541

Craniofacial Venous Plexuses: Angiographic Study

Anne G. Osborn 1 Venous drainage patterns at the craniocervical junction and skull base have been thoroughly described in the radiographic literature. The facial veins and their important anastomoses with the intracranial venous system are less well appreciated. This study of 54 consecutive normal cerebral angiograms demonstrates that visualization of the pterygoid plexus as well as the anterior facial, lingual, submental, and ophthalmic veins can be normal on common carotid angiograms. In contrast to previous reports, opaci­ fication of ophthalmic or orbital veins occurs in most normal internal carotid arterio­ grams. Visualization of the anterior facial vein at internal carotid angiography can also be normal if the extraocular branches of the ophthalmic artery are prominent and nasal vascularity is marked.

The angiographic anatomy of the cranial dural sinuses and subependymal veins has been thoroughly discussed in the radiographic literature. While many authors have described the venous drainage patterns of the craniocervical junction [1-3], middle cranial fossa [4, 5], cavern ous sinus area [6-9], tentorium [4], and orbit [10, 11], no systematic examination of the facial veins has been performed. This study describes the normal angiographic anatomy of the super­ ficial and deep facial veins. Their anastomoses with the intracrani al basilar venous plexuses are briefly reviewed and th e incidence of their visualizati on on normal cerebral angiograms is outlined.

Material and Methods

Fifty-four consecutive norm al cerebral angiograms were selected for stu dy. A total of 84 vessels was injected for a vari ety of clinical indications including seizu res, headache, syncope, and transient cerebral ischemia. There were 67 comm on carotid and 17 intern al carotid studies. Selecti ve extern al carotid angiograms were not obtained. Common carotid angiography was performed using 10 ml 60% Conray (M allinckrodt) injected at a rate of 8 ml / sec. For the selecti ve intern al caroti d studies, 8 ml at 7 ml / sec was used . Subtracti on masks were made of each study and all films from the late arterial through late venous phase were examined. Midvenous phase films in th e lateral projecti on were also selected from each angiogram for routine single order subtraction prints. The type of cavernous or Received M arch 7, 1980; accepted June 26, paracavern ous venous drainage as well as visualization of the pterygoid plexus and the 1980. various facial ve ins was noted. Presented at th e annual meeting of the Am eri­ can Society of Neuroradiology, Los Angeles, March 1980. Normal Gross Anatomy IDepartm ent of Radiology, University of Utah College of Medicine, 50 N. Medical Dr., Salt Lake Sphenobasal em issary channels pass through th e foramina ovale, spinosum , City, UT 8 41 32. and lacerum to connect th e cavernous sinus with th e pterygoid venous plexus, This article appears in November/ December an extensive network of small vascul ar channels that overli es the lateral pterygoid 1980 AJNR and January 1981 AJR. muscle (fig. 1). The pterygoid pl exus also communicates with the ophthalmic AJNR 1 :541-545, November/ December 1980 01 95-6108 / 80/ 001 6-0541 $ 00.00 veins through the inferior orbital fi ssure, with the anteri or facial ve in via a deep © Am eri can Roentgen Ray Society facial branch, and receives tri butari es corresponding to branches of the ptery- 542 OSBORN AJNR: 1 , November/ December 1 980

Fig. 1.- Anatomy pterygoid venous plexus. 1 = superficial temporal vein; Fig. 2.-Anatomy of superficial facial veins, deep venous plexuses, and 2 = pterygoid plexus; 3 = maxillary ve in ; 4 = retromandibular vein; 5 = their anastomoses with intracrani al venous system. 1 = superficial temporal deep facial vein; 6 = anterior facial vein; 7 = submental vein; 8 = internal vein ; 2 = superior oph thalmic vein; 3 = inferior ophthalmic vein; 4 = jugular vein; 9 = external jugular. superficial middle cerebral vein ; 5 = angular vein; 6 = cavernous sinus; 7 = pterygoid plexus; 8 = basilar plexus; 9 = in ferior petrosal sinus; 10 = superior petrosal sinus; 11 = retromandibular vein; 12 = occipital vein; 13 = anterior facial vein ; 14 = external jugular vein; 15 = internal jugular vein.

gopalatine maxillary artery segment. The pterygoid pl exus drainage patterns. If the basilar vein of Rosenthal, vein of drain s posteriorly into a .s hort trunk called the maxillary vein Labbe, or superficial cortical veins are prominent, neither (fig. 1). The maxillary vein then courses posteroinferiorly the cavernous sinus nor the pterygoid plexus may be opa­ and unites with the superficial temporal vein to form the cified [13-15]. The cavernous sinus was visualized in 35 retromandibular vein. This vessel is usually a major tributary (4 1.7%) of the 84 angiograms, draining into the petrosal of the external jugul ar vein (fig. 2). The pterygoid plexus sinuses, basilar or pterygoid plexus, or a combination of may also drain via the posteri or and common facial veins these vessels (fig. 3). in to the internal jugular vei n [1 2]. Superficial middle cerebral venous tributaries were iden­ The anterior facial vein begin s near the medial palpebral tified on 61 of 84 studies. Th ese vessels often cross the angle as a di rect continuation of the angular vein . It de­ greater sphenoid wing, draining directly into sphenoidal scends obliquely across the face, crosses over the masse­ emissary veins that exit from the skull (usually through the teric muscle, then curves over the inferior border of the foramen oval e) to communicate with the pterygoid pl exus mandible. During its course the anteri or facial vein receives [7]. This sphenobasal pattern was identified in 21 (34.5%) tributaries from the orbit, lips, facial muscles, and submental of the 61 angiograms (fig. 4). Both the cavernous sinus and region. pterygoid venous plexus may be bypassed if the superficial The facial vein usually crosses the external carotid artery middle cerebral vein drains into the transverse sinus instead to drain into the internal jugul ar vein although it may also (fig . 5). This sphenopetrosal configuration was present in become a tributary of the external jugular system. The eight (13%) of 61 of the angiograms. Combinations of the anterior facial vein anastomoses with the pterygoid plexus different basal drainage patterns may also exist, resulting in via the deep facial vein and with the cavern ous sinus vi a the variable visualization of the pterygoid plexus (fig. 6). Com­ angular and ophthalmic veins (figs. 1 and 2). bined drainage patterns were identified in 24.5% (15/ 61) Normal Angiographic Anatomy and Results of the examinations. The superior and inferior ophthalmic or small orbital veins Visuali zation of many deep facial veins, particularly th e were identified in 31 of the 67 common carotid angiograms pterygoid plexus, is directly dependent on the intracranial and 12 of 17 intern al carotid studies (fig. 7). The direction AJNR:1 , November/ December 1980 CRANIOFACIAL VENOUS PLEXUSES 543

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Fig. 3.-Normal left internal carotid angiogram, midvenous phase, lateral Fig . 5. -Normal left internal carotid angiogram, venous phase, lateral view. 1 = superficial middle cerebral veins; 2 = cavernous sinus; 3 = basilar view. Predominant sphenopetrosal drainage pattern. 1 = superficial middle plexus; 4 = superi or petrosal sinus; 5 = inferior petrosal sinus; 5 = pterygoid cerebral vein; 2 = sphenopetrosal vein; 3 = superior petrosal sinus; 4 = plexus; 7 = internal jugular vein; 8 = suboccipital venous plexus; 9 = pterygoid plexus (faintly opacified). maxillary vein. Fig. 4.-Normal left common carotid ang iog ram, venous phase, lateral view. Dominant sphenobasal drainage pattern. Superficial middle cerebral Fig. 5.-Left internal carotid angiogram, venous phase, lateral view, in vein drains into pterygoid plexus and petrosal sinuses, largely bypassing patient with suprasellar meningioma (arrowheads). Combin ed sphenobasal­ cavernous sinus. 1 = superficial middle cerebral vein; 2 = sphenobasal sphenopetrosal pattern . Single large superficial middle cerebral vein (large emissary veins passing through foramen ovale; 3 = pterygoid plexus; 4 = black arrow) drains into pterygoid plexus (outlined arrow) and superi or maxillary vein; 5 = superficial temporal vein; 5 = retromandibular vein; 7 = petrosal sinus (small black arrows). This case is a particularly striking pharyngeal vein. example of combined basilar drainage. 544 OSBORN AJNR:1, November/ December 1980

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Fig . 7.-Normal I fl common carolid angiogram, venous ph ase, lateral Fig . 8.-Normal left common carotid angiogram, venous phase, lateral vi w. 1 = superior ophthalmic vein; 2 = anterior facial vein ; 3 = lingual view. 1 = anterior facial vein; 2 = submental vein; 3 = common facial vein. v in ; 4 = pterygoid plexus.

of flow through the ophthalmic veins was extra- to intracra­ investigators. However, some have stated that visualization ni al in all these normal examinations. Superficial veins such of the superior ophthalmic vein following selective internal as the anterior or common facial, lingual, or thyroidal veins carotid angiograms is a rarity except when the extraocular were apparent on 19 of 67 common carotid angiograms (fig. ophthalmic artery branches are prominent [10). In contrast, 8). The anterior facial vein was identified on only one of the we found that opacification of the superior or inferior oph­ 17 intern al carotid studies; in this particular angiogram the thalmic veins or small orbital veins occurs in most cases e traocular and ethmoidal branches of the ophthalmic artery when serial subtraction films are carefully studied. If anas­ were unusually prominent. tomoses between ethmoidal branches of the opthalmic and maxillary arteries are prominent and nasal vascularity is marked, the anterior facial vein may also be visualized even Discussion on selective internal carotid angiograms. The facial, lingual, Althougll variations in venous drainage patterns around submental, and even superior thyroidal veins are frequently the cavernous sinus and skull base have been widely rec­ visualized after common carotid studies. Visualization of the ognized [4-9], the connections that normally exist between opthalmic, pterygoid, and other facial veins at cerebral th intracranial veins, dural sinuses, and facial veins are angiography is therefore normal. Identification of these I s w II appreci ted. While recognizing that the cavernous structures should not be considered indicative of a vascular i not invariabl y opacified at carotid angiography, abnormality. uthors have stated that drainage into th e pterygoid indicates possible posterior obstruction of the cav- REFERENCES rnou inu [6]. We ha e found that visualization of the 1. Brown JP, Tournade A. Venous drainage in the craniocervical pt r goid nou pie us is both common and normal. region. Neuroradiology 1977; 13: 1 55-158 Vi u Iization of the ophthalmic and facial veins on selec- 2. Dilenge D, Perey B. An angiographic study of the meningo­ ti t mal c rotid studies ha been documented by other rachidian venous system. Radiology 1973;108:333-337 AJNR:1, November/ December 1980 CRANIOFACIAL VENOUS PLEXUSES 545

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