Relation between bilateral differences in internal jugular vein caliber and flow patterns of dural venous sinuses
We measured the calibers of the left and right internal jugular veins (IJV) and sizes of the left and right transverse sinuses (TS) in 91 cadavers, compared them between the left and right sides, and also evaluated the drainage patterns of the superior sagittal sinus (SSS) and straight sinus (=rectal sinus, RS) in the torcular Herophili. In addition, the running type of groove for the SSS was investigated. The results were as follows: (1) The right IJV was larger in 81.3 %, while the left IJV was larger in only 11.0 %. (2) The drainage pattern of the SSS was the right type in 73.6 %, intermediate type in 14.3 %, and left type in 12.1 %. (3) The drainage pattern of the RS was the right type in 27.5 %, intermediate type in 25.3 %, and left type in 47.3 %. (4) The running type of groove for the SSS was mostly consistent with the drainage pattern of this sinus. (5) Concerning the relationships among these findings including the size of the TS, the drainage pattern of the SSS was mostly consistent with the side showing a larger TS as well as the side showing a larger IJV. These results suggest that the pattern of drainage of the SSS into the left and right TS affects the size of the TS and the running type of groove for the SSS, and is also closely involved in the caliber of the IJV. A discussion of the embryological, genetic, and clinical implications of these results is presented.
KeywordsInternal jugular vein Superior sagittal sinus Transverse sinus Groove for superior sagittal sinus Bilateral differences
The internal jugular vein (IJV) is a major vein collecting blood from the head and neck and is also a clinically important vein. The right IJV is known empirically to be larger than the left IJV. In recent years, ultrasonographic studies on the differences in IJV caliber between the left and right sides have been performed (Matsuda et al. 2005). However, there have been few macroscopic anatomical studies (Goto and Koda 2000) and no studies in which measurements or statistical analysis were performed.
Goto and Koda (2000) described in their book that the right IJV is frequently larger than the left IJV, and the side showing a larger IJV is mostly consistent with the side showing a larger sigmoid sinus, suggesting a relationship between the dural sinus pathway and IJV caliber. Concerning the dural sinus pathway, an anatomy textbook mentions that the superior sagittal sinus (SSS) often drains into the right transverse sinus (TS), while the straight sinus (=rectal sinus, RS) tends to drain into the TS contralateral to SSS drainage (Standring 2005: Gray’s anatomy). Gibbs and Gibbs (1934), Woodhall (1936), Kaplan et al. (1972), and Goto and Koda (2000) evaluated the drainage patterns of these sinuses, and confirmed the above tendencies. In recent years, Singh et al. (2004) and Fukusumi et al. (2010) performed image reconstruction to evaluate flow in the SSS in the torcular Herophili region using CT and MRI, and observed similar tendencies. These findings suggest that the drainage pattern of the dural sinuses, particularly the SSS and RS, affects the IJV caliber.
To date, there have been no detailed studies investigating the drainage patterns of the SSS and RS, quantitative comparison of the sizes of the TS and IJV between the left and right sides, or the detailed evaluation of these relationships. The IJV and subclavian vein are the veins used most commonly for central venous catheterization, involving the risk of pneumothorax and injury of the thoracic duct or the right lymphatic duct due to puncture. In addition, thrombosis occasionally occurs in the dural sinuses, and its incidence is high in the SSS and TS (Ferro et al. 2004). Therefore, it is also clinically important to correctly understand the difference in IJV caliber between the left and right sides and the pathway of the dural sinuses.
In order to clarify the relationship between the SSS drainage pattern and sizes of the left and right TS as well as the calibers of the left and right IJVs, in this study, we measured IJV and TS sizes, and investigated the SSS and RS drainage patterns in the torcular Herophili. In addition, the relationship between the groove for the SSS and the groove for the TS in the internal occipital protuberance on the inner surface of the skull was also investigated.
Materials and methods
We investigated 91 Japanese cadavers (47 males and 44 females; age range 35–98 years) used in autopsy training in the School of Medicine, Nagasaki University. All cadavers were supplied by body donation, and consent for their use for education and research had been obtained. Since no data allowing the identification of individuals were presented, there were no ethical problems in this study.
Measurement of the IJV caliber
Measurement of the dural sinuses
Classification of the drainage patterns of the SSS and RS
Classification of groove running type for the SSS on the inner surface of the skull
The mean caliber and cross-sectional area were analyzed using the paired t test, and categories were analyzed using the χ2 test by a computer software package from ‘Excel Statics version 5.0, 2002’ (Esumi, Tokyo, Japan).
Right and left side difference in caliber of the internal jugular (IJV), subclavian (ScV) and brachiocephalic (BcV) veins
R > L
R ≒ L
L > R
81.3 % (74/91)
7.7 % (7/91)
11.0 % (10/91)
25.3 % (23/91)
57.1 % (52/91)
17.6 % (16/91)
60.4 % (55/91)
24.2 % (22/91)
15.4 % (14/91)
Measurement values of the dural sinuses and the size difference between the right TS and left TS
Right and left side difference in size of the transverse sinus as shown in previous studies
R > L
R ≒ L
R < L
Kaplan et al. (1972)
Goto and Koda (2000)
Fukusumi et al. (2002)
Fukusumi et al. (2010)
Relationship between SSS drainage pattern and TS size
Classification of the RS drainage pattern and its relationship with the SSS drainage pattern
The RS drainage pattern was classified as complete R type in 11.0 %, incomplete R type in 16.5 %, confluence type in 2.2 %, bifurcation type in 23.1 %, incomplete L type in 25.3 %, and complete L type in 22.0 % (Fig. 5). When the RS drainage pattern was classified into the R, RL, and L types, the incidences were 27.5, 25.3, and 47.3 %, respectively, showing a high incidence of the L type. Concerning the relationship between the RS and SSS drainage patterns, the R type of the SSS was observed more frequently in cases showing the L type of the RS, while the L type of the SSS was observed more frequently in cases showing the R type of the RS, although the differences were not significant (Fig. 9b).
Relationship between the pattern of the groove in the internal occipital protuberance and the SSS
The GS-L type was observed in 12 cases, the GS-RL type in 9, and GS-R type in the other 70 (Fig. 9c). The groove pattern was mostly consistent with the SSS drainage pattern in both cases showing the GS-R type and those showing the GS-L type.
Relationship between the TS size and IJV caliber
SSS drainage pattern affects IJV caliber
Frequencies (%) of drainage patterns of continuity the SSS with the TS as shown in previous studies
Kaplan et al. (1972)
Goto and Koda (2000)
Fukusumi et al. (2002)
Singh et al. (2004)
Fukusumi et al. (2010)
Relationship between drainage pattern of SSS, sectional sizes of TS, and IJV size
Although the SSS drainage pattern was consistent with the IJV caliber in most cases, a reverse relationship was observed in 5 of the 91 cases (Table 4). This suggests that the IJV caliber is also affected by draining veins after the TS (such as the superior and inferior petrosal sinuses and facial vein). In addition, certain diseases may also cause poor flow in the unilateral IJV and its surrounding veins, resulting in an increase in the contralateral IJV caliber.
The RS showed a slightly higher incidence of drainage into the left TS, although no significant difference was present. The RS drainage pattern may not have sufficient influence to determine the left–right difference in IJV caliber.
Why does the SSS frequently drain into the right TS?: embryological discussion
To confirm this speculation, the absence of the predominance of the right IJV in cases of persistent left superior vena cava should be shown. However, this anomaly is very rarely observed, and time is necessary for the evaluation of substantial data. In addition, to clarify the embryological flow in the dural sinuses and IJV further, more detailed autopsy studies on the prenatal venous system are necessary.
Relationship between SSS drainage pattern and groove around the internal occipital protuberance: genetics and group difference
In the internal occipital protuberance on the inner surface of the occipital bone, the SSS continues to the TS; a groove forms along the TS flow. However, there have been no studies in which the degree of consistency between the groove arrangement and sinus flow was confirmed. In this study, this consistency was also evaluated, and, as a result, the SSS drainage pattern was mostly consistent with the groove running type (Fig. 10).
Incidences (%) of the sagittal sinus groove to the left in various populations in East Asia
Modern Japanese (Kanto and Tohoku)
Dodo and Ishida (1990)
Modern Japanese (Nagasaki)
Saiki et al. (2000)
Yayoi people (Northern Kyushu, Japan)
Dodo and Ishida (1992)
Yayoi people (Yamaguchi, Japan)
Dodo and Ishida (1988)
Yayoi people (Northwestern Kyushu, Japan)
Saiki et al. (2000)
Jomon people (Eastern Japan area, Japan)
Dodo and Ishida (1990)
Modern Chinese (Shanxi Province)
Wang and Sun (1988)
Eastern Zhou dynasty age Chinese (Zhouzhuang)
Wakebe et al. (2011)
Eastern Zhou dynasty age Chinese (Xinghong)
Wakebe et al. (2011)
Iron age Tagar people
Modern Japanese (Cadavers for the dissection course)
The right IJV is used most frequently as the site for central venous catheterization since the catheter can be advanced linearly to the superior vena cava, and the risk of pneumothorax as a complication is low. In general, the catheter is inserted into the right IJV for central venous catheterization (e.g., Yamayoshi 1996), but the right IJV is smaller than the left IJV in some patients, as was shown by the results of this study. This fact should be taken into consideration for this procedure. For accurate and safe central venous catheterization, the size and arrangement of the IJV should be confirmed using ultrasonography before puncture, as is recommended in the anesthesiological field (e.g., Karakitsos et al. 2006; Kunisawa 2009).
In the dural sinuses, thrombosis or stenosis sometimes occurs. Dural sinus occlusion due to thrombi is observed most frequently in the SSS, followed by the TS (Ferro et al. 2004; Saposnik et al. 2011). Multiple sinuses were reported to be involved in about one-third of patients (Bousser 1999). For the diagnosis of dural sinus thrombosis, CT and MRI have been used frequently in recent years. However, the interpretation of imaging findings is difficult, and misdiagnosis often occurs (Provenzale and Kranz 2011). Studies on the SSS drainage pattern in the torcular Herophili have shown individual differences and difficulty in determining whether the blood flow is original or due to thrombosis or occlusion when the flow is thin on the images obtained. In patients with dural sinus diseases such as sinus thrombosis, it should be taken into consideration that the drainage pattern of each sinus shows a certain tendency, but is not the same among patients, and appropriate diagnosis and treatment are necessary.
Moreover, Zamboni et al. (2006, 2009) recently proposed a new hypothesis for pathomechanisms of multiple sclerosis (MS): chronic cerebrospinal venous insufficiency (CCSVI). Research reports to verify this hypothesis have also increased (Doepp et al. 2010; Baracchini et al. 2011; Tanaka et al. 2011). The IJV and dural sinus are considerably associated with CCSVI. Although this study does not reveal the details of this relationship, we should conduct an investigation based on this hypothesis in future studies.
This study was performed in cadavers. After patient death, about 10 l preservative (containing formalin, ethanol, and water) was injected into the femoral and radial arteries. Therefore, the possibility that blood returned to the venous side, and the veins were dilated compared with the premortem state cannot be excluded. There is a possibility that the measurement results regarding veins in this study slightly differ from the premortem in vivo state.
Conflict of interest
- Dodo Y, Ishida H (1988) Nonmetric analyses of the Doigahama crania of the Aeneolithic Yayoi period in western Japan (in Japanese with English summary). In: Yokoyama K (ed) Establishment of Japanese peoples and cultures. Rokko, Tokyo, pp 127–142Google Scholar
- Dodo Y, Ishida H (1990) Population history of Japan as viewed from cranial nonmetric variation. Anthropol Sci 98:269–287Google Scholar
- Dodo Y, Ishida H (1992) Consistency of nonmetric cranial trait expression during the last 2,000 years in the habitants of the central islands of Japan. Anthropol Sci 100:417–423Google Scholar
- Fukusumi A, Tanaka T, Koh S, Nakagawa H, Taoka T, Takayama K, Sakamoto M, Kichikawa K, Iwasaki S (2002) Anatomical variations of the torcular Herophili evaluated with MR venography. Jpn J Clin Radiol 47:625–631Google Scholar
- Goto N, Koda M (2000) Blood vessels in the central nervous system (in Japanese). In: Sato T, Akita K (eds) Anatomical variations in Japanese. University of Tokyo Press, Tokyo, pp 401–429Google Scholar
- Karakitsos D, Labropoulos N, Groot E, Patrianakos AP, Kouraklis G, Poularas J, Samonis G, Tsoutsos DA, Konstadoulakis MK, Karakitsos AK (2006) Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care 10:R162. doi:10.1186/cc5101 PubMedCrossRefGoogle Scholar
- Masaki S (1959) Studies on the development of the dural sinuses of the human fetus (in Japanese). Fukuoka Acta Medica 50:2769–2788Google Scholar
- Moore KL (1988) The developing human: 4th edn. Saunders, PhiladelphiaGoogle Scholar
- Padget DH (1957) The development of cranial venous system in man: from the view point of comparative anatomy. Contrib Embryol 247:81–138Google Scholar
- Standring S (ed) (2005) Gray’s anatomy, 39th edn. Elsevier Churchill Livingstone, SpainGoogle Scholar
- Susa Y (1950) Patterns of the torcular Herophili, measurement of sinus lumen and histology of sinus wall (in Japanese). J Nippon Med School 27:247–263Google Scholar
- Tanaka M, Uchizumi H, Tanaka K (2011) Evaluation of blood flow and the cross-sectional area of internal jugular vein in Japanese multiple sclerosis and neuromyelitis optica patients. Clin Neurol 51:430–432 (in Japanese with English abstract)Google Scholar
- Wakebe T, Saiki K, Tsurumoto T, Okamoto K, Kitagawa Y, Okazaki K, Cai Q, Fan W, Han G, Nakahashi T (2011) Cranial nonmetric analyses of the human remains of the spring and autumn, and warring states period excavated from Henan, China. Anthropol Sci 119:324Google Scholar
- Wakebe T, Saiki K, Tsurumoto T, Okamoto K, Kitagawa Y, Okazaki K, Han G, Nakahashi T (2012) Nonmetric analyses of the human crania of the spring and autumn, and warring states period excavated from Henan, China (in Japanese). In: Proceeding of the 117th annual meeting of the Japanese association of anatomist, p 138Google Scholar
- Wang L, Sun F (1988) A study on the skulls from Taiyuan, SHANXI (in Chinese with English abstract). Acta Anthropologia Sinica 7:206–214Google Scholar
- Yamaguchi B (1977) A comparative study of the skulls of the Ontario Iroquoians and of Asiatic populations. Bull Nat Sci Museum, D-3:23–35Google Scholar
- Yamayoshi S (1996) Percutaneous internal jugular vein puncture and cannulation (in Japanese). Emerg Med 18(7):849–854Google Scholar
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