Chapter 7

The Meninges
D.E. Haines

maximum protection, they can be very unforgiving in the case

Overview-107 of trauma or in a disease process. For example, growth of a
Development of the Meninges-107 tumor creates a mass that may increase intracranial pressure
and compress or displace various portions of the brain. Some-
Overview of the Meninges-108 thing has to give inside the skull when a space-occupying lesion
Dura Mater-109 develops, and it is the delicate tissue of the brain that gives.
Periosteal and Meningeal Dura-109 The neurologic deficits that result depend on the location of the
Dural Border Cell Layer-109 mass, the rapidity with which it enlarges, and which parts of the
Blood Supply-110 brain are damaged.
Nerve Supply-110
Dural Infoldings and Sinuses-110 DEVELOPMENT OF THE MENINGES
Compartments and Herniation Syndromes-111 The meninges develop from cells of the neural crest and mesen-
Cranial Versus Spinal Dura-112 chyme (mesoderm), which migrate to surround the developing
CNS between 20 and 35 days of gestation (Fig. 7.1A-C). Collec-
Arachnoid Mater-112 tively, these neural crest and mesodermal cells form the primi-
Arachnoid Barrier Cell Layer-112 tive meninges (meninx primitiva). At this stage, no obvious spaces
Arachnoid Trabeculae and the Subarachnoid Space-113 (venous sinuses, subarachnoid space) are present in the meninges.
Arachnoid Villi-113 Between 34 and 48 days of gestation, the primitive meninges dif-
Meningioma-114 ferentiate into an outer, more compact layer called the ectomeninx
Origins and Locations-114 and an inner, more reticulated layer called the endomeninx (Fig.
General Histologic Features-114 7.1D). As development progresses (45 to 60 days of gestation),
Symptoms and Treatment-115 the ectomeninx becomes more compact, and spaces appear in this
layer that correlate with the positions of the future venous sinuses.
Meningeal Hemorrhages-116 Concurrently, the endomeninx becomes more reticulated, and the
Extradural and “Subdural” Hemorrhages-116 spaces that appear in its inner part correspond to the subarach-
Hygroma-116 noid spaces and cisterns of the adult. In general, the ectomeninx
Pia Mater-116 will become the dura mater, and the endomeninx will form the
Cisterns, Subarachnoid Hemorrhages, and Meningitis-118 arachnoid mater and pia mater (the leptomeninges) of the adult
nervous system (Fig. 7.1D). By the end of the first trimester, the
general plan of the meninges is established.
One developmental defect associated with closure of the neu-
The human nervous system is extremely delicate and lacks the ral tube and formation of the meninges in the lumbosacral area is
internal connective tissue framework seen in most organs. For the congenital dermal sinus (also called just dermal sinus) (Fig.
protection, the brain and spinal cord are each encased in a bony 7.1E). This defect is caused by a failure of the ectoderm (future
shell, enveloped by a fibrous coat, and delicately suspended skin) to completely pinch off from the neuroectoderm and the
within a fluid compartment. In the living state, the nervous sys- primitive meninges that envelop it. As a result, the meninges are
tem has a gelatinous consistency, but when treated with fixatives, continuous with a narrow, epithelium-lined channel that extends
it becomes firm and easy to handle. to the skin surface (Fig. 7.1E). Dermal sinuses are sometimes
discovered in young patients who have recurrent but unexplained
OVERVIEW bouts of meningitis. These lesions are surgically removed, and
The brain and spinal cord are surrounded by the skull and ver- recovery is usually complete.
tebral column, respectively. With the exception of the inter- The ectomeninx around the brain is continuous with the
vertebral foramina, through which the spinal nerves and their skeletogenous layer that forms the skull. This relationship is
associated vessels pass, and the foramina in the skull, which serve maintained in the adult, in whom the dura is intimately adher-
as conduits for arteries, veins, and cranial nerve roots, this bony ent to the inner surface of the skull. In the spinal column,
encasement is complete. The membranous coverings of the cen- the ectomeninx is also initially continuous with the develop-
tral nervous system (CNS), the meninges, are located internal ing vertebrae. However, as development proceeds, the spinal
to the skull and vertebral column. The meninges (1) protect the ectomeninx dissociates from the vertebral bodies. A layer of
underlying brain and spinal cord; (2) serve as a support frame- cells remains on the vertebrae to form the periosteum lining
work for important arteries, veins, and sinuses; and (3) enclose the vertebral canal, and the larger part of the ectomeninx con-
a fluid-filled cavity, the subarachnoid space, that is vital to the denses to form the spinal dura. The intervening space becomes
survival and normal function of the brain and spinal cord. the spinal epidural space (Fig. 7.2). In the vertebral column,
The presence of this bony and meningeal encasement of the this space may be used for the administration of epidural
CNS is a double-edged sword. Although these structures offer anesthetics.

107
108 Regional Neurobiology

Neural groove Arachnoid villus

Superior sagittal sinus
Subarachnoid
space
Neural crest Arachnoid and pia
Neural tube Dura mater
Notochord Falx Cerebrum
A cerebri

Neural crest Lateral

ventricle
Neural tube

Developing
vertebra Transverse
sinus
Notochord
Third ventricle
B
Cerebellum
Neural tube Primitive meninges Cerebral
aqueduct
Neural crest Tentorium
cerebelli

Cistern
Vertebra Mesoderm
Fourth ventricle

Subarachnoid space
C
Neural tube Endomeninx
Ectomeninx Intervertebral foramen
Mantle layer (future arachnoid
(future dura) and posterior root
Marginal layer and pia) ganglion

Posterior root
Denticulate ligament

Spinal nerve

Vertebrae

Anterior root Posterior Epidural space

root ganglion
D Conus medullaris
Dermal sinus
Arachnoid
Dura mater Cauda equina
and pia
Lumbar cistern
Filum terminale internum

Filum terminale externum

E Coccyx
Fig. 7.1 Development of the meninges. After the neural tube closes (A and B),
cells from the neural crest and mesoderm (C, arrows) migrate to surround the
Fig. 7.2 The relation of the meninges to the brain and spinal cord and to their
neural tube and form the primordia of the dura and of the arachnoid and pia (D).
surrounding bony structures. The dura is represented in blue, the arachnoid in
A dermal sinus (E) is a malformation in which there is a channel from the skin
red.
into the meninges.

OVERVIEW OF THE MENINGES by the epidural space (Fig. 7.2). Around the brain the inner por-
In general, the meninges consist of fibroblasts and varying amounts tions of the dura give rise to infoldings or septa, such as the falx
of extracellular connective tissue fibrils. The fibroblasts of each cerebri and tentorium cerebelli (Fig. 7.2), which separate brain
meningeal layer are modified to serve a particular function. regions from each other. Major venous sinuses are found at the
The human meninges are composed of the dura mater, arach- points where these septa originate. Spinal and cranial nerves, as
noid mater, and pia mater (Figs. 7.2 and 7.3). The outermost por- they enter or exit the CNS, must pass through a cuff of the dura
tion, the dura mater, also called the pachymeninx, is adherent to that is continuous with the connective tissue of the peripheral
the inner surface of the skull but is separated from the vertebrae nerve. Blood vessels traverse the dura in similar fashion. Rostrally,
 The Meninges 109

Skull

Vessel Periosteal
dura

Dura
mater
Meningeal
dura

Dural
border
cells

Arachnoid
barrier
cells

Basement
membrane
Subarachnoid Arachnoid Arachnoid
space (SAS) trabeculae mater
in SAS

Vessel

Pia mater
Basement
Brain membrane

Collagen
Fig. 7.3 The structure of the meninges. Layers of the dura are shown in shades of gray, the arachnoid in
shades of pink, and the pia in green.

the dura sac is attached to the rim of the foramen magnum. Cau- cell portions. There is no distinct border between periosteal and
dally the sac ends at about the level of the second sacral vertebrae meningeal portions of the dura (Fig. 7.3). Fibroblasts of the peri-
and is attached to the coccyx by the filum terminale externum osteal dura are larger and slightly less elongated than other dural
(or dural part of the filum terminale) (Fig. 7.2). cells. This portion of the dura is adherent to the inner surface
The inner two layers of the meninges, the arachnoid mater of the skull, and its attachment is particularly tenacious along
and the pia mater (Figs. 7.2 and 7.3), are collectively known suture lines and in the cranial base. In contrast, the fibroblasts
as the leptomeninges. This term is also commonly used in of the meningeal dura are more flattened and elongated, their
clinical medicine (as in leptomeningeal cysts and leptomenin- nuclei are smaller, and their cytoplasm may be darker than
gitis). Meningeal infections are frequently sequestered in the that of periosteal cells. Although cell junctions are rarely seen
subarachnoid space; hence they are within the leptomeninges. between dural fibroblasts, the large amounts of interlacing col-
The arachnoid is a thin cellular layer that is attached to the lagen in periosteal and meningeal portions of the dura give these
overlying dura but, with the exception of the arachnoid tra- layers of the meninges great strength.
beculae, is separated from the pia mater by the subarachnoid
space. The arachnoid around the brain is directly continuous Dural Border Cell Layer
with the arachnoid lining the inner surface of the spinal dura The innermost part of the dura is composed of flattened fibro-
(Fig. 7.2). Consequently, the spinal and cerebral subarachnoid blasts that have sinuous processes. Collectively, these cells form
spaces are also directly continuous with each other at the fora- the dural border cell layer (Fig. 7.3). The extracellular spaces
men magnum. The subarachnoid space contains cerebrospi- between the flattened cell processes of dural border cells con-
nal fluid (CSF) and vessels and is bridged by fibroblasts of tain an amorphous substance but no collagen or elastic fibers.
various sizes and shapes that collectively form the arachnoid Cell junctions (desmosomes, gap junctions) are occasionally
trabeculae. The arachnoid is avascular and does not contain seen between dural border cells and cells of the underlying
nerve fibers. arachnoid.
The pia mater is located on the surface of the brain and spinal Because of its loose arrangement, enlarged extracellular
cord and closely follows all their various grooves and elevations spaces, and lack of extracellular connective tissue fibrils, the
(Figs. 7.2 and 7.3). Around the spinal cord, the pia mater con- dural border cell layer constitutes a plane of structural weak-
tributes to the formation of the denticulate ligaments and the ness at the dura-arachnoid junction. This layer is externally
filum terminale internum (or pial part of the filum terminale) continuous with the meningeal dura and internally continuous
(Fig. 7.2). with the arachnoid. Consequently, bleeding into this area of
the meninges will likely disrupt and dissect open the dural
DURA MATER border cell layer rather than invade the overlying dura or the
Periosteal and Meningeal Dura underlying arachnoid. In the normal (and healthy) human,
The dura mater (pachymeninx) is composed of elongated fibro- there is not a naturally occurring, or preexisting, space at the
blasts and copious amounts of collagen fibrils (Fig. 7.3). This dura-arachnoid interface (Fig. 7.3). A space may be created at
membrane contains blood vessels and nerves and is generally this interface by, for example, trauma, bleeding from traversing
divided into outer (periosteal), inner (meningeal), and border veins, or a pathologic process.
110 Regional Neurobiology

Superior sagittal sinus

Falx cerebri

Inferior sagittal
sinus

Frontal sinus
Great
Crista galli cerebral Straight sinus
vein

Confluence
of sinuses

Falx cerebelli
Sphenoidal sinus
Occipital sinus

Groove for sphenoid sinus

Jugular foramen
Tentorium cerebelli

Diaphragma sellae
and sella turcica
Fig. 7.4 Midsagittal view of the skull showing the dural infoldings (reflections) and venous sinuses associ-
ated with each.

Blood Supply through the intervertebral foramina and are distributed to the
The arterial supply to the dura of the anterior cranial fossa origi- spinal dura and to some adjacent structures.
nates from the cavernous portion of the internal carotid, the
ethmoidal arteries (via the ethmoidal foramina), and branches of Dural Infoldings and Sinuses
the ascending pharyngeal artery (via the foramen lacerum). The The periosteal dura lines the inner surface of the skull and func-
middle meningeal artery serves the dura of the middle cranial tions as its periosteum. The meningeal dura is continuous with
fossa and may be compromised by skull fractures of the parietal the periosteal dura but draws away from it at specific locations
bone or the squamous portion of the temporal bone, potentially to form the dural infoldings (or reflections). The largest of these
resulting in an epidural hematoma. It is a branch of the maxillary is the falx cerebri (Figs. 7.4 and 7.5A). It is attached to the crista
artery and enters the skull through the foramen spinosum. The galli rostrally, to the midline of the inner surface of the skull,
accessory meningeal artery (via the foramen ovale) and small and to the surface of the tentorium cerebelli caudally. The falx
branches from the lacrimal artery (via the superior orbital fis- cerebri separates the right hemisphere from the left. The supe-
sure) also serve the dura of the middle fossa. The dura of the rior sagittal sinus is found where the falx cerebri attaches to the
posterior fossa is served by small meningeal branches of ascend- skull, the straight sinus where it fuses with the tentorium cer-
ing pharyngeal and occipital arteries and by minute branches of ebelli, and the inferior sagittal sinus at its free edge (Fig. 7.4).
the vertebral arteries. Many large superficial veins located on the surface of the cere-
The spinal dura is served by branches of major arteries (such bral hemispheres empty into the superior sagittal sinus (see Fig.
as vertebral, intercostal, and lumbosacral) that are located close 7.13).
to the vertebral column. These small meningeal arteries enter the The tentorium cerebelli is the second largest of the dural infold-
vertebral canal via the intervertebral foramina to serve the dura ings (Figs. 7.4, 7.5B, C, and 7.6). It attaches rostrally to the clinoid
and adjacent structures. processes, rostrolaterally to the petrous portion of the temporal
bone (location of the superior petrosal sinus), and caudolaterally
Nerve Supply to the inner surface of the occipital bone and a small part of the
The nerve supply to the dura of the anterior and middle fossae parietal bone (location of the transverse sinus) (Figs. 7.4, 7.5B,
is from branches of the trigeminal nerve. Ethmoidal nerves and C, and 7.6). The tent shape of the tentorium divides the cranial
branches of the maxillary and mandibular nerves innervate the cavity into supratentorial (above the tentorium) and infratentorial
dura of the anterior fossa; the dura of the middle fossa is served (below the tentorium) compartments (Figs. 7.5B and 7. 6). The
mainly by branches from the maxillary and mandibular nerves. supratentorial compartment is divided into right and left halves
The dura of the posterior fossa receives sensory branches from by the falx cerebri (Fig. 7.5A, B). The sweeping edges of the right
dorsal roots of C1 to C3 and may have some innervation from and left tentoria, as they arch from the clinoid processes to join at
the vagus nerve. The tentorial nerve, a branch of the ophthalmic the straight sinus, form the tentorial notch (Fig. 7.6). The occipital
nerve, courses caudally to serve the tentorium cerebelli. Auto- lobe is above the tentorium, the cerebellum is below it, and the
nomic fibers to the vessels of the dura originate from the superior midbrain passes through the tentorial notch.
cervical ganglia and simply follow the progressive branching pat- Located below the tentorium cerebelli on the midline of the
terns of the vessels on which they lie. occipital bone is the falx cerebelli (Fig. 7.4). This small dural
Nerves to the spinal dura originate as recurrent branches of infolding extends into the space found between the cerebellar
the spinal nerve located at that level. These delicate strands pass hemispheres and usually contains a small occipital sinus.
 The Meninges 111

Falx cerebri

Hemisphere in right
supratentorial
compartment Hemisphere in left
supratentorial
compartment

Hemisphere in right Hemisphere in left

supratentorial supratentorial
compartment compartment

Falx cerebri

Choroid plexus
in atrium

Tentorium
Cerebellum in cerebelli
infratentorial
compartment

Choroid plexus
Hemisphere in in atrium
supratentorial
compartment

Tentorium
cerebelli
Cerebellum in
infratentorial
compartment

Fig. 7.5 Axial (A), coronal (B), and sagittal (C) T1-weighted magnetic resonance images showing the
relationships of the falx cerebri (A, B) and the tentorium cerebelli (B, C). Note the positions of the right
and left supratentorial compartments and the infratentorial compartment in relation to these large dural
reflections in all three planes.

The smallest of the dural infoldings, the diaphragma sellae sinus. This tear may allow venous blood to enter the subarach-
(Figs. 7.4 and 7.6), forms the roof of the hypophyseal fossa and noid space or may create a hematoma within the dural border
encircles the stalk of the pituitary. The cavernous sinuses are cell layer at the dura-arachnoid interface, a subdural hematoma
found on either side of the sella turcica, and the anterior and pos- (see Fig. 7.13).
terior intercavernous sinuses are found in their respective edges
of the diaphragma sellae. Compartments and Herniation Syndromes
It is emphasized that venous sinuses are endothelium-lined The interior of the cranial cavity is divided into a supratento-
spaces that communicate with each other. In addition, large veins rial compartment located superior to the tentorium cerebelli and
from the surface of the brain empty into the venous sinuses. As consisting of right and left halves (separated by the falx cerebri)
they enter the sinus, these veins are attached to a cuff of dura. and a single infratentorial compartment located inferior to the
Consequently, a blow to the head (or a minor bump to the head tentorium cerebelli (Fig. 7.5). The concept of supratentorial and
in an aged person) may cause the brain to shift just enough in the infratentorial compartments, with an understanding of their con-
subarachnoid space to tear a vein at the point where it enters the tents and relationships, is an essential element in the diagnosis
112 Regional Neurobiology

Diaphragma sellae
Crista galli

Clinoid processes:

Anterior
Posterior

Grooves for: Tentorial notch

(tentorial incisure)
Inferior petrosal
sinus Edge of tentorium
Superior Superior
petrosal sinus petrosal sinus

Sigmoid sinus Tentorium

cerebelli To sigmoid sinus
Transverse sinus

Transverse sinus
Jugular foramen

Straight sinus Confluence of sinuses

Fig. 7.6 View of the cranial base from the dorsal aspect showing the tentorium cerebelli (and its associ-
ated sinuses) and the diaphragma sellae. Also indicated are the positions of grooves formed by some of the
major sinuses. The red-shaded area indicates the position of the tentorial incisura (tentorial notch), which
is the space continuation between the supratentorial compartments and the infratentorial compartment.

of what are commonly called herniation syndromes. In general, Cranial Versus Spinal Dura
a herniation syndrome occurs when there is an intracranial event At the margin of the foramen magnum, the periosteal dura essen-
(hemorrhage, rapid tumor growth, traumatic brain injury) that tially stops, but the meningeal dura continues caudally in the ver-
causes an increase in intracranial pressure, forcing the compara- tebral canal to eventually attach to the inner aspect of the coccyx
tively gelatinous brain over the edge of a dural reflection. These as the filum terminale externum (dural part of the filum ter-
syndromes are considered in more detail in later chapters. minale or coccygeal ligament) (Fig. 7.2). The spinal dural sac is
The following are examples of herniation syndromes related to anchored rostrally at the edge of the foramen magnum, caudally
the supratentorial compartments. A lesion in one cerebral hemi- to the coccyx by the filum terminale externum, and is separated
sphere may expand toward the midline, deform the falx cerebri, from the adjacent vertebrae by an epidural space that contains
and force the cingulate gyrus under the edge of the falx into the venous channels, some lymphatics, and fat deposits. There are
opposite hemisphere; this is a subfalcine or cingulate herniation. no dural infoldings around the cord; consequently, there are no
In this example, the deficits may reflect occlusion of the adjacent venous sinuses in the spinal dura.
anterior cerebral artery. Central (or transtentorial) herniation
is the situation in which the diencephalon is forced downward ARACHNOID MATER
through the tentorial incisure or notch. This is a neurologic emer- The arachnoid mater is located internal to the dural border cell
gency, and in about 90% of patients, there is serious disability or layer and is regarded as having two parts (Fig. 7.3). The portion
death. Uncal herniation is the case when a rapidly expanding of the arachnoid directly apposed to the dural border cells is the
lesion, usually a hematoma, forces the uncus, a medial structure arachnoid barrier cell layer, and the spindly cells that traverse
of the temporal lobe, over the edge of the tentorium cerebelli the subarachnoid space constitute the arachnoid trabeculae.
with resultant damage to the midbrain. The most common defi- The subarachnoid space is located between the arachnoid bar-
cits are (1) a decreased level of consciousness, (2) dilation of the rier cell layer and the pial cells on the surface of the brain or
pupil and a loss of most eye movement reflecting damage to the spinal cord. This space contains CSF, many superficial vessels,
ipsilateral oculomotor nerve, and (3) a contralateral hemiplegia and the roots of cranial and spinal nerves as they enter or exit the
reflecting damage to the descending corticospinal fibers. How- nervous system. Enlarged regions of the subarachnoid space are
ever, this early stage is likely to be followed by serious complica- called subarachnoid cisterns.
tions or death.
Examples of herniation syndromes related to the infratentorial Arachnoid Barrier Cell Layer
compartment include upward cerebellar herniation and tonsillar Fibroblasts of this layer are more plump than the flattened cells
herniation. In upward cerebellar herniation, a mass or pressure of the dura (Fig. 7.3). The arachnoid barrier cell layer is tenuously
increase in the posterior fossa may force the cerebellum upward attached to the dural border cell layer by occasional cell junc-
through the tentorial incisura, inflicting damage to the midbrain. tions. In contrast, arachnoid barrier cells have closely apposed
In tonsillar herniation, the tonsils of the cerebellum are forced cell membranes and are joined to each other by numerous tight
downward into and possibly through the foramen magnum. The (occluding) junctions—hence the “barrier” characteristic of this
resulting pressure on the medulla may damage respiratory cen- layer. This close apposition of cell membranes excludes any sig-
ters and result in sudden death. All of the herniation syndromes nificant extracellular space; consequently, no collagen is found
are potentially serious, and all measures should be taken to avoid in this layer of the meninges. The tight junctions between these
their occurrence or to treat their consequences. arachnoid cells not only serve as a barrier against the movement
 The Meninges 113

Skull

Venous sinus
Endothelium

Periosteal dura

Meningeal
dura
Dural border
cells
Arachnoid
barrier
cells Meningeal
Pia mater dura

Subarachnoid space (Falx

cerebri)

Brain

Fig. 7.7 Structure of the arachnoid villi. Note the continuity of the cell layers of the villus with those of
the meninges. Cerebrospinal fluid (arrows) passes from the subarachnoid space into the villus and then
into the venous sinus.

of fluids but also impart strength to the membrane. A basement fluid milieu of the subarachnoid space by the numerous delicate
membrane (basal lamina) is found on the surface of the barrier strands of the arachnoid trabeculae. This is possible because the
cell layer that faces the subarachnoid space. brain loses about 97% of its weight when it is suspended in CSF.
For example, a brain that weighs about 1400 g in air will weigh
Arachnoid Trabeculae and the Subarachnoid Space only about 45 to 50 g in fluid.
The arachnoid trabeculae are composed of flattened, irregu- Because the arachnoid trabeculae are not rigid, the brain may
larly shaped fibroblasts that bridge the subarachnoid space in a move within the fluid-filled subarachnoid space. In a closed head
random fashion (Fig. 7.3). Trabecular cells attach to the barrier injury, the brain may move on its trabecular tethers in response to
layer and may attach to each other, to pial cells, or to blood ves- a sudden blow and be subjected to minor damage (concussion or
sels in the subarachnoid space. Although much of the extracel- contusion). This injury may result in no or only momentary loss
lular collagen associated with trabecular cells is confined in the of consciousness. Such a minor injury may be found at the point
folded processes of these cells, some may be found free in the of the blow or at a site opposite the contact (contrecoup injury).
subarachnoid space. The attachments of the trabecular cells and
their framework of collagen fibrils give added strength to the Arachnoid Villi
arachnoid mater. The small specialized portions of the arachnoid that protrude
The subarachnoid space is located internal to the barrier cell into the superior sagittal sinus through openings in the dura form
layer and external to the pia mater (Figs. 7.2 and 7.3). This the arachnoid villi or arachnoid granulations (Figs. 7.7 and 7.8).
space, and its contiguous cisterns, contain CSF, trabecular cells If they are especially large or calcified (as in older persons), they
and collagen fibrils, arteries and veins, and the roots of cranial may be called pacchionian bodies.
nerves. Although some vessels may lie free in the subarachnoid Arachnoid villi extend into the sinus through tight cuffs in the
space, most are covered by a thin layer of the leptomeninges (Fig. meningeal dura and are found just off the midline or in cul-de-
7.3). These vessels may be damaged from trauma or may rupture sacs (the lateral or venous lacunae) of the sinus (Figs. 7.7 and
spontaneously, resulting in the spread of blood around the brain; 7.8). The vast majority of arachnoid villi are located in the lateral
this event is a subarachnoid hemorrhage. CSF is produced by lacunae of the superior sagittal sinus (see also Fig. 7.11). The
the choroid plexuses of the lateral, third, and fourth ventricles. space in the center of each villus is continuous with the subarach-
It exits the ventricular system via the foramina of Magendie and noid space around the brain. This space is enclosed in a layer
Luschka to enter the subarachnoid space (arrows in Fig. 7.2). of cells that are markedly similar to arachnoid barrier cells, and
After circulating around the brain and spinal cord, CSF reen- these arachnoid cells, in turn, are surrounded by a capsule of cells
ters the vascular system primarily through the arachnoid villi, that are essentially the same as dural border cells. These two lay-
although a small amount enters the lymphatic vessels via the ers are continuous with their respective meningeal layers through
nasal mucosa (see Chapter 6). The subarachnoid space around the stalk of the villus (Fig. 7.7). The endothelial lining of the
the spinal cord is the route used to administer spinal anesthesia. sinus is reflected onto the villus and may cover this structure
Although it is common to refer to the brain as “floating” in the entirely or may leave a few arachnoid cells exposed; the exposed
CSF of the subarachnoid space, it is actually suspended within cells are called arachnoid cap cells. The endothelium covering
this space. The structural basis for this fact is as follows. The dura the villus sits on a basement membrane, beneath which some
is adherent to the skull, the arachnoid to the dura, the arachnoid extracellular collagen may be found.
trabeculae to the pia, and the pia to the surface of the brain. Con- Arachnoid villi are structurally adapted for the transport of
sequently, the brain is suspended, through this chain, within the CSF from the subarachnoid space into the venous circulation
114 Regional Neurobiology

Superior sagittal sinus

(SSS)
Middle meningeal
artery

Superior sagittal sinus

Lateral
lacunae Arachnoid villi in
lateral lacunae
of the SSS

B Arachnoid villus in SSS Fig. 7.9 Axial magnetic resonance (T1-weighted) image of a meningioma in the
frontal lobe of a 62-year-old woman. Note the sharp interface between the tumor
Fig. 7.8 A superior view of the superior sagittal sinus (A) and a detail (B) show-
and the brain (arrows) and the midline shift. The tumor is clearly external to the
ing the sinus and the arachnoid granulations, which are found primarily in the
brain substance.
lateral lacunae.

In descending order of occurrence, meningiomas are found

(Fig. 7.7). CSF moves only from the villus into the sinus. The in the following locations: parasagittal (about 21%), convexity
two routes of fluid movement are through small intercellular (15%), tuberculum sellae (13%), ridge of the sphenoid (12%),
channels located between cells and by way of a vacuole-medi- olfactory groove (10%), and falx cerebri (8%) (Fig. 7.9A). It is
ated transport of fluid and other elements (bacteria, blood common to refer to these tumors by their location, for example,
cells) through villus cells. As CSF traverses the villus, it moves a parasagittal meningioma, a convexity meningioma, and a ten-
down a pressure gradient from a point of higher pressure (the torial meningioma (Figs. 7.10 and 7.11). Convexity meningio-
subarachnoid space) to a point of lower pressure (the venous mas may also be designated by the lobe in which they are located,
sinus). If the pressure on the venous side exceeds that on the such as a frontal lobe meningioma (Fig. 7. 9). In this type of
subarachnoid space side, the flow of CSF will slow or stop. meningioma, the deficits experienced by the patient may reflect
Venous blood, however, never flows from the sinus into the sub- characteristics of the lobe involved. Because of the position of
arachnoid space. the tentorium cerebelli, a meningioma of this structure (tentorial
meningioma) may extend into supratentorial and infratentorial
MENINGIOMA compartments (Fig. 7.11).
Meningiomas (tumors of the meninges) are characterized as Patients presenting with meningiomas are typically in the range
slow-growing, benign (usually), extraaxial (located outside the of 40 to 60 years (peak incidence at about 45 years) and, by a
brain substance) tumors that may be calcified and may result in small margin, are more likely to be female (ratio of 3:2). These
abnormal growth of adjacent bone (hyperostosis). These tumors tumors are usually single, but some patients may have more than
may be discovered as an incidental finding, be asymptomatic, are one. Multiple meningiomas may be seen in patients with neuro-
malignant in less than 2% of cases, and are the most common fibromatosis (of the central type); these patients may also have
primary intracranial tumor. The treatment of choice is surgical bilateral vestibular schwannomas.
removal, which usually results in a complete cure. These growths
are primary intracranial tumors but not primary tumors of the General Histologic Features
brain. This means that these tumors originate from structures The vast majority of meningiomas are histologically character-
that are intimately associated with the CNS (indeed, portions of ized as benign (about 95%) and are rarely diagnosed as malignant
the meninges arise from the neural crests that are derived from (1.5% to 2.0%). However, when these tumors are malignant,
the neural plate) but do not originate from the brain substance they may invade brain tissue or the dura, thereby significantly
itself. complicating their treatment. Malignant tumors contain many
mitotic figures and may metastasize to distant sites.
Origins and Locations On the basis of their histologic characteristics, meningiomas
Meningiomas arise from arachnoid cells found in the villi, at can be divided into three general types. There are variations on
points where blood vessels and cranial nerves traverse the dura, these types, but these variations are beyond the scope of this
and along the base of the skull. In clinical parlance, these specific book. Meningotheliomatous (or syncytial) meningiomas are
cells are called arachnoid cap cells. As one would expect, most composed of polygon-shaped cells with large, centrally located
meningiomas (about 90%) are found in the cranial cavity or in nuclei that contain nucleoli and sometimes vacuoles (Fig.
association with the spinal cord (about 9%). Ectopic meningio- 7.12A). These cells are arranged in sheets, and some cells form
mas are tumors with the histologic features of meningiomas that small concentric aggregations suggesting whorls. In many areas
are found outside the brain and spinal cord (about 1%). of these tumors, the borders between cells are obscured, giving
 The Meninges 115

Meningioma

Parasagittal
Falcine
Convexity

Sellar or
suprasellar

Meningioma
A
Olfactory groove
Sphenoid wing
Sellar or
suprasellar Whorl
Of the clivus
Of the foramen
magnum
Septa

Septa
Petrosal

B Psammoma body
Fig. 7.10 Coronal view of the brain (A) and a view of the base of the skull (B)
illustrating the locations of meningiomas. In these examples, note that the name
of this tumor usually signifies its position in relation to a meningeal reflection or B
bony landmark.

C
Fig. 7.12 Histologic features of a meningotheliomatous (syncytial) meningioma
(A), a transitional meningioma (B), and a fibroblastic meningioma (C). Sheets of
elongated cells and structures suggesting whorls (arrows) are seen in the syncy-
tial tumor (A). Thin septa of elongated fibroblasts are insinuated between obvious
whorl formations in the transitional tumor (B); note the psammoma body. The
fibroblastic tumor contains many elongated cells forming sheets of various sizes (C).

(or fibrous) meningiomas contain layers of long spindle-shaped

cells with elongated nuclei; in some areas the sheets are many
cells thick and contain large amounts of collagen (Fig. 7.12C).
Fig. 7.11 Tentorial meningioma on the patient’s left side. Note the dural tail Whorl formations and psammoma bodies may also be present in
(arrows) indicative of an attachment point of this tumor. This tumor extends into this tumor.
the supratentorial and infratentorial compartments and, although relatively large,
has not displaced the brain or ventricular system to any noticeable degree. This is
a testament to its slow growth.
Symptoms and Treatment
Because meningiomas are slow growing, symptoms may
appear very slowly or not at all. It is not uncommon to see
the tumors the appearance of a syncytium. Transitional menin- meningioma as an incidental finding in patients who have died
giomas have an appearance intermediate between syncytial and of other causes or who have been subjected to imaging stud-
fibrous meningiomas and are characterized by cells arranged in ies for some other problem, such as trauma or stroke. Con-
tight concentric whorl formations separated by thin septa of trast medium–enhanced computed tomography (CT) and
spindle-shaped cells (Fig. 7.12B). These whorls may form around magnetic resonance imaging (MRI) are especially valuable in
a centrally located cell or a small blood vessel. Psammoma bod- the evaluation of this tumor; edema surrounding the lesion is
ies (Greek for “grains of sand”), made up of concentric layers of especially evident in MRI. A diagnosis may require histologic
calcium, are also seen in this type of meningioma. Fibroblastic confirmation.
116 Regional Neurobiology

Skull
Epidural hematoma

Vessel
Endothelium

Periosteal dura
Venous sinus

Meningeal dura

Dural
border cells Meningeal dura
Arachnoid
barrier cells Falx cerebri

Vein in SAS

Pia mater
Brain Subarachnoid space
(SAS)
Fig. 7.13 The relationship of extravasated blood to the meninges. The epidural hematoma is located
between the dura and the skull. Bleeding into the dura-arachnoid interface, classically called a subdural
hematoma, is actually into a structurally weak cell layer at this juncture.

Neurologic symptoms or signs in patients with meningioma are intracranial pressure. These deficits are, in order of occurrence,
generally due to compression of brain structures, involvement of headache, confusion and disorientation, lethargy, and finally a
cranial nerves, or secondary causes such as edema. In addition, state of unresponsiveness. In some cases of head trauma, the
these patients may present with seizures or with slowly devel- patient may initially be rendered unconscious, followed by a
oping personality or behavioral changes that may (or may not) lucid interval (the patient is wide awake and conversant), then
accompany specific deficits related to cranial nerve or long tract subsequently deteriorates rapidly and dies; this is called talk and
involvement. die. Keeping this in mind, it is essential to observe these patients
The treatment of choice for meningioma is surgical removal. closely.
The location of the mass may dictate the ease or difficulty of In contrast to extradural hemorrhages, bleeding into the
its removal. A convexity meningioma is rather straightforward, meninges at the junction of the arachnoid with the dura origi-
whereas a parasagittal tumor is more complex because of its nates mainly from venous structures. A common cause is the
potential involvement of the superior sagittal sinus. In like man- tearing of “bridging veins” as they pass through the subarachnoid
ner, meningiomas in the region of the cavernous sinus may involve space and enter a dural venous sinus (Fig. 7.13). Although these
branches of cranial nerves III, IV, V, and VI or the internal carotid lesions are commonly called subdural, as noted previously, there
artery; a tumor of the sella may envelop optic structures. Radia- is no naturally occurring space at the arachnoid-dura junction.
tion therapy may be used to treat specific types of meningiomas, Hematomas at this junction are usually caused by extravasated
but chemotherapy has not proven to be particularly effective. blood that splits open the dural border cell layer (Figs. 7.13 and
7.15). In contrast to epidural lesions, so-called subdural hemato-
MENINGEAL HEMORRHAGES mas appear “long and thin” because they are not constrained by
At this point, it is appropriate to consider meningeal hemorrhages any dural attachments (Fig. 7.15). This extravascular blood does
that are specifically related to the dura-skull interface and to the not collect within a preexisting space but rather creates a space
arachnoid-dura interface. These lesions share the common fea- at the dura-arachnoid junction. Because these so-called subdural
ture of being most likely caused by trauma. hematomas are usually found within a specific layer of cells, they
actually constitute “dural border” hematomas. These lesions
Extradural and “Subdural” Hemorrhages generally contain blood in their central area and myofibroblasts,
If we exclude, for the moment, subarachnoid hemorrhages, which fibroblasts, mast cells, proliferating blood vessels, and dural bor-
are considered later in this chapter, meningeal hemorrhages can der cells in the surrounding capsule.
be generally described as extravasated blood that strips the dura
from the skull or dissects open the dural border cell layer (Fig. Hygroma
7.13). The most common cause in both situations is an injury Trauma to the skull (present in 35% or more of cases) may also
to the head, with or without skull fracture. In a head injury, the result in tearing of the arachnoid membrane. In such instances,
periosteal dura may be traumatically loosened from the skull CSF, which is under pressure (100 to 180 mm H2O in a recum-
with consequent damage to a major artery; the middle and acces- bent position), also may dissect open and collect within the dural
sory meningeal arteries are common victims. Extravascular blood border cell layer. These lesions are called hygromas. These may
dissects the periosteal dura from the skull and collects to form present as a simple hygroma (CSF only) or a complex hygroma
an extradural (epidural) hematoma (Figs. 7.13 and 7.14). These (CSF plus subdural, epidural, or blood in the brain parenchyma).
lesions tend to be lenticular and appear “short and wide” owing
to the fact that they do not cross the dural attachment at suture Pia Mater
lines (Fig. 7.14). The neurologic deficits seen in patients with The pia mater consists of flattened cells with long, equally flat-
epidural hemorrhage are usually those characteristic of increased tened processes that closely follow all the surface features of the
 The Meninges 117

A B
Fig. 7.14 A and B, Examples of epidural hematomas (arrows) in computed tomography scans on the
patient’s right side. The smaller lesion in A is obviously of traumatic origin; this patient has soft tissue
damage, a fractured skull, blood in the substance of the brain, and blood in the anterior horn of the lateral
ventricle and in the third ventricle. The cause of the larger lesion (B) is not obvious. Compare the shape of
these lesions with that of a “subdural” hematoma in Fig. 7.15.

space. Pial cells at the brain surface may be arranged in a single

layer or in several layers. Single pial cell processes and their sub-
jacent collagen correspond to the pia intima; these closely follow
surface features of the brain and spinal cord. When there are
several tiers of pial cell processes, the outer layers correspond to
the epipial layer. In general, the pia is thicker on the spinal cord
than on the brain.
Where small vessels penetrate the surface of the brain and spi-
nal cord, they pull along a small envelope of pial cell processes
and extracellular space. These perivascular spaces (Virchow-
Robin spaces) extend for varying distances into the parenchyma
of the nervous system and may serve as conduits for the move-
ment of extracellular fluid between the subarachnoid space and
the minute spaces around neurons and glial cells.
The spinal cord is anchored in the subarachnoid space by three
structures: two pial modifications plus a reticulated septum of
arachnoid cell processes that attaches to the posterior midline
of the cord. The first of the pial structures, the denticulate liga-
ments, run longitudinally along each side of the spinal cord about
midway between the posterior and anterior roots and attach to
the inner surface of the arachnoid-lined dural sac (Fig. 7.2). From
each ligament a series of 20 to 22 structures, shaped much like
shark’s teeth, extend laterally to attach to the inner surface of
the arachnoid-lined dural sac. Second, extending caudally from
the conus medullaris is a tough strand composed primarily of
pia; this is the filum terminale internum (pial part of the filum
Fig. 7.15 An example of a so-called subdural hematoma (arrows) in com- terminale). The filum terminale internum attaches to the caudal
puted tomography scan on the patient’s left side. This lesion is long and thin and
extends for considerable distance over the surface of the hemisphere by dissect-
end of the dural sac, which in turn attaches to the coccyx as
ing through the dural border cell layer; note the shift in the midline. Compare the the filum terminale externum (dural part of the filum terminale
shape of this lesion with that of the epidural hematomas in Fig. 7.14. or coccygeal ligament) (Fig. 7.2). Together, these two anchor-
ing structures serve a function analogous to that of the arach-
brain and spinal cord (Fig. 7.3). The pia and arachnoid together noid trabeculae around the brain. The dorsally located septum
constitute the leptomeninges. Vessels in the subarachnoid space of arachnoid is not a continuous membrane and serves a minimal
(Fig. 7.3) may be covered by a single layer of pial cells, may be anchoring function.
enveloped by several layers of leptomeningeal cells, or may lie The large space caudal to the conus medullaris, which con-
essentially free in this space. The pia is separated from the brain tains CSF, posterior and anterior roots (constituting the cauda
surface by a glial basement membrane and by occasional places equina), and the filum terminale internum, is the lumbar cistern
where pial cells pull away from the brain to form a small subpial (Fig. 7.2). The retrieval of CSF is an important diagnostic tool
118 Regional Neurobiology

Skull

Skull

Cisterns
Lamina terminalis
Superior (quadrigeminal)
Ambient Cerebellopontine
Lateral cerebellomedullary Chiasmatic
Dorsal cerebellomedullary Interpeduncular
(cisterna magna) Prepontine
Fig. 7.16 The locations of the major subarachnoid cisterns in relation to brain structures. Although the
cerebellopontine, lateral cerebellomedullary, and ambient cisterns are located on the lateral aspect of the
brainstem, their approximate positions are indicated on this midsagittal view. Compare with Table 7.1.

for evaluation of a variety of CNS disorders. A needle that is found in or next to the cistern. For example, an aneurysm pro-
introduced into the lumbar cistern (spinal tap or lumbar punc- truding into the interpeduncular cistern may affect the oculomo-
ture) between the third and fourth or the fourth and fifth lumbar tor nerve (Table 7.1) and consequently eye movements or pupil
vertebrae is the primary method used to collect a sample of CSF size. Knowledge of the nerves and vessels in the various cisterns
from this cistern (see Fig. 9.2). is a valuable diagnostic skill (Fig 7.16; Table 7.1).

Cisterns, Subarachnoid Hemorrhages, and Subarachnoid Hemorrhage

Meningitis A subarachnoid hemorrhage is an extravasation of blood (usu-
The subarachnoid space is the thin envelope of space located ally arterial) into the subarachnoid space (Figs. 7.18 and 7.19).
between the arachnoid and pia (Figs. 7.2 and 7.7). This space The most common cause of blood in the subarachnoid space
has a number of naturally enlarged regions called subarachnoid (subarachnoid hemorrhage) is trauma; the second most com-
cisterns, which contain CSF, arteries and veins, and in some cases mon cause of subarachnoid blood is rupture of an intracranial
cranial nerve roots (Fig. 7.16; Table 7.1). Cisterns occur where aneurysm (also called nontraumatic or spontaneous subarach-
the brain draws away from the skull as part of its natural variation noid hemorrhage).
in shape, thus enlarging the subarachnoid space. In addition to In traumatic subarachnoid hemorrhage, the source of the
discussing cisterns, we shall consider subarachnoid hemorrhage blood may be due to damage to large veins. In either case, blood
and meningitis at this point because these clinical problems are is extruded into the subarachnoid space and may be sequestered
most specifically related to the leptomeninges. in cisterns or migrate through the subarachnoid space and sub-
CisternsCisterns are usually named according to the structures sequently may be seen, as hyperdense areas, on imaging studies
on which they border. For example, the interpeduncular cistern to outline structures such as brain divisions or dural reflections
is found in the interpeduncular fossa, and the dorsal cerebellom- (Fig. 7.19). Aneurysms are clearly defined dilations in the walls
edullary cistern (cisterna magna) is found between the cerebel- of arteries (Fig. 7.18). Although some aneurysms are thought to
lum and the medulla (Fig. 7.16). Typically, the shapes of cisterns, be congenital, they may also be caused by an ongoing pathologic
as seen on MRI and CT, are determined by the corresponding process or by trauma or may be secondary to a general systemic
shapes of surrounding brain structures (Figs. 7.17 and 17.19); problem such as hypertension. Subarachnoid hemorrhage from a
this characteristic relationship is useful in diagnosis. The cisterna ruptured aneurysm is most common in persons between 40 and
magna is a potential source of CSF if the lumbar cistern is not 65 years of age and is a potentially catastrophic event. About one
accessible. In a cisternal puncture, a needle is carefully intro- third of affected patients die before or soon after admission to a
duced into the cisterna magna through the atlantooccipital mem- medical facility, about one third have permanent and significant
brane and a sample of fluid is withdrawn. disabilities (cognitive, motor), and about one third may recover
Cisterns are bordered by particular brain structures, contain with minimal neurologic sequelae.
segments of major vessels, and may also contain cranial nerve The occurrence of a subarachnoid hemorrhage, consequent to
roots or other structures (Table 7.1). Consequently, a progres- aneurysm rupture, may be signaled by a sudden excruciating head-
sively enlarging aneurysm or a slow hemorrhage into a particular ache, neck stiffness, vomiting or nausea, and a depression or loss
cistern may result in signs or symptoms related to the structures of consciousness. Patients who do not become unconscious at the
 The Meninges 119

Table 7.1 Some Principal Cisterns and the Main Arteries, Veins, Cranial Nerves, and Other Structures Associated with Them
CISTERN ARTERIES VEINS CRANIAL NERVES STRUCTURES
Ambient Portions of posterior cerebral, Basal vein (of Rosenthal) Trochlear Lateral aspect of crus cerebri
quadrigeminal, and supe-
rior cerebellar arteries
Cerebellopontine (infe- Vertebral artery and proximal Retroolivary and lateral Glossopharyngeal, vagus, spinal Pyramid, inferior olivary eminence,
rior; also called lateral branches of PICA medullary veins accessory, and hypoglossal and choroid plexus
cerebellomedullary)
Cerebellopontine Distal branches of anterior Pontomesencephalic and Trigeminal, facial, and
(superior) inferior cerebellar, labyrin- petrosal veins vestibulocochlear
thine, and basilar arteries
Chiasmatic Ophthalmic artery and small Optic nerve and optic chiasm
branches to chiasm and
hypophysis
Cisterna magna Distal branches of PICA, Tonsillar and dorsal Roots of C1, C2
(also called dorsal posterior spinal artery, and medullary veins
cerebellomedullary) branches to choroid plexus
of fourth ventricle
Interpeduncular Rostral end of basilar artery Portions of basal vein Oculomotor root Mammillary body, medial edge of
and portions of posterior (of Rosenthal) crus cerebri
cerebral, choroidal, and
thalamogeniculate arteries
Prepontine Basilar artery and its branches Pontine veins Abducens
Quadrigeminal Portions of posterior cerebral, Great cerebral vein (of Trochlear root Pineal, superior and inferior colliculi
quadrigeminal, and choroi- Galen)
dal arteries

Data from Yasargil MG. Microneurosurgery. Vol I: Microsurgical Anatomy of the Basal Cisterns and Vessels of the Brain, Diagnostic Studies, General Operative Techniques and Pathological
Considerations of the Intracranial Aneurysms. Stuttgart: Georg Thieme; 1984.
PICA, posterior inferior cerebellar artery.
  

5 1
2
1

4 2

A B
Fig. 7.17 Magnetic resonance images in sagittal (A) and axial (horizontal, B) planes with some of the
major cisterns indicated: 1, interpeduncular; 2, superior (quadrigeminal); 3, cisterna magna (dorsal cer-
ebellomedullary); 4, prepontine; 5, of the lamina terminalis; 6, ambient.

time of the hemorrhage may describe the headache as “explosive subarachnoid hemorrhage (leaking aneurysm). These include
and awful,” or “the absolutely worst headache I have ever had.” intermittent headache, nausea or vomiting, and fainting spells
This is commonly called a “thunderclap headache.” A sudden (syncope). In persons with neurologic signs that can be traced to
headache that clears (a warning or sentinel headache) may sig- an aneurysm, the treatment of choice is to clip the aneurysm or its
nal an impending aneurysmal repture or intracranial bleed. Bloody stalk, thereby separating it from the cerebral circulation.
CSF obtained by lumbar or cisternal puncture is diagnostic of sub-
arachnoid hemorrhage, and blood can be clearly identified in the Meningitis
subarachnoid space on CT examination (Fig. 7.19). In some cases, Meningeal infection may be of either bacterial or viral ori-
a patient may have warning signs and symptoms of an impending gin or occur as a sequel to some other disease process, such as
120 Regional Neurobiology

Dural border
cells

Arachnoid
barrier cells

SAS Arachnoid
trabeculae
Subarachnoid
space (SAS)

Artery in SAS

Pia mater

Collagen Aneurysm ruptured into SAS

Subarachnoid hemorrhage
Fig. 7.18 Bleeding into the subarachnoid space (subarachnoid hemorrhage) after rupture of an aneurysm
into the subarachnoid space.

Blood
between
frontal
lobes

Sylvian
cistern

Midbrain Interpeduncular
cistern
Superior
cistern Ambient cistern

Blood along Cerebellum

tentorium
cerebelli

Fig. 7.19 Computed tomography scan showing subarachnoid hemorrhage from

a ruptured aneurysm in a 64-year-old man. Note the blood in the cisterns and also
outlining the midbrain and tentorium cerebelli.

tuberculosis or fungal infections. With bacterial meningitis, the

meningeal infection is most often located in the subarachnoid
space and involves the arachnoid and pia; hence the designation
leptomeningitis (Fig. 7.20). If the infection involves the dura
mater, it is called pachymeningitis.
Fig. 7.20 Axial magnetic resonance (T1-weighted) image of a patient with
Such infections may result from a variety of causes, including meningitis. Note the hyperintense (white) appearance of the subarachnoid space
trauma (which may introduce bacteria into the head or spine, such around the periphery of the temporal lobe, the dural reflections (especially the
as Staphylococcus aureus), septicemia, and metastasis from another area representing the tentorium cerebelli), and the tendrils of white that repre-
site of infection in the body. Bacterial meningitis is generally clas- sent infectious material in the sulci. Blood vessels may also enhance because the
sified as acute or subacute, depending on how rapidly the disease infection may infiltrate the vessel wall.
progresses. The more common causative agents are Streptococcus
agalactiae and Escherichia coli (birth to 2 years) and Streptococcus of hydrocephalus (Fig. 7.20). Although the death rate is low in
pneumoniae and Neisseria meningitidis (2 years to >50 years). acute cases with proper treatment, the patient may become ill
Signs of acute bacterial meningitis include elevated temper- suddenly and may die within 2 to 3 days in rapidly advancing
ature, alternating chills and fever, and headache; the patient cases.
is acutely ill and may have a depressed level of consciousness. Chronic meningitis may be seen in patients with tubercu-
These signs and symptoms seen in concert with increased CSF losis or fungal infections (with, as examples, Cryptococcus
pressure and cloudy CSF containing many white blood cells, neoformans or Candida aspergillus). In these diseases, the
increased protein, and bacteria are diagnostic of the disease. The infection may be named according to the causative agent, for
inflammatory process may result in thickening of the leptomen- example, tuberculous meningitis or cryptococcal meningi-
inges with consequent partial obstruction of CSF flow and signs tis. The course of the disease is longer (encompassing weeks
 The Meninges 121

rather than days), and the onset is slow and characterized by altered level of consciousness. In a minority of cases, more serious
headache, fever, irritability, and wakefulness at night. In acute, signs and symptoms may be seen, such as seizures, rigidity, or cra-
subacute, and chronic meningitis, the prognosis is excellent nial nerve palsies. Treatment in mild cases is supportive and gener-
(with about a 90% cure rate) with early diagnosis and proper ally focuses on medications for fever, pain, and general discomfort.
treatment. After an acute period of 1 to 2 weeks, the signs and symptoms
Viral meningitis is caused by a range of viral agents, is most moderate, and the patient generally recovers without permanent
commonly seen in younger patients (younger than 25 years), and deficits.
is a disease for which no antiviral medications are available. The
patient becomes ill during a period of days and experiences fever, Sources and Additional Reading
headaches of increasing intensity, and confusion and possibly an The complete list is available online at www.studentconsult.com.
Sources and Additional Reading Peters A, Palay SL, Webster HD. The Fine Structure of the Nervous System:
Alcolado R, Weller RO, Parrish EP, Garrod D. The cranial arachnoid and pia Neurons and Supporting Cells. 3rd ed. Philadelphia: WB Saunders; 1991.
mater in man: Anatomical and ultrastructural observations. Neuropathol Appl Ropper AH, Samules MA, Klein JP. Adams and Victor’s Principles of Neurology.
Neurobiol. 1988;14:1–17. 10th ed. New York: McGraw-Hill Education; 2014.
Al-Mefty O. Meningiomas. New York: Raven Press; 1991. Rowland LP, Pedley TA, eds. Merritt’s Neurology. 12th ed. Baltimore: Lippin-
Frederickson RG. The subdural space interpreted as a cellular layer of meninges. cott Williams & Wilkins; 2010.
Anat Rec. 1991;230:38–51. Schachenmayr W, Friede RL. The origin of subdural neomembranes: I. Fine
Greenberg MS. Handbook of Neurosurgery. New York: Thieme; 2010. structure of the dura-arachnoid interface in man. Am J Pathol. 1978;92:
Haines DE. On the question of a subdural space. Anat Rec. 1991;230:3–21. 53–68.
Haines DE, Harkey LH, Al-Mefty O. The “subdural space”: a new look at an Van Denabeele F, Creemans J, Lambrichts I. Ultrastructure of the human spinal
outdated concept. Neurosurgery. 1993;32:111–120. arachnoid mater and dura mater. J Anat. 1996;189:417–430.
Nabeshima S, Reese TS, Landis DMD, Brightman MW. Junctions in the menin- Williams PL, ed. Gray’s Anatomy. 38th ed. New York: Churchill Livingstone;
ges and marginal glia. J Comp Neurol. 1975;164:127–170. 1995.
Nicholas DS, Weller RO. The fine anatomy of the human spinal meninges. J Yasargil MG. Microneurosurgery. Vol. I: Microsurgical Anatomy of the Basal
Neurosurg. 1988;69:276–282. Cisterns and Vessels of the Brain, Diagnostic Studies, General Operative
Orlin JR, Osen K, Hovig T. Subdural compartment in pig: a morphologic Techniques and Pathological Considerations of the Intracranial Aneurysms.
study with blood and horseradish peroxidase infused subdurally. Anat Rec. Stuttgart, Germany: Georg Thieme; 1984.
1991;230:22–37.

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