• Jared S Rosenblum, Mateus Neto, Walid I Essayed, Wenya Linda Bi, Nirav J Patel, Mohammad A Aziz-Sultan, John D Heiss, and Ossama Al-Mefty.
• Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA; Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA; Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA. Electronic address: Jared.rosenblum@nih.gov.
• World Neurosurg. 2019 Nov 1; 131: e38-e45.

BackgroundDescribed variations of tentorial venous anatomy impact surgical sectioning of the tentorium in skull base approaches; however, described configurations do not consistently explain postoperative complications. To understand the outcomes of 2 clinical cases we studied the tentorial venous anatomy of 2 cadavers.MethodsThe venous anatomy of the tentorium isolated in 2 uninjected fresh cadaver head specimens with preserved bridging veins was observed by transillumination before and after methylene blue injection of the dural sinuses and tentorial veins. Our findings in cadavers were applied to explain the clinical and radiologic (magnetic resonance imaging and computed tomographic venography) findings in the 2 cases presented.ResultsA consistent transtentorial venous system, arising from transverse and straight sinuses, communicating with supra- and infratentorial bridging veins was seen in the cadaver and patient radiography (magnetic resonance imaging and computed tomographic venography). Our first patient had a cerebellar venous infarct from compromise of the venous drainage from the adjacent brain after ligation of a temporal lobe bridging vein to the tentorium. Our second patient suffered no clinical effects from bilateral transverse sinus occlusion due to drainage through the accessory venous system within the tentorium.ConclusionsHerein, we elaborate on transtentorial venous anatomy. These veins, previously reported to obliterate in completed development of the tentorium, remain patent with consistent observed configuration. The same transtentorial venous system was observed in both cases and provided insight to their outcomes. These findings emphasize the importance of the transtentorial venous system physiologically and in surgical approaches.Published by Elsevier Inc.

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