4g. The Meninges of the Brain and Medulla Spinalis

The brain and medulla spinalis are enclosed within three membranes. These are named from without inward: the dura mater, the arachnoid, and the pia mater. 1 The Dura Mater The dura mater is a thick and dense inelastic membrane. The portion which encloses the brain differs in several essential particulars from that which surrounds the medulla spinalis, and therefore it is necessary to describe them separately; but at the same time it must be distinctly understood that the two form one complete membrane, and are continuous with each other at the foramen magnum. 2 The Cranial Dura Mater (dura mater encephali; dura of the brain) lines the interior of the skull, and serves the twofold purpose of an internal periosteum to the bones, and a membrane for the protection of the brain. It is composed of two layers, an inner or meningeal and an outer or endosteal, closely connected together, except in certain situations, where, as already described (page 654), they separate to form sinuses for the passage of venous blood. Its outer surface is rough and fibrillated, and adheres closely to the inner surfaces of the bones, the adhesions being most marked opposite the sutures and at the base of the skull its inner surface is smooth and lined by a layer of endothelium. It sends inward four processes which divide the cavity of the skull into a series of freely communicating compartments, for the lodgement and protection of the different parts of the brain; and it is prolonged to the outer surface of the skull, through the various foramina which exist at the base, and thus becomes continuous with the pericranium; its fibrous layer forms sheaths for the nerves which pass through these apertures. Around the margin of the foramen magnum it is closely adherent to the bone, and is continuous with the spinal dura mater. 3

FIG. 765– Dura mater and its processes exposed by removing part of the right half of the skull and the brain. (See enlarged image) Processes.—The processes of the cranial dura mater, which projects into the cavity of the skull, are formed by reduplications of the inner or meningeal layer of the membrane, and are four in number: the falx cerebri, the tentorium cerebelli, the falx cerebelli, and the diaphragma sellæ. 4 The falx cerebri (Fig. 765), so named from its sickle-like form, is a strong, arched process which descends vertically in the longitudinal fissure between the cerebral hemispheres. It is narrow in front, where it is attached to the crista galli of the ethmoid; and broad behind, where it is connected with the upper surface of the tentorium cerebelli. Its upper margin is convex, and attached to the inner surface of the skull in the middle line, as far back as the internal occipital protuberance; it contains the superior sagittal sinus. Its lower margin is free and concave, and contains the inferior sagittal sinus. 5 The tentorium cerebelli (Fig. 766) is an arched lamina, elevated in the middle, and inclining downward toward the circumference. It covers the superior surface of the cerebellum, and supports the occipital lobes of the brain. Its anterior border is free and concave, and bounds a large oval opening, the incisura tentorii, for the transmission of the cerebral peduncles. It is attached, behind, by its convex border, to the transverse ridges upon the inner surface of the occipital bone, and there encloses the transverse sinuses; in front, to the superior angle of the petrous part of the temporal bone on either side, enclosing the superior petrosal sinuses. At the apex of the petrous part of the temporal bone the free and attached borders meet, and, crossing one another, are continued forward to be fixed to the anterior and posterior clinoid processes respectively. To the middle line of its upper surface the posterior border of the falx cerebri is attached, the straight sinus being placed at their line of junction. 6

FIG. 766– Tentorium cerebelli seen from above. (See enlarged image) The falx cerebelli is a small triangular process of dura mater, received into the posterior cerebellar notch. Its base is attached, above, to the under and back part of the tentorium; its posterior margin, to the lower division of the vertical crest on the inner surface of the occipital bone. As it descends, it sometimes divides into two smaller folds, which are lost on the sides of the foramen magnum. 7 The diaphragma sellæ is a small circular horizontal fold, which roofs in the sella turcica and almost completely covers the hypophysis; a small central opening transmits the infundibulum. 8 Structure.—The cranial dura mater consists of white fibrous tissue and elastic fibers arranged in flattened laminæ which are imperfectly separated by lacunar spaces and bloodvessels into two layers, endosteal and meningeal. The endosteal layer is the internal periosteum for the cranial bones, and contains the bloodvessels for their supply. At the margin of the foramen magnum it is continuous with the periosteum lining the vertebral canal. The meningeal or supporting layer is lined on its inner surface by a layer of nucleated flattened mesothelium, similar to that found on serous membranes. 9 The arteries of the dura mater are very numerous. Those in the anterior fossa are the anterior meningeal branches of the anterior and posterior ethmoidal and internal carotid, and a branch from the middle meningeal. Those in the middle fossa are the middle and accessory meningeal of the internal maxillary; a branch from the ascending pharyngeal, which enters the skull through the foramen lacerum; branches from the internal carotid, and a recurrent branch from the lacrimal. Those in the posterior fossa are meningeal branches from the occipital, one entering the skull through the jugular foramen, and another through the mastoid foramen; the posterior meningeal from the vertebral; occasional meningeal branches from the ascending pharyngeal, entering the skull through the jugular foramen and hypoglossal canal; and a branch from the middle meningeal. 10

The veins returning the blood from the cranial dura mater anastomose with the diploic veins and end in the various sinuses. Many of the meningeal veins do not open directly into the sinuses, but indirectly through a series of ampullæ, termed venous lacunæ. These are found on either side of the superior sagittal sinus, especially near its middle portion, and are often invaginated by arachnoid granulations; they also exist near the transverse and straight sinuses. They communicate with the underlying cerebral veins, and also with the diploic and emissary veins. 11 The nerves of the cranial dura mater are filaments from the semilunar ganglion, from the ophthalmic, maxillary, mandibular, vagus, and hypoglossal nerves, and from the sympathetic. 12 The Spinal Dura Mater (dura mater spinalis; spinal dura) (Fig. 767) forms a loose sheath around the medulla spinalis, and represents only the inner or meningeal layer of the cranial dura mater; the outer or endosteal layer ceases at the foramen magnum, its place being taken by the periosteum lining the vertebral canal. The spinal dura mater is separated from the arachnoid by a potential cavity, the subdural cavity; the two membranes are, in fact, in contact with each other, except where they are separated by a minute quantity of fluid, which serves to moisten the apposed surfaces. It is separated from the wall of the vertebral canal by a space, the epidural space, which contains a quantity of loose areolar tissue and a plexus of veins; the situation of these veins between the dura mater and the periosteum of the vertebræ corresponds therefore to that of the cranial sinuses between the meningeal and endosteal layers of the cranial dura mater. The spinal dura mater is attached to the circumference of the foramen magnum, and to the second and third cervical vertebræ; it is also connected to the posterior longitudinal ligament, especially near the lower end of the vertebral canal, by fibrous slips. The subdural cavity ends at the lower border of the second sacral vertebra; below this level the dura mater closely invests the filum terminale and descends to the back of the coccyx, where it blends with the periosteum. The sheath of dura mater is much larger than is necessary for the accommodation of its contents, and its size is greater in the cervical and lumbar regions than in the thoracic. On each side may be seen the double openings which transmit the two roots of the corresponding spinal nerve, the dura mater being continued in the form of tubular prolongations on them as they pass through the intervertebral foramina. These prolongations are short in the upper part of the vertebral column, but gradually become longer below, forming a number of tubes of fibrous membrane, which enclose the lower spinal nerves and are contained in the vertebral canal. 13

FIG. 767– The medulla spinalis and its membranes. (See enlarged image) Structure.—The spinal dura mater resembles in structure the meningeal or supporting layer of the cranial dura mater, consisting of white fibrous and elastic tissue arranged in bands or lamellæ which, for the most part, are parallel with one another and have a longitudinal arrangement. Its internal surface is smooth and covered by a layer of mesothelium. It is sparingly supplied with bloodvessels, and a few nerves have been traced into it. 14 The Arachnoid—The arachnoid is a delicate membrane enveloping the brain and medulla spinalis and lying between the pia mater internally and the dura mater externally; it is separated from the pia mater by the subarachnoid cavity, which is filled with cerebrospinal fluid. 15 The Cranial Part (arachnoidea encephali) of the arachnoid invests the brain loosely, and does not dip into the sulci between the gyri, nor into the fissures, with the exception of the longitudinal. On the upper surface of the brain the arachnoid is thin and transparent; at the base it is thicker, and slightly opaque toward the central part, where it extends across between the two temporal lobes in front of the pons, so as to leave a considerable interval between it and the brain. 16 The Spinal Part (arachnoidea spinalis) of the arachnoid is a thin, delicate, tubular membrane loosely investing the medulla spinalis. Above, it is continuous with the cranial arachnoid; below, it widens out and invests the cauda equina and the nerves proceeding from it. It is separated from the dura mater by the subdural space, but here and there this space is traversed by isolated connective-tissue trabeculæ, which are most numerous on the posterior surface of the medulla spinalis. 17 The arachnoid surrounds the cranial and spinal nerves, and encloses them in loose sheaths as far as their points of exit from the skull and vertebral canal. 18 Structure.—The arachnoid consists of bundles of white fibrous and elastic tissue intimately blended together. Its outer surface is covered with a layer of low cuboidal mesothelium. The inner surface and the trabeculæ are likewise covered by a somewhat low type of cuboidal mesothelium which in places are flattened to a pavement type. Vessels of considerable size, but few in number, and, according to Bochdalek, a rich plexus of nerves derived from the motor root of the trigeminal, the facial, and the accessory nerves, are found in the arachnoid. 19 The Subarachnoid Cavity (cavum subarachnoideale; subarachnoid space) is the interval between the arachnoid and pia mater. It is occupied by a spongy tissue consisting of trabeculæ of delicate connective tissue, and intercommunicating channels in which the subarachnoid fluid is contained. This cavity is small on the surface of the hemispheres of the brain; on the summit of each gyrus the pia mater and the arachnoid are in close contact; but in the sulci between the gyri, triangular spaces are left, in which the subarachnoid trabecular tissue is found, for the pia mater dips into the sulci, whereas the arachnoid bridges across them from gyrus to gyrus. At certain parts of the base of the brain, the arachnoid is separated from the pia mater by wide intervals, which communicate freely with each other and are named subarachnoid cisternæ; in these the subarachnoid tissue is less abundant. 20 Subarachnoid Cisternæ (cisternæ subarachnoidales) (Fig. 768).—The cisterna cerebellomedullaris (cisterna magna) is triangular on sagittal section, and results from the arachnoid bridging over the interval between the medulla oblongata and the under surfaces of the hemispheres of the cerebellum; it is continuous with the subarachnoid cavity of the medulla spinalis at the level of the foramen magnum. The cisterna pontis is a considerable space on the ventral aspect of the pons. It contains the basilar artery, and is continuous behind with the subarachnoid cavity of the medulla spinalis, and with the cisterna cerebellomedullaris; and in front of the pons with the cisterna interpeduncularis. The cisterna interpeduncularis (cisterna basalis) is a wide cavity where the arachnoid extends across between the two temporal lobes. It encloses the cerebral peduncles and the structures contained in the interpeduncular fossa, and contains the arterial circle of Willis. In front, the cisterna interpeduncularis extends forward across the optic chiasma, forming the cisterna chiasmatis, and on to the upper surface of the corpus callosum, for the arachnoid stretches across from one cerebral hemisphere to the other immediately beneath the free border of the falx cerebri, and thus leaves a space in which the anterior cerebral arteries are contained. The cisterna fossæ cerebri lateralis is formed in front of either temporal lobe by the arachnoid bridging across the lateral fissure. This cavity contains the middle cerebral artery. The cisterna venæ magnæ cerebri occupies the interval between the splenium of the corpus callosum and the superior surface of the cerebellum; it extends between the layers of the tela chorioidea of the third ventricle and contains the great cerebral vein. 21

FIG. 768– Diagram showing the positions of the three principal subarachnoid cisternæ. (See enlarged image) The subarachnoid cavity communicates with the general ventricular cavity of the brain by three openings; one, the foramen of Majendie, is in the middle line at the inferior part of the roof of the fourth ventricle; the other two are at the extremities of the lateral recesses of that ventricle, behind the upper roots of the glossopharyngeal nerves and are known as the foramina of Luschka. It is still somewhat uncertain whether these foramina are actual openings or merely modified areas of the inferior velum which permit the passage of the cerebrospinal fluid from the ventricle into the subarachnoid spaces as through a permeable membrane. 22 The spinal part of the subarachnoid cavity is a very wide interval, and is the largest at the lower part of the vertebral canal, where the arachnoid encloses the nerves which form the cauda equina. Above, it is continuous with the cranial subarachnoid cavity; below, it ends at the level of the lower border of the second sacral vertebra. It is partially divided by a longitudinal septum, the subarachnoid septum, which connects the arachnoid with the pia mater opposite the posterior median sulcus of the medulla spinalis, and forms a partition, incomplete and cribriform above, but more perfect in the thoracic region. The spinal subarachnoid cavity is further subdivided by the ligamentum denticulatum, which will be described with the pia mater. 23 The cerebrospinal fluid is a clear limpid fluid, having a saltish taste, and a slightly alkaline reaction. According to Lassaigne, it consists of 98.5 parts of water, the remaining 1.5 per cent. being solid matters, animal and saline. It varies in quantity, being most abundant in old persons, and is quickly secreted. 24 The Arachnoid Villi (granulationes arachnoideales; glandulæ Pacchioni; Pacchionian bodies) (Fig. 769) are small, fleshy-looking elevations, usually collected into clusters of variable size, which are present upon the outer surface of the dura mater, in the vicinity of the superior sagittal sinus, and in some other situations. Upon laying open the sagittal sinus and the venous lacunæ on either side of it villi will be found protruding into its interior. They are not seen in infancy, and very rarely until the third year. They are usually found after the seventh year; and from this period they increase in number and size as age advances. They are not glandular in structure, but are enlarged normal villi of the arachnoid. As they grow they push the thinned dura mater before them, and cause absorption of the bone from pressure, and so produce the pits or depressions on the inner wall of the calvarium. 25

FIG. 769– Diagrammatic representation of a section across the top of the skull, showing the membranes of the brain, etc. (Modified from Testut.) (See enlarged image) Structure.—An arachnoidal villus represents an invasion of the dura by the arachnoid membrane, the latter penetrates the dura in such a manner that the arachnoid mesothelial cells come to lie directly beneath the vascular endothelium of the great dural sinuses. It consists of the following parts: (1) In the interior is a core of subarachnoid tissue, continuous with the meshwork of the general subarachnoid tissue through a narrow pedicle, by which the villus is attached to the arachnoid. (2) Around this tissue is a layer of arachnoid membrane, limiting and enclosing the subarachnoid tissue. (3) Outside this is the thinned wall of the lacuna, which is separated from the arachnoid by a potential space which corresponds to and is continuous with the subdural cavity. (4) And finally, if the villus projects into the sagittal sinus, it will be covered by the greatly thinned wall of the sinus which may consist merely of endothelium. It will be seen, therefore, that fluid injected into the subarachnoid cavity will find its way into these villi, and it has been found experimentally that it passes from the villi into the venous sinuses into which they project. 26 The Pia Mater—The pia mater is a vascular membrane, consisting of a minute plexus of bloodvessels, held together by an extremely fine areolar tissue and covered by a reflexion of the mesothelial cells from the arachnoid trabeculæ. It is an incomplete membrane, absent probably at the foramen of Majendie and the two foramina of Luschka and perforated in a peculiar manner by all the bloodvessels as they enter or leave the nervous system. In the perivascular spaces, the pia apparently enters as a mesothelial lining of the outer surface of the space; a variable distance from the exterior these cells become unrecognizable and are apparently lacking, replaced by neuroglia elements. The inner walls of these perivascular spaces seem likewise covered for a certain distance by the mesothelial cells, reflected with the vessels from the arachnoid covering of these vascular channels as they traverse the subarachnoid spaces. 27 The Cranial Pia Mater (pia mater encephali; pia of the brain) invests the entire surface of the brain, dips between the cerebral gyri and cerebellar laminæ, and is invaginated to form the tela chorioidea of the third ventricle, and the choroid plexuses of the lateral and third ventricles (pages 840 and 841); as it passes over the roof of the fourth ventricle, it forms the tela chorioidea and the choroid plexuses of this ventricle. On the cerebellum the membrane is more delicate; the vessels from its deep surface are shorter, and its relations to the cortex are not so intimate. 28

FIG. 770– Diagrammatic transverse section of the medulla spinalis and its membranes. (See enlarged image) The Spinal Pia Mater (pia mater spinalis; pia of the cord) (Figs. 767, 770) is thicker, firmer, and less vascular than the cranial pia mater: this is due to the fact that it consists of two layers, the outer or additional one being composed of bundles of connective-tissue fibers, arranged for the most part longitudinally. Between the layers are cleft-like spaces which communicate with the subarachnoid cavity, and a number of bloodvessels which are enclosed in perivascular lymphatic sheaths. The spinal pia mater covers the entire surface of the medulla spinalis, and is very intimately adherent to it; in front it sends a process backward into the anterior fissure. A longitudinal fibrous band, called the linea splendens, extends along the middle line of the anterior surface; and a somewhat similar band, the ligamentum denticulatum, is situated on either side. Below the conus medullaris, the pia mater is continued as a long, slender filament (filum terminale), which descends through the center of the mass of nerves forming the cauda equina. It blends with the dura mater at the level of the lower border of the second sacral vertebra, and extends downward as far as the base of the coccyx, where it fuses with the periosteum. It assists in maintaining the medulla spinalis in its position during the movements of the trunk, and is, from this circumstance, called the central ligament of the medulla spinalis. 29 The pia mater forms sheaths for the cranial and spinal nerves; these sheaths are closely connected with the nerves, and blend with their common membranous investments. 30 The ligamentum denticulatum (dentate ligament) (Fig. 767) is a narrow fibrous band situated on either side of the medulla spinalis throughout its entire length, and separating the anterior from the posterior nerve roots. Its medial border is continuous with the pia mater at the side of the medulla spinalis. Its lateral border presents a series of triangular tooth-like processes, the points of which are fixed at intervals to the dura mater. These processes are twenty-one in number, on either side, the first being attached to the dura mater, opposite the margin of the foramen magnum, between the vertebral artery and the hypoglossal nerve; and the last near the lower end of the medulla spinalis. 31

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