 cm/s, adapted to the venous system) 4D-flow MRI sequence at 3 Tesla. Flow and pulsatility index (PI) were calculated for cerebral veins, sinuses and internal jugular veins in 36 elderly volunteers (79 ± 5 years). The high-VENC acquisitions allowed visualization of nearly all venous structures. Mean flow differences were small and the correlation, strong, when comparing both acquisitions across sinuses ( R  = 0.90–0.99, difference = -8–7%) and cortical veins ( R  = 0.93, difference = − 6%). Inflow-outflow differences at the confluence of sinuses were similar between acquisitions. PI showed moderate to strong agreement except in the straight sinus. Both the vein of Galen and the jugular veins suffered from aliasing in the venous VENC acquisitions. In summary, this study demonstrated that a VENC setting adapted for the arterial cerebral circulation was feasible for studying cerebral venous flow and pulsatility.

ObjectiveSusceptibility-weighted imaging (SWI) can be used to evaluate deep medullary veins (DMVs). This study aimed to apply texture analysis on SWI to evaluate developmental and ischemic changes of DMV in infants.MethodsA total of 38 infants with normal brain MRI (preterm [n = 12], term-equivalent age [TEA] [n = 18], and term [n = 8]) and seven infants with ischemic injury (preterm [n = 2], TEA [n = 1], and term [n = 4]) were included. Regions of interests were manually drawn to include DMVs. First-order texture parameters including entropy, skewness, and kurtosis were derived from SWI. The parameters were compared between groups according to age and presence of ischemic injury. A regression analysis was performed to correlate postmenstrual age (PMA) and parameters. A ROC analysis was performed to differentiate ischemic infants from normal infants.ResultsAmong parameters, entropy showed a significant difference between the age groups (preterm vs. TEA vs. term; 5.395 vs. 4.885 vs. 4.883, p = 0.001). There was a significant positive relationship between PMA and entropy (R square = 0.402, p < 0.001). Skewness was significantly higher in the ischemic group compared with that in the normal group (1.37 vs. 0.70, p = 0.001). The ROC on skewness resulted in an AUC of 0.87 (accuracy, 83.2%) for differentiating infants with ischemic injury.ConclusionA texture analysis of DMVs on SWI showed differences according to age and presence of ischemic injury. The texture parameters can potentially be used as quantitative markers for differentiating infants with ischemic injury through DMV changes.Key Points• The DMV structure of the infant brain could be quantified on SWI with texture analysis.• Entropy from texture analysis on SWI increased as infants got older.• Normal and ischemic injured infants could be differentiated with a cutoff value of 1.025 for skewness.

White matter hyperintensities (WMH) are prevalent. Although arteriolar disease has been implicated in their pathogenesis, venous pathology warrants consideration. We investigated relationships of WMH with histologic venous, arteriolar and white matter abnormalities and correlated findings with premortem neuroimaging. Three regions of periventricular white matter were sampled from archived autopsy brains of 24 pathologically confirmed Alzheimer disease (AD) and 18 age-matched nonAD patients. Using trichrome staining, venous collagenosis (VC) of periventricular veins (<150 µm in diameter) was scored for severity of wall thickening and occlusion; percent stenosis by collagenosis of large caliber (>200 µm) veins (laVS) was measured. Correlations were made between WMH in premortem neuroimaging and vascular and white matter pathology. We found greater VC (U(114) = 2092.5, p = 0.005 and U(114) = 2121.5, p = 0.002 for small and medium caliber veins, respectively) and greater laVS (t(110) = 3.46, p = 0.001) in patients with higher WMH scores; WMH scores correlated with VC (rs(114) = 0.27, p = 0.004) and laVS (rs(110) = 0.38, p < 0.001). By multiple linear regression analysis, the strongest predictor of WMH score was laVS (β = 0.338, p < 0.0001). VC was frequent in patients with periventricular infarcts identified on imaging. We conclude that periventricular VC is associated with WMH in both AD and nonAD patients and the potential roles of VC in WMH pathogenesis merit further study.

Sphenoid wing meningiomas (SWMs) often cause occlusion or stenosis of the superficial middle cerebral vein (SMCV) by tumor compression. This study aimed to analyze the correlation between SMCV compression and peritumoral brain edema (PTBE) in SWM patients and to clarify the importance of surgical preservation of the SMCV in SWM surgery. This retrospective study included 31 patients who underwent surgery for SWM at our institution from April 2011 to March 2022. Patient demographics, tumor characteristics, PTBE size, and SMCV patency before and after surgery were evaluated using preoperative and postoperative MRI or digital subtraction angiography. Of the 31 patients, 24 (77.4 %) exhibited PTBE, with varying degrees of severity: mild (32.3 %), moderate (25.8 %), and severe (41.9 %). Preoperative MRI showed SMCV patency in 14 patients (45.2 %) and SMCV compression in 17 patients (54.8 %). There was a significant association between PTBE severity and SMCV compression (p = 0.002). Postoperatively, SMCV recanalization was observed in 4 out of 16 patients (25.0 %) with preoperative SMCV compression. These patients had significantly smaller tumors (p = 0.013) and larger preoperative PTBE volumes (p = 0.042) compared to those without recanalization. Our study demonstrates a significant correlation between SMCV compression and severe PTBE in SWM patients. A subset of patients showed postoperative SMCV recanalization, particularly those with smaller tumors and more pronounced PTBE. These findings highlight the importance of SMCV preservation during SWM surgery to potentially improve postoperative outcomes. •Sphenoid wing meningioma often cause compression to superficial middle cerebral vein.•Venous compression correlate with severe brain edema in sphenoid wing meningioma.•Postoperative venous recanalization observed in smaller tumors with severe edema.•Venous preserving strategy may improve outcomes in sphenoid wing meningioma surgery.

Background and objective The posterior interhemispheric approach provides optimal access to lesions located in a number of areas. A major advantage of this approach is that the parieto-occipital vein is typically the only venous structure encountered, which minimizes venous interference during exposure. In a surgical series of 12 patients, we identified a previously undescribed venous variant extending from the cuneus to the falx cerebri. Here, we characterize this venous structure and propose a microsurgical strategy to preserve it. Methods A total of 303 posterior interhemispheric approaches were performed from September 2005 to August 2025. We retrospectively reviewed clinical and radiological data collected from patients’ electronic medical records and searched the operative database to locate surgical videos. Results In 12 patients undergoing the posterior interhemispheric approach (12/303, 4%), we identified a previously unreported venous variation in which a cortical vein extended from the cuneus to the falx cerebri. We have termed this structure the cuneus vein . Among these 12, 2 were observed during a right-sided approach (2/157, 1.3%) and 10 during a left-sided approach (10/146, 6.8%). The vein-releasing technique was used in 7 patients, while the falx-cutting technique was done in 4. In all but one patient, the cuneus vein was successfully preserved. In one patient with hydrocephalus, excessive brain relaxation after CSF drainage limited mobilization and caused vein injury, without hemorrhagic or ischemic morbidity during follow-up. Conclusions The cuneus vein, a cortical vein extending from the cuneus to the falx cerebri, is an anatomical variation that has not been described previously but requires careful consideration during the posterior interhemispheric approach. The cuneus vein drains the visual cortex; thus, its sacrifice may lead to postoperative complications, including visual deficits secondary to venous infarction. In this study, we identified and characterized this venous variation and demonstrated its preservation using the vein-releasing technique and the falx-cutting technique.

Objectives We aim to investigate whether cerebral small vessel disease (cSVD) imaging markers correlate with deep medullary vein (DMV) damage in small vessel occlusion acute ischemic stroke (SVO-AIS) patients. Methods The DMV was divided into six segments according to the regional anatomy. The total DMV score (0–18) was calculated based on segmental continuity and visibility. The damage of DMV was grouped according to the quartiles of the total DMV score. Neuroimaging biomarkers of cSVD including white matter hyperintensity (WMH), cerebral microbleed (CMB), perivascular space (PVS), and lacune were identified. The cSVD score were further analyzed. Results We included 229 SVO-AIS patients, the mean age was 63.7 ± 23.1 years, the median NIHSS score was 3 (IQR, 2–6). In the severe DMV burden group (the 4th quartile), the NIHSS score grade (6 (3–9)) was significantly higher than other groups ( p  < 0.01). The grade scores for basal ganglia PVS (BG-PVS) were positively correlated with the degree of DMV ( R  = 0.67, p  < 0.01), rather than centrum semivole PVS (CS-PVS) ( R  = 0.17, p  = 0.1). In multivariate analysis, high CMB burden (adjusted odds ratio [aOR], 25.38; 95% confidence interval [CI], 1.87–345.23) was associated with severe DMV scores. In addition, BG-PVS was related to severe DMV burden in a dose-dependent manner: when BG-PVS score was 3 and 4, the aORs of severe DMV burden were 18.5 and 12.19, respectively. Conclusion The DMV impairment was associated with the severity of cSVD, which suggests that DMV burden may be used for risk stratification in SVO-AIS patients. Clinical relevance statement The DMV damage score, based on the association between small vessel disease and the deep medullary veins impairment, is a potential new imaging biomarker for the prognosis of small vessel occlusion acute ischemic stroke, with clinical management implications. Key Points • The damage to the deep medullary vein may be one mechanism of cerebral small vessel disease. • Severe burden of the basal ganglia perivascular space and cerebral microbleed is closely associated with significant impairment to the deep medullary vein. • The deep medullary vein damage score may reflect a risk of added vascular damage in small vessel occlusion acute ischemic stroke patients.