• Neuroradiology

The Normal Anterior Inferior Cerebellar Artery

Anatomic-Radiographic Correlation with Emphasis on the Lateral Projection 1

Thomas P. Naidlch, M.D. 2 , Irvin I. Krlcheff, M.D., Ajax E. George, M.D., and
Joseph P. Lin, M.D.

Previous descriptions of the course and anatomic relationships of the anterior inferior
cerebellar artery (AICA), as visualized in the lateral projection, have not been found by
the authors. Dissection and radiography of 32 injected human cerebella show that AICA
and its major branches define the position of the pontomedullary sulcus; supra-olivary
fossette; 5th-11th cranial nerves; brachium pontis; flocculus; great horizontal fissure;
posterolateral fissure; superior semilunar lobule; inferior semilunar lobule; biventral lob-
ule; foramen of Luschka; and the choroid plexus of the lateral recess of the 4th ventricle.
With magnification and high-quality subtraction, AICA and its associated structures may
be identified in the lateral projection in the large majority of patients.

INDEX TERMS: Arteries, cerebellar. Brain, anatomy • Cerebral blood vessels, anatomy

Radiology 119:355-373, May 1976

HE ANTERIOR inferior cerebellar artery
T carries the major arterial supply to the anterior or
petrosal aspect of the inferior surface of the cerebellar
hemispheres. The artery, however, has remained in-
completely described because of the difficulties en-
countered in visualizing it adequately prior to the wide-
spread use of magnification and subtraction radiograph-
ic techniques. This paper presents a detailed analysis
of the course and anatomic relationships of AlGA in
frontal and lateral projections.
MATERIALS AND METHODS
Thirty-two cerebella from patients 2 months to 68
years of age, were removed at postmortem within 24
hours of death. injected with a Micropaque-gelatin mix-
ture (19) via the vertebral artery, suspended carefully in
10% formalin to minimize distortion, and allowed to fix
for 3-12 months. Preliminary study of these specimens
demonstrated surprising lack of symmetry of the poste-
rior fossa vessels, corroborating the results of Stopford
and others (6, 21). Therefore, the 63 usable hemicere-
bella available from the 32 specimens were grouped to-
gether, radiographed, dissected, and analyzed as 63 in-
dependent examples of the potential courses and rela-
tionships of the AICA and its branches. All measure-
ments were made on the fixed specimens. Postfixation
volume changes, estimated at ±5 %, were disregarded
(9). The results of the anatomic study were then utilized
in the analysis of 100 normal, direct 2X magnification
selective vertebral angiograms.
A single vessel of substantial size that pursued a typ-
ical course (vide infra) was termed AICA. A second ar-
(AlGA) tery of significant size that appeared to supplement or
replace a portion of the distribution of AICA was termed
an accessory artery, and designated as either a superi-
or or an inferior accessory artery. In those cases with
an accessory artery, the more typical artery was desig-
nated "AlGA". Two arteries of significant size, neither
of which pursued a typical course, were considered ab-
errant. Specimens without large middle cerebellar
branches, representing 2-3 % of cases in other series
(3, 21), were excluded from this study. Because of the
limitations of photographic depth of field, the photo-
graphs of the specimens were obtained in slight de-
grees of obliquity rather than true lateral position.
BRAIN STEM AND CEREBELLAR
ANATOMY (2, 10, 11. 12,24)
The cerebellar hemispheres are conveniently divided
into a superior surface which faces the tentorium. and
an inferior surface which faces the bony confines of the
posterior fossa (Figs. 1, 2, and 7, B). This inferior sur-
face may be further subdivided into an anterior or petro-
sal portion, which faces the posterior aspect of the pe-
trous pyramids, and a posterior or occipital portion,
which faces the occipital squama. The superior surface
is sharply demarcated from the other surfaces by the
anterolateral (ALM) and posterolateral (PLM) cerebellar
margins (Fig. 1). The ALM extends from the anterior
angle (A) to the lateral angle (L) and is formed by the
quadrangular lobule (0) and part of the superior semilu-
nar lobule (S).
The cerebellar hemispheres are divided into lobules
by deep fissures. The posterior superior fissure (PSF)

1 From the Department of Radiology, Section of Neuroradiology, New York University Medical Center, New York, N. Y. Accepted for publi-
cation in December 1975.
2 NINDS Fellow in Neuroradiology, Assistant Professor in Radiology. Current address: Department of Radiology, Montefiore Hospital and
Medical Center, 111 E. 210 St., Bronx, N. Y. 10467.
Cornelius Dyke Award Presentation, American Society of Neuroradiology, Vancouver, B. C. Canada, 1975.
Supported in part QY NINDS Grant #NSD-5433-11. elk

355
356 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 1. Surface anatomy of brain stem and cerebellum, unfixed specimen. Symbols defined in TABLE I. A. True lateral view.
B. Anterior view of pons (P), medulla (M) and the petrosal surface of the cerebellum.
Fig. 2. Surface anatomy of brain stem and cerebellum. A. True lateral view. Drawing modified from Bassett's Figure 23-4 (2). The
shading (/ / / /) indicates the quadrangular lip below the anterolateral margin (ALM). B. Anterior view.

on the superior surface of the cerebellum divides that

Fig. 3. Typical AICA in relationship to brain stem and petrosal
surface of the cerebellum. Antero-inferior view. Supra-olivary fos-
sette. Diagram modified from Bassett's Figure 28-3 (2).
surface into the quadrangular lobule anteriorly and the
superior semilunar lobule posteriorly (Figs. 1 and 2).
The portion of the quadrangular lobule which lies be-
neath the anterolateral margin on the petrosal surface
of the cerebellum is the quadrangular lip (QL). The su-
perior semilunar lobule is separated from the inferior
semilunar lobule beneath it by the great horizontal fis-
sure (GHF) (•• G •• in the figures) (Figs. 1, 2, and 7).
This fissure starts in the midline posteriorly, sweeps
obliquely across the occipital aspect of the hemisphere
below the lateral angle, and then turns onto the petrosal
aspect of the hemisphere anterolateral to the brachium
pontis (BP). Here it lies between the lip of the quadran-
gular lobule anterosuperiorly and the inferior semilunar
lobule postero-inferiorly (2, 12). In lateral view the pe-
trosal portion of the GHF characteristically inclines 45°.
The GHF then extends anteriorly to pass above and lat-
eral to the flocculus (F) (suprafloccular portion of the
great horizontal fissure). The third (suprafloccular) por-
tion of the vein of the lateral recess often runs in the
suprafloccular portion of the GHF (11). The biventral
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 357 Neuroradiology

Fig. 4. Typical AICA. A. Lateral view. B. Anterior view. The quadrangular lip (0), most of the flocculus (F) (dotted
in) and a portion of the biventral lobule (BV) have been resected. AICA crosses the sixth nerve, 6, superficially 5 mm ros-
tral to the pontomedullary sulcus (_._-, The short meatal loop (ML) was not related to the porus acusticus. Note the caudal
point of the caudomedial artery (CM) in the supraolivary fossette and its relationships to cranial nerves 9, 10, and 11. The
caudomedial artery (LL, BVS, AHB) outlines the inferior surface of the hemisphere.

lobule (BV) occupies the lower lateral surface of the
cerebellum beneath the inferior semilunar lobule and
posterior to the flocculus (Figs. 1 and 2). The inferior-
most edge of the biventral lobule is a sharp rim of tis-
sue known as the biventral ridge (BVR).
The posterolateral fissure (PLF) is a deep transverse-
ly running fissure which extends from the vermis to the
superficial aspect of the hemisphere (Figs. 1, 2, and 5,
B). It separates the flocculus from the biventral lobule
and the posterior medullary velum and nodulus from the
superior pole of the tonsil and the uvula. The peduncu-
lar portion of the PLF runs below and behind the lateral
recess of the fourth ventricle and contains within it the
first (peduncular) segment of the vein of the lateral re-
cess (11)(Fig. 15, B).
The flocculus is a small (7-15 mm), laterally project-
ing lobule situated at the anterolateral aspect of the
cerebellopontomedullary angle cistern (Figs. 1, 2, and
3). The flocculus is related superiorly to the lip of the
quadrangular lobule and posteriorly to the biventral lob-
ule while antero-inferolaterally it presents a free sur-
face to the lateral pontine and lateral medullary cisterns
(11). Posterosuperomedially, the flocculus is attached
by the floccular peduncle to the nodulus of the vermis
(Figs. 15 and 16). This peduncle forms the posterolater-
al wall of the deep (peduncular) portion of the lateral re-
cess and the anterosuperomedial wall of the posterolat-
eral fissure (11). The flocculus is circumscribed by the
numerous arteries and veins which run in the surround-
ing fissures. The vein of the lateral recess courses pos-
tero-inferiorly to the flocculus (second or floccular seg-
ment) and then superior to the flocculus (third or supraf-
loccular segment) en route to the petrosal vein at the
anterior angle (11, 12) (Fig. 24, B).
The pons (P) is separated from the medulla by the
pontomedullary sulcus (PMS) which courses anterosu-
perior to the medullary pyramid (PV) and to the olive (0)
to reach the supra-olivary fossette (SOF). The sixth cra-
nial nerve (6) emerges from the PMS at the .lateral bor-
der of the pyramid.
The supra-olivary fossette is the most medial portion
of the cerebellopontomedullary angle (Figs. 1 and 3)
(11, 12). It may be regarded as the confluence of the
PMS, posterolateral fissure, and cerebellomedullary fis-
sure. Its relationships to the brachium pontis (BP), floc-
culus, and olive are illustrated in Figures 1, 3, and 17.
The flocculus forms the posterolateral wall of the fora-
men of Luschka and the lateral recess in the supra-oli-
vary fossette (Figs. 3, 17, B). A membrane of adherent
arachnoid and ependyma forms the anteromedial wall.
The choroid plexus of the lateral recess (CH) emerges
from the foramen of Luschka and protrudes into the
cerebellopontomedullary angle to cover the antero-in-
feromedial aspect of the flocculus and the adjacent por-
tions of the posterolateral fissure and biventral lobule.
The roots of the 9th and 10th cranial nerves emerge
from the posterolateral medullary sulcus and become
adherent to the membranous anteromedial wall of the
lateral recess. The 11th nerve fibers are just caudal
(11).
The pons is separated from the BP by the lateral pon-
tine sulcus (Figs. 1,2, and 3) (12). The BP on each side
passes posterosuperolaterally into the cerebellar hemi-
spheres, deep to the overhanging lip of the quadrangu-
lar lobule anterosuperiorly, and to the flocculus and the
inferior semilunar lobule postero-inferiorly. The fibers
of the fifth cranial nerve (5) emerge from the anterosup-
eromedial aspect of the BP, just lateral to the lateral
pontine sulcus and in front of the anterior angle. The fi-
bers of the seventh and eighth cranial nerves (7, 8)
358 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 5. Typical AICAs. A. lateral view. Single meatal loop. The quadrangular lip (Ql) and flocculus (F) have been partially re-
sected. The long single meatal loop (Ml) lay within the porus in situ. Note the tiny caudomedial artery (CM), twigs of supply to the lat-
eral aspect of the pons ( ~), the parallelism between the suprafloccular segment of the rostrolateral artery (SFR) on the brachium
pontis (BP) and the marginal artery (MA) on the anterolateral margin (AlM), and the characteristic hairpin turns ( ...... ) at the origins of
the inferior semilunar (IA) and biventral (BVA) lobular branches.
B. lateral view, other side same specimen. M segment. Artery of the lateral recess. The meatal loop is partially obscured by the
seventh and eighth nerves. The trigeminal point [apex of the brachial loop (Bl)] and the genu (white.Al"'" ) of the marginal artery
(MA) bracket the origin of the fifth nerve (dashed in). Resection of the biventral and inferior semilunar lobules exposes the lateral sur-
face of the tonsil (T) and the anterosuperomedial wall (* *) of the posterolateral fissure. The descending artery (DA) in the lateral
portion of the fissure gives rise to the artery of the lateral recess (AlR).

Fig. 6. The rostrolateral artery. M segment. Portions of the hemisphere abutting on the horizontal and posterolateral fissures have been
resected. A. lateral view. A single rostrolateral artery is formed by two roots passing on either side of the sixth nerve. The trigeminal point
(TP) touches the postero-inferior aspect of the fifth nerve, 5. A small recurrent choroidal artery ( +-)
and the descending artery (DA) both sup-
ply the choroid (CH).
B. Towne's projection. The relationships of the three laterally, medially and laterally-directed components of the rostrolateral artery to the
cranial nerves, 5, 7, 8, brachium pontis, flocculus (F), and hemisphere are well demonstrated. The termination of the first laterally directed
segment (*) is the descent of the meatal loop (Ml) (See text p365).

emerge from behind the inferior edge of the BP at the
superolateral aspect of the supra-olivary fossette (Fig.
17, A) and pass anteriorly, laterally, and, to a variable
extent, superiorly, to lie either superior or inferior to the
more laterally placed flocculus.
THE TYPICAL AICA
sixth nerve superficially or deeply (Figs. 3-6, and 8-
11). In this course it supplies the lateral aspect of the
lower %of the pons and the upper medulla (1) (Fig. 5,
A). On or a few millimeters lateral to the sixth nerve,
AICA bifurcates into its two major branches (Figs. 3 and
4). In view of their ultimate distribution these may be
termed the rostrolateral (RL) artery and the caudomedial
artery (eM).

In a typical case, AICA arises from the first or middle

The Rostrolateral Artery
third of the basilar artery and passes posteriorly, inferi-
orly, and laterally on the belly of the pons to cross the At its origin or after a short posterolateral course, the
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 359 Neuroradiology

rostrolateral branch (rostrclateral artery) (RL) of AICA Table I: Symbols Used in Illustrations
turns superolaterally or anterosuperolaterally. With the A Anterior angle
main trunk of AICA it forms a caudal loop on the lateral AHB Ascending hem ispheric branches
AI, AICA Anterior inferior cerebellar artery
aspect of the pons (Figs. 4, 5, 6, A, and 8-11). The ALM Anterolateral margin
most postero-inferior point reached by this caudal loop ALR Artery of the lateral recess
AS Ascending artery to the great horizontal fissure
is designated the caudal point (e) of the RL. BA Basilar artery
The RL then continues superolaterally to reach the BL Brachial loop of rostrolateral artery
seventh and eighth cranial nerves anterior to the floccu- BP Brachium pontis
BS Brachial segment
lus. On the seventh cranial nerve, eighth cranial nerve, BV Biventral lobule
and the BP, the RL describes either a single arterial BVA Biventral lobular artery
BVR Biventral ridge
loop (Figs. 5, A and 11), or, more frequently, a double BVS Biventral segment
arterial loop (Figs. 4, 5, Band 8-10). The single arterial CA Choroidal arteries
CH Choroid plexus of the lateral recess
loop is designated the single meatal loop because it is CM Caudomedial artery
related to the porus acusticus in almost %of patients CMF Cerebellomedullary fissure
DA Descending artery
(18, 22). The double arterial loop is designated the M E External auditory canal
segment because of its resemblance to the letter M. F Flocculus, Floccular loop
The M segment is viewed as consisting of a meatal FL Foramen of Luschka
FP Floccular point
loop proximally plus a brachial loop (BL) on/or close to FPD Floccular peduncle
the BP distally. G Great horizontal fissure (horizontal fissure)
I Inferior semilunar lobule
In those- cases with a single meatal loop, the RL as- IA Inferior semilunar lobular artery
cends on the anterior, superficial aspect of the seventh IAA Internal auditory artery
lAC Inferior accessory artery
nerve, frequently giving off the internal auditory artery L Lateral angle
(Fig. 5, A). The RL then forms the apex of the meatal LL Lateral loop
loop on the seventh nerve, usually near to or within the LPS Lateral pontine sulcus
M Medulla
internal auditory canal. Reversing its course it descends MA Marginal artery
postero-inferomedially onto the BP by passing between ML Meatal loop of rostrolateral artery
the seventh and eighth nerves or between the eighth
a Olive
P Pons
nerve and the flocculus. On the BP it gives off arterial PCHA Prechoroidal artery
PICA Posterior inferior cerebellar artery
feeders to supply the brachium and adjacent pons (Fig. PJ Posterior aspect of the vertebro-basilar junction
5, A)(1). PLF Posterolateral fissure
PLM Posterolateral margin
In those cases with an M segment (Figs. 4, 5, B, 6, A, PMS Pontomedullary sulcus (also _._.)
and 8-10) the RL first forms a meatal loop and then PSF Posterior superior fissure
again reverses course to ascend as the brachial loop PT Posterior turn of the lateral loop
py Pyram id of the medulla
on either the superficial aspect of the eighth nerve or Q Quadrangular lobule
on the BP deep to the eighth nerve. Not infrequently the QL Quadrangular lip
R Right
apex of the brachial loop of the M segment (trigeminal RCH Recurrent choroidal artery
point) passes sufficiently far anterosuperiorly on the BP RF Retrofloccular segment of descending artery
RL Rostrolateral artery
to touch the postero-inferior aspect of the origin of the S Superior semilunar lobule
sensory division of the trigeminal nerve, and thus SC Superior accessory artery
SCA Superior cerebellar artery
serves as an arterial landmark for that nerve (Figs. 5, B, SFG Suprafloccular portion of the great horizontal
6, 8, and 9). At the apex of the brachial loop, the RL fissure
again reverses direction and passes postero-inferiorly SFR Suprafloccular segment of the rostrolateral
artery
on the BP to complete the brachial loop and the M seg- SOF Supra-ol ivary fossette
ment. Both the single meatal loop and the M segment T Tonsil
TP Trigem inal point
lie anterior to the flocculus defining its anterior aspect V Vertebral artery
(Figs. 4, 5, 6, A, and 8-11). VLR Vein of the lateral recess
Distal to the M or the single meatal loop, the rostrola- 1 First or peduncular portion of the VLR
2 Second or floccular portion of the VLR
teral artery courses posteriorly (and usually inferiorly) 3 Third or suprafloccular portion of the VLR
on the BP to enter the suprafloccular portion of the GHF 4 Fourth ventricle
5 Trigem inal nerve
(suprafloccular segment of the RL) (Figs. 5, 6, A, and 6 Abducens nerve
8-12). The suprafloccular segment plus the brachial 7 Facial nerve
loop of the M (or the distal portion of the single meatal 8 Cochleo-vestibular nerve
9 Glossopharyngeal nerve
loop) both lie on the BP and may be considered togeth- 10 Vagus nerve
er as the brachial segment of the RL (Fig. a, A). 11 P\ccessory nerve
On the superior aspect of the flocculus at or near to •<:> 0
Caudal point of the rostrolateral artery
Caudal point of the caudomed ial artery
the posterosuperior corner, the RL divides into an as- *' Defined in context-used variably
cending branch to the GHF and a descending branch to • Defined in context-used variably
Porus acusticus
the posterolateral fissure (Figs. 6, A, 8-10, and 12). Cerebellar margins or outlines of resected tissue
The ascending artery initially courses posterosuperola- ..G .. Great horizontal fissure
Pontomedullary sulcus
terally at the 45° inclination characteristic of this por-
360 THOMAS
Fig. 7. Large ascending artery defining the GHF. A. True lateral view.
B. Posterior view. Note the characteristic 45 0 inclination of the proximal (petrosal) portion of the ascending artery (AS). A side
branch ( +) of an ascending hemispheric branch of PICA (horizontal arrowheads) to the horizontal fissure anastomoses with the as-
cending artery. Above the fissure, PICA branches ( *}
tion of the GHF and is distributed to the petrosal aspect
of the cerebellum (Figs. 6-9). If large, this branch may
continue in the GHF for several centimeters more,
passing below the lateral angle to gain the occipital as-
pect of the cerebellum. On the occipital surface it
courses posterosuperomedially at a shallower angle
and is distributed variably to the superior and the inferi-
or semilunar lobules (Figs. 6-9 and 11).
The descending artery initially passes inferiorly in the
posterolateral fissure between the flocculus anteriorly
and the biventral lobule posteriorly (Figs. 3-6, A). This
portion of the descending artery, situated directly poste-
rior to the flocculus, may be termed the retrofloccular
segment of the descending artery. Together the M seg-
ment [or single meatal loop (ML)], the suprafloccular
segment, and the retrofloccular segment form a floccu-
lar loop which outlines the flocculus (Figs. 3 and 5-12).
The retrofloccular segment of the descending artery
frequently gives rise to inferior semilunar and biventral
lobular branches which pass laterally out of the fissure
to supply the adjacent petrosal and occipital aspects of
the corresponding lobules (Figs. 4, 5, 8-10, and 12).
Frequently this segment also gives rise to a small artery
or plexus of arteries which runs posterosuperomedially
in the depths of the posterolateral fissure (Figs. 5, B
and 15). Because this artery or plexus accompanies the
vein of the lateral recess, it has been termed the artery
of the lateral recess (11, 15).
When the posterior inferior cerebellar artery (PICA)
is small, the descending branch of the rostrolateral ar-
tery (RL) enlarges and often continues inferiorly and
posteriorly on the free lateral surface of the biventral
lobule, on the biventral ridge, or in the cerebellomedul-
lary fissure to reach the posterior inferior aspect of the
cerebellum. This portion of the artery may be termed
the biventral segment of the descending artery (Figs. 8
and 9). The biventral segment may anastomose with
P. NAIDICH AND OTHERS May 1976
show a marked change in caliber (white arrowheads = PLM).
PICA or give rise to ascending hemispheric branches
which supplement or replace the hemispheric branches
of PICA.
The Caudomedial Artery (CM)
The caudomedial branch (caudomedial artery) of
AICA may be found consistently, but is quite variable in
size (Figs. 4, 5A, 11, and 12). From its origin on the lat-
eral aspect of the pons in the vicinity of the sixth nerve,
the CM passes posterosuperiorly, toward the PMS, to
describe its own caudal loop on the lateral aspect of
the pons and medulla (Figs. 3, 4, 11, and 12). This loop
is similar to, but situated postero-inferior to, the caudal
loop of the RL described previously.
When the CM is small, it will often terminate on the
lateral aspect of the pons or in the PMS as a small twig
supplying the pons, the PMS, the supra-olivary fossette
and/or the 9th and 10th cranial nerves (Fig. 5, A). When
it is slightly larger, it may also contribute to the supply
of the lateral aspect of the flocculus and the biventral
lobule.
In approximately Y3 of patients in whom the CM is
large, it frequently courses laterally from the supra-oli-
vary fossette to describe a laterally directed loop about
the rootlets of the 9th, 10th, and 11th cranial nerves,
the foramen of Luschka, and the tuft of choroid plexus
which emerges from the foramen (Figs. 3, 4, 11, 12,
17, Band 22). This lateral loop of the CM lies, in order,
on the antero-inferolateral aspect of the flocculus (ante-
rosuperior to the rootlets), on the petrosal aspect of the
biventral lobule (lateral to the rootlets), and on the pe-
trosal aspect of the undersurface of the biventral lobule
(postero-inferior to the rootlets of the cranial nerves).
Multiple small arteries to the choroid plexus of the lat-
eral recess often arise from the inner aspect of this lat-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 361 Neuroradi

Fig. 8. Single typical AICA. Normal left vertebral an-

giogram-arterial phase subtraction. A. Lateral projec-
tion. The basilar artery obscures the origin of AICA (1 ).
No caudomedial artery is visualized. The rostrolateral ar-
tery forms a prominent M segment, a floccular loop (F),
an ascending (AS), and a descending (DA) artery. The
meatal loop (ML) of the M segment lies in relationship to
the subtraction artifact of the external auditory canal (E).
An inconstant infrafloccular artery probably represents
the recurrent choroidal artery ( +). The terminations of
the ascending hemispheric branches of PICA ( , , ,) de-
fine a portion of the great horizontal fissure. Note the
genu (*) of the marginal artery at the anterior angle and
the floccular point (also+).
B. Towne's projection, same patient. The apex of the
meatal loop (ML) is at the internal auditory canal ( ) ). The
medially directed segment ( ! ) represents the descent
of the meatal loop plus the ascent of the brachial loop.
Note the parallelism between the loop (4+) and the mar-
ginal artery (MA), and the characteristic angulation in the
course of the ascending artery (AS).

Fig. 9. Diagram of brainstem and cerebellar anatomy established from the course of AICA (cf. Fig. 8, A). The ascent of the meatal loop
(ML) marks the ventral superficial aspect of the seventh nerve, 7, in most cases, and the crotch of the M marks the approximate site of the
eighth nerve, 8. The brachial loop and the suprafloccular segment (SF) of the rostrolateral artery define the brachium pontis, and the marginal
artery (MA) of the superior cerebellar artery delineates the anterolateral margin. The genu of the marginal artery (*) is the anterior angle (A).
MA, SFR and the 45 0 portion of AS define the quadrangular lip (\\ \ \). The terminations of the multiple ascending hemispheric branches of
PICA t , , , ) define the great horizontal fissure. The distal ascending artery runs above the horizontal fissure (normal variation). The de-
scending artery (DA) defines the anterior aspect of the biventral lobule. The vertebrobasilar junction (PJ), caudal point (.) of the rostrolateral
artery (RL), and floccular point (.) mark the location of the pontomedullary sulcus (_._.).

eral loop (Fig. 17). Distal to the loop the biventral seg-
ment of the CM turns postero-inferiorly on the lateral
aspect of the biventral lobule, on the biventral ridge, or
within the cerebellomedullary fissure to reach the pos-
terior surface of the cerebellum (Figs. 4, 11, 17, and
18). In a manner analagous to the descending branch of
the RL, the CM may also anastomose with PICA or give
rise to ascending hemispheric branches which supple-
ment or replace the hemispheric branches of PICA
(Figs. 4 and 12).
DETAILED ANATOMY AND ANGIOGRAPHIC
APPEARANCE
A single typical AICA was encountered in 60 % of
specimens (Fig. 4). The combination of "AICA " and
362 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 11. Typical single AICA, large rostrolateral and caudom-

Fig. 10. Single typical AICA, rostrolateral artery. Lateralprojec-
tion. No caudomedial branch is seen. The characteristic hairpin turn
( J.-) marks the posterolateral fissure. The ascending artery ( ! ) is
small, but ascending hemispheric branches of PICA define a portion
edial arteries. Lateral projection. The single meatal loop (ML) and
floccular loop (F) of the rostrolateral artery are well defined. The an-
terior convexity of the ascending segment of the meatal loop ( J... )
is an infrequent variation. (+) = the superior cerebellar arteries at
the posterolateral margin, and ( t) = the great horizontal fissure
(G). Small tortuous vessels ( .... ) arising from the descending artery

margin is identified (*) +).

of the horizontal fissure ( A small branch to the anterolateral
(cf. Fig. 6, A).
(DA) may represent the arterial plexus of the lateral recess (cf. Fig.
4). LL, BVS and AHB outline the inferior surface of the hemisphere.

Fig. 12. Large rostrolateral and caudomedial branches, common AICA-PICA trunk. A. Lateral projection. No PICA is seen. Distal to the
posterior turn (+), the caudomedial artery forms the tonsillar loop (T) and gives off hemispheric branches to supply the PICA distribution.
B. Straight anteroposterior projection (earlier arterial phase, tonsillar loop not filled). The caudomedial artery first passes postero-inferior-
Iy to its caudal point (0) and then around the cranial nerve roots (" LL, -+. =$=) toward the posterior turn (+).

one accessory artery of either the superior or inferior
type was observed in 29 % (Figs. 19, 20, and 22) and
the combination of "AICA" and both superior and inferi-
or accessory arteries in 1% (Fig. 21). Two aberrant ar-
teries were identified in 10%.
The anterior inferior cerebellar arteries arise from
the lateral aspect of the basilar artery at variable levels.
In those cases with a single AlGA, the origin is approxi-
mately equally frequent from the first third (47 %) and
from the second third (53 %) of the basilar artery (Figs.
4 and 5 A). No single AlGA was seen to arise from the
distal third of the basilar artery. In those specimens with
an "AlGA" and a superior accessory artery, AICA al-
most always arises from the first third of the basilar ar-
tery (Fig. 22). In those specimens with an "AlGA" and
an inferior accessory artery, "AlGA" almost always
arises from the second third of the basilar artery (Fig.
19). In the 1 case with an "AlGA", a superior accessory
artery, and an inferior accessory artery, each artery
arose from its own third (Fig. 21). "AlGA" is larger than
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 363 Neuroradiology

either its superior or its inferior accessory artery in

70 % of cases (Figs. 20 and 22 left side). In each case
in which "AICA" was smaller than its accessory artery,
it was still a vessel of significant size (Fig. 19).

Relation To The Sixth Nerve

Whether AICA crosses the sixth nerve superficially

or deeply appears to be related to the distance along
the nerve from the PMS to the point at which the artery
actually crosses the nerve. In all cases in which the ar-
tery crosses the nerve less than 6 mm rostral to the
PMS, the artery was found superficial to the nerve (Fig.
4). In all cases in which the artery crossed the nerve
from 8 to 11 mm rostral to the PMS, the artery was
found to cross deep to the sixth nerve (Fig. 5, A). These
relationships held even when there were multiple arte-
ries each crossing the nerve at a different level (Fig. 6,
Fig. 13. Localization of the pontomedullary sulcus. In order from
A). The region from 6 to 8 mm rostral to the PMS ap- antero-inferior to posterosuperior the four squares (_) along the
pears to represent a transition zone in which the artery pontomedullary sulcus (- - -) represent the posterior aspect of the
may pass superficial to, deep to, or through the sixth vertebrobasilar junction, the caudal point of the rostrolateral artery,
the caudal point of the caudomedial artery. and the floccular point.
nerve (Fig. 20) (4, 21). When AICA is more than 11 mm
The numbers represent the range (in millimeters) over which these
rostral to the pontomedullary fissure it bears no relation points may be found in 90 % or more of cases.
to the sixth nerve. The point of origin of AICA from the
basilar artery and the distance between the caudal point
and the PMS bore no constant relationship to whether
90 % of cases (Figs. 4 and 22). The caudal point of the
the artery crossed the nerve superficially or deeply.
caudomedial branch also serves as a landmark for the
The bifurcation of AICA and the caudal point of the
supra-olivary fossette, and lies on its anterior border
RL may help to localize the sixth nerve angiographical-
(42 %), or deep within the supra-olivary fossette (46 % )
Iy. AICA usually divides into its rostrolateral and caudo-
(Figs. 4 and 22). (d) The flocculus and floccular loop al-
medial branches on or within a few millimeters lateral
ways straddle the PMS, marking its posterosuperior end
to the sixth nerve (Fig. 4). In 5 % of cases it divides a
(Figs. 5, A, 6, and 20). The midpoint of the inferior bor-
few millimeters medial to the sixth nerve (Fig. 16, A),
der of the floccular loop (the floccular point) lies from 4
and in 5 % at or distal to the seventh and eighth nerves
mm caudal to 4 mm rostral to the posterosuperior end
anterior to the flocculus. The caudal point of the RL
of the pontomedullary sulcus (PMS) in 96% of cases. In
usually lies lateral to the sixth nerve (Figs. 5, A and 20),
20 % of cases the floccular point lies exactly at the sul-
but in 20 % of typical cases it lies at the sixth nerve
cus.
(Fig. 4). In the typical case therefore the sixth nerve
The combination of these four arterial landmarks,
may be found at the AICA bifurcation, at or antero-infe-
each related to a slightly more posterior and superior
rior to the caudal point of the RL (Figs. 8, 9, and 11).
portion of the PMS, allows a reasonable estimate of the
position of the sulcus in most cases (Figs. 8-11 and
Pontomedu/lary Sulcus 24). The use of four criteria enables the variant position
of anyone of these landmarks to be recognized and
Four distinct landmarks were observed to lie in close discounted (Fig. 5, A).
relationship to the PMS (Fig. 13). (a) The posterior as-
pect of the vertebra-basilar arterial junction (PJ) lies
Rostro/ateral Artery (RL)
from 4 mm caudal to 4 mm rostral to the anterior mid-
line portion of the PMS in 90% of cases (Figs. 4, 19, The RL is usually larger than the caudomedial artery
and 20). (b) The caudal point of the RL lies from 2 mm (CM) (80% of specimens), except when the caudom-
caudal to 5 mm rostral to the lateral portion of the PMS edial branch is supplementing flow to the distribution of
in 90 % of those specimens with a single AICA or an a small PICA (Fig. 4), or the marginal branch of the su-
"AICA" plus accessory arteries (Figs. 4, 6, and 20), and perior cerebellar artery supplies the region of the GHF
in 80 % of those classified as aberrant. (c) When the (8, 16).
caudomedial artery (CM) is of sufficient size to have a In more than 90 % of cases with an AICA or "AICA"
definable caudal point, this lies from 4 mm caudal to 2 the RL describes either an M segment or a single mea-
mm rostral to the posterolateral portion of the PMS tal loop on the seventh and eighth nerves and the bra-
(Figs. 4 and 22) and is a more accurate indicator of the chium pontis. The M configuration is present in approxi-
position of the PMS than the caudal point of the RL in mately 70 % of specimens, and the single meatal loop
364 THOMAS
Fig. 14. A. Bilateral AICA symmetry in lateral projection, with differing appearance in Towne's projection, B. Note the open supero-
medial arterial knuckle (i-+) on the left rather than the figure-of-eight on the right. The suprafloccular segment (SFR) and the descending ar-
tery (DA) form an acute angle (*) in Towne's projection. Note the proximity of the genus (+) of the marginal arteries to the brachial loops
(small arrowheads) in both lateral and Towne's projections defining the fifth nerve origins. (cf. Fig. 6, B).
is present in approximately 23 %. No M segment or
loop was identifiable in any of the specimens classified
as aberrant.
Meatal Loop (ML): The M segment most frequently
begins its ML with an upsweep on the anterosuperficial
aspect of the seventh nerve (80-85 %) (Figs. 4, 6, and
22, right side). Less frequently the upswing is on the su-
perficial aspect of the groove between the seventh and
eighth nerves (12-15 %) (Fig. 22, left side), or in the
groove between the eighth nerve and the flocculus
(5 %). The peak of the ML usually lies on the superficial
aspect of the seventh nerve. In 64 % of cases it lies
near to, or within, the internal auditory canal (Fig. 22,
right side), but in 36 % of cases the apex of the loop is
not related to the porus (Figs. 4 and 6) (17, 18, 22, 27).
The descending limb of the ML of the M segment
may lie on the superficial aspect (Figs. 4, 6, 21, and 22,
right side), or the deep aspect (Fig. 5, B) of the seventh
nerve, or exactly between the seventh and eighth
nerves. In approximately Y4 of cases it extends further
postero-inferiorly to lie on either the superficial or deep
aspect of the eighth nerve. The crotch of the M lies (a)
superficial to the seventh and eighth nerves overlying
the groove between them (25 %) (Fig. 4), (b) actually
within the inter-neural groove (25 %) (Fig. 6), (c) super-
ficial or deep to the eighth nerve (12% each) (Fig. 22),
or (d) between the eighth nerve and the flocculus
(25%).
Brachial Loop: If the rostrolateral artery did not pass
deep to the seventh and eighth nerves and onto the bra-
chium pontis (BP) in the descending portion of the ML, it
usually does so just distal to the crotch of the M by
passing between the seventh and eighth nerves (Fig. 6),
or between the eighth nerve and the flocculus (Fig. 4) to
lie on the BP deep to and extending a variable distance
anterosuperior to both the seventh and eighth nerves
(85 %) (Figs. 4, 5, B, and 6). Rarely the "brachial" loop
may lie on the superficial aspect of the eighth nerve
P. NAIDICH AND OTHERS May 1976
just lateral to the brachium. The RL then reaches the
BP, distal to the "brachial" loop, by coursing between
the eighth nerve and the flocculus to begin the supraf-
loccular segment.
When the RL forms a single meatal loop, this loop
most frequently ascends on the anterosuperficial as-
pect of the seventh nerve (55 %) (Figs. 5, A, 19, and
20). Less frequently it ascends superficial to the groove
between the seventh and eighth nerves (22 %), or su-
perficial to the groove between the eighth nerve and
the flocculus (22 %). It then descends superficial or
deep to the seventh and eighth nerves to gain the BP in
the same fashion as the ML of the M segment.
Internal Auditory Artery: In our specimens the inter-
nal auditory artery was identified with certainty in only
% of cases. In 85 % of these it was seen to arise from
the upswing (70 %), apex (25 %), or downswing (5 %) of
the ML (Figs. SA, 21, and 22). In 10% the internal audi-
tory artery was a separate branch of the basilar artery,
which arose several millimeters rostral to the origin of
AICA. The other 5 % of internal auditory arteries identi-
fied had highly variable origins. A detailed analysis of
the internal auditory artery has been presented by
Walker (28).
Angiography of the M Segment
Angiographically, the M segment is usually well de-
fined in both frontal and lateral projections (Figs. 8-12,
14, 18, 24, and 25). The ascent of the M segment or the
ML may be taken to indicate the anterosuperficial as-
pect of the seventh cranial nerve in most cases. The
crotch of the M may be taken to indicate the approxi-
mate position of the eighth cranial nerve in many
cases. In lateral projection, the portion of the ML as-
cending along the seventh and eighth nerves is usually
either convex posterosuperiorly or horizontally (Figs. 8,
A, 10, and 12). In a small number of normal patients
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY
(Fig. 11), especially when the RL is tortuous, or has ab-
errant origin, as from PICA (Fig. 18), this ascending
segment is concave posterosuperiorly. At present, we
regard reversal of the curvature of this segment from
convexity posterosuperior to concavity posterosuperior
as potentially abnormal and recommend further evalua-
tion of the patient. In frontal view, the apex of the ML is
most often visualized just at or within the porus of the
internal auditory canal (Figs. 8, Band 14, B). In lateral
projection the peak of the ML is visualized in apparent
relationship to the external auditory canal (Figs. 8, A
and 9). In 36 % of cases the meatal loop is not related
to the porus or the vessel is aberrant.
The brachial segment of the RL defines the position
and orientation of the BP and the marginal artery the
position and orientation of the anterolateral margin and
quadrangular lip. In lateral projection one can see the
brachial segment on the BP lying parallel and just ant-
ero-inferior to the marginal artery on the anterolateral
margin (Figs. 8-10, 12, and 14, A). Occasionally these
arteries may appear to overlie or even cross each other
slightly (Fig. 23).
The location of the BP may be confirmed in lateral
venous phase by visuaHzing the third (suprafloccular)
segment of the vein of the lateral recess (Fig. 24), the
suprafloccular segment of the vein of the GHF, or a
prominent brachial tributary of the precentral cerebellar
vein (11, 12). When present, the vein of the anterolater-
al margin defines that structure (12).
In the Towne's projection, the M segment or ML
forms an exceedingly complex series of overlapping
vessel loops (6). Slight changes in the degree of angu-
lation of the x-ray beam and slight variations in the
course of the rostrolateral branch produce significant
variations in their radiographic appearance. However,
this series of loops can frequently be analyzed into
three components by bearing in mind that the RL on the
seventh and eighth nerves lies lateral to the BP and that
the BP passes laterally, posteriorly, and superiorly as it
diverges out into the hemisphere (Figs. 2 and 3). (a) In
Towne's projection the first laterally-directed segment
of these loops represents the passage of the RL across
the belly of the pons and along the seventh and eighth
cranial nerves to the region of the porus acusticus
(Figs. 6, 8, B, and 14, B). The distal extent of this later-
ally-directed portion usually corresponds to the apex of
the ML at the porus. (b) The next medially-directed seg-
ment of the M or of the single ML represents whichever
portions of the RL actually pass from the nerves onto
the BP. It also includes any portion of the artery on the
BP that runs anteromedially back toward the fifth nerve
and the pons (Fig. 6). In patients with a single ML, this
medially directed segment usually corresponds to the
proximal portion of the descent of the ML. In patients
with an M segment, the medially-directed segment usu-
ally corresponds to the descent of the ML and/or the
ascent of the brachial loop. In unusual cases the me-
dially-directed segment may correspond to other por-
365 Neuroradiology
tions of the M segment. As a function of projection this
medially-directed segment appears to lie above, lie
below, or cross the portion of the RL proximal to the
porus (Figs. 8, B, 14, B, and 25, A). (c) The second lat-
erally-directed segment immediately distal to the me-
dially-directed segment represents that portion of the
artery on the BP that runs laterally and posteriorly
towards the hemispheres before bifurcating into as-
cending and descending arteries, l.e., the brachial seg-
ment (Fig. 6). In patients with a single ML, this laterally
directed segment usually corresponds to the distal por-
tion of the descent of the ML plus the suprafloccular
segment. In patients with an M segment, it usually cor-
responds to the descent of the brachial loop plus the
suprafloccular segment. Less frequently, it may include
more proximal portions of the descent of a single ML or
the ascent of the brachial loop of an M. In both groups
this laterally-directed segment lies inferomedial and
parallel to the portion of the marginal artery on the an-
terolateral margin. This second laterally-directed seg-
ment lies first anterosuperior to the flocculus and then
directly superior to it. In most cases, it defines the loca-
tion of the BP and its distal portion defines the top of
the flocculus (Figs. 8, B, 14, B, and 25, A).
The series of loops visualized in Towne's projection
often shows an unusually prominent superomedially di-
rected arterial knuckle at or just distal to the porus
acusticus (Figs. 6, 8, B, and 14, B). This knuckle repre-
sents an exaggeration of the medially-directed and lat-
erally-directed segments discussed above and is most
prominent whenever there is an enlarged ML, 'brachial
loop, or suprafloccular segment. It appears to arise at
approximately right angles to the superolateral line es-
tablished by the pontine portion of the RL proximal to
the knuckle and by the ascending artery within the pe-
trosal portion of the GHF distal to the knuckle (Figs. 8,
B, 14, Band 25, A). Because this loop lies predomi-
nantly on the BP, its position and orientation define the
location and inclination of the brachium in the Towne's
projection. In many cases the lateral portion of the
knuckle defines the top of the flocculus.
Trigeminal Nerve: In 40 % of cases the brachial
loop of the M segment extends anterosuperiorly to lie
within 2 mm postero-inferior to the origin of the sensory
division of the trigeminal nerve. The apex of such a pro-
nounced brachial loop may be termed the trigeminal
point and is utilized angiographically to approximate the
position of the trigeminal nerve origin in both frontal
and lateral projections (Figs. 8, 9, and 14). Because the
trigeminal point approximates the postero-inferior as-
pect of the fifth nerve origin, and the genu of the mar-
ginal artery at the anterior angle approximates the post-
erosuperior aspect of the fifth nerve origin, these land-
marks may be utilized angiographically to bracket the
nerve origin (Figs. 5, B, 6, 8, and 14), Occasionally, the
course of the superior accessory artery will outline the
antero-inferior aspect of the fifth nerve origin (Figs,
21-23).
366 THOMAS
Fig. 15. Arteries of the lateral recess. A. True lateral view. B. Postero-inferior view. Note the artery of the lateral recess (ALR) cours-
ing with the vein of the lateral recess (VLR) in the peduncular portion of the posterolateral fissure, and the supratonsillar and lateral tonsillar
tributaries(+ ) of the vein of the lateral recess. The artery of the lateral recess which lies below and behind the choroid plexus of the lateral
recess (CH) appears to lie above it due to projection in the postero-inferior view. (TA lateral tonsillar attachment).
Floccular Loop: Anatomically and angiographically,
the position of the flocculus is defined in lateral projec-
tion by the components of the floccular loop: the M
segment or meatal loop (ML) anteriorly; the suprafloc-
cular segment posterosuperiorly; and the retrofloccular
segment postero-inferiorly (Figs. 5-12 and 24, A). The
bifurcation of the suprafloccular segment usually de-
fines the posterosuperior angle of the flocculus at the
confluence of the GHF and posterolateral fissures (Figs.
6, 8, and 11). A complete (three-sided) floccular loop is
visualized in many lateral vertebral angiograms. Occa-
sionallya four-sided loop may be formed by the addition
of an inconstant, infrafloccular branch (Fig. 8). When
the floccular loop is anomalous, the vein of the lateral
recess may help to localize the flocculus (Fig. 24). In
straight anteroposterior projection and Towne's projec-
tion, the retrofloccular segment may be identified only if
large and not obscured by overlying vessels (Figs. 6, B
and 14, B). In both these frontal projections the retro-
floccular segment forms an acute angle with the supraf-
loccular segment. The suprafloccular segment extends
postero-inferolaterally to this angle and the retrofloccu-
lar segment extends postero-inferomedially from the
angle (Figs. 3, A and 14, B).
Ascending Artery to the Great Horizontal Fissure (GHF)
The ascending artery supplies the quadrangular lip,
the superior surface of the quadrangular lobule and the
superior and inferior semilunar lobules. It is of good
size in 75% of cases and quite small in 14%. It may be
replaced by a branch of the superior cerebellar artery
(8). Angiographically the ascending branch of AICA may
be taken to represent the GHF on the petrosal aspect of
the hemisphere in almost all cases and on the occipital
surface of the hemisphere in most cases (Figs. 8, A, 9,
P. NAIDICH AND OTHERS May 1976
=
11, and 24, A). It is a complementary landmark to the
vein of the GHF (12).
Occasionally, the descending branch of the RL gives
rise to large biventral and inferior semilunar lobular
branches which pass across the petrosal and occipital
surfaces of the hemisphere to reach the GHF. These
may be confused with the ascending artery (Fig. 4),
especially if the ascending artery is postfixed and origi-
nates from the retrofloccular segment. Ascending
hemispheric branches of PICA (or of AICA when this re-
places PICA) frequently send numerous perpendicular
branches into the depths of the GHF and then decrease
in caliber (Fig. 7). In the lateral projection, identification
of these multiple perpendicular branches and of the
"petering out" of the ascending hemispheric branches
defines the location of the fissure and its relationship to
the ascending branch of the RL (Figs. 8, 9, and 24, A).
The marginal branch of the superior cerebellar artery at
the anterior angle and on the anterolateral margin es-
tablishes the relationship of the ascending artery to
these structures (Figs. 8 and 11). The curving of the su-
perior cerebellar artery branches as they descend over
the posterolateral margin (Fig. 11) establishes the rela-
tionship of the ascending artery to the posterolateral
margin. A marginal artery that actually enters the GHF
may be utilized as a landmark for the fissure (8, 16).
Use of these multiple criteria clearly delineates the
contours and landmarks of the upper portions of the pe-
trosal and occipital surfaces of the hemisphere and
provides a diagram of its surface anatomy.
In the frontal projection, the portion of the ascending
artery in the GHF describes a characteristic acute, lat-
erally convex, angle as it passes first posterosuperola-
terally to the lateral edge of the cerebellum below the
lateral angle (L), and then posterosuperomedially on the
occipital surface of the cerebellum to reach the posteri-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY
Fig. 16. Prechoroidalloop. A. Lateral view. The small prechoroidal artery (PCHA) arises from the caudomedial artery (CM) and passes
toward the posterolateral fissure.
B. Postero-inferior view. Lateral is to the reader's left. BV, I, T, and most of the vermis are resected. The prechoroidal branch (PCHA)
loops over the flocculus (F) into the lateral recess of the fourth ventricle where it extends along the length of the choroid plexus of the lateral
=
recess to the lateral angle of the fourth ventricle. (N nodulus).
or cerebellar incisura in the midline (Figs. 8, Band 25,
A). It will be seen medial to the marginal artery and the
other superior cerebellar artery branches that run on
the perimeter of the superior surface of the cerebellum
(Fig. 25, A). The normal variant of the ascending artery
that runs on the superior semilunar lobule above the
GHF and near to the lateral angle may be detected by
its usually lateral position (Fig. 8).
Descending Artery and the Artery of the Lateral Recess
In most cases, the descending branch of the RL (de-
scending artery) arises from the bifurcation of the su-
prafloccular segment of the RL (Figs. 4-6, 8-12, 14,
and 24, A). Occasionally, this artery arises from a supe-
rior accessory artery (Figs. 21 and 22), an ascending
branch of PICA, or from the superior cerebellar artery.
The descending artery could be identified in 87 % of
specimens, but was quite small in %of these.
The retrofloccular segment of the descending artery
usually gives rise to arterial feeders to the adjacent bi-
ventral and inferior semilunar lobules (Figs. 4, 5, A,
8-10, 12, 14, and 22). These branches course laterally
to emerge from the posterolateral fissures and then
pass posteriorly or posterosuperiorly over the JateraJ-
most aspect of the biventral and inferior semilunar lob-
ules of the cerebellum. A characteristic hairpin curve
(convexity downward) marks their point of emergence
from the posterolateral fissure (Figs. 5, A, 10, 12, and
14).
In % of all specimens (% of those with modest or
large descending arteries) the proximal 1-2 em of the
retrofloccuJar segment give rise to the artery of the lat-
eral recess (Figs. 5, Band 15). This passes posterosu-
peromedially in the peduncular portion of the postero-
lateral fissure, below and behind the lateral recess and
367 Neuroradiology
the vein of the lateral recess, to reach the supratonsil-
lar portion of the posterolateral fissure (15).
Choroidal Arteries
The arterial supply to the choroid plexus of the later-
al recess is from variable (often multiple) sources. In
some cases, a small recurrent choroidal artery origi-
nates from the ML of the rostrolateral artery (RL) and
passes postero-inferiorly beneath the flocculus to sup-
ply the choroid plexus (Figs. 6 and 20). In other cases,
the choroidal supply arises from the caudomedial artery
(CM), from an inferior accessory artery, or from loops
of PICA in the cerebellomedullary fissure.
In %- Y3 of specimens the choroid plexus was sup-
pi ied by a modest arterial branch of the basilar, CM, or
inferior accessory artery designated the prechoroidal
artery (Figs. 16 and 22). This artery is characterized by
its laterally looping course and by its lack of a caudal
point at the pontomedullary junction.
The lateral loop of the CM or of an inferior accessory
artery quite frequently also supplies the choroid plexus
of the lateral recess. Single or multiple small branches
arise from the inner aspect of the lateral loop, usually
just proximal to the posterior turn, and quickly form a
spray of 3-4 small, almost parallel vessels on the cho-
roid plexus (Fig. 17). These ramify on the plexus and
pass with it toward the lateral angle of the fourth ventri-
cle.
Caudomedial Artery ( CM)
In approximately Y3 of specimens with a large CM ar-
tery and in % of those with a large inferior accessory
artery, a lateral arterial loop is formed in relation to the
anterosuperior, lateral, and postero-inferior aspects of
368 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 17. Choroidal supply from the lateral loop. A. Lateral projection. Cranial nerves 9-11 and the flocculus are removed. The inferior
=
accessory artery (lAC) describes a typical lateral loop which gives off a choroidal trunk ( 'X). (+ supra-olivary fossette).
B. Anterior view, second specimen. The ninth, 9, and tenth, 10, cranial nerves are retracted anteromedially. A black circle marks the fora-
men of Luschka. Note the anatomic relationships of the supra-olivary fossette (covered by the retracted nerves), and the structures surround-
=
ing the foramen of Luschka (ct. Fig. 3). ( ~ ) choroidal trunk.

turns postero-inferolaterally across the flocculus and

Fig. 18. Aberrant origin of AICA. Lateral projection. The rostra-
+).
lateral artery (RL) arises directly from PICA ( The anterior con-
vexity of the ascending portion of the meatal loop is common in
AICAs arising aberrantly (ct. Figs. 4 and 9).
the 9th, 10th, and 11th cranial nerve roots, the foramen
of Luschka, and the choroid tuft emerging from the
foramen (Figs. 4, 17, 19, and 22, left side). This loop
commences at the caudal point of the eM (or inferior
accessory artery) within or just anterior to the supra-oli-
vary fossette. From the caudal point, the lateral arterial
loop turns anterosuperolaterally, usually lying first di-
rectly on the nubbin of choroid superior to the ninth
nerve (Fig. 17, A), and next on the antero-inferolateral
aspect of the flocculus (Figs. 3 and 4). The loop then
across the posterolateral fissure to lie on the petrosal
aspect of the biventral lobule lateral to the exiting root-
lets of the 9th, 10th, and 11th cranial nerves at the
point where they pass into bone (Figs. 4, 19, and 22,
left side). At the postero-inferior extent of this row of
rootlets, or at a variable distance postero-inferior to
that, the loop turns medially or anteromedially deep to
the 11th and 10th nerves to reach the postero-inferior
aspect of the choroid tuft which it supplies (Figs. 4, 17,
B, and 22, left side). The artery then turns posteriorly or
postero-inferiorly in the cerebellomedullary fissure, on
the biventral ridge, or on the lateral aspect of the biven-
tral lobule to reach the posterior aspect of the hemi-
sphere (Figs. 3, 4, and 17). The lateral loop is markedly
foreshortened in true lateral projection. This foreshort-
ening plus the reversals of curvature at the caudal point
anterior to the rootlets and at the posterior turn posteri-
or or deep to the rootlets, permit ready identification of
this loop (Figs. 4, 11, 12, and 18)
When present the lateral loop may be used to define
the medial aspect of the petrosal surface of the hemi-
sphere (Figs. 11, 12, and 18). Distortions of that surface
will be reflected in an alteration of the plane of the lat-
eral loop. Normally the lateral loop should be closed on
angiograms in lateral projection and widely open in the
anteroposterior projection (Figs. 4, 11, 12, 17, and 18).
Opening of the lateral loop in lateral projection and
closing of the loop in anteroposterior projection should
be taken to indicate abnormality. Because of the nor-
mally partially closed configuration of the loop in
Towne's projection, opening or closing of the loop in
this projection is difficult to appreciate unless marked.
Because the lateral loop lies on the sloping petrosal
surface of the cerebellum, the lateral loop almost al-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 369 Neuroradiology

ways inclines postero-inferiorly from the caudal point to

the posterior turn (Figs. 11 and 18). Very rarely, the lat-
eral loop lies in a true horizontal plane. Reversal of the
postero-inferior inclination of the lateral loop is abnor-
mal.
The inferomedial aspect of the cerebellar hemi-
sphere posterior to the lateral loop is defined by the bi-
ventral segments of the eM or inferior accessory artery
(Figs. 4, 11, 17, and 18). The ascending hemispheric
branches outline the back and sides of the hemisphere.
The lateral loop, biventral segment, and ascending
hemispheric branches may be utilized in conjunction to
define the entire inferior surface of the cerebellum
(Figs. 18 and 19). Even when a CM or inferior accesso-
ry artery is sufflciently aberrant not to form a lateral
loop, it may still outline the undersurface of the laterally Fig. 19. "AICA" plus a large inferior accessory artery supple-
projecting bulk of the cerebellum (Fig. 20). menting supply to the PICA distribution. PICA is small. The large in-
ferior accessory artery (lAC) pursues the course already described
forthe cauclomedial artery.
Cranial Nerves 9, 10, and 11

The positions of the 9th, 10th, and 11th cranial

nerves, the foramen of Luschka, and the choroid tuft
emerging from the foramen may be established from
the location of the lateral loop in most cases (Figs. 4,
17, 19, and 22). In 65% of specimens, the widest ex-
tent of the lateral loop bracketed these structures suffi-
ciently closely to be utilized as a landmark for them
(Figs. 3, 4, and 22, left side). However, in more than %
of these cases the narrower area defined by the caudal
point and posterior turn of the lateral loop bracketed the
structures more accurately than did the widest extent of
the lateral loop (Fig. 17, A). Angiographically, therefore,
use of the caudal point and posterior turn, or of the full
extent of the lateral loop, should provide approximate
anatomic localization of the 9th, 10th and 11th cranial Fig. 20. "AICA" plus inferior accessory artery coursing on the
nerves, the foramen of Luschka, and the choroid tuft in lateral aspect of the biventral lobule. Lateral view. Portions have
been resected; PICA is small. "AICA" (rostrolateral artery) pierces
%of patients (Figs. 11, 12, and 18). In the absence of a the fibers of the sixth, 6, nerve 7 mm rostral to the pontomedullary
lateral loop, the confluence of the lower end of the pos- sulcus (inset). A recurrent choroidal artery ( =F) arises from the
terolateral fissure (defined by the retrofloccular seg- meatal loop.• = the floccular point.
ment) and the pontomedullary sulcus (defined in Fig. 13)
may be taken to indicate the position of these same
structures (Figs. 8 and 9). while the vermian supply arises from a smaller "PICA"
trunk. Because of its variable, often confusing, appear-
ANATOMle VARIANTS ance and its significance in diagnosis, the common
Anomalous Origins AICA-PICA trunk will be the subject of a separate re-
port.
In rare cases AICA may arise from the vertebral ar-
Accessory Arteries
tery (21) or even from the cavernous portion of the ca-
rotid artery (20). More frequently AICA may originate An inferior accessory artery of significant size was
from PICA either proximally, from a short common demonstrated in 20 % of specimens. This artery may be
trunk, or more distally from the lateral or posterior me- regarded in almost all respects as a caudomedial
dullary segments of PICA (Fig. 18). After an initial branch of AICA which has acquired a separate origin
anomalous course by which it regains its normal posi- from the basilar artery, caudal to the origin of AICA. Its
tion, such an AICA may pursue a typical path with M course, distribution and variations are as described for
segment, floccular loop, and ascending and descending the CM (Figs. 17, A and 19).
arterial branches (Fig. 18). PICA may also arise from A superior accessory artery is a variant found in ap-
AICA. The complete supply to the PICA distribution may proximately 15 % of specimens. This artery most fre-
arise from the CM (Fig. 12) or only the hemispheric quently arose from the distal Y3 of the basilar artery, but
supply to the PICA distribution may arise from the CM, in 1 case arose from high in the middle %of the basilar
370 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 21. "AICA" plus large superior and inferior accessory arte- Fig. 22. Bilateral superior accessory arteries. Prechoroidal
ries. Lateral view. The superior accessory artery (SC) pursues a typ- loop. Water's view, unfixed specimen. Bilateral superior accessory
ical course. F = bed of resected flocculus. A small "AICA" forms a arteries (SC) cradst the roots of the trigeminal nerves, 5, and extend
meatal loop ( , ) on the seventh nerve. Its ascending branch (+) well onto the quadrangular lip (QL) before turning postero-inferome-

retracted medially) *=
anastomoses (~) with the superior accessory artery. Inset: (9, 10
Foramen of Luschka.
dially into the posterolateral fissures (PLF) as descending arteries.
Note the course of the prechoroidal artery ( ! ) on the right.

Fig. 23. Superior accessory arteries. A. Lateral view. A large superior accessory artery (SC) appears to cradle the origin of
the fifth nerve, 5, as judged by its curvature at that point in relationship to the genu (*) of the marginal artery (MA) above. "AICA"
forms a caudal loop ( ~ ) and suprafloccular (SFR) segment without any sharply defined meatal or brachial loops.
B. Straight anteroposterior projection; earlier arterial phase.

artery. Superior accessory arteries pursue a tortuous
path, coursing postero-inferolaterally on the lateral as-
pect of the high pons to pass immediately ventral and
deep to the fifth nerve (Figs. 21 and 22). They then con-
tinue posterolaterally, usually passing superior to the
seventh and eighth nerves (% cases) on the quadrangu-
lar lobule and/or within the suprafloccular portion of the
GHF (Figs. 21 and 22). Within the GHF, superior acces-
sory arteries behave exactly like a rostrolateral branch
of AlGA, bifurcating into typical ascending and de-
scending arteries (%) (Fig. 21), or passing without sig-
nificant bifurcation directly into the posterolateral fis-
sure as typical descending arteries (%) (Fig. 23). Angio-
graphically these features of the superior accessory ar-
tery are readily demonstrated.
In some cases the course of AlGA and its branches
is more complex than that described above. Redundant
branches may describe complete loops about the floc-
culus and redundant segments of arteries may loop
deep within fissures they ordinarily pass straight
through or over. Gaudomedial branches may arise distal
to their usual site, e.g., at the base of the seventh nerve
or anterior to the flocculus, and describe aberrant
courses antero-inferior or lateral to the flocculus prior
to reaching their ultimate distribution. Entire arteries
may be postfixed. Arteries may even arise which ap-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY
pear to have little other function than to pass postero-
inferolaterally to anastomose with other segments of
AICA or PICA. In general however, the features of AICA
are sufficiently constant to be identifiable on subtracted
direct 2X magnification angiograms.
DISCUSSION
The nomenclature of the branches of AICA has dif-
fered from author to author (1, 6, 14, 23). Some have
considered the main bifurcation of AICA to be the divi-
sion of the RL into its ascending and descending
branches, called by them the lateral and medial arte-
ries, respectively (23, 24, 26). These authors have de-
scribed the AICA bifurcation as occurring immediately
proximal or distal to the seventh and eighth nerves (25)
and appear to consider the eM a variable anastomotic
channel to PICA. Other authors have called proximal
and distal portions of an enlarged CM the medial and
371 Neuroradiology
Fig. 24. Arterial-venous correlation; vein of the lateral
recess. A. Lateral projection; arterial phase. "AICA" plus
inferior accessory artery. The inferior accessory artery (lAC)
anastomoses with PICA (=$=).
B. Lateral projection; venous phase. The vein of the later-
al recess (VLR) and its peduncular, 1, floccular, 2, and su-
prafloccular, 3, segments are shown. The suprafloccular seg-
ment runs over the flocculus and onto the brachium pontis to
reach the petrosal vein (PV) at or just lateral to the anterior
angle.
C. Composite diagram. The suprafloccular segment of
the VLR falls between the portions of the marginal artery
(MA) on the anterolateral margin and the suprafloccular seg-
ment of the rostrolateral artery on the brachium pontis. The
floccular segment of the VLR, 2, falls over the descending
branch (DA) of the rostrolateral artery. Both the genu of the
marginal artery and the petrosal vein mark the approxlrnate
site of the anterior angle. Were it visualized, the artery of the
lateral recess would lie adjacent to the VLR, 1.
lateral branches of AICA (7). in this paper we have fol-
lowed the anatomic nomenclature of Atkinson (1). In
plate lIa of his work, he clearly illustrates the bifurca-
tion of AICA into its two typical branches designated
medial and lateral. We have added the prefixes rostro
and caudo to emphasize that the RL lies generally supe-
rior as well as lateral to the CM. We feel that the
branch of the RL which passes superiorly into the GHF
should be called the ascending artery and that the
branch of the RL which passes inferiorly along the ant-
ero-inferomedial aspect of the biventral lobule and bi-
ventral ridge should be called the descending artery
(composed of retrofloccular and biventral segments). In
terms of this nomenclature, the bifurcation of AICA into
its rostrolateral and caudomedial branches then occurs
on or a few millimeters lateral to the sixth nerve in most
cases, and the bifurcation of the RL into its ascending
and descending arteries occurs above the flocculus dis-
tal to the eighth nerve in most cases.
372 THOMAS P. NAIDICH AND OTHERS
The majority of the vessels discussed are readily de-
tected angiographically, as we have shown. Some of
the smaller vessels are visualized less frequently. To
date, there has been difficulty in recognizing the de-
scending artery in frontal projection although on occa-
sion (Fig. 14, B) it may be demonstrated. The artery of
the lateral recess and the choroidal blush of the lateral
recess have not yet been identified in situ unequivocal-
ly, although we believe now that what has been called
the "medullary blush" (5, 13) in some cases really rep-
resents contrast within the choroid plexus of the lateral
recess. In some cases with good filling there is diffi-
culty in determining the configurations and laterality of
superimposed left and right AICA loops.
May 1976
Fig. 25. Arterial-venous correlation; vein of the lateral
recess. A. Towne's projection; arterial phase. The rostro-
lateral artery forms a prominent superomedial loop, (Bl,
SFR), outlining the position of the brachium pontis and the
top of the flocculus (F).
B. Towne's projection, venous phase. Peduncular, 1, floc-
cular, 2, and suprafloccular segments, 3, of the vein of the
lateral recess (VlR) are well seen.
C. Composite diagram. The suprafloccular segment of
the VlR superimposes on the suprafloccular segment of the
rostrolateral artery. The floccular segment projects beneath
the suprafloccular segment of the rostrolateral artery. In most
cases at least the suprafloccular portions of both artery and
vein are superimposable.
CONCLUSION
We have demonstrated that AICA can be visualized
routinely in lateral projection in well-penetrated, sub-
tracted magnification radiographs. Familiarity with its
detailed anatomy in this projection permits identification
of the belly of the pons, pontomedullary sulcus, supra-
olivary fossette, 5th, 6th, 7th, 8th, 9th, 10th, and 11th
cranial nerves, flocculus, brachium pontis, great hori-
zontal and posterolateral fissures, superior semilunar,
inferior semilunar, and biventral lobules of the cerebel-
lum.
ACKNOWLEDGMENTS: We wish to express our deepest thanks to
Ms. Linda Michaels, Ms. Evelynne Shaw, Mr. George Ozaki, Mr.
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 373 Neuroradiology

Jean-Pierre Lahary, and Dr. John Pearson for their assistance in pre- 13. Huang YP, Wolf BS: Angiographic features of fourth ventri-
paring this paper. cle tumors with special reference to the posterior inferior cerebellar
artery. Am J Roentgenol 107:543-564, Nov 1969
14. Huang YP, Wolf BS: Angiographic features of brain stem
tumors and differential diagnosis from fourth ventricle tumors. Am J
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