PLEXO VENOSO DE BATSON(SISTEMA VENOSO CEREBROESPINAL)

Aluno: Juan ZambonMonitoria Neuroanatomia

Prof. Henrique Záquia LeãoNeuroanatomia

Prof. Cláudio Galleano Zettler Patologia Aplicada

INTRODUÇÃO (UM POUCO DE HISTÓRIA)

ANATOMIA (O QUE E ONDE)

FISIOLOGIA (PRA QUÊ E COMO)

CLÍNICA (PATOLOGIA E IMPLICAÇÕES)

Introduction• Before the 18th century, the vertebral

venous plexus (VVP) received scant mention, had no clinical relevance, and was largely ignored by anatomists…(1)

• Gilbert Breschet in 1819 first detailed the VVP: a large plexiform valveless network of vertebral veins (…) and spanning the entire spinal column with connections to the cranial dural sinuses , (…) parallel to and communicating with the venae cavae, and having multiple interconnections

• More than a century passed before…

1. Neurosurgery: November 2011 - Volume 69 - Issue 5 Breschet: Essai sur les veines du rachis, 1819.

Oscar V. Batson. In 1940, he reported the true functionality of the VVP by proving the continuity of the prostatic venous plexus with the VVP and proposed this route as the most plausible explanation for the distribution of prostate metastatic disease.

(…) proving the continuity of the prostatic venous plexus with the VVP and proposed this route as the most plausible explanation for the distribution of prostate metastatic disease. Batson reclassified the human venous system to consist of the caval, pulmonary, portal, and vertebral divisions. Further advances in imaging technology confirmed Batson's results.

Cerebrospinal venous system

(…) A unique, large-capacitance, valveless plexiform venous network in which flow is bidirectional that plays an important role in the regulation of intracranial pressure with changes in posture and in venous outflow from the brain, whereas in disease states, it provides a potential route for the spread of infection, emboli or tumor.

Jaffe HJ: Tumors and Tumorous Conditions of the Bones and Joints. Philadelphia, Lea & Febiger, 1958.

Anatomy

• Scalp, Skull, and Face

• Thoracoabdominal Wall

• Azygous, Pulmonaryand Caval Venous Systems

• Pelvic, Prostatic and Sacral Veins

Communication of Batson Venous Plexus and:

Methods of study:• Corrosion casting• Fluoroscopic/radiographic injection

studies• Ultrasound flow studies• CT• MRI• Experimental evidence

• Patterns of infection• Patterns of embolization• Patterns of metastasis

www.allposters.co.uk

• Crânio

"Throughout the cranium the veins of the brain, the veins of the meninges (the venous sinuses), and the veins of the skull bones themselves (the diploic veins), and the veins of the various extracranial plexuses anastomose richly." Batson

"The facial veins and their important anastomoses with the intracranial venous system are less well appreciated." Osborn Breschet in Recherches anatomiques physiologiques et

pathologiques sur le systáeme veineux. Paris, France: Rouen fráeres; 1829.

Dural Venous Sinuses

A. Sup. Sag. SinusB. G. Cerebral V.C. Ophthalmic Vs.D. Facial V.E. Cavernous SinusF. Inf. Pet. SinusG. Jugular V.H. Sigmoid SinusI. Sup. Pet. SinusJ. Transv. SinusK. Straight SinusL. Inf. Sag. Sinus

Loyola University, Chicago: Dural Venous Sinuses Gross Anatomy - http://www.meddean.luc.edu/lumen/meded/grossanatomy/h_n/cn/dvs/dvs2.htm

Haines, Duane E. Neuroanatomy: An atlas of structures, sections, and systems. Vol. 153. No. 2004. Lippincott Williams & Wilkins, 2004.

Haines, Duane E. Neuroanatomy: An atlas of structures, sections, and systems. Vol. 153. No. 2004. Lippincott Williams & Wilkins, 2004.

Haines, Duane E. Neuroanatomy: An atlas of structures, sections, and systems. Vol. 153. No. 2004. Lippincott Williams & Wilkins, 2004.

• Thorax

“(…) This system communicates with the segmental (intercostal) veins of the thoracico-abdominal wall (including those of the breast) and with the azygous system of veins." Batson

del Regato JA: Pathways of metastatic spread of malignant tumors. Semin Oncol 4:33, 1977.)August 1, 2004 25 Oxford Journals. European Society of Cardiology Online ISSN 1522-9645 - Print ISSN 0195-668x

Imagens: Renan Uflacker. Atlas of Vascular Anatomy an Angiographic Approach: Second Edition. Philadelphia, Lippincott Williams & Wilkins © 2007

• Anastomoses of the VVS With the Azygous, Pulmonary, and Caval Venous Systems

• Pelvis

Imagens: Renan Uflacker. Atlas of Vascular Anatomy an Angiographic Approach: Second Edition. Philadelphia, Lippincott Williams & Wilkins © 2007

• Communication of the Vertebral Venous Plexuses and the Pelvic, Prostatic, and Sacral Veins

For what?• "... the vertebral venous plexus provides one of the major circulatory

compensations that allows man to remain conscious while sitting or standing." Eckenhoff

• Neuroscientists demonstrated venous outflow from the brain predominantly through the CSVS when one is standing:

• Eckenhoff JE. The physiologic significance of the vertebral venous plexus. Surg Gynecol Obstet. 1970;131:72-78.• Epstein HM, Linde HW, Crampton AR, et al. The vertebral venous plexus as a major cerebral venous outflow tract.

Anesthesiology. 1970;32:332-337.• Eckenhoff JE. The vertebral venous plexus. Can Anaesth Soc J. 1971;18:487-495.• Gisolf J, van Lieshout JJ, van Heusden K, et al. Human cerebral venous outflow pathway depends on posture and central

venous pressure. J Physiol. 2004;560(pt1):317-327.• Doepp F, Schreiber SJ, von Munster T, et al. How does the blood leave the brain? A systematic ultrasound analysis of

cerebral venous drainage patterns. Neuroradiology. 2004;46:565-570.• Grevy V, Escuret E. The cerebral venous outflow tract [in French]. Ann Fr Anesth Reanim. 1998;17:144-148.• Hoffmann O, Klingebiel R, Braun JS, et al. Diagnostic pitfall: atypical cerebral venous drainage via the vertebral venous

system. AJNR Am J Neuroradiol. 2002;23:408-411.• Hoffmann O, Weih M, von Munster T, et al. Blood flow velocities in the vertebral veins of healthy subjects: a duplex

sonographic study. J Neuroimaging. 1999;9:198-200.

The four Fluid System

• CSF• Arteries• Jugular Venous

System• Batson's venous

plexus

Monroe-Kellie hypothesis: the sum of the volume of the various components of the intracranial cavity (blood, brain, and CSF) always remains constant.

Jugular and the Starling resistor.

"... we are correct in regarding the vertebral veins as the largest and by far the most important accessory pathway for venous return from the cranium." Herlihy

Show me!Epstein Contrasts: • sagittal sinus was injected with contrast media in rhesus monkeys in upright position,

the VVS was the main route of venous efflux from the brain.

Valdueza color-coded US findings: • internal jugular flow decreased from 700 mL/minute in the supine position to

70mL/minute at 90° elevation• (…) found a corresponding increase in vertebral vein flow from 40 mL/minute at 0°

elevation to 210 mL/minute at 90°• the unmeasured flow ? Through internal vertebral venous plexus!

Schreiber color-coded US findings:• healthy volunteers supine position, internal jugular veins (720 ± 232 mL/minute) and (47

± 33mL/ minute) through the vertebral veins.• (…) found that 6% of healthy human volunteers had a predominantly nonjugular pattern

of cerebral venous drainage when in the supine position.

• Gisolff:• Valsava and opening of internal Jugular

(…) a two-way avenue of metastatic spread of pelvic, abdominal, and thoracic tumors. A large portion of bony metastases results from dissemination of neoplastic cells through the vertebral vein system. (Adapted from del Regato JA: Pathways of metastatic spread of malignant tumors. Semin Oncol 4:33, 1977.)

CLINICAL CORRELATIONS

Panikkath, Ragesh, et al. "Metastasis of lung cancer through Batson’s plexus: very rare but possible." The Southwest Respiratory and Critical Care Chronicles1.4 (2013): 45-49.

• “(…) tumor cells somehow escaped the filtering function of the pulmonary capillaries

• (…) The absence of grossly demonstrable pulmonary lesions • there was only one site of metastasis in an unusual location.

It remained for Batson to solve that riddle“Hussey, 1976

Metastasis in the Cranial Direction via the CSVS

• 90% of prostate cancer metastases involve the spine (2)

• 15% to 30% of prostate cancer metastases have been directly attributed to passage through the VVS to the lumbar spine. (4)

metastasis to the cavernous sinus as the initial presentation of metastatic breast carcinoma. (6)

malignant melanoma that metastasized to the ethmoid sinus (3)

brain mass that was found to be an ileal carcinoid tumor by biopsy, without evidence of bony, pulmonary, or hepatic metastases (5)

Metastasis in the Caudal Direction via the CSVS

metastasis to the cauda equina and cavernous sinus of a squamous cell carcinoma of the face (7)

the case of a 21-year-old man who presented with pain in his hip and lower back with a 3-month history of difficulty walking. Brain MRI revealed a cerebellar medulloblastoma, confirmed by brain biopsy. MRI of the lumbar spine and hip revealed metastases to all lumbar vertebrae and both hips, and CT-guided biopsy of the L3 vertebrae revealed metastatic medulloblastoma. (9)

intramedullary spinal cord metastasis has been reported from lung carcinoma, breast carcinoma, melanoma, renal cell carcinoma, colorectal tumors, cervical carcinoma, lymphoma, and ovarian carcinoma. (10)

• osteomyelitis from transmission of infection by way of the CSVS following prostate surgery (11)

• Bacterial sinusitis• Teeth, oral cavity• Parasitic infections

Embolization via the CSVS• air• Infection• Clot• cement embolization occurring via CSVS

vertebroplasty and kyphoplasty

Transmission of Infection via the Valveless Venous System :

Girolamo Geraci & cols. “Asymptomatic Bone Cement Pulmonary Embolism after Vertebroplasty: Case Report and Literature Review,” Case Reports in Surgery, vol. 2013, Article ID 591432, 5 pages, 2013. doi:10.1155/2013/591432

Conclusion• extends from the head to the pelvis

• group of veins and venous plexuses that freely communicate because they lack valves

• cortical veins, the dural sinuses, the cavernous sinuses, and the ophthalmic veins

• VVS: vertebral venous plexuses, which flow along the entire length of the spine

• sacral and pelvic veins and the prostatic venous plexus• flow is bidirectional• It is the main venous drainage while standing

Conclusion• regulation of intracranial pressure with changes in

posture and venous outflow from the brain • direct vascular route for the spread of tumors, infection,

or emboli in either direction

• Neurologists, neurosurgeons, anatomists and medicine students like YOU should have a familiarity with the CSVS.

OBRIGADO!

Maksim Shapiro, MD. Deep Venous System, Venous Brain Anatomy: neuroangio.org . New York University Langone Medical CenterNeurosurgery: November 2011 - Volume 69 - Issue 5 - p 1007–1014 doi: 10.1227/NEU.0b013e3182274865Edward Tobinick, MD . The Cerebrospinal Venous System: Anatomy, Physiology, and Clinical Implications; Medscape General Medicine. 2006;8(1):53Batson OV. The function of the vertebral veins and their role in the spread of metastases. Ann Surg. 1940;112:138-149.Breschet G. Recherches anatomiques physiologiques et pathologiques sur le systáeme veineux. Paris, France: Rouen fráeres; 1829.Herlihy WF. Revision of the venous system: the role of the vertebral veins. Med J Aust. 1947;1:661-672.Eckenhoff JE. The physiologic significance of the vertebral venous plexus. Surg Gynecol Obstet. 1970;131:72-78.Schaller B. Physiology of cerebral venous blood flow: from experimental data in animals to normal function in humans. Brain Res Brain Res Rev. 2004;46:243-2606. Ryan MW, Rassekh CH, Chaljub G. Metastatic breast carcinoma presenting as cavernous sinus syndrome. Ann Otol Rhinol Laryngol. 1996;105:666-668.12. Geldof AA. Models for cancer skeletal metastasis: a reappraisal of Batson's plexus. Anticancer Res. 1997;17:1535-1539.4. Bubendorf L, Schopfer A, Wagner U, et al. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum Pathol. 2000;31:578-583.3. Bizon JG, Newman RK. Metastatic melanoma to the ethmoid sinus. Arch Otolaryngol Head Neck Surg. 1986;112:664-667.5. Raymond PL, Balaa MA. Diplopia and diarrhea: ileal carcinoid metastatic to the central nervous system. Am J Gastroenterol. 1992;87:240-243.2. Sakata R, Ohiwa Y, Shinmura F, et al. Intracerebral metastasis of esophageal carcinoma--a case report and review of literature [in Japanese]. No Shinkei Geka. 1985;13:647-651.7. Zhu JJ, Padillo O, Duff J, et al. Cavernous sinus and leptomeningeal metastases arising from a squamous cell carcinoma of the face: case report. Neurosurgery. 2004;54:492-498.9. Barai S, Bandopadhayaya GP, Julka PK, et al. Cerebellar medulloblastoma presenting with skeletal metastasis. J Postgrad Med. 2004;50:110-112.8. Rajagopalan V, Kamar FG, Thayaparan R, et al. Bone marrow metastases from glioblastoma multiforme -- a case report and review of the literature. J Neurooncol. 2005;72:157-161.10. Rastelli F, Benedetti G, Di Tommaso L, et al. Intramedullary spinal metastasis from ovarian cancer. Lancet Oncol. 2005;6:123-125.11. De Feo E. Osteomyelitis of the spine following prostatic surgery. Radiology. 1954;62:396-401.

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