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Arterial Supply to the Pituitary Gland: A Comprehensive Review

Katherine A. Cironi, Tess Decater, Joe Iwanaga, Aaron S. Dumont, R. Shane Tubbs

PII: S1878-8750(20)31497-2
DOI: https://doi.org/10.1016/j.wneu.2020.06.221
Reference: WNEU 15448

To appear in: World Neurosurgery

Received Date: 21 March 2020

Revised Date: 26 June 2020
Accepted Date: 28 June 2020

Please cite this article as: Cironi KA, Decater T, Iwanaga J, Dumont AS, Tubbs RS, Arterial Supply to
the Pituitary Gland: A Comprehensive Review, World Neurosurgery (2020), doi: https://doi.org/10.1016/
j.wneu.2020.06.221.

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Review

Arterial Supply to the Pituitary Gland: A Comprehensive Review

Katherine A. Cironi1, Tess Decater4, Joe Iwanaga1, Aaron S. Dumont1, R. Shane Tubbs1-4

The affiliations and address of the authors

1. Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane

University School of Medicine, New Orleans, LA, USA

2. Department of Structural & Cellular Biology, Tulane University School of Medicine,

New Orleans, LA, USA

3. Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health

System, New Orleans, LA, USA

4. Department of Anatomical Sciences, St. George’s University, St. George’s, Grenada

Running title

Arterial Supply to the Pituitary Gland

The affiliation and address of the corresponding author:

Joe Iwanaga, DDS, PhD

Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University

School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA 70112, USA

iwanagajoeca@gmail.com

Tel:5049885565 Fax: 5049885793

Keywords

Pituitary gland; internal carotid artery; superior hypophyseal artery; inferior hypophyseal artery;

pituitary stalk

2
Abstract

Knowledge of the blood supply to the pituitary gland is important for clinicians and surgeons

alike. Therefore, a good working knowledge of this anatomy is important. The aim of this article

is to review current anatomical knowledge of the blood supply to the pituitary gland and its

clinical relevance.

Keywords

Pituitary gland; internal carotid artery; superior hypophyseal artery; inferior hypophyseal artery;

pituitary stalk

3
Review
Arterial Supply to the Pituitary Gland: A Comprehensive Review

Katherine A. Cironi1, Tess Decater4, Joe Iwanaga1, Aaron S. Dumont1, R. Shane Tubbs1-4

The affiliations and address of the authors

1. Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane

University School of Medicine, New Orleans, LA, USA

2. Department of Structural & Cellular Biology, Tulane University School of Medicine,

New Orleans, LA, USA

3. Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health

System, New Orleans, LA, USA

4. Department of Anatomical Sciences, St. George’s University, St. George’s, Grenada

Running title

Arterial Supply to the Pituitary Gland

The affiliation and address of the corresponding author:

Joe Iwanaga, DDS, PhD

Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University

School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA 70112, USA

iwanagajoeca@gmail.com

Tel:5049885565 Fax: 5049885793

Keywords

Pituitary gland; internal carotid artery; superior hypophyseal artery; inferior hypophyseal artery;

pituitary stalk

2
Abstract

Knowledge of the blood supply to the pituitary gland is important for clinicians and surgeons

alike. Therefore, a good working knowledge of this anatomy is important. The goal of this article

is to review current anatomical knowledge of the blood supply to the pituitary gland and its

clinical relevance.

Keywords

Pituitary gland; internal carotid artery; superior hypophyseal artery; inferior hypophyseal artery;

pituitary stalk

3
Abbreviation

ACTH, adrenocorticotropic hormone; CDI, central diabetes insipidus; ICA, internal carotid

artery; DI, diabetes insipidus; IHA, inferior hypophyseal artery; SHA, superior hypophyseal

artery;

4
Introduction

The blood supply of the pituitary gland is intricate and derived from multiple sources (Fig. 1).

Historically, knowledge of this blood supply was important primarily to neurosurgeons

performing intracranial procedures around the sella turcica. However, with an increased

understanding of this vascular supply, various endocrinological disorders are better understood

with such knowledge. For example, disruption of various arterial branches to the pituitary gland

might result in diabetes insipidus. Lastly, more minimally invasive surgical approaches to the

pituitary gland e.g., transnasal approaches, demand a detailed understanding of the blood supply

to the pituitary gland. Therefore, this paper reviews the literature on this topic and uses cadaveric

and schematic drawings to illustrate this anatomy.

A multi-database literature search using standard online search engines (e.g., PubMed, Ovid, and

Science Direct) was performed to identify relevant full text articles in English from January 1954

to January 2020. Search terms included “superior hypophyseal artery,” “pituitary blood supply,”

“inferior hypophyseal artery,” and “internal carotid artery branch.” The bibliographies of

appropriate articles were screened for further relevant citations. Papers that were relevant to the

blood supply of the pituitary gland were then reviewed and data synthesized into this review

paper.

Superior Hypophyseal Artery (SHA)

Origin

5
The SHA (Figs. 2 and 3) typically arises medial to the internal carotid artery (ICA) and from the

ophthalmic segment (C6 Bouthillier classification).2,4,15 More specifically, it originates distal to

the origin of the ophthalmic artery (within approximately 5 mm of it) but can arise more distally

but no further than proximal to the posterior communicating artery.2,4 In contrast, Truong el al.1

found that one third of their cases had the SHAs originating from the ophthalmic segment of the

ICA and two thirds from the clinoid segment (C5 Bouthillier classification), arising either from

the carotid cave or proximal to it. Most research supports the SHA origin of the ophthalmic

segment, but it should be noted that the SHAs have been found to originate from the clinoid

segment of the ICA as well.

Branching Patterns

Multiple studies have described the SHA as a collection of vessels, typically between 0-3

branches off the ICA (some sources cite as many as five), but with an average range from 1.83 to

2.2 branches among studies.1,4,5 Truong et al.1 reviewed the branching patterns in 30 human

specimens and classified them on the basis of the number of trunks emerging from the ICA.

They found one SHA emerging from the ICA in 18.3% of cases, two in 70%, and three in 8.3%;

the remaining 3.4% had no defined SHA emerging from the ICA.

In all cases, the first SHA to arise from the ICA is termed the primary SHA or pSHA. The pSHA

supplies blood to several structures along the preinfundibular space and branches into three main

groups (infundibular, optic, and descending) in order to do so.1 The infundibular group branches

off the pSHA to supply the upper infundibulum, the optic branches supply the optic nerve and

6
optic chiasm, and the descending branches run down the stalk toward the upper recess of the

adenohypophysis.1 The more distal SHA to arise from the ICA is termed the secondary SHA or

sSHA. Coursing through the retroinfundibular or parainfundibular space, the sSHA supplies the

infundibulum and in some cases the tuber cinereum, optic tracts, or mammillary bodies.1 In a

small percentage (6.7%) of cases, the sSHA gives rise to the descending branches usually

attributable to the pSHA.1 When there is no pSHA, the infundibular and prechiasmal arteries can

act as irrigation sources for the infundibulum and optic nerve.1

There are four defined branching patterns of the pSHA: candelabra-like, tree-like, no-descending

type, and no-optic type.1 In the candelabra type the main arterial trunk splits and creates a

junction of two to three branch groups (optic, infundibular, descending). Doglietto et al.6

reviewed 19 adult specimens and SHAs were identified in 37/38 of their slides. They analyzed

various configurations of the pSHA; the candelabra branching pattern was the most common

variant (62.9% of their specimens). There were four branch groups in 22.9% of their specimens,

the fourth being dubbed “chiasmatic.”

In the tree-like (also called early-optic branching) type, the branches arise in succession from the

main arterial branch. Here, the optic branch tends to arise first followed by the infundibular

branch and then the descending branch. The descending branch can arise directly from the main

arterial branch but tends to come off the infundibular branch. In the no-descending type, the

main arterial trunk lacks a descending branch, so it remains closer to the optic nerve and chiasm.

Lastly, the no-optic type occurs when the main arterial trunk lacks an optic branch from the

pSHA.1

7
The descending branch of the SHA is also referred to as the loral or trabecular artery. The

trabecular artery passes through the pars distalis to supply the lower part of the infundibulum18,21

and the neurohypophysis.18 There is a disagreement between studies on this artery’s supply to the

anterior pituitary gland. Xuereb et al.18 reported that the trabecular artery does not give off

branches that supply the anterior lobe, whereas Stanfield9 documented that this artery does

contribute blood to the anterior lobe, but the amount was found to be insignificant. Adams et al.17

reported a more significant contribution from the trabecular artery by postulating that the

parenchymal cells of the anterior lobe that lay directly adjacent to this artery might survive

disruption to the pituitary stalk.

Trajectory and Anastomosis

The SHA goes on to project superiorly and posteromedially over the anterior clinoid process and

across the ventral surface of the suprasellar cistern towards the upper infundibulum. It provides

arterial branches to the optic nerve, optic chiasm, median eminence, infundibulum, and

adenohypophysis. The part of it that originates proximal to the carotid cave traverses the dural

floor of the carotid collar along the ICAs until it reaches the subarachnoid space of the

suprasellar cistern.10 The contralateral SHA anastomoses anteriorly to the infundibulum as

“preinfundibular anastomoses” before the descending branches join the infundibular and

prechiasmal arteries in the circuminfundibular anastomosis,1,4 which gives rise to both ascending

and descending arterial branches. The descending branches running alongside or arising from the

circuminfundibular anastomosis can then reach the diaphragma sella and consequently the

8
adenohypophysis,1 while the ascending branches go on to supply the optic chiasm, tuber

cinereum, and median eminence.15

Inferior Hypophyseal Artery (IHA)

Origin

The IHA originates from the cavernous segment of the ICA either directly at the posterior bend

or as a branch off the meningohypophyseal trunk (Figs. 1-3).3,7 After crossing medially within

the cavernous sinus, it goes on to supply the posterior lobe of the pituitary gland and its

capsule.3,8

Branching Patterns

Vutskits et al. (1996)7 reviewed the branching patterns of the IHA by analyzing 25 tissue samples

from the sellar and parasellar areas of human cadavers. In all their specimens, the IHA gave

branches to the posterior clinoid process and the lateral part of the dorsum sellae. After

traversing laterally around the pituitary gland, it gives off ascending and descending branches at

the interlobar groove.3

Anastomosis

The ascending and descending branches of the IHA anastomose with their counterparts on either

side of the pituitary in the interlobar tissue.3 Three main branching groups arise from this

anastomotic arterial circle anterior to the dorsum sellae: the direct groups that penetrate the

posterior pituitary gland, the capsular branches that supply the penetrating branches, and the

9
interlobar arteries that supply the area between the anterior and posterior pituitary lobes.9 The

descending branch of the SHA (i.e., the loral or trabecular artery) anastomoses with the

interlobar branches of the IHA forming a transverse anastomosis,1,3,9 which connects the arterial

circle of the IHA with the SHA.

Capsular Artery

The capsular arteries have two branches, inferior and anterior. The inferior capsular artery

originates from the inferomedial section of the cavernous ICA and travels towards the sella

turcica in the inferior compartment of the medial cavernous sinus wall.13,14 It goes on to

anastomose with the IHA and give branches to both the anterior pituitary and the floor of the

sella turcica.13,25 Owing to their anastomosis pattern, the capsular arteries are difficult to

distinguish from the IHA in many dissections. In contrast, the anterior capsular artery originates

from the anteromedial aspect of the cavernous ICA and goes on to supply the lateral aspect of the

diaphragma sella.13,14 Furthermore, Wojciech et al. (1987)25 injected 150 pituitary glands with

India ink to study the gland’s vascularization and found the IHA and ICA had several

anastomotic patterns with each other. Arising from these anastomoses are the penetrating

branches that supply parts of the anterior lobe, found in 78% of their specimens.25

One capsular artery on each side of the carotid siphon may give off a branch that travels through

the craniopharyngeal canal to enter the sphenoidal sinus. Though rarely visible, these branches

may supply lesions that arise within this sinus, such as nasopharyngeal angiofibromas.19 Also,

variations exist in which the capsular arteries are completely absent or originate from the inferior

hypophyseal artery.20

10
Infundibular Artery

The infundibular arteries (Fig. 4) most commonly originate from the posterior communicating

artery, a branch off the cerebral portion of the ICA, and go on to supply both the pituitary stalk

and the posterior pituitary lobe.4 Infundibular arteries are not always present or identifiable. Gibo

et al. (1981)15 examined 50 cerebral hemispheres from adult cadavers and found no infundibular

arteries in 76%, one in 14%, and two in 10%. Along their path to the pituitary, infundibular

arteries cross medially over the optic chiasm to join the SHA at the pituitary stalk, forming the

circuminfundibular anastomosis.15

Prechiasmal Artery

Originating from the superior section of the ophthalmic artery, the prechiasmal artery (Fig. 2)

goes on to supply anterior portions of the optic chiasm and the anterior pituitary stalk.4,15 Like

the infundibular arteries, the prechiasmal arteries are not found in every cadaver. Gibo et al.

(1981)15 found them, supplying the infundibulum, in only two of the 50 cadaver hemispheres

they examined.

Posteroinferior Hypophyseal Artery

The posteroinferior hypophyseal artery is a constant artery that originates from the C5 portion of

the carotid siphon. It immediately branches into the medial artery of the clivus, which supplies

the surrounding meninges. During angiography of the ascending pharyngeal artery, which

anastomosis with the medial artery of the clivus via the clival branch of its hypoglossal branch,

11
the pituitary gland can be seen. This confirms the presence of a common posteroinferior

hypophyseal/medial clival arterial trunk.19

Clinical/Surgical Relevance

The blood supply to the pituitary stalk and gland is of great importance as its infarction is

believed to cause post-operative diabetes insipidus and amenorrhea.1,4 There has been ample

research on the effect of the SHA blood supply and other branches of the ICA to the optic nerve,

chiasm, and tract, but here we summarize the effects of sacrificing the pituitary gland blood

supply.

Aneurysms stemming from the ICA, affecting the SHA, are clinically important because of their

direction and the large size to which they can grow, enabling them to compress the optic

pathway and pituitary gland. This can cause both visual field defects and impaired blood supply

to the hypophysis. Aneurysms in the clinoid and supraclinoid region (from where the ICA exits

the cavernous sinus to the origin of the posterior communicating artery) made up 14% of a

sample of 1695 intracranial aneurysms.11 Of those 238 patients, 19% had an aneurysm distal to

the ophthalmic artery, affecting the SHA and its branches to the pituitary and neighboring

structures.11

Godbole et al.12 suggested a classification of SHA aneurysms based on four factors: size,

anatomical relationship, origin, and morphology (saccular or fusiform). Seven types of SHA

aneurysm were distinguished: Antero-super-medial, antero-inferior-medial, superomedial,

12
inferomedial, posteromedial, fusiform, and giant. The inferomedial and posteromedial aneurysms

were characterized by distinct growth deep to the optic nerve and chiasm into the dorsum sellae,

compressing the pituitary stalk and gland (inferomedial) or just the pituitary stalk

(posteromedial). Through this classification system, the authors identified various surgical

challenges associated with each type on the basis of their relationship to significant anatomical

structures: ICA, optic nerve, anterior clinoid, dorsum sellae, pituitary stalk, pituitary gland, etc.

Tumors close to these prominent anatomical structures can cause serious clinical complications.

Truong et al.1 discussed a case where surgical removal of the descending branch of the pSHA

during tumor resection could play a role in their patient’s resulting diabetes insipidus,

amenorrhea, and adrenal insufficiency post-procedure. The adamantinomatous

craniopharyngioma to be resected was located in the suprasellar space, compressing the optic

pathway, with a tree-like pSHA running superiorly over it and a significantly calcified lesion

attaching it to the pituitary stalk. Upon dissection of one of the three main groups of the pSHA,

low pituitary function resulted in a deficiency of adrenocorticotropic hormone (ACTH), causing

adrenal gland defects. This case further demonstrates that displacement or rearrangement of the

SHA and its branches during surgery can entail a risk of lesions in the main arterial supply to the

pituitary gland, highlighting the clinical significance of identifying and understanding the

branching pattern of the SHA.

Post-surgical visual impairment can result from an SHA aneurysm after paraclinoid carotid

artery aneurysm surgery. Horiuchi et al.22 analyzed 70 patients with SHA aneurysms, of those,

13% experienced postoperative visual defects. Authors attributed the postoperative visual

13
disturbances in patients to surgical manipulation and clipping of bilateral paraclinoid carotid

artery aneurysms. Due to the vast anastomoses network of the SHA, its compromise during

surgical procedures is not a factor in postoperative visual impairment despite its role in supplying

the optic nerve and chiasm (Fig. 5).22 However, this arterial network is deficient during

simultaneous treatment of bilateral SHA aneurysms as all three patients with such were more

prone to ischemia of the optic nerve and chiasm resulting in all three experiencing postoperative

visual impairments.22

Handling of the surrounding structures of the IHA may have a larger post-surgical clinical

impact than removing the blood supply of the IHA to the pituitary gland. Truong et al.3 examined

20 patients retrospectively to determine the effect of the IHA on pituitary function post-

endonasal endoscopic transcavernous surgery for a chordoma, epidermoid cyst,

hemangiopericytoma, or meningioma. To resect those tumors, a bilateral posterior clinoidectomy

was performed with coagulation of the bilateral IHAs. The only patient to experience anterior

gland dysfunction post-surgery was the one who had presented with a hemangiopericytoma,

which was also the third largest tumor of the 20 patients. Four of the patients experienced

diabetes insipidus (DI) postoperatively; the DI resolved within eight days of the procedure in two

of these cases but remained permanent in the other two. Since only 10% were affected in this

way, Truong et al.3 believe the DI is related more to surgical manipulation of the posterior lobe

and stalk than to ischemia due to the IHA blood supply. These diminished symptoms post-IHA

sacrifice could also be due to the compensating SHA.24 Furthermore, these surgical manipulation

and transposition techniques of the pituitary can be more or less safe. A purely extradural

approach to the pituitary can cause more risk of dysfunction and not assist with direct

14
visualization of the posterior clinoid.24 In contrast, the intradural approach of endoscopic

endonasal transcavernous posterior clinoidectomy has been shown to lessen the risk of potential

pituitary impairment and increase visualization of the cavernous sinus.24

In contrast, in patients already diagnosed with DI, the disease can be attributed to lack of supply

from the IHA to the posterior pituitary. Mohamad et al.16 showed that extensive vascular injury

to the IHA can be associated with idiopathic central diabetes insipidus (CDI). They studied 19

patients with permanent CDI using MRI imaging and found that all of them had a normal

pituitary stalk and anterior pituitary, but the posterior pituitary gland lacked hyperintensity. This

abnormal finding suggested that lack of blood supply to the posterior pituitary via the IHA had

caused the CDI symptoms. This study helped to validate the importance of the IHA supply to the

posterior pituitary gland; ischemia there can lead to diabetic insipidus.

Amenorrhea, DI, and renal insufficiency have been more commonly noted as correlating with

post-operative pituitary gland or stalk infarction. However, pituitary apoplexy can be further

described to elaborate on the importance of the blood supply to the pituitary gland. Apoplexy is

typically as a result of hemorrhage or necrosis usually due to a benign tumor.22 Bills et al.22

studied 37 patients with pituitary apoplexy over a 16-year period and noted prominent, abrupt

onset of symptoms: headache, vomiting, ocular paresis, and other visual field/acuity defects. The

authors attributed the apoplexy to various events: increased intracranial pressure or changes in

blood supply, abrupt cessation of steroid use, pregnancy, and head trauma.22

The inferior capsular artery should be specifically identified and considered during pituitary

gland surgeries. If the lateral and inferior sections of the sella turcica are approached, this artery

15
is likely to be injured with more serious arterial bleeding, e.g., the IHA.14 Despite its minor

contribution to the supply to the anterior pituitary gland, its sacrifice can still lead to pituitary

gland dysfunction.14

The blood supply of the pituitary can impact the behavior of associated pituitary adenomas.

After analyzing the tumor shrinkage patterns of 31 patients on MRI, Ito et al.23 found a strong

correlation with regression of pituitary tumors with poor blood supply versus the lack of

shrinkage of tumors with rich blood supply. Since such shrinkage is associated with insufficient

blood supply, the neurosurgeon must understand the vasculature around the operative tumor,

especially the superior hypophyseal artery.23 Additionally, Zhang et al.27 correlated cystic

change, of the 79 patients with pituitary adenomas studied, with insufficient blood supply and

uneven distribution of existing blood supply to the tumor thus potentially causing tumor

infarction. Thus, vascularization in and around pituitary adenomas must be well understood.

Furthermore, it is imperative to discuss and understand common branching and anastomotic

patterns in order for the neurosurgeon to be well equipped when faced with a rare anatomical

variant.

Conclusion

Clinicians should have a good working knowledge of the blood supply to the pituitary gland.

Surgeons working in the region of the pituitary gland should have a detailed understanding of

this vasculature.

16
17
References
1
Truong HQ, Najera E, Zanabria-Ortiz R, et al. Surgical anatomy of the superior hypophyseal

artery and its relevance for endoscopic endonasal surgery. J Neurosurg. 2018;13:154-162

2
Krisht AF, Barrow DL, Barnett DW, Bonner GD, Shengalaia G. The Microsurgical Anatomy of

the Superior Hypophyseal Artery. Neurosurgery. 1994;35(5):899-903

3
Truong HQ, Borghei-Razavi H, Najera E, et al. Bilateral coagulation of inferior hypophyseal

artery and pituitary transposition during endoscopic endonasal interdural poseterior

cliniodectomy: do they affect pituitary function. J Neurosurg. 2018; 131: 141-146

4
Gibo H, Kobayashi S, Kyoshima K, Hokama M. Microsurgical anatmoy of the arteries of the

pituitary stalk and gland as viewed from above. Acta Neurochir (Wien). 1988;90(1):60-66

5
Joo W, Funaki T, Yoshioka F, Rhoton AL. Microsurgical anatomy of the carotid cave. Oper

Neurosurg. 2012;70(2 Suppl Operative):ons300-ons312

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Doglietto F, Prevedello D, Belotti F, et al. The Superior Hypophyseal Arteries: Anatomical

Study with an Endoscopic Endonasal Perspective. Operative Neurosurgery. 2019;17: 321-331

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Vutskits L, Reisch R, Patonay L, et al. The ‘Rete Mirabile’ of the Clivus and the Dorsum Sellae.

A Microanatomical Study. Minimally Invasive Neurosurgery. 1996; 39(4):138-40

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8
Reisch R, Vutskits L, Patonay L, et al. The Meningohypophyseal Trunk and its Blood Supply to

Different Intracranial Structures. An Anatomical Study. Minimally Invasive Neurosurgery. 1996;

39:78-81

9
Stanfield JP. The Blood Supply of the Human Pituitary Gland. J Anat. 1960; 94: 257-273

10
Hitotsumatsu T, Natori Y, Matsushima T, et al. Micro-Anatomical Study of the Carotid Cave.

Acta Neurochir (Wien). 1997;139:869-874

11
Hoh BL, Carter BS, Budzik RF, Putman CM, Ogilvy CS. Results after surgical and

endovascular treatment of paraclinoid aneurysms by a combined neurovascular team.

Neurosurgery. 2001;48:78-90

12
Godbole C, Behari S, Bhaisora KK, et al. Surgery for superior hypophyseal artery aneurysms:

A new classification and surgical considerations. Neurol India. 2017;65:588-599

13
Wallace S, Goldberg H, Leeds N, et al. The Cavernous Branches of the Internal Carotid Artery.

Am J Roentgenology. 1967;101:34-36

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Nunes C, Beer-Furlan A, Doglietto F, et al. The McConnells Capsular Arteries and Their

Relevance in Endoscopic Endonasal Approach to the Sellar Region. Oper Neurosurgery. 2017;

14: 171–177

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15
Gibo H, et al. Microsurgical Anatomy of the Supraclinoid Portion of the Internal Carotid

Artery. J Neurosurg. 1981; 55: 560–574

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Mohamad M, et al. Idiopathic Central Diabetes Insipidus is Associated with Abnormal Blood

Supply to the Posterior Pituitary Gland caused by Vascular Impairment of the Inferior

Hypophyseal Artery System. J Clin Endocrinol & Metab. 2004; 89: 1891–1896

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Daniel PM. The blood supply of the hypothalamus and pituitary gland. British Medical

Bulletin. 1966; 22:202-208

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The Lancet. Blood-supply of the Pituitary Gland. 1954;264(6838):584

19
Lasjaunias PL. Craniofacial and Upper Cervical Arteries: Functional, Clinical and

Angiographic Aspects. William & Wilkins, 1981. Print.

20
Bron, AJ, Tripathi, RC, Tripathi, BJ. Wolff’s Anatomy of the Eye and Orbit: Eighth Edition.

Chapman & Hall, 1997. Print.

21
Standring, S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. Forty-first ed.

Elsevier Limited, 2016. Print.

22
Bills D, Meyer F, Laws E, et al. A Retrospective Analysis of Pituitary Apoplexy Clinical

Study. Neurosurgery. 1993; 33(4), 602–609.

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22
Horiuchi, T., Goto, T., Tanaka, Y., Kodama, K., Tsutsumi, K., Ito, K., & Hongo, K. (2015).

Role of superior hypophyseal artery in visual function impairment after paraclinoid carotid artery

aneurysm surgery. Journal of Neurosurgery, 123(2), 460–466.

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Ito, M., Kuge, A., Matsuda, K. ichiro, Sato, S., Kayama, T., & Sonoda, Y. (2017). The

Likelihood of Remnant Nonfunctioning Pituitary Adenomas Shrinking Is Associated with the

Lesion’s Blood Supply Pattern. World Neurosurgery, 107, 137–141.

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Fernandez-Miranda, J. C., Gardner, P. A., Rastelli, M. M., Peris-Celda, M., Koutourousiou, M.,

Peace, D., Snyderman, C. H., & Rhoton, A. L. (2014). Endoscopic endonasal transcavernous

posterior clinoidectomy with interdural pituitary transposition: Technical note. Journal of

Neurosurgery, 121(1), 91–99. https://doi.org/10.3171/2014.3.JNS131865

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Wojciech Forczyca, J. H. (1987). Arterial Supply of the Human Anterior Pituitary Gland.

Congress of Neurological Surgeons, 20, 369–378. http://repositorio.unan.edu.ni/2986/1/5624.pdf

Figure Legends:

Figure 1. Schematic drawing of the hypothalamus, pituitary stalk, pituitary gland and sella

turcica in sagittal section. The superior and inferior hypophyseal arteries are highlighted in this

image. Also note the portal venous system of the pituitary gland in blue.

Figure 2. Superior view of the skull base emphasizing the internal carotid artery branches to

structures around the sella turcica. Note the meningohypophyseal trunk (white arrow) arising

21
from the cavernous part of the internal carotid artery. One of this trunk’s branches, the inferior

hypophyseal artery, is shown at the black arrow. The superior hypophyseal arteries are shown

arising at their most common (left) and less common (right) origins. The variant prechiasmal

artery is seen at the yellow arrow arising from the ophthalmic artery

Figure 3. Anteroinferior view of the pituitary gland. Note the anterior and posterior lobes of the

pituitary gland (APG, PPG), C4 and C3 segments of the internal carotid artery with superior

hypophyseal artery (upper arrow) and inferior hypophyseal arteries (lower arrows). Also shown

are the optic nerves (ON) and ophthalmic arteries (OA). Figure courtesy of Dr. Albert Rhoton.

Figure 4. Schematic drawing of the circle of Willis and infundibular branches of the posterior

communicating arteries (*)

Figure 5. Endoscopic view of the anterior pituitary gland, optic nerves/chiasm and frontal lobe

and proximal anterior circulation. The superior hypophyseal arteries (arrows) are seen arising

from the ophthalmic segment of the internal carotid artery. Note the ophthalmic arteries (OA),

pituitary stalk (PS), optic chiasm (OC), left optic nerve (LON), right optic nerve (RON), anterior

communicating artery (ACOM), and left A2 segment (LA2) of the anterior cerebral artery.

Figure courtesy of Dr. Albert Rhoton.

22
Abbreviation

ACTH, adrenocorticotropic hormone; CDI, central diabetes insipidus; ICA, internal carotid

artery; DI, diabetes insipidus; IHA, inferior hypophyseal artery; SHA, superior hypophyseal

artery;
Declaration of interests

☒ The authors declare that they have no known competing financial interests or personal relationships
that could have appeared to influence the work reported in this paper.

☐The authors declare the following financial interests/personal relationships which may be considered
as potential competing interests: