The Posterior Cranial Fossa

Neurosurgery, Vol. 47, No.
3, September 2000 Supplement S1

Superficial dissection showing the anterior musculature. Bartolommeo Eustachio (1520–1574) is considered to have been the most
scientific anatomist of the High Renaissance. His use of copper engraving enabled him to obtain a more delicate delineation of
detail. From, Bartolommeo Eustachio, Tabulae anatomicae. Rome, Sumptibus Laurentii & Thomae Pagliarini, 1728. Courtesy, Rare
Book Room, Norris Medical Library, Keck School of Medicine, Los Angeles, Califorina. (Also see pages S28, S130, S154, S194, and S298.)
Prefaces
It is a great honor for me to be chosen as one the people geon. I need not say more about Albert L. Rhoton as a man
privileged to write a preface to the special supplement edition and as a neurosurgeon. This supplement to Neurosurgery will
of Neurosurgery dedicated to the work of Dr. Albert L. Rhoton, not join the other issues but will have a dedicated place in my
Jr. As one of his first fellows in the laboratory at the University library.
of Florida, I have personally witnessed Dr. Rhoton’s tireless
Bernard George
commitment to achieving professional excellence. The old
Paris, France
laboratory, today replaced by a fancy state-of-the-art facility,
was the stage for the performance of many artists, sculptors of
the naturally beautiful gem that is the human brain. Dr. Neurosurgeons all over the world await the compilation of
Rhoton’s daily display of dedication, hard work, and persis- the astounding anatomic encyclopedic work of Dr. Albert L.
tence has made him a role model for the fellows. His inquis- Rhoton, Jr., in volume form. The present study on the poste-
itive mind and diligent guidance has set the standards for the rior fossa will be a ready reference in the library and surgical
microsurgical laboratory to a level unparalleled in the world. theater. Dr. Rhoton’s anatomic work is based on extensive,
This long-awaited supplement, although but a part of an meticulous, and precise dissections of cadavers. His tech-
endless collection of masterpieces of anatomic dissections, niques of preservation of the cadaver head, injection of the
pays a long-due homage to the person responsible for show- arteries and veins, and depiction of the anatomic details will
ing the young and even the older generation of neurosur- remain a landmark feature for a long time. His anatomic work
geons that the answer to the majority of our surgical problems has been oriented toward the surgical approach and has
lies in knowledge of the basics of anatomy. helped all of us in the formulation and planning of surgery.
His concepts, ideas, and revelations will be a treasure for us
Evandro de Oliveira all forever. On the personal side, he has guided me on innu-
São Paulo, Brazil merable occasions, nurtured me, and seen me evolve. On
behalf of all his students, including many Japanese colleagues
who have had a chance to work in his laboratory, I whole-
It is a wonderful idea to publish in a supplement to Neu- heartedly welcome the publication of this magnificent special
rosurgery the best of Dr. Albert L. Rhoton’s work on the issue.
anatomy and surgery of the posterior cranial fossa. Moreover,
this publication will be followed in 2002 by another supple- Shigeaki Kobayashi
ment, which will focus on the cerebrum and supratentorial Matsumoto, Japan
areas.
With the development of surgical assistance by endoscopy,
computed imaging, robotics, and other techniques, many sur- Dr. Albert L. Rhoton’s scientific work as a neurosurgeon—
geons, especially the youngest, may wonder about the rele- his life’s work—demonstrates his dedication to topographic
vance and usefulness of a perfect knowledge of anatomy. anatomy in neurosurgery. The exposure of anatomic details in
Whatever instruments we use, however, the brain on which the posterior fossa is unique in the history of neurosurgery.
we work will remain the same, and knowledge of its anatomy Dr. Rhoton is one of the most prestigious personalities within
will always have great importance. modern neurosurgery, because of his neurosurgical skill and
Someday, we may be able to integrate anatomic pictures his wonderful human qualities.
into our surgical devices, in the same way that computed For 30 years, I have had the privilege of knowing this
images are incorporated today. Moreover, these anatomic wonderful person and admiring his inexhaustible talent,
pictures could be modified according to the pathological fea- which enabled him to contribute to modern neurosurgery in a
tures, based on the imaging scans. Thus, the surgeon might very meaningful way. He has mainly devoted himself to the
compare his or her real surgical field with the virtual anatomy field of topographic anatomy. His attention is principally
of the same case. Whatever the future, comprehensive knowl- focused on the surgical approaches to the different regions,
edge and understanding of what we are working on will be particularly the posterior fossa. His intention is always to
always essential. Dr. Rhoton’s work is a masterpiece that will search for easier and more accurate surgical techniques, not
help to acquire and maintain this knowledge. just for selected experts but for all neurosurgeons. He has
Every neurosurgeon in the world knows and appreciates developed advanced technical standards for exposure of the
Dr. Rhoton as a master of surgical anatomy. Many, including cerebral vessels in beautiful color illustrations in cadavers.
myself, have collected his wonderfully illustrated articles. This contribution to the world of neurosurgery is unique and
Some societies, such as the Neurosurgical Society of Australa- exceptional. Almost all neurosurgeons have benefited from
sia, use Dr. Rhoton’s pictures on their examinations. Person- his effort to achieve a better understanding of neuroanatomy.
ally, I think that the incredible quality of these pictures reflects His artistic talent has made him an invaluable teacher and a
the quality of the man himself. During congress presentations, great master of neurosurgery.
I often observe that, behind every nice and demonstrative This special supplement issue, The Posterior Cranial Fossa:
operative slide, there is a good, honest, and experienced sur- Microsurgical Anatomy and Surgical Approaches, in 10 chapters
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement S3

S4 Rhoton
with more than 500 color illustrations, will be the highlight of knowledge for neurosurgeons than Dr. Albert L. Rhoton, Jr.
every neurosurgeon’s study! Dr. Rhoton has given a great gift The microsurgical anatomic preparations from his laboratory
to all of us. have provided a whole generation of neurosurgeons with the
Madjid Samii anatomic armamentarium to reach every aspect of the central
Hannover, Germany nervous system safely. This special supplement, The Posterior
Cranial Fossa: Microsurgical Anatomy and Surgical Approaches,
Anatomy to the surgeon is like the sun for our planet. will provide life-sustaining sunlight to countless neurosur-
Anatomy gives us the life-sustaining knowledge to traverse geons and will thereby directly benefit their respective
the intricate pathways throughout the brain. As our anatomic patients.
knowledge has grown, our entire specialty has evolved. No Robert F. Spetzler
single neuroanatomist can lay greater claim to expanding this Phoenix, Arizona
Surgical instruments as shown in

Joannis Sculteti’s Armamentarium
Chirurgicum. . . . This limited
edition of 2500 copies was bound
in half leather and Hahnemühle
paper. From, Joannis Sculteti,
Armamentarium Chirurgicum XLII
Tabulis Aeri Elegantissime
Incisis. . . . Ulm, B. Kühnen, 1655.
Courtesy, Rare Book Room,
Norris Medical Library, Keck
School of Medicine, Los Angeles,
California.
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

FOREWORD
The Posterior Cranial Fossa: Microsurgical Anatomy

and Surgical Approaches
T
his work has grown out of my personal desire to im- TABLE 1. Residents and Fellows Who Have Worked in Dr.
prove the care of my patients. It represents a lifelong Rhoton’s Microsurgery Laboratory
attempt to gain an understanding of the anatomy and
Name Location
intricacies of the brain that would improve the safety, gentle-
ness, and accuracy of surgery for my patients. During college, Hajime Arai Tokyo, Japan
I planned to pursue a career in social work but, during a Allen S. Boyd, Jr. Memphis, Tennessee
course on psychology and the brain, I became captivated by Robert Buza Salem, Oregon
the possibility of serving humanity through a career in neu- Christopher C. Carver Salinas, California
Evandro de Oliveira São Paulo, Brazil
rosurgery. During medical school, I began working in a neu- W. Frank Emmons Olympia, Washington
roscience laboratory in my spare time and, at the end of my J. Paul Ferguson Rome, Georgia
residency, I completed a fellowship in neuroanatomy. It was Andrew D. Fine Gainesville, Florida
during this fellowship that I realized the potential for greater Brandon Fradd Gainesville, Florida
knowledge about microneurosurgical anatomy to improve Kiyotaka Fujii Fukuoka, Japan
the care of my patients. This volume, a distillation of our Hirohiko Gibo Nagano, Japan
John L. Grant Portsmouth, Virginia
studies of the posterior fossa, represents nearly 40 years of
Kristinn Gudmundsson Reykjavik, Iceland
work and study in which more than 50 residents and fellows David G. Hardy Cambridge, England
have participated, resulting in several hundred publications. Frank S. Harris Temple, Texas
It has been gratifying to view the role of our fellows and Tsutomo Hitotsumatsu Fukuoka, Japan
trainees in spreading this knowledge to other countries and Takuya Inoue Fukuoka, Japan
around the world and to see the benefits of neurosurgeons Tooru Inoue Fukuoka, Japan
applying this knowledge to improve surgery for their patients Chang Jin Kim Seoul, South Korea
Toshiro Katsuta Fukuoka, Japan
(Table 1). Especially gratifying has been the association with Drs.
Shigeaki Kobayashi Matsumoto, Japan
Katsutoshi Kitamura, Masashi Fukui, and Toshio Matsushima in William Lineaweaver Stanford, California
Fukuoka, Japan, and Drs. Evandro de Oliveira, Helder Tedeschi, J. Richard Lister Peoria, Illinois
and Hung Wen in São Paulo, Brazil. It is to the fellows and Qing Liang Liu Beijing, China
associates in the microsurgery laboratory that this volume is Jack E. Maniscalco Tampa, Florida
dedicated. Special thanks go to our medical illustrators, David Richard G. Martin Huntsville, Alabama
Haruo Matsuno Fukuoka, Japan
Peace and Robin Barry, who have worked with us for 2
Toshio Matsushima Fukuoka, Japan
decades; to Ron Smith, who has directed the microsurgery J. Robert Mozingo (Deceased)
laboratory for many years; and to Laura Dickinson and Fran Hiroshi Muratani Fukuoka, Japan
Johnson, who have labored over these and earlier manuscripts. Antonio C. M. Mussi São Paulo, Brazil
In the beginning, nearly 40 years ago, even with microsur- Shinji Nagata Fukuoka, Japan
gical techniques, our dissections were crude by current stan- Yoshihiro Natori Fukuoka, Japan
dards, with photographs needing to be retouched to bring out Kazunari Oka Fukuoka, Japan
Michio Ono Tokyo, Japan
the facets of anatomy important in achieving a satisfactory
T. Glenn Pait Little Rock, Arkansas
outcome at surgery. Over the years, as we have learned to Wayne S. Paullus Amarillo, Texas
expose fine neural structures, the display of microsurgical David Perlmutter Sarasota, Florida
anatomy has become more vividly accurate and beautiful Wade H. Renn Valdosta, Georgia
than we had imagined at the onset, and it has enhanced the Saran S. Rosner Hawthorne, New York
accuracy and beauty of our surgery. We hope that it will do Naokatsu Saeki Chiba, Japan
the same for our readers. We plan to produce a second issue Shuji Sakata Fukuoka, Japan
Eduardo Seoane Buenos Aires, Argentina
on the cerebrum and supratentorial areas in 2002 for the 25th Xiang-en Shi Beijing, China
anniversary of Neurosurgery, which I had some role in birth- Ryusui Tanaka Tokyo, Japan
ing, as President of the Congress of Neurological Surgeons 22 Helder Tedeschi São Paulo, Brazil
years ago. Erdener Timurkaynak Ankara, Turkey
In the early development of neurosurgery, approaches to Hung T. Wen São Paulo, Brazil
the posterior fossa were directed largely via the occipital C. J. Whang Seoul, South Korea
Isao Yamamoto Yokohama, Japan
squama and less frequently via the subtemporal transtentorial
Arnold A. Zeal Jacksonville, Florida
route. With the development of microsurgery and cranial base

S6 Rhoton
surgery, it became possible to work in long, narrow expo- neurosurgery at the University of Florida. These gifts have
sures, thus setting the stage for opening virtually all of the endowed the following chairs and professorships: the R.D.
cranial base through carefully placed windows exposing Keene Family Chair, the C.M. and K.E. Overstreet Chair, the
small and selective parts of the posterior fossa. These devel- Mark Overstreet Chair, the Albert E. and Birdie W. Einstein
opments led to approaches to the posterior fossa via the Chair, the James and Newton Eblen Chair, the Dunspaugh-
temporal bone as well as set the stage for approaches directed Dalton Chair, the Edward Shed Wells Chair, the Robert Z. and
via the anterior and middle cranial base. In this volume, we Nancy J. Greene Chair, the L.D. Hupp Chair, the William
have attempted not only to display the brain and cranial base Merz Professorship, and the Albert L. Rhoton, Jr. Chairman’s
in the best views for understanding the anatomy, but also to Professorship. The most recent of these is the $4 million gift
show the anatomy as exposed in opening multiple surgical establishing the Albert L. Rhoton, Jr. Neurosurgery Professor-
routes to the posterior fossa. For those wanting even greater ship, held by William A. Friedman, who has followed me as
detail than displayed in this volume, our prior works, pub- Chairman of Neurosurgery. The efforts of the numerous cli-
lished largely in Neurosurgery and the Journal of Neurosurgery, nicians and scientists recruited, as a result of the Endowed
can be consulted. Chairs, contributed greatly to the founding of the University
This work has been sustained by numerous private contri- of Florida Brain Institute, where our studies of microsurgical
butions to our department and the University of Florida. Most anatomy are being completed. With this volume, we join our
prominent among these has been the R.D. Keene family, who
donors in their aspiration to improve the lives of those un-
made the first $1 million gift to the University of Florida, a gift
dergoing brain surgery throughout the world.
that has supported our work for many years. Their gift was
followed by additional endowments, totaling $16 million, Albert L. Rhoton, Jr.
which support many aspects of education and research in Gainesville, Florida
Cranial cavity drawing by Leonardo da Vinci captures the growing sense of a science of proporations for Renaissance
artists. In addition to serving as anatomical specimens, his drawings remain consummate examples of draftsmanship.
Courtesy, Dr. Edwin Todd, Pasadena, California. (Also see pages S193 and S286.)

CHAPTER 1
Cerebellum and Fourth Ventricle
Albert L. Rhoton, Jr., M.D.

Department of Neurological Surgery, University of Florida, Gainesville, Florida
Key words: Cerebellar artery, Cranial nerve, Fourth ventricle, Intracranial vein, Microsurgical anatomy
T
he posterior cranial fossa, the largest and deepest of the This section on the cerebellum and fourth ventricle will begin
three cranial fossae, contains the most complex intracra- at the cerebellar surfaces and progress to the deeper neural
nial anatomy. Here, in approximately one-eighth the structures.
intracranial space, are found the pathways regulating con-
sciousness, vital autonomic functions, and motor activities
and sensory reception for the head, body, and extremities, in CEREBELLAR SURFACES
addition to the centers for controlling balance and gait. Only
2 of the 12 pairs of cranial nerves are located entirely outside The cortical surfaces are divided on the basis of the struc-
the posterior fossa; the 10 other pairs have a segment within tures they face, or along which they may be exposed, to make
the posterior fossa (22, 25) (Fig. 1.1). The posterior fossa is this description more readily applicable to the operative set-
strategically situated at the outlet of the cerebrospinal fluid ting (Fig. 1.2). The first surface, the tentorial surface, faces the
flow from the ventricular system. The arterial relationships tentorium and is retracted in a supracerebellar approach; the
are especially complex, with the vertebral and basilar arteries second surface, the suboccipital surface, is located below and
having relatively inaccessible segments deep in front of the between the lateral and sigmoid sinuses and is exposed in a
brainstem and the major cerebellar arteries coursing in rela- suboccipital craniectomy; and the third surface, the petrosal
tion to multiple sets of cranial nerves before reaching the surface, faces forward toward the posterior surface of the
cerebellum (9, 10, 18, 19). petrous bone and is retracted to expose the cerebellopontine
The posterior fossa extends from the tentorial incisura, angle. Each of the surfaces has the vermis in the midline and
through which it communicates with the supratentorial space, the hemispheres laterally and is divided by a major fissure
to the foramen magnum, through which it communicates named on the basis of the surface that it divides. The hemi-
with the spinal canal. It is surrounded by the occipital, tem- spheric lobules forming each of the three surfaces commonly
poral, parietal, and sphenoid bones (Fig. 1.1). It is bounded in overlap onto and form a part of the adjacent surfaces (22). The
front by the dorsum sellae, the posterior part of the sphenoid fissures dividing the three cortical surfaces are to be distin-
body, and the clival part of the occipital bone; behind by the guished from the fissures between the cerebellum and the
lower portion of the squamosal part of the occipital bone; and brainstem.
on each side by the petrous and mastoid parts of the temporal
bone, the lateral part of the occipital bone, and above and
behind by a small part of the mastoid angle of the parietal Tentorial surface
bone. Its intracranial surface is penetrated by the jugular The tentorial surface faces and conforms to the lower sur-
foramen, internal acoustic meatus, hypoglossal canal, the ves- face of the tentorium (Figs. 1.2–1.4). The anteromedial part of
tibular and cochlear aqueducts, and several venous emissary this surface, the apex, formed by the anterior vermis, is the
foramina, all of which will be explored in greater detail. The highest point on the cerebellum. This surface slopes down-
upper surface of the cerebellum is separated from the supra- ward from its anteromedial to its posterolateral edge. On the
tentorial space by the tentorium cerebelli. Optimizing an op- tentorial surface, the transition from the vermis to the hemi-
erative approach to the posterior fossa requires an under- spheres is smooth and not marked by the deep fissures on the
standing of the relationships of the cerebellum, cranial nerves, suboccipital surface between the vermis and hemispheres.
brainstem, the cerebellar arteries, veins, and peduncles, and Deep notches, the anterior and posterior cerebellar incisurae,
the complex fissures between the cerebellum and brainstem. groove the anterior and posterior edges of the tentorial sur-
The relationships of the fourth ventricle to the cerebellar face in the midline. The brainstem fits into the anterior cere-
surfaces and the fissures through which the ventricle is ap- bellar incisura and the falx cerebelli fits into the posterior
proached surgically are among the most complex in the brain. incisura (Fig. 1.2).

S8 Rhoton
directed anteriorly above the origin of the posterior root of the

trigeminal nerve. The posterior border between the tentorial
and the suboccipital surfaces also has a lateral and a medial
part. The lateral part (the posterolateral margin) is parallel
and adjacent to the lateral sinus and separates the hemi-
spheric part of the suboccipital and tentorial surfaces, and the
short medial part (the posteromedial margin) faces the poste-
rior cerebellar incisura and separates the vermic part of the
two surfaces. The lateral angle, formed by the junction of
the anterolateral and posterolateral margins, is located at the
junction of sigmoid, lateral, and superior petrosal sinuses.
Veins often converge on the anterior and lateral angles.
The hemispheric part of the tentorial surface includes the
quadrangular, simple, and superior semilunar lobules, and
the vermian part includes the culmen, declive, and folium.
The vermian and the related hemispheric parts from above to
below in sequence are the culmen and the quadrangular
lobule, the declive and the simple lobule, and the folium and
the superior semilunar lobule. The tentorial surface is divided
at the site of its major fissure, the tentorial fissure, into ante-
rior and posterior parts. This fissure, located between the
quadrangular and the simple lobules on the hemisphere and
the culmen and the declive on the vermis, has also been called
the primary fissure. The postclival fissure separates the sim-
ple and the superior semilunar lobules. The interfolial fissures
on this surface pass anterolaterally from the midline and are
continuous with the fissures on the superior half of the petro-
sal surface.
FIGURE 1.1. A, superior view of the posterior cranial fossa. Suboccipital surface
The osseus walls of the posterior fossa are formed by the The suboccipital surface, located below and between the
occipital, temporal, and sphenoid bones. The fossa is lateral and sigmoid sinuses, is the most complex of the three
bounded in front by the dorsum sellae and posterior part of surfaces (Figs. 1.2 and 1.5). Operative approaches to the fourth
the sphenoid bone and the clival part of the occipital bone; ventricle and most cerebellar tumors are commonly directed
behind by the lower portion of the squamosal part of the around or through this surface. It has a deep vertical depres-
occipital bone; and on each side by the petrous and mastoid sion, the posterior cerebellar incisura, which contains a fold of
parts of the temporal bone, and the lateral part of the occipi- dura, the falx cerebelli. The vermis is folded into and forms
tal bone. One small part above the temporal bone is formed the cortical surface within this incisura. The lateral walls of
by the inferior angle of the parietal bone. B, nerves and the incisura are formed by the medial aspects of the cerebellar
arteries of the posterior fossa. Only 2 of the 12 pairs of cra- hemispheres. Deep clefts, the vermohemispheric fissures, sep-
nial nerves course entirely outside the posterior fossa. The arate the vermis from the hemispheres. The vermian surface
tentorium, which is attached along the petrous ridges, roofs within the incisura has a diamond shape. The upper half of
the posterior fossa. A., artery; Ac., acoustic; A.I.C.A., antero- the diamond-shaped formation has a pyramidal shape and is
inferior cerebellar artery; Bas., basilar; CN, cranial nerve; called the pyramid. The folium and the tuber, superior to the
For., foramen; Int., internal; Jug., jugular; Occip., occipital; pyramid, form the apex of the suboccipital part of the vermis.
P.C.A., posterior cerebral artery; P.I.C.A., posteroinferior cer- The lower half of the diamond-shaped formation, the uvula,
ebellar artery; S.C.A., superior cerebellar artery; Temp., tem- projects downward between the tonsils, thus mimicking the
poral; Tent., tentorial; Vert., vertebral. situation in the oropharynx. The rostromedial margin of the
tonsils borders the tapering edges of the uvula. The nodule,
The anterior border, separating the tentorial and petrosal the lowermost subdivision of the vermis, is hidden deep to the
surfaces, has a lateral part (the anterolateral margin) that is uvula. The strip of vermis within the incisura is broadest at
parallel to the superior petrosal sinus and separates the hemi- the junction of the pyramid and uvula. Inferiorly, the poste-
spheric part of the tentorial and petrosal surfaces, and a rior cerebellar incisura is continuous with the vallecula cer-
medial part (the anteromedial margin) that faces the midbrain ebelli, a cleft between the tonsils that leads through the fora-
and forms the posterior border of the fissure between the men of Magendie into the fourth ventricle.
midbrain and cerebellum. The anterior angle formed by the The hemispheric portion of the suboccipital surface is
junction of the anterolateral and anteromedial margins is formed by the superior and inferior semilunar and biventral

Cerebellum and Fourth Ventricle S9
FIGURE 1.2. Tentorial, suboccipital, and petrosal cerebellar

surfaces. A, the tentorial surface faces the lower surface of
the tentorium. The anterior vermis is the most superior part
of the tentorial surface. This surface slopes downward to its
posterior and lateral margins. The vermian subdivisions of
this surface are superior to their corresponding hemispheric
parts. The classical nomenclature applied to the vermian
and hemispheric subdivisions of the tentorial surface is
listed on the right, and our simplified nomenclature is listed
on the left. The culmen and quadrangular lobules
correspond to the anterior part of the tentorial surface, and
the declive, simple lobules, and part of the superior
semilunar lobules correspond to the posterior part of the
tentorial surface. The fissure separating the tentorial surface
into anterior and posterior parts is referred to as the
tentorial fissure in our nomenclature, but is the primary
fissure in older nomenclature. This fissure separates the
hemispheric surface between the quadrangular and simple
lobules and the vermis between the declive and culmen. The
anterior part of the superior surface of the cerebellum
surrounds the posterior half of the midbrain to form the
cerebellomesencephalic fissure. B, suboccipital surface. The
suboccipital surface is located below and between the
sigmoid and lateral sinuses and is the surface that is exposed
in a wide bilateral suboccipital craniectomy. The classical
nomenclature applied to this surface is shown on the right,
and our simplified nomenclature is on the left. The vermis
sits in a large median depression, the posterior cerebellar
incisura, between the cerebellar hemispheres. According to
classical nomenclature, the portions of the vermis within the
incisura from above to below are the folium, tuber, pyramid,
and uvula. The parts of the hemispheric surface from above
to below are the superior and inferior semilunar and
biventral lobules and the tonsils. These lobules extend
beyond the suboccipital surface to the other surfaces of the
cerebellum. The prebiventral fissures between the inferior
semilunar and the biventral lobules separate the hemispheres
into superior and inferior parts, and the prepyramidal fissure
between the pyramid and tuber separates the vermis into
superior and inferior parts. We refer to the union of the
prebiventral and the prepyramidal fissures that divide the
suboccipital surface into superior and inferior parts as
the suboccipital fissure. From below to above the
corresponding vermian and hemispheric parts are the uvula
and the tonsils, the pyramid and the biventral lobules, the
tuber and inferior semilunar lobules, and the folium and the superior semilunar lobules. The petrosal (horizontal) fissure, the
most prominent fissure on the petrosal surface, extends onto the suboccipital surface and divides the superior half of the
suboccipital surface between the superior and inferior semilunar lobules. The cerebellomedullary fissure extends superiorly
between the cerebellum and medulla. C, petrosal surface. The petrosal surface faces forward toward the petrous temporal
bone and is the surface that is retracted to surgically expose the cerebellopontine angle. The classical nomenclature applied
to this surface is shown on the right, and our simplified nomenclature is on the left. The petrosal fissure divides the petrosal
surface into superior and inferior parts. The superior part is formed by the quadrangular, simple, and a small part of the
superior semilunar lobules. The inferior part is formed by the inferior semilunar and biventral lobules and the tonsil. The
cerebellopontine fissures are V-shaped fissures formed where the cerebellum wraps around the pons and the middle cerebellar
peduncles. These fissures have a superior and an inferior limb, which meet at a lateral apex. The petrosal fissure extends laterally
from the apex of the cerebellopontine fissures. Ant., anterior; Cer.Med., cerebellomedullary; Cer.Pon., cerebellopontine; CN,
cranial nerve; Fiss., fissure; Horiz., horizontal; Inf., inferior; Pet., petrosal; Post., posterior; Quad., quadrangular; Suboccip.,
suboccipital; Sup., superior; Tent., tentorial.

S10 Rhoton
FIGURE 1.3. Tentorial surface and cerebellomesencephalic fissure. A, the tentorial surface faces the tentorium, which has
been removed. The surface slopes downward from the apex to the posterior and lateral margins. The upper part of the tento-
rial surface surrounds the posterior half of the midbrain and forms the posterior lip of the cerebellomesencephalic fissure.
The anterior cerebellar incisura, the notch where the brainstem fits into the anterior part of the tentorial surface, is located
anteriorly and the posterior cerebellar incisura, the notch where the falx cerebelli fits into the cerebellum, is located posteri-
orly. B, enlarged view of the cerebellomesencephalic fissure, which extends downward between the midbrain and the cere-
bellum. The superficial part of the posterior lip is formed by the culmen in the midline and the quadrangular lobule laterally.
The quadrigeminal cistern extends caudally from the pineal into the cerebellomesencephalic fissure. C, the culmen has been
removed to expose the central lobule and its wings, which form part of the posterior lip of the cerebellomesencephalic fis-
sure. D, the central lobule and its wings, the lingula, the superior medullary velum, and medial part of the superior cerebellar
peduncles have been removed to expose the fourth ventricle. The lower half of the roof is formed in the midline by the

lobules and the tonsils, and the vermic portion is formed by the superior pole faces the uvula medially and the biventral
the folium, tuber, pyramid, and uvula. The vermian and the lobule laterally.
related hemispheric parts from above to below are the folium
and the superior semilunar lobules, the tuber and the inferior Petrosal surface
semilunar lobules, the pyramid and the biventral lobules, and
The petrosal or anterior surface faces the posterior surface
the uvula and the tonsils.
of the petrous bones, the brainstem, and the fourth ventricle
The suboccipital surface is divided at its major fissure, the
(Figs. 1.2 and 1.7). The lateral or hemispheric part of the
suboccipital fissure, into superior and inferior parts. The sub-
petrosal surface rests against the petrous bone and is retracted
occipital fissure has a vermian and a hemispheric part. The
to expose the cerebellopontine angle. The median or vermian
vermian part of this fissure, the prepyramidal fissure, sepa-
part of the petrosal surface has a deep longitudinal furrow,
rates the tuber and the pyramid, and the hemispheric part, the
the anterior cerebellar incisura, that wraps around the poste-
prebiventral fissure, separates the biventral and the inferior
rior surface of the brainstem and fourth ventricle. The right
semilunar lobules. The prebiventral and prepyramidal fis-
and left halves of the petrosal surfaces are not connected from
sures are continuous at the vermohemispheric junction, and
side to side by a continuous strip of vermis, as are the suboc-
together they form the suboccipital fissure. The petrosal fis-
cipital and tentorial surfaces, because of the interposition of
sure, the major fissure on the petrosal surface, extends from
the fourth ventricle between the superior and inferior part of
the petrosal surface onto the suboccipital surface, and sepa-
the vermis. The vermal components rostral to the fourth ven-
rates the superior and inferior semilunar lobules laterally and
tricle are the lingula, the central lobule, and the culmen, and
the folium and the tuber medially. The tonsillobiventral fis-
those caudal to the fourth ventricle are the nodule and the
sure separates the tonsil and the biventral lobule.
uvula. The hemispheric surfaces are formed by the wings of
The tonsils, the most prominent structure blocking access to
the central lobule and the anterior surfaces of the quadrangu-
the caudal part of the fourth ventricle, are a hemispheric
lar, simple, biventral, and superior and inferior semilunar
component (Figs. 1.5 and 1.6). Each tonsil is an ovoid structure
lobules, the tonsils, and the flocculi. The vermian and related
in the inferomedial part of the suboccipital surface that is
hemispheric parts are the central lobule and the wings of the
attached to the remainder of the cerebellum along its supero-
central lobule, the culmen and the quadrangular lobules, the
lateral border by a white matter bundle called the tonsillar
nodule and the flocculi, and the uvula and the tonsils. The
peduncle. The remaining tonsillar surfaces are free surfaces.
major fissure on this surface, the petrosal fissure, also called
The inferior pole and posterior surface face the cisterna
the horizontal fissure, splits the petrosal surface into superior
magna and are visible inferomedial to the remainder of the
and inferior parts and extends onto the suboccipital surface
suboccipital surface. The lateral surface of each tonsil is cov- between the superior and inferior semilunar lobules.
ered by, but is separated from, the biventral lobule by a
narrow cleft, except superiorly at the level of the tonsillar
peduncle. The medial, anterior, and superior surfaces all face THE FOURTH VENTRICLE AND THE
other neural structures, but are separated from them by nar- CEREBELLAR-BRAINSTEM FISSURES
row fissures. The anterior surface of each tonsil faces and is
separated from the posterior surface of the medulla by the Fourth ventricle
cerebellomedullary fissure. The medial surfaces of the tonsils The fourth ventricle is a broad, tent-shaped midline cavity
face each other across a narrow cleft, the vallecula, which located between the cerebellum and the brainstem. It is con-
leads into the fourth ventricle. The ventral aspect of the su- nected rostrally through the aqueduct with the third ventricle,
perior pole of each tonsil faces the three structures (tela cho- caudally through the foramen of Magendie with the cisterna
roidea, inferior medullary velum, and nodule) forming the magna, and laterally through the foramina of Luschka with
lower half of the roof of the fourth ventricle. The superior pole the cerebellopontine angles. Most of the cranial nerves arise
is separated from the surrounding structures by a posterior near its floor. It has a roof, a floor, and two lateral recesses. It
extension of the cerebellomedullary fissure, called either the is ventral to the cerebellum, dorsal to the pons and medulla,
telovelotonsillar or supratonsillar cleft. The posterior aspect of and medial to the cerebellar peduncles.
Š
nodule and laterally by the inferior medullary velum, which passes laterally above, but is separated from the rostral pole of
the tonsils by the cerebellomedullary fissure. E, some of the middle peduncle has been removed to expose the choroid plexus
extending through the lateral recess into the cerebellopontine angle below the facial and vestibulocochlear nerves. F, oblique
view of the lower half of the roof formed by the inferior medullary velum and the tela choroidea in which the choroid plexus
arises. The inferior medullary velum arises on the surface of the nodule and extends laterally to blend into the flocculus and,
with the flocculus and nodule, forms the flocculonodular lobe of the cerebellum. A.I.C.A., anteroinferior cerebellar artery;
Cent., central; Cer., cerebellar; Cer.Mes., cerebellomesencephalic; Chor., choroid; CN, cranial nerve; Coll., colliculus; Dent.,
dentate; Fiss., fissure; Flocc., flocculus; Inf., inferior; Lat., lateral; Mid., middle; Med., median, medullary; Nucl., nucleus;
Ped., peduncle; Plex., plexus; Post., posterior; Quad., quadrangular; Sulc., sulcus; Sup., superior; Tent., tentorial; Vel., velum;
Vent., ventricle.

S12 Rhoton
FIGURE 1.4. Tentorial surface and cerebellomesence-

phalic fissure. A, the tentorial cerebellar surface faces
the tentorium and slopes downward from its apex
located below the tentorial apex. The cerebellomesence-
phalic fissure extends forward between the cerebellum
and midbrain. This surface, in which the vermis is the
highest part, differs from the suboccipital surface in
which the vermis is folded into a deep cleft, the incisura,
between the cerebellar hemispheres. The straight sinus
and tentorial edge have been preserved. The SCA exits
the cerebellomesencephalic fissure and supplies the ten-
torial surface. B, the right half of the posterior lip of the
cerebellomesencephalic fissure has been removed. The
anterior wall of the fissure is formed in the midline by
the collicular plate and lingula, and laterally by the supe-
rior cerebellar peduncles. The middle cerebellar pedun-
cle wraps around the lateral surface of the superior
peduncle. The trochlear nerve arises below the inferior
colliculi. C, the right half of the lingula and superior
medullary velum have been removed to expose the fourth ventricle. Additional white matter has been removed below the right superior
peduncle to expose the dentate nucleus in which the superior peduncular fibers arise. D, enlarged view. The dentate nucleus appears to
wrap around the rostral pole of the tonsil. E, oblique view into the fourth ventricle. Additional cerebellum has been removed to expose
the nodule and rostral pole of the tonsil. The dentate nucleus wraps around the rostral pole of the tonsil. The upper half of the roof is
formed by the superior medullary velum, which has the lingula layered on its outer surface. The upper part of the lower half of the roof is
formed by the nodule in the midline and by the inferior medullary velum laterally. The inferior medullary velum, an almost transparent
membrane, stretches laterally across the upper pole of the tonsil. F, the left half of the upper part of the roof has been removed. The
velum arises on the nodule and sweeps laterally above both tonsils. The SCA courses within the cerebellomesencephalic fissure. A.I.C.A.,
anteroinferior cerebellar artery; Cer.Mes., cerebellomesencephalic; Chor., choroidal; CN, cranial nerve; Coll., colliculus; Dent., dentate;
Fiss., fissure; Inf., inferior; Lat., lateral; Med., medullary; Mid., middle; Nucl., nucleus; Ped., peduncle; S.C.A., superior cerebellar artery;
Str., straight; Sup., superior; Tent., tentorial; Vel., velum; Vent., ventricle.

FIGURE 1.5.
Suboccipital sur-
face of the cere-
bellum and the
cerebellomedullary
fissure. A, the sub-
occipital surface is
located below and
between the sig-
moid and lateral
sinuses and is the
surface that is
exposed in a wide
suboccipital crani-
ectomy. The ver-
mis sits in a
depression, the
posterior cerebel-
lar incisura,
between the hemi-
spheres. The cer-
ebellomedullary
fissure extends
superiorly between
the cerebellum
and medulla along
the inferior half of
the ventricular
roof. The vallecula
extends upward
between the ton-
sils and communi-
cates through the
foramen of
Magendie with the
fourth ventricle.
The PICA supplies
the suboccipital
surface. B,
enlarged view. The lower parts of the vermis behind the ventricle are the pyramid and uvula. C, the right tonsil has
been removed to expose the lower part of the roof formed by the inferior medullary velum and tela choroidea. The nod-
ule on which the velum arises is hidden in front of the uvula. The uvula hangs downward between the tonsils, thus mim-
icking the situation in the oropharynx. The choroid plexus arises on the inner surface of the tela and extends through
the foramen of Luschka behind the glossopharyngeal and vagus nerve. The inferior medullary velum arises on the sur-
face of the nodule, drapes across the superior pole of the tonsil, and blends into the flocculus laterally. D, both tonsils
have been removed to expose the inferior medullary velum and tela choroidea bilaterally. The telovelar junction is the
junction between the velum and tela. The cerebellomedullary fissure extends upward between the rostral pole of the
tonsil on one side and the tela choroidea and inferior medullary velum on the opposite side. The segment of the PICA
passing through this cleft is called the telovelotonsillar segment. The rhomboid lip is a sheet-like layer of neural tissue
attached to the lateral margin of the ventricular floor, which extends posterior to the glossopharyngeal and vagus nerves
and joins the tela choroidea to form a pouch at the outer extremity of the lateral recess. E, the right half of the tela has
been removed to expose the ventricle and the lateral recess. The inferior medullary velum extends laterally to form a
peduncle, the peduncle of the flocculus, which blends into the flocculus at the outer margin of the lateral recess. F, the
tela has been removed on both sides. The lateral wall of the upper half of the ventricle is formed by the superior cere-
bellar peduncles. The inferior cerebellar peduncles ascend along the dorsolateral medulla and form the anterior and ros-
tral margins of the lateral recess. Cer.Med., cerebellomedullary; Chor., choroid; CN, cranial nerve; Fiss., fissure; Flocc.,
flocculus; For., foramen; Inf., inferior; Lat., lateral; Med., medullary; Ped., peduncle; P.I.C.A., posteroinferior cerebellar
artery; Plex., plexus; Suboccip., suboccipital; Sup., superior; Telovel., telovelar; Vel., velum.

S14 Rhoton
FIGURE 1.6. Suboccipital surface and cerebel-

lomedullary fissure. A, the cerebellomedullary
fissure extends upward between the tonsils and
medulla. Both tonsils have been removed by
dividing the peduncle of the tonsil. Removing
the tonsil exposes the inferior medullary velum
and tela choroidea forming the lower part of the
ventricular roof. The inferior cerebellar
peduncle ascends along the posterolateral
medulla. The choroid plexus arises on the inner
surface of the tela choroidea. The taeniae are
the site of attachment of the tela choroidea
along the inferolateral margins of the ventricle
floor. The telovelar junction is the site of
attachment of the inferior medullary velum to
the tela choroidea. The nodule, on which the
inferior medullary velum arises, is hidden deep
to the uvula. B, the tela, in which the choroid
plexus arises, has been removed to expose both
lateral recesses. The superior cerebellar
peduncle forms the lateral wall of the upper half of the ventricle. The inferior cerebellar peduncle forms the anterior and
upper margin of the lateral recess. The middle cerebellar peduncle, which forms a large prominence on the lateral surface of
the pons, is separated from the ventricular surface by the superior and inferior cerebellar peduncles. C, lateral surface of the
left tonsil. All of the tonsillar surfaces, except at the superolateral margin, are free surfaces. The peduncle of the tonsil,
located along the superolateral margin of the tonsil, attaches the tonsil to the remainder of the cerebellum. The posterior
surface of the tonsil faces the cisterna magna. The medial surface faces the other tonsil. The anterior surface faces the
posterior medulla. The rostral pole faces the inferior medullary velum and tela choroidea. The lateral surface below the
peduncle of the tonsil faces the biventral lobule. D, posterior view of the left tonsil. The peduncle of the tonsil is located
along the superolateral margin. Dividing the narrow peduncle allows the tonsil to be separated from the remaining
cerebellum. Bivent., biventral; Inf., inferior; Lat., lateral; Med., medullary; Ped., peduncle; Post., posterior; Rost., rostral; Sup.,
superior; Telovel., telovelar; Vel., velum.
The ventricular roof is tent-shaped (Figs. 1.8 and 1.9). The part is formed largely by thin membranous layers and the
roof expands laterally and posteriorly from its narrow rostral superior part is formed by thicker neural structures.
end just below the aqueduct to the level of the fastigium and The external or cisternal surfaces of the structures forming
lateral recess, the site of its greatest height and width, and the roof are intimately related to the fissures between the
from there it tapers to a narrow caudal apex at the level of the cerebellum and brainstem. The three fissures formed by the
foramen of Magendie. The apex of the roof, the fastigium, embryological folding of the cerebellum around the brainstem
divides it into superior and inferior parts. The superior part is are the cerebellomesencephalic fissure, which extends inferi-
distinctly different from the inferior part, in that the inferior orly between the cerebellum and mesencephalon and is inti-

FIGURE 1.7. Brainstem, petrosal surface, and cerebellopontine fissure. A, oblique view. The petrosal surfaces of the cerebellum
face forward toward the petrous bone and is the surface that is retracted to expose the cerebellopontine angle. The cerebellopon-
tine fissure, which might also be referred to as the cerebellopontine angle, is a V-shaped fissure formed where the cerebellum
wraps around the pons and middle cerebellar peduncle. The superior and inferior limbs meet laterally at the apex located at the
anterior end of the petrosal fissure that divides the petrosal surface into superior and inferior parts. Cranial nerves V through XI
arise within the margins of the cerebellopontine fissure. The flocculus and choroid plexus extend laterally from the foramen of
Magendie above the lower limb of the fissure. The basilar sulcus is a shallow longitudinal groove on the anterior surface of the
pons, which accommodates the basilar artery. B, enlarged view. The petrosal fissure extends laterally from the apex of the cerebel-
lopontine fissure. The abducens nerve arises in the medial part of the pontomedullary sulcus rostral to the medullary pyramids. The
facial and vestibulocochlear nerves arise just rostral to the foramen of Luschka near the flocculus at the lateral end of the pontomedullary
sulcus. The hypoglossal nerves arise anterior to and the glossopharyngeal, vagus, and accessory nerves arise posterior to the olives. Cho-
roid plexus protrudes from the foramen of Luschka behind the glossopharyngeal and vagus nerves. C, enlarged view of another brain-
stem. The facial and vestibulocochlear nerves join the brainstem 2 or 3 mm rostral to the glossopharyngeal nerve on a line drawn dorsal
to the olive along the origin of the rootlets of the glossopharyngeal, vagus, and accessory rootlets. The rhomboid lip, a thin neural mem-
brane in the ventral margin of the lateral recess, extends laterally behind the glossopharyngeal, vagus, and accessory nerves with the cho-
roid plexus. D, enlarged view of another cerebellopontine fissure. The cerebellopontine angle is the area situated between the superior
and inferior limbs of the cerebellopontine fissure. The glossopharyngeal, vagus, and accessory nerves arise near the inferior limb, dorsal to
the olive, and anterior to the choroid plexus protruding from the foramen of Luschka. The facial and vestibulocochlear nerves arise in the
midportion of the fissure and the trigeminal nerve near the superior limb of the fissure. The hypoglossal rootlets arise in front of the olive
and the cranial rootlets of the accessory nerve. Bas., basilar; Cer.Pon., cerebellopontine; Chor., choroid; CN, cranial nerve; Fiss., fissure;
Flocc., flocculus; For., foramen; Inf., inferior; Mid., middle; Ped., peduncle; Pet., petrosal; Plex., plexus; Sup., superior.
mately related to the superior half of the roof (Figs. 1.3 and 1.7 and 1.8); and the cerebellomedullary fissure, which
1.4); the cerebellopontine fissures, which are formed by the extends superiorly between the cerebellum and the me-
folding of the cerebellum around the lateral sides of the dulla and is intimately related to the inferior half of the roof
pons and are intimately related to the lateral recesses (Figs. (Figs. 1.5 and 1.6).

S16 Rhoton
FIGURE 1.8. A–F. Brainstem, fourth ventricle, and petrosal cerebellar surface. Stepwise anterior exposure. A, the petrosal
surface faces forward toward the posterior surface of the temporal bone. The fourth ventricle is located behind the pons and
medulla. The midbrain and pons are separated by the pontomesencephalic sulcus and the pons and medulla by the pon-
tomedullary sulcus. The trigeminal nerves arise from the midpons. The abducens nerve arises in the medial part of the pon-
tomedullary sulcus, rostral to the medullary pyramids. The facial and vestibulocochlear nerves arise at the lateral end of the
pontomedullary sulcus immediately rostral to the foramen of Luschka. The hypoglossal nerves arise anterior to the olives and
the glossopharyngeal, vagus, and accessory nerves arise posterior to the olives. Choroid plexus protrudes from the foramen of
Luschka behind to the glossopharyngeal and vagus nerves. B, right cerebellopontine angle following removal of some of the
medulla. The foramen of Luschka opens into the cerebellopontine angle below the junction of the facial and vestibuloco-
chlear nerves with the lateral end of the pontomedullary sulcus. Choroid plexus protrudes from the lateral recess and fora-
men of Luschka behind the glossopharyngeal, vagus, and accessory nerves. The cerebellopontine fissure, a V-shaped fissure
formed by the cerebellum wrapping around the pons and middle cerebellar peduncle, has a superior and inferior limb that

FIGURE 1.8. G–J. Brainstem, fourth ventricle, and petrosal cerebellar surface. G, the left half of the medulla has been
removed. The superior half of the roof is formed by the superior medullary velum, which has the lingula of the vermis lay-
ered on its outer surface. The lower half of the roof is formed by the inferior medullary velum, which arises on the surface of
the nodule, and the tela choroidea in which the choroid plexus arises. The choroid plexus is composed of paired L-shaped
fringes, which have medial and lateral segments. The lateral segments extend laterally through the foramen of Luschka and
the medial segments extend longitudinally through the foramen of Magendie. H, the right half of the tela choroidea and cho-
roid plexus have been removed to expose the upper pole of right tonsil. I, the right cerebellar tonsil has been removed. All of
the surfaces of the tonsils are free surfaces except the superolateral margin, the site of the tonsillar peduncle, a bundle of
white matter, which attaches the tonsil to the remainder of the cerebellum. The inferior medullary velum is a thin membra-
nous layer of neural tissue that arises on the nodule and extends laterally above the rostral pole of the tonsil to blend into the
flocculus and form the flocculonodular lobe of the cerebellum. The cranial loop of the PICA courses between the rostral pole
of the tonsil and the inferior medullary velum. J, both tonsils have been removed. The inferior medullary velum sweeps later-
ally from the surface of the nodule.
Š
define the margins of the cerebellopontine angle. The superior limb extends above the trigeminal nerve and the inferior limb
passes below the flocculus and the nerves that pass to the jugular foramen. C, the part of the pons and medulla forming the
left half of the floor of the ventricle has been removed to expose the fastigium, which divides the ventricular roof into supe-
rior and inferior parts. D, the right half of the pons has been removed to expose the upper half of the roof. The superior part
of the roof is formed by the superior medullary velum. The rostral part of the lower half of the roof is formed by the nodule
and inferior medullary velum and the caudal part is formed by the tela choroidea, a thin arachnoid-like membrane, in which
the choroid plexus arises. E, the cerebellopontine fissure has upper and lower limbs, which meet at a later apex located at
the medial end of the petrosal fissure, also called the horizontal fissure, which divides the petrosal surface into upper and
lower halves. The junction of the pons and medulla, which forms the anterior wall of the left lateral recess, has been
removed to expose the choroid plexus protruding through the lateral recess into the cerebellopontine angles. F, enlarged
view. The choroid plexus protrudes laterally through the foramen of Luschka into the cerebellopontine angle below the floc-
culus. Cer.Pon., cerebellopontine; Chor., choroid; CN, cranial nerve; Fiss., fissure; Flocc., flocculus; For., foramen; Inf., infe-
rior; Lat., lateral; Med., medial, medullary; Mid., middle; Ped., peduncle; Pet., petrosal; Plex., plexus; Pon.Med., pontomedul-
lary; Pon.Mes., pontomesencephalic; Seg., segment; Sulc., sulcus; Sup., superior; Vel., velum.

S18 Rhoton
FIGURE 1.9. A–F. Posterior views. Stepwise dissection examining the relationships of the inferior medullary velum, dentate
nucleus, tonsil, and the cerebellomedullary and cerebellomesencephalic fissures. A, the PICAs pass around the posterior
medulla to reach the lower margin of the cerebellomedullary fissure. The left PICA courses around the lower pole of the ton-
sil. The right PICA descends well below the tonsil to the level of the foramen magnum before ascending along the medial ton-
sillar surface. B, the PICAs ascend between the tonsils and medulla to reach the interval between the tonsil and uvula and to
supply the suboccipital surface. C, the posterior medullary segment of the right PICA divides into a medial trunk supplying
the vermis and paravermian area and a lateral trunk supplying the hemisphere. D, the cerebellum has been sectioned in an
oblique coronal plane to show the relationship of the rostral pole of the tonsil to the inferior medullary velum and dentate
nucleus. The dentate nucleus is located above the posterolateral part of the ventricular roof, near the fastigium, where it
wraps around, and is separated from, the rostral pole of the tonsil by the inferior medullary velum. The left tonsil has been
removed while preserving the left half of the inferior medullary velum. The SCAs course in the cerebellomesencephalic fis-
sure. The PICA passes between the walls of the cerebellomedullary fissure formed above by the inferior medullary velum and

FIGURE 1.9. G–J. Posterior views. G, the tela choroidea, in which the choroid plexus arises, has been folded downward to
expose the lower part of the floor. H, enlarged view of the left lateral recess and the foramen of Luschka. The rhomboid lip is
a thin layer of neural tissue, which extends laterally from the anterior margin of the lateral recess and, with the tela cho-
roidea, forms a pouch at the outer edge of the lateral recess. Choroid plexus extends through the lateral recess and foramen
of Luschka into the cerebellopontine angle. I, the tela has been removed to expose the parts of the floor located above and
below the nodule and inferior medullary velum. J, the nodule and the inferior medullary velum have been removed to expose
the full length of the floor, which is divided in the midline by the median sulcus and craniocaudally into pontine, junctional,
and medullary parts. The superior and inferior peduncles face the ventricular surface. The middle cerebellar peduncle is sepa-
rated from the ventricular surface by the superior and inferior peduncles. Chor., choroid; Dent., dentate; Inf., inferior; Lat.,
lateral; Med., median, medullary; Mid., middle; Nucl., nucleus; P.I.C.A., posteroinferior cerebellar artery; Ped., peduncle;
Plex., plexus; Sup., superior; Vel., velum.
A major cerebellar artery and vein course in each fissure. fissure are intimately related to the cerebellomedullary fis-
The superior cerebellar artery (SCA) and the vein of the sure. These arteries and veins will be reviewed in the next two
cerebellomesencephalic fissure course within the cerebel- chapters on the cerebellar arteries and posterior fossa veins
lomesencephalic fissure, the anteroinferior cerebellar artery (10, 18, 19).
(AICA) and the vein of the cerebellopontine fissure are related Each fissure communicates with the adjacent fissure. The
to the cerebellopontine fissure, and the posteroinferior cere- cerebellopontine fissures are continuous around the rostral
bellar artery (PICA) and the vein of the cerebellomedullary surface of the middle cerebellar peduncles with the caudal
Š
below by the upper pole of the tonsil. E, both tonsils have been removed. The PICAs ascend through the cleft between the
inferior medullary velum and rostral pole of the tonsil. F, the superior part of the ventricular roof has been removed and the
nodule and the inferior medullary velum has been folded downward to expose the floor. A., artery; Cer. Med., cerebellomed-
ullary; Cer.Mes., cerebellomesencephalic; CN, cranial nerve; Dent., dentate; Fiss., fissure; Inf., inferior; Lat., lateral; Med.,
medial, medullary; Nucl., nucleus; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar
artery; Suboccip., suboccipital; Telovel. Ton., telovelotonsillar; Vel., velum; Vent., ventricle; Vert., vertebral.

S20 Rhoton
FIGURE 1.9. K and L.

Posterior views. K,
enlarged view of the
floor of the fourth
ventricle. The median
sulcus divides the
floor longitudinally in
the midline. Each half
of the floor is divided
longitudinally by an
irregular sulcus, the
sulcus limitans, which
deepens lateral to the
facial colliculus and
hypoglossal triangles
to form the superior
and inferior foveae. A
darkened area of cells,
the locus ceruleus, is
located at the rostral
end of the sulcus
limitans. The stria
medullaris crosses the
floor at the level of
the lateral recess. The
hypoglossal and vagal
nuclei and the area
postrema are stacked
one above the other in the lower part of the floor to give the configuration of a pen nib and, thus, the area is referred to as
the calamus scriptorius. L, another fourth ventricular floor. The paired veins of the superior cerebellar peduncle course on
the outer surface of the superior peduncles and join superiorly to form the vein of the cerebellomesencephalic fissure. The
median posterior medullary vein ascends on the medulla and splits into the paired veins of the inferior cerebellar peduncle
at the caudal margin of the floor. That left vein is hypoplastic. The left vein of the cerebellomedullary fissure passes
along the lateral recess and ascends to join the petrosal group of veins in the cerebellopontine angle. Cer.Med.,
cerebellomedullary; Cer., cerebellar; CN, cranial nerve; Coll., colliculus; Emin., eminence; Fiss., fissure; Hypogl., hypoglossal;
Inf., inferior; Med., median, medullary; Mid., middle; Ped., peduncle; Post., posterior; Striae Med., Stria medullaris; Sup.,
superior; V., vein.
edges of the cerebellomesencephalic fissure and around the medial surface of the superior cerebellar peduncle, and the cau-
caudal margin of the middle cerebellar peduncles with the dal part is formed by the inferior cerebellar peduncle.
rostral limits of the cerebellomedullary fissure. These fissures The middle cerebellar peduncle, although it is the largest
will be reviewed in greater detail in the discussion of the roof component of the fiber bundle formed by the union of the
and lateral recesses of the fourth ventricle. three cerebellar peduncles, is separated from the ventricular
surface by the fibers of the inferior and superior peduncles on
Upper ventricular roof and the its medial surface (Fig. 1.9). The fibers of the inferior cerebellar
cerebellomesencephalic fissure peduncle ascend in the posterolateral medulla and turn pos-
teriorly in the inferomedial part of the fiber bundle formed by
The ventricular surface of the superior part of the roof of the
the union of the three peduncles to line the ventricular surface
fourth ventricle is divided into a single median and two lateral
parts (Figs. 1.3 and 1.4). The median part is formed by the of the superior margin of the lateral recess and the inferior
superior medullary velum, and the lateral parts (also referred to part of the lateral wall. The fibers of the superior cerebellar
as the lateral walls) are formed by the inner surface of the peduncle arise in the dentate nucleus and ascend on the
cerebellar peduncles. The superior medullary velum is a thin medial side of the middle cerebellar peduncle to form the
lamina of white matter that spans the interval between the ventricular surface of the superior part of the lateral wall.
superior cerebellar peduncles and has the lingula, the uppermost The cisternal (external) surface of the structures forming the
division of the vermis, on its outer surface. It is continuous at the superior part of the roof also form the anterior wall of the
fastigium with the inferior medullary velum. The rostral portion cerebellomesencephalic fissure. This fissure, which extends
of the ventricular surface of each lateral wall is formed by the inferiorly between the cerebellum and midbrain, is V-shaped

when viewed from superiorly (Figs. 1.3 and 1.4). This fissure The tela choroidea forms the caudal part of the inferior
has also been referred to as the precentral cerebellar fissure. portion of the roof and the inferior wall of each lateral recess
The dorsal half of the midbrain sits within the limbs of the (Figs. 1.5, 1.6, and 1.9). It consists of two thin, semitransparent
V-shaped notch, and the cerebellum forms the outer margin, membranes, each having a thickness comparable to arach-
with the apex being posterior. The inner wall of the fissure, noid, between which is sandwiched a vascular layer com-
which forms the outer surface of the superior part of the roof, is posed of the choroidal arteries and veins. The choroid plexus
composed of the lingula, the dorsal surface of the superior cer- projects from the ventricular surface of the tela choroidea into
ebellar peduncles, and the rostral surface of the middle cerebel- the fourth ventricle. The line of attachment of the inferior
lar peduncles. The lingula, a thin, narrow tongue of vermis, sits medullary velum to the tela choroidea, the telovelar junction,
on the outer surface of the superior medullary velum. The su- extends from the nodule into each lateral recess. The tela
perior cerebellar peduncles form smooth longitudinal promi- choroidea sweeps inferiorly from the telovelar junction
nences on each side of the lingula before disappearing into the around the superior pole of each tonsil to its attachment to the
midbrain beneath the colliculi. The rostral surface of the middle inferolateral edges of the floor along narrow white ridges, the
cerebellar peduncles appear to wrap around the caudal margin taeniae, which meet at the obex. Cranially, the taeniae turn
of the superior cerebellar peduncles. A shallow groove, the in- laterally over the inferior cerebellar peduncles and pass hor-
terpeduncular sulcus, marks the junction of the superior and the izontally along the inferior borders of the lateral recesses. The
middle cerebellar peduncles. The interpeduncular sulcus is con- tela choroidea does not completely enclose the inferior half of
tinuous anteriorly with the pontomesencephalic sulcus, a trans- the fourth ventricle, but has three openings into the subarach-
verse groove between the pons and midbrain, and superiorly noid space: the paired foramina of Luschka located at the
with the lateral mesencephalic sulcus, a longitudinal fissure dor- outer margin of the lateral recesses and the foramen of Ma-
sal to the cerebral peduncle. The trochlear nerves arise in the gendie located at the caudal tip of the fourth ventricle.
cerebellomesencephalic fissure below the inferior colliculi and The cisternal (external) surface of the caudal half of the roof
pass anterolateral to exit the anterior part of the fissure. The faces and is intimately related to the cerebellomedullary fis-
outer wall of the cerebellomesencephalic fissure is formed by the sure (Figs. 1.6, 1.8, and 1.9). This fissure is one of the most
culmen and the central lobule and its wings. complex fissures in the brain. The ventral wall of the fissure is
The neural structures separating the ventricular and cister- formed by the posterior surface of the medulla, the inferior
nal surfaces of the superior part of the roof are thinnest in the medullary velum, and the tela choroidea. The dorsal wall of
area of the superior medullary velum and lingula and thickest the fissure is formed by the uvula in the midline and the
in the area of the cerebellar peduncles. The rostral portion of tonsils and biventral lobules laterally. It extends superiorly to
each lateral wall, formed by only the superior cerebellar pe- the level of the lateral recesses and communicates around the
duncle, is thinner than the caudal portion, which is formed by superior poles of the tonsils with the cisterna magna, through
the three cerebellar peduncles after they have united. the foramen of Magendie with the fourth ventricle, and
around the foramina of Luschka with the cerebellopontine
fissures. The rostral pole of the tonsils faces the inferior med-
Lower roof and cerebellomedullary fissure ullary velum, the tela choroidea, and the peritonsillar part of
The inferior portion of the roof slopes sharply ventral and the uvula and the biventral lobule in the superior part of the
slightly caudal from the fastigium to its attachment to the fissure (Figs. 1.3–1.6). The portion of the fissure between the
inferolateral borders of the floor (Figs. 1.3–1.6). The ventricular tonsil, the tela choroidea, and the inferior medullary velum is
and cisternal surfaces are formed by the same structures, the tela called the telovelotonsillar cleft, and the superior extension of
choroidea and the inferior medullary velum, except in the rostral this cleft over the superior pole of the tonsil has been called
midline, where the ventricular surface is formed by the nodule the supratonsillar cleft.
and the cisternal surface is formed by the uvula. The choroid
plexus is attached to the ventricular surface of the tela choroidea. LATERAL RECESS AND
The ventricular surface is divided into a cranial part formed CEREBELLOPONTINE FISSURE
by the nodule and the inferior medullary velum and a caudal
part formed by the tela choroidea. The inferior medullary The lateral recesses are narrow, curved pouches formed by
velum is a membranous layer and is all that remains of the the union of the roof and the floor. They extend laterally
connection between the nodule and the flocculi that form the below the cerebellar peduncles and open through the foram-
flocculonodular lobe of the primitive cerebellum (14) (Figs. 1.8 ina of Luschka into the cerebellopontine angles (Figs. 1.3, 1.5,
and 1.9). It is a thin bilateral semitranslucent butterfly-shaped 1.6, and 1.8). The ventral wall of each lateral recess is formed
sheet of neural tissue that blends into the ventricular surface by the junctional part of the floor and the rhomboid lip, a
of the nodule medially and stretches laterally across, but is sheetlike layer of neural tissue that extends laterally from the
separated from, the superior pole of the tonsil by a narrow, floor and unites with the tela choroidea to form a pouch at the
rostral extension of the cerebellomedullary fissure. It blends outer extremity of the lateral recess. The rostral wall of each
into the dorsal margin of each lateral recess and forms the lateral recess is formed by the caudal margin of the cerebellar
peduncle of each flocculus. The inferior medullary velum is peduncles. The inferior cerebellar peduncle courses upward
continuous at the level of the fastigium with the superior in the floor ventral to the lateral recess and turns posteriorly
medullary velum. Caudally it is attached to the tela choroidea. at the lower part of the pons to form the ventricular surface

S22 Rhoton
of the rostral wall. The peduncle of the flocculus intercon- parts are widest at their junction with the lateral segments.
necting the inferior medullary velum and the flocculus The tonsillar parts are anterior to the tonsils and extend
crosses in the dorsal margin of the lateral recess. The caudal inferiorly through the foramen of Magendie. The rostral and
wall is formed by the tela choroidea that stretches from the caudal ends of the medial segments are often fused.
lateral part of the taenia to the peduncle of the flocculus. The lateral segments form a transversely oriented fringe
The biventral lobule is dorsal to the lateral recess. The that attach to the rostral part of the medial segments and
flocculus is superior to the outer extremity of the lateral extend parallel to the telovelar junction through the lateral
recess. The rootlets of the glossopharyngeal and vagus recesses into the cerebellopontine angles. Each lateral segment
nerves arise ventral to and the facial nerve arises rostral to is subdivided into a medial or peduncular part and a lateral or
the lateral recess. The fibers of the vestibulocochlear nerve floccular part. The peduncular part forms a narrow fringe that
cross the floor of the recess. is continuous with the rostral part of the medial segment and
Each lateral recess opens into the cerebellopontine angle is attached to the tela choroidea covering the lateral recess
along the cerebellopontine fissure (Fig. 1.7). This V-shaped fis- inferior to the cerebellar peduncles. The floccular part is con-
sure is formed by the folding of the cerebellar hemisphere tinuous with the peduncular part at the lateral margin of the
around the lateral side of the pons and the middle cerebellar cerebellar peduncles and protrudes through the foramen of
peduncle. It has a superior limb between the rostral half of the Luschka into the cerebellopontine angle below the flocculus.
middle cerebellar peduncle and the superior part of the petrosal
surface and an inferior limb between the caudal half of the
middle cerebellar peduncle and the inferior part of the petrosal
surface. The middle cerebellar peduncle fills the interval be- BRAINSTEM AND FLOOR
tween the two limbs. The apex of the fissure is located laterally
Brainstem
where the superior and inferior limbs meet. The petrosal fissure
extends laterally from the apex. The lateral recess and the fora- The brainstem and ventricle floor are considered together
men of Luschka open into the medial part of the inferior limb. because the brainstem forms the fourth ventricular floor. The
Other structures located along the inferior limb are the flocculus, brainstem in the posterior fossa is composed of the mesen-
the rhomboid lip, the choroid plexus protruding from the fora- cephalon, pons, and medulla (Figs. 1.7–1.9). The mesenceph-
men of Luschka, and the facial, vestibulocochlear, glossopharyn- alon consists of the cerebral peduncles, the tegmentum, and
geal, and vagus nerves. The trigeminal nerve arises from the the tectum. It is demarcated superiorly from the diencephalon
pons along the superior limb of the fissure. by the sulcus between the optic tracts and the cerebral pe-
The superior limb of the cerebellopontine fissure commu- duncles, and inferiorly from the pons by the pontomesence-
nicates above the trigeminal nerve with the lateral part of the phalic sulcus. The interpeduncular fossa, a wedge-shaped
cerebellomesencephalic fissure, and the inferior limb commu- depression between the cerebral peduncles, has the posterior
nicates with the lateral part of the cerebellomedullary fissure perforated substance in its floor. The rootlets of the oculomo-
at the level of the lateral recess. The flocculus projects into the tor nerves arise in the depths of the interpeduncular fossa and
cerebellopontine angle at the confluence of the cerebellopon- form the fossa’s walls lateral to the posterior perforated sub-
tine and cerebellomedullary fissures. The vestibulocochlear stance. A small depression, the superior foramen cecum, is
and facial nerves enter the brainstem anterosuperior to the located in the caudal part of the interpeduncular fossa. The
flocculus, and the fila of the glossopharyngeal and the vagal pontomesencephalic sulcus runs from the superior foramen
nerves cross anteroinferiorly to it. cecum around the cerebral peduncles to join the lateral mes-
encephalic sulcus, a vertical sulcus between the tegmentum
and the cerebral peduncle.
CHOROID PLEXUS The belly of the pons is convex from side to side, as well as
The choroid plexus of the posterior fossa is composed of from top to bottom, and is continuous on each side with the
two inverted L-shaped fringes that arise on the ventricular middle cerebellar peduncles. It has a shallow midline groove,
surface of the tela choroidea and are located on each side of the basilar sulcus, which extends from its superior to its
the midline (7) (Figs. 1.3 and 1.8). The paired longitudinal inferior border. The posterior root of the trigeminal nerve
limbs bordering the median plane are the medial segments. emerges from the upper portion of the middle cerebellar
The transverse limbs that originate from the rostral ends of peduncle just below the anterior angle of the cerebellum. The
the medial segments are the lateral segments. The entire struc- pons is demarcated inferiorly from the medulla by the pon-
ture presents the form of a letter T, the vertical limb of which, tomedullary sulcus, which extends laterally from the inferior
however, is double. foramen cecum (a midline dimple) to the supraolivary fossette
The medial segments are located in the roof near the mid- (a depression located rostral to the olive). The rootlets of the
line, and the lateral segments extend through the lateral re- facial and the vestibulocochlear nerves arise superior to this
cesses and the foramina of Luschka into the cerebellopontine fossette and the rootlets of the glossopharyngeal and the vagal
angles. The medial segments stretch from the level of the nerves originate dorsal to it.
nodule anterior to the tonsils to the level of the foramen of The anterior surface of the medulla is formed by the med-
Magendie. Each medial segment is subdivided into a rostral ullary pyramids, which face the clivus, the anterior edge of
or nodular part and a caudal or tonsillar part. The nodular the foramen magnum, and the rostral part of the odontoid

process (Figs. 1.7 and 1.8). The anteromedian sulcus divides inferolateral margins of the floor. Its caudal tip, the obex, is
the upper medulla in the anterior midline between the pyra- anterior to the foramen of Magendie.
mids and disappears on the lower medulla at the level of the The floor is divided longitudinally from the rostral apex to
decussation of the pyramids, but it reappears below the de- the caudal tip into symmetrical halves by the median sulcus.
cussation and is continuous caudally with the anteromedian The sulcus limitans, another longitudinal sulcus, divides each
fissure of the spinal cord. The lateral surface of the medulla is half of the floor into a raised median strip, called the median
formed predominantly by the inferior olives, which are situ- eminence, that borders the midline and a lateral region called
ated lateral to and separated from the pyramids by the an- the vestibular area.
terolateral (preolivary) sulcus. The rootlets of the hypoglossal Each median eminence, the strip between the sulcus limi-
nerves arise in the anterolateral sulcus. The lateral surface is tans and the median sulcus, from above to below contains the
demarcated posteriorly by the exits of the rootlets of the facial colliculus, a rounded prominence related to the facial
glossopharyngeal, vagus, and accessory nerves just dorsal to nerve, and three triangular areas overlying the hypoglossal
the posterolateral (postolivary) sulcus, which courses along and vagus nuclei and the area postrema. The three triangular
the dorsal margin of the olive and is continuous below with areas are paired and are stacked along the median sulcus to
the posterolateral sulcus of the spinal cord. The abducens give the caudal part of the floor a feather or pen nib config-
nerves emerge from the pontomedullary sulcus rostral to the uration; thus, the area is called the calamus scriptorius. At the
pyramids. The posterior surface of the medulla is divided into pontine level the median eminence has a width equal to that
superior and inferior parts. The superior part is composed in the of the full half of the floor and thus the sulcus limitans
midline of the inferior half of the floor of the fourth ventricle and corresponds with the lateral limit of this part of the floor.
laterally by the inferior cerebellar peduncles. The inferior part of The sulcus limitans is discontinuous and is most prominent
the posterior surface is divided into two halves in the midline by in the pontine and medullary portions of the floor, where it
the posteromedian sulcus, and each half is composed of the deepens at two points to form dimples called foveae, and is
gracile fasciculus and tubercle medially, and the cuneate fascic- least distinct in the junctional part of the floor. One of the two
ulus and tubercle laterally. The posteromedian sulcus of the dimples, the superior fovea, is located in the pontine portion
medulla, which separates the paired gracile fasciculi in the mid- of the floor and the other, the inferior fovea, is located in the
line, ends superiorly at the obex of the fourth ventricle and is medullary part of the floor. At the level of the superior fovea,
continuous inferiorly with the posteromedian sulcus of the spi- the median eminence forms an elongated swelling, the facial
nal cord. The posterior intermediate sulcus, which separates the colliculus, which overlies the nucleus of the abducens nerve
gracile and cuneate fasciculi, is continuous inferiorly with the and the ascending section of the root of the facial nerve. At the
posterior intermediate sulcus of the spinal cord. The lower me- rostral tip of each sulcus limitans in the lateral margin of the
dulla blends indistinguishably into the upper spinal cord at the floor is a bluish gray area, the locus ceruleus, which owes its
level of the C1 nerve roots (Figs. 1.5–1.7). color to a group of pigmented nerve cells. The hypoglossal
triangle is medial to the inferior fovea and overlies the nu-
cleus of the hypoglossal nerve. Caudal to the inferior fovea
Floor and between the hypoglossal triangle and the lower part of
The floor has a rhomboid shape (Fig. 1.9). The rostral two- the vestibular area is a triangular dark field, the vagal triangle,
thirds of the floor is posterior to the pons and the caudal that overlies the dorsal nucleus of the vagus nerve. A trans-
one-third is posterior to the medulla. Its cranial apex is at the lucent ridge, the funiculus separans, crosses the lower part of
level of the cerebral aqueduct; its caudal tip, the obex, is the vagal triangle. The area postrema forms a small tongue-
located at the rostral end of the remnant of the spinal canal, shaped area between the funiculus separans and the gracile
anterior to the foramen of Magendie; and its lateral angles tubercle in the lower limit of the median eminence immedi-
open through the lateral recesses and foramina of Luschka ately rostral to the obex.
into the cerebellopontine angles. A line connecting the orifices The vestibular area, the portion of the floor lateral to the
of the lateral recesses is located at the level of the junction of median eminence and sulcus limitans, is widest in the interme-
the caudal and the middle third of the length of the floor and diate part of the floor, where it forms a rounded elevation that
also at the level of the junction of the pons and the medulla. extends into the lateral recess. White strands, the striae med-
The floor is divided into three parts: a superior or pontine ullaris, course transversely from the region of the lateral recess
part, an intermediate or junctional part, and an inferior or across the inferior cerebellar peduncles above the hypoglossal
medullary part. The superior part has a triangular shape: its triangles toward the midline and disappear in the median sul-
apex is at the cerebral aqueduct, its base is represented by an cus. The vestibular nuclei lie beneath the vestibular area. The
imaginary line connecting the lower margin of the cerebellar auditory tubercle produced by the underlying dorsal cochlear
peduncles, and its lateral limbs are formed by the medial nucleus and the cochlear part of the vestibulocochlear nerve
surfaces of the cerebral peduncles. The intermediate part is forms a prominence in the lateral part of the vestibular area.
the strip between the lower margin of the cerebellar pe-
duncles and the site of attachment of the tela choroidea to the
taeniae just below the lateral recesses. The intermediate part VASCULAR RELATIONSHIPS
extends into the lateral recesses. The inferior part has a trian- Each wall of the fourth ventricle has surgically important
gular shape and is limited laterally by the taeniae marking the arterial relationships: the SCA is intimately related to the supe-

S24 Rhoton
rior half of the roof; the PICA is intimately related to the inferior peduncle course on the superior part of the roof, the veins of
half of the roof; the AICA is intimately related to the lateral the cerebellomedullary fissure and the inferior cerebellar pe-
recess and the foramen of Luschka; and the basilar and duncle drain the inferior half of the roof, and the veins of the
vertebral arteries give rise to many perforating branches cerebellopontine fissure and the middle cerebellar peduncle
that reach the floor of the fourth ventricle (5, 7, 9, 10, 18, 19) drain the lateral wall and the cerebellopontine angle around
(Figs. 1.9 and 1.10). The choroidal branches of the AICA the lateral recess. These vascular relationships will be ex-
supply the portion of the choroid plexus in the cerebel- plored in greater detail in the next two chapters on the cere-
lopontine angle and the adjacent part of the lateral recess, bellar arteries and posterior fossa veins.
and the PICA supplies the choroid plexus in the roof and
the medial part of the lateral recess (7).
There are no major veins within the cavity of the fourth DISCUSSION
ventricle. The veins most intimately related to the fourth ventri-
cle are those in the fissures between the cerebellum and the Effects of neural injury
brainstem and on the cerebellar peduncle (21). The veins of The operative approaches to the cerebellum and fourth
the cerebellomesencephalic fissure and the superior cerebellar ventricle may require splitting of the vermis, resection of part
FIGURE 1.10. A–D. Telovelar approach to the fourth ventricle. A, the cerebellomedullary fissure extends upward between
the tonsils posteriorly and the medulla anteriorly. The vallecula opens between the tonsils into the fourth ventricle. B, both
tonsils have been retracted laterally to expose the inferior medullary velum and tela choroidea that form the lower part of
the ventricular roof. The nodule of the vermis, on which the inferior medullary arises, is hidden deep to the uvula. C,
enlarged view of the left half of the cerebellomedullary fissure. The choroidal arteries course along the tela choroidea from
which the choroid plexus projects into the roof of the fourth ventricle. The vein of the cerebellomedullary fissure, which
crosses the inferior medullary velum, is the largest vein in the cerebellomedullary fissure. The interrupted line shows the site
of the incision in the tela to provide the exposure seen in the next step. The telovelar junction is the line of attachment of the
tela to the velum. D, the tela choroidea has been opened extending from the foramen of Magendie to the junction with the
inferior medullary velum. The uvula has been displaced to the right side to provide this view extending from the aqueduct to
the obex. A., artery; Cer.Med., cerebellomedullary; Chor., choroidal; Fiss., fissure; For., foramen; Inf., inferior; Med., medul-
lary; P.I.C.A., posteroinferior cerebellar artery; Telovel., telovelar; V., vein; Ve., vermian; Vel., velum.

FIGURE 1.10. E–H. Telovelar approach to the fourth ventricle. E, the tip of a nerve hook placed inside the fourth ventricle is
seen through the paper-thin inferior medullary velum. F, the left half of the inferior medullary velum has been divided to
expose the superolateral recess and the ventricular surface formed by the superior and inferior peduncles. G, the uvula has
been retracted to the right to expose all of the floor and much of the roof of the ventricle. H, the right half of the cerebellum
was removed by dividing the vermis sagittally and the cerebellar peduncles transversely. The tonsil has been removed and the
inferior medullary velum and the cranial loop of the PICA have been displaced downward to expose the opening into the lat-
eral recess. The dentate nucleus forms a prominence, the dentate tubercle, in the superolateral recess of the roof of the
fourth ventricle near the site of attachment of the inferior medullary velum. Dent., dentate; Inf., inferior; Lat., lateral; Med.,
medullary; Nucl., nucleus; P.I.C.A., posteroinferior cerebellar artery; Ped., peduncle; Sup., superior; Vel., velum.
of the hemisphere, removal of the tonsil, opening of the infe- the extremities (8, 11, 12, 16). Injury to the vestibular projec-
rior medullary velum, separation of tumor from the floor and tions from the brainstem to the flocculonodular lobe also
roof, dissection in the region of the cerebellar peduncles and causes nystagmus that is present in all directions of gaze.
deep cerebellar nuclei, and retraction or removal of the floc- Cerebellar mutism is a transient complication that may ap-
culus. Horsley pointed out that large amounts of cerebellar pear after removal of cerebellar tumors, usually in children,
tissue could be sacrificed with little or no demonstrable loss of characterized by lack of speech output in the awake patient,
function (13). A common approach to the fourth ventricle is with intact speech comprehension, sometimes associated with
by splitting the vermis on the suboccipital surface, as recom- oropharyngeal apraxia (2, 4, 24). Although the exact anatomic
mended by Dandy (3) and Kempe (15). Dandy stated that the substrate for the mutism remains unknown, the majority oc-
vermis could be opened at its center to gain access to fourth curred after removal of midline tumors involving the vermis
ventricular tumors without causing a disturbance of function, (2, 4, 24, 26). The inferior part of the vermis, including the
provided that the operator carefully avoided the dentate nu- pyramid, uvula, and nodule has been implicated.
clei (3). Small lesions in the vermis caused no symptoms or Hemispheric resection may be required to reach lesions of
deficit, but larger lesions of the uvula, nodule, and flocculus, the lateral part of the roof or the lateral recess of the fourth
involving cerebellar fibers related to the vestibular system, ventricle. Frazier resected the lateral part of the hemisphere
cause equilibratory disturbances, with truncal ataxia, stagger- without permanent sequelae (6). Unilateral resection of the
ing gait, and oscillation of the head and trunk on assumption part of the hemisphere lateral to the dentate nuclei results in
of the erect position without ataxia on voluntary movement of ataxia of voluntary movement, hypotonia, and adiadochoki-

S26 Rhoton
ksnesia in the ipsilateral limbs with errors in rate, range, direction, walls of the cerebellomedullary fissure, we have found that
and force of movement, which are often transient (8, 11, 12, 16). opening the tela alone will provide adequate ventricular ex-
If the ablation involves the dentate nucleus, these disturbances posure in most cases without splitting the vermis (20, 22, 23)
are more severe and enduring and there is, in addition, intention (Fig. 1.10). The inferior medullary velum, another paper-thin
tremor with voluntary movement of the extremities. During an layer, can also be opened if opening the tela does not provide
operation on the caudal part of the roof, one should remember adequate exposure. Opening the tela alone provides access to
that the denate nuclei are located just rostral to the superior pole the full length of the floor and all of the ventricular cavity
of the tonsils and are wrapped around the superolateral recess of except, possibly, the fastigium, superolateral recess, and the
the ventricle near the inferior medullary velum. Dysarthria re- superior half of the roof. Opening the inferior medullary
sults when resection extends into the paravermian part of the velum accesses the latter areas and the superior half of the
cerebellar hemisphere and occurs more frequently from left
roof. Extending the telar opening laterally toward the foramen
hemisphere injury than from vermal or right hemisphere injury
of Luschka opens the lateral recess and exposes the peduncu-
(17). Nystagmus with hemispheric lesions is associated with an
lar surfaces bordering the recess. Tumors in the fourth ven-
ocular rest point 10 to 30 degrees toward the unaffected side,
tricle may stretch and thin these two semi-translucent mem-
with greater oscillation upon looking to the side of the lesion.
The addition of a vermian lesion or a lesion extending to the branes to a degree that one may not be aware that they are
contralateral hemisphere produces more marked symptoms being opened in exposing a fourth ventricular tumor. There
than a unilateral hemispheric lesion and is associated with dis- are no reports of deficits following isolate opening of the tela
turbances of standing, walking, and speech. Lesions of the an- and velum. However, other structures exposed in the ventri-
terior part of the tentorial surface result in increased tone in the cle walls and at risk for producing the deficits described
muscles used for maintaining the erect posture. If the lateral half above include the dentate nuclei, cerebellar peduncles, floor
of this area is damaged, the hypertonia is predominantly in the of the fourth ventricle, and the PICA. During an operation on
ipsilateral extremities. the caudal part of the roof, one should remember that the
All of the cerebellar peduncles converge on the lateral wall dentate nuclei are located just rostral to the superior pole of
and roof and may be damaged here. The inferior and superior the tonsils underlying the dentate tubercles in the posterolat-
cerebellar peduncles are more likely to be injured during eral part of the roof where they are wrapped around the
procedures within the ventricle because they abut directly on superolateral recesses near the lateral edges of the inferior
the ventricular surface; the middle cerebellar peduncle would medullary velum (Figs. 1.9 and 1.10). All of the cerebellar
be more susceptible to injury in procedures near the external peduncles converge on the lateral wall and roof where they
wall such as those in the cerebellopontine angle because it may be damaged. The superior cerebellar peduncle is more
forms a major part of the cisternal surface of the ventricular likely to be injured during operations on lesions involving the
wall. Lesions of the middle cerebellar peduncle cause ataxia superior part of the roof above the level of the dentate tubercles;
and dysmetria during voluntary movement of the ipsilateral the inferior peduncles are most susceptible to damage in expos-
extremities with hypotonia similar to that produced by dam- ing lesions within the lateral recess; and the middle cerebellar
age to the lateral part of the hemisphere. Lesions of the peduncle is susceptible to injury in procedures near the external
superior cerebellar peduncle cause severe ipsilateral intention
wall of the superior half of the roof, such as those in the cerebel-
tremor, dysmetria, and decomposition of movement. The syn-
lopontine angle, because the middle peduncle forms a major part
drome is mild and subsides rapidly if there is only a partial
of the cisternal surface of the ventricular wall. The consequences
section of the peduncle. Section of the inferior cerebellar pe-
of removal or gentle manipulation of tumors attached to the
duncle causes disturbances of equilibrium similar to those
produced by ablation of the flocculonodular lobe, with truncal floor of the fourth ventricle have been reviewed.
ataxia and staggering gait. The PICA is frequently exposed in approaches directed
The consequences of removal or gentle manipulation of through the tela choroidea or inferior medullar velum, but
tumors attached to the floor of the fourth ventricle include only infrequently occluded during operative approaches to
intraoperative blood pressure decrease, apnea, and/or respi- the fourth ventricle. Occlusion of the branches of the PICA
ratory rate increase and postoperative diplopia, disturbances distal to the medullary branches at the level of roof of the fourth
of speech and swallowing, and poor cough reflex associated ventricle avoids the syndrome of medullary infarction but pro-
with incidental disturbances of gastrointestinal bleeding, as- duces a syndrome resembling labyrinthitis, which includes ro-
piration pneumonia, and electrolyte disturbances (1). tatory dizziness, nausea, vomiting, inability to stand or walk
unaided, and nystagmus without appendicular dysmetria (11).
The main trunk of the AICA is infrequently exposed in opening
Telovelar approach to fourth ventricle the cerebellomedullary fissure, but it may also send choroidal
Lesions of the fourth ventricle have posed a special chal- branches to the tela and choroid plexus in the lateral recess.
lenge to neurosurgeons because of the severe deficits that may
follow injury to the structures in the ventricular walls and Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro-
floor. In the past, operative access to the fourth ventricle was logical Surgery, University of Florida, Brain Institute, P.O. Box
obtained by splitting the cerebellar vermis or removing part of 100265, 100 South Newell Drive, Building 59, L2-100, Gainesville, FL
a cerebellar hemisphere (1, 3, 15). In examining the clefts and 32610-0265.

REFERENCES 15. Kempe LG: Operative Neurosurgery. New York, Springer-Verlag,

1970, vol 2, pp 14–17.
1. Baker GS: Physiologic abnormalities encountered after removal of 16. Larsell O: The cerebellum: A review and interpretation. Arch
brain tumors from the floor of the fourth ventricle. J Neurosurg Neurol Psychiatry 38:580–607, 1937.
23:338–343, 1965. 17. Lechtenberg R, Gilman S: Speech disorders in cerebellar disease.
2. Dailey AT, McKahann GM, Berger MS: The pathophysiology of Ann Neurol 3:285–290, 1978.
oral pharyngeal apraxia and mutism following posterior fossa 18. Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical
tumor resection in children. J Neurosurg 83:467–475, 1995. anatomy of the posterior inferior cerebellar artery. Neurosurgery
3. Dandy WE: The Brain. Hagerstown, WF Prior Co., 1966, pp 452–458. 10:170–199, 1982.
4. Dietze DD, Mickle JP: Cerebellar mutism after posterior fossa 19. Martin RG, Grant JL, Peace D, Theiss C, Rhoton AL Jr: Microsurgical
surgery. Pediatr Neurosurg 16:25–31, 1990–1991. relationships of the anterior inferior cerebellar artery and the facial-
5. Duvernoy HM: Human Brainstem Vessels. Berlin, Springer-Verlag,
vestibulocochlear nerve complex. Neurosurgery 6:483–507, 1980.
1978.
20. Matsushima T, Fukui M, Inoue T, Natori Y, Baba T, Fujii K:
6. Frazier CH: Remarks upon the surgical aspects of tumors of the
Microsurgical and magnetic resonance imaging anatomy of the
cerebellum. N Y State J Med 18:272–280, 332–337, 1918.
cerebellomedullary fissure and its application during fourth ven-
7. Fujii K, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the
tricle surgery. Neurosurgery 30:325–330, 1992.
choroidal arteries: Fourth ventricle and cerebellopontine angles.
21. Matsushima T, Rhoton AL Jr, de Oliveira E, Peace D: Microsur-
J Neurosurg 52:504–524, 1980.
gical anatomy of the veins of the posterior fossa. J Neurosurg
8. Fulton JF, Dow RS: The cerebellum: A summary of functional
59:63–105, 1983.
localization. Yale J Biol Med 10:89–119, 1937.
9. Hardy DG, Rhoton AL Jr: Microsurgical relationship of the supe- 22. Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the
rior cerebellar artery and the trigeminal nerve. J Neurosurg 49: fourth ventricle: Part I—Microsurgical anatomy. Neurosurgery
669–678, 1978. 11:631–667, 1982.
10. Hardy DG, Peace DA, Rhoton AL Jr: Microsurgical anatomy of 23. Mussi A, Rhoton AL Jr: Telovelar approach to the fourth ventricle:
the superior cerebellar artery. Neurosurgery 6:10–28, 1980. Microsurgical anatomy. J Neurosurg 92:812–823, 2000.
11. Holmes G: The Croonian lectures on the clinical symptoms of 24. Pollack IF, Polinko P, Albright L, Towbin R, Fitz C: Mutism and
cerebellar disease and their interpretation. Lancet 1:1177–1182, pseudobulbar symptoms after resection of posterior fossa tumors
1231–1237, 1922. in children: Incidence and pathophysiology. Neurosurgery 37:
12. Holmes G: The Croonian lectures on the clinical symptoms of 885–893, 1995.
cerebellar disease and their interpretation. Lancet 2:59–65, 111– 25. Rhoton AL Jr: Microsurgical anatomy of posterior fossa cranial
115, 1922. nerves, in Barrow DL (ed): Surgery of the Cranial Nerves of the Posterior
13. Horsley V: On the technique of operations on the central nervous Fossa: Neurosurgical Topics. Chicago, AANS, 1993, pp 1–103.
system. Br Med J 2:411–423, 1906. 26. Van Calenbergh F, Van de Laar A, Plets C, Goffin J, Casaer P:
14. Johnston TB: A note on the peduncle of the flocculus and the Transient cerebellar mutism after posterior fossa surgery in chil-
posterior medullary velum. J Anat 68:471–479, 1934. dren. Neurosurgery 37:894–898, 1995.
Cranial floor and contents of the

posterior fossa. Vesalius (1514 –1564) was
only 28 years old when his publication
was printed. The woodcuts, with their
innovative landscape background, were
by Jan Stephan Kalkar. From, Andreas
Vesalius, De Humani Corporis Fabrica.
Basel, Ex officina Ioannis Oporini, 1543.
Courtesy, Rare Book Room, Norris
Medical Library, Keck School of
Medicine, Los Angeles, California. (Also
see pages S68, S209, and S285.)

Deep dissection exposing posterior skeletal and neural structures. Although Eustachio’s anatomical plates were originally engraved
in 1552, they were not printed until 160 years later. From, Bartolommeo Eustachio, Tabulae anatomicae. Rome, Sumptibus
Laurentii & Thomae Pagliarini, 1728. Courtesy, Rare Book Room, Norris Medical Library, Keck School of Medicine, Los Angeles,
California. (Also see pages S2, S130, S154, S194 and S298).
CHAPTER 2
The Cerebellar Arteries

Key words: Anteroinferior cerebellar artery, Cerebellum, Cerebrovascular disease, Cranial nerves, Microneurosurgery, Posterior cranial fossa,
Posteroinferior cerebellar artery, Superior cerebellar artery
O
ptimizing operative approaches to the posterior fossa relationship to the abducens, facial, and vestibulocochlear
requires an understanding of the relationship of the nerves to reach the surface of the middle cerebellar peduncle,
cerebellar arteries to the cranial nerves, brainstem, where it courses along the cerebellopontine fissure and ter-
cerebellar peduncles, fissures between the cerebellum and minates by supplying the petrosal surface of the cerebellum.
brainstem, and the cerebellar surfaces (45). When examining The lower complex includes the PICA, medulla, inferior
these relationships, three neurovascular complexes are de- cerebellar peduncle, cerebellomedullary fissure, suboccipital
fined: an upper complex related to the superior cerebellar surface of the cerebellum, and the glossopharyngeal, vagus,
artery (SCA); a middle complex related to the anteroinferior spinal accessory, and hypoglossal nerves. The PICA arises at
cerebellar artery (AICA); and a lower complex related to the the medullary level, encircles the medulla, passing in relation-
posteroinferior cerebellar artery (PICA) (Figs. 2.1 and 2.2) (35). ship to the glossopharyngeal, vagus, accessory, and hypoglos-
Other structures, in addition to the three cerebellar arteries, sal nerves to reach the surface of the inferior cerebellar pe-
occurring in sets of three in the posterior fossa that bear a duncle, where it dips into the cerebellomedullary fissure and
consistent relationship to the SCA, AICA, and PICA are the terminates by supplying the suboccipital surface of the
parts of the brainstem (midbrain, pons, and medulla); the cerebellum.
cerebellar peduncles (superior, middle, and inferior); the fis-
sures between the brainstem and the cerebellum (cerebel-
lomesencephalic, cerebellopontine, and cerebellomedullary); THE SUPERIOR CEREBELLAR ARTERY
and the surfaces of the cerebellum (tentorial, petrosal, and
suboccipital). Each neurovascular complex includes one of the Overview
three parts of the brainstem, one of the three surfaces of the The SCA or its branches are exposed in surgical approaches
cerebellum, one of the three cerebellar peduncles, and one of to the basilar apex, tentorial incisura, trigeminal nerve, cer-
the three major fissures between the cerebellum and the brain- ebellopontine angle, pineal region, clivus, and the upper part
stem. In addition, each neurovascular complex contains a of the cerebellum (18, 19).
group of cranial nerves. The upper complex includes the The SCA is intimately related to the cerebellomesencephalic
oculomotor, trochlear, and trigeminal nerves that are related fissure, the superior half of the fourth ventricular roof, the
to the SCA. The middle complex includes the abducens, facial, superior cerebellar peduncle, and the tentorial surface (Figs.
and vestibulocochlear nerves that are related to the AICA. The 2.3-2.5). The SCA arises in front of the midbrain, usually from
lower complex includes the glossopharyngeal, vagus, acces- the basilar artery near the apex, and passes below the oculo-
sory, and hypoglossal nerves that are related to the PICA. motor nerve, but may infrequently arise from the proximal
In summary, the upper complex includes the SCA, mid- PCA and pass above the oculomotor nerve. It dips caudally
brain, cerebellomesencephalic fissure, superior cerebellar pe- and encircles the brainstem near the pontomesencephalic
duncle, tentorial surface of the cerebellum, and the oculomo- junction, passing below the trochlear nerve and above the
tor, trochlear, and trigeminal nerves. The SCA arises in front trigeminal nerve. Its proximal portion courses medial to the
of the midbrain, passes below the oculomotor and trochlear free edge of the tentorium cerebelli, and its distal part passes
nerves and above the trigeminal nerve to reach the cerebel- below the tentorium, making it the most rostral of the infrat-
lomesencephalic fissure, where it runs on the superior cere- entorial arteries. After passing above the trigeminal nerve, it
bellar peduncle and terminates by supplying the tentorial enters the cerebellomesencephalic fissure, where its branches
surface of the cerebellum. make several sharp turns and give rise to the precerebellar
The middle complex includes the AICA, pons, middle cer- arteries, which pass to the deep cerebellar white matter and
ebellar peduncle, cerebellopontine fissure, petrosal surface of the dentate nucleus. On leaving the cerebellomesencephalic
the cerebellum, and the abducens, facial, and vestibuloco- fissure where its branches are again medial to the tentorial
chlear nerves. The AICA arises at the pontine level, courses in edge, its branches pass posteriorly under the tentorial edge

S30 Rhoton
FIGURE 2.1. Each of the three

neurovascular complexes in the
posterior fossa includes one of the
three cerebellar arteries, one of
the three parts of the brainstem,
one of the three cerebellar
peduncles, one of the three
cerebellar surfaces, one of the
three fissures between the
brainstem and the cerebellum,
and one of the three groups of
cranial nerves. The upper complex
is related to the SCA, the middle
complex is related to the AICA,
and the lower complex is related
to the PICA. The upper complex
includes the SCA, midbrain,
superior cerebellar peduncle,
cerebellomesencephalic fissure,
tentorial cerebellar surface, and
the oculomotor, trochlear, and
trigeminal nerves. The middle complex includes the PICA, pons, middle cerebellar peduncle, cerebellopontine fissure,
petrosal surface, and the abducens, facial, and vestibulocochlear nerves. The lower complex includes the PICA, medulla,
inferior cerebellar peduncle, cerebellomedullary fissure, suboccipital surface, and the glossopharyngeal, vagus, accessory, and
hypoglossal nerves. The SCA is divided into four segments: anterior pontomesencephalic (green), lateral pontomesencephalic
(orange), cerebellomesencephalic (blue), and cortical (red ). Each segment may be composed of one or more trunks,
depending on the level of bifurcation of the main trunk. The AICA is divided into four segments: anterior pontine (green),
lateral pontomedullary (orange), flocculonodular (blue), and cortical (red ). The PICA is divided into five segments: anterior
medullary (green), lateral medullary (orange), tonsillomedullary (blue), telovelotonsillar (yellow), and cortical (red ). A.I.C.A.,
anteroinferior cerebellar artery; CN, cranial nerve; Fiss., fissure; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery;
S.C.A., superior cerebellar artery.
and are distributed to the tentorial surface. It usually arises as Lateral pontomesencephalic segment
a single trunk, but may also arise as a double (or duplicate)
This segment begins at the anterolateral margin of the
trunk. The SCAs arising as a single trunk bifurcate into a
brainstem and frequently dips caudally onto the lateral side of
rostral and a caudal trunk. The SCA gives off perforating
the upper pons (Figs. 2.1, 2.7, and 2.8). Its caudal loop projects
branches to the brainstem and cerebellar peduncles. Precer-
toward and often reaches the root entry zone of the trigeminal
ebellar branches arise within the cerebellomesencephalic fis-
nerve at the midpontine level. The trochlear nerve passes
sure. The rostral trunk supplies the vermian and paravermian
above the midportion of this segment. The anterior part of this
area and the caudal trunk supplies the hemisphere on the
segment is often visible above the tentorial edge, but the
suboccipital surface. The SCA frequently has points of contact
caudal loop usually carries it below the tentorium. This seg-
with the oculomotor, trochlear, and trigeminal nerves.
ment terminates at the anterior margin of the cerebellomes-
encephalic fissure. The basal vein and the PCA course above
Segments and parallel to this SCA.
The SCA is divided into four segments: anterior pontomes- Cerebellomesencephalic segment
encephalic, lateral pontomesencephalic, cerebellomesence-
phalic, and cortical (Fig. 2.1). Each segment may be composed This segment courses within the cerebellomesencephalic
of one or more trunks, depending on the level of bifurcation fissure (Figs. 2.7-2.9). The SCA branches enter the shallowest
of the main trunk (Fig. 2.6). part of the fissure located above the trigeminal root entry zone
and again course medial to the tentorial edge with its
branches intertwined with the trochlear nerve. The fissure in
Anterior pontomesencephalic segment which the SCA proceeds progressively deepens medially and
This segment is located between the dorsum sellae and the is deepest in the midline behind the superior medullary ve-
upper brainstem. It begins at the origin of the SCA and lum. Through a series of hairpin-like curves, the SCA loops
extends below the oculomotor nerve to the anterolateral mar- deeply into the fissure and passes upward to reach the ante-
gin of the brainstem. Its lateral part is medial to the anterior rior edge of the tentorial surface. The trunks and branches of
half of the free tentorial edge. the SCA are held in the fissure by branches that penetrate the

Cerebellar Arteries S31
FIGURE 2.2. A, anterior view of

the brainstem and cerebellar
arteries. B, posterior view of the
cranial base with the cranial
nerves and arteries preserved.
A and B, the SCA arises at the
midbrain level and encircles
the brainstem near the
pontomesencephalic junction. The
SCA courses below the oculomotor
and trochlear nerves and above the
trigeminal nerve. The SCA loops
down closer to the trigeminal nerve
in B than in A. The AICA arises at
the pontine level and courses by
the abducens, facial, and
vestibulocochlear nerves. In A,
both AICAs pass below the
abducens nerves. In B, the left
abducens nerve passes in front of
the AICA and the right abducens
nerve passes behind the AICA.
The PICAs arise from the vertebral
artery at the medullary level and
course in relation to the
glossopharyngeal, vagus, accessory,
and hypoglossal nerves. The origin
of the SCAs are quite symmetrical
from side to side. There is slight
asymmetry in the level of origin of
the AICAs and marked asymmetry
in the level of the origin of the
PICAs, especially in A. A., artery;
A.I.C.A., anteroinferior cerebellar
artery; Ant., anterior; CN, cranial
nerve; P.C.A., posterior cerebral
artery; P.I.C.A., posteroinferior
cerebellar artery; S.C.A.,
superior cerebellar artery; Sp.,
spinal; Vert., vertebral.
fissure’s opposing walls. Identification of individual branches of the SCA, although rare, has been reported (50). In our
of the SCA within this fissure is made difficult by the sharp previous study of 50 SCAs, 43 arose as a single trunk and 7
curves of the branches and by the large number of intermin- arose as two (duplicate) trunks (19). Duplicate trunks were
gled arterial loops. present bilaterally in only one of the brains we examined.
Triplication of the origin is rare. All but 2 of the 50 SCAs
Cortical segment examined arose from the basilar artery. The two exceptions
arose solely or in part from the posterior cerebral artery and
This segment includes the branches distal to the cerebel-
passed above the oculomotor nerve, after which they followed
lomesencephalic fissure that pass under the tentorial edge and
are distributed to the tentorial surface and, if a marginal the typical distal course. The solitary trunk of nonduplicated
branch is present, to the upper part of the petrosal surface SCAs and the rostral trunk of duplicate SCAs usually arise
(Figs. 2.6-2.9). from the basilar artery below, but directly adjacent to, the
origin of the PCA. The arteries not arising adjacent to the origin
of the PCA arise within 2.5 mm of the PCA origin.
Origin The origin of the right and left SCAs and PCAs frequently
The SCA is the most consistent of the infratentorial cere- takes a cruciate configuration in which the limbs cross at the
bellar arteries in its presence and area of supply (49). Absence apex of the basilar artery (Fig. 2.2). The height of the bifurca-

S32 Rhoton
FIGURE 2.3. Relationships of the cere-

bellar arteries. A, posterior view with
the left and part of the right half of the
cerebellum removed. B, lateral view
with the left half of the cerebellum re-
moved to expose the fourth ventricle.
The SCAs (yellow) are intimately related
to the superior half of the fourth ven-
tricular roof and the cerebellomesence-
phalic fissure; the AICAs (orange) are
intimately related to the cerebellopon-
tine fissures and the lateral recesses;
and the PICAs (red ) are intimately re-
lated to the caudal half of the roof and
the cerebellomedullary fissure. The
SCAs pass around the midbrain above
the trigeminal nerve and divide into
rostral and caudal trunks. The branches
of these trunks loop deeply into the
cerebellomesencephalic fissure and give
off the precerebellar arteries, which
pass along the superior cerebellar pe-
duncles to the dentate nuclei. The PI-
CAS arise from the vertebral arteries
and pass between the glossopharyngeal,
vagus, and accessory nerves to reach
the cerebellomedullary fissure. After
passing near the caudal pole of the ton-
sils, where they form a caudal loop,
they ascend through the cerebellomed-
ullary fissure, where they are intimately
related to the caudal part of the ven-
tricular roof. They pass around the ros-
tral pole of the tonsil and through the
telovelotonsillar cleft, where they form
a cranial loop. In their course around
the tonsils, they divide into medial and
lateral trunks. They give off branches to
the dentate nuclei near the superior
pole of the tonsils. The AICAs arise
from the basilar artery and pass near or
between the facial and vestibuloco-
chlear nerves and are intimately related
to the cerebellopontine fissures, the
flocculi, and the lateral recesses. The
AICAs divide into rostral and caudal
trunks before reaching the facial and
vestibulocochlear nerves. The rostral
trunk passes between the nerves and
along the middle cerebellar peduncle
near the cerebellopontine fissure. The
caudal trunk passes below the nerves
and near the lateral recess to supply the lower part of the petrosal surface. The AICA and the PICA give rise to the choroidal arteries,
which supply the tela choroidea and attached choroid plexus. (From, Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the fourth
ventricle: Part I—Microsurgical anatomy. Neurosurgery 11:631–667, 1982 [35].) A., artery; A.I.C.A., anteroinferior cerebellar artery; B.,
basilar; Ca., caudal; Cer., cerebellar; Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; Ch., choroid, choroidal; Coll.,
colliculus; Dent., dentate; F., foramen; Inf., inferior; Lat., lateral; Med., medial, medullary; Mid., middle; Nucl., nucleus; P.C.A., posterior
cerebral artery; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Pl., plexus; Ro., rostral; S.C.A., superior cerebellar artery; Sup.,
superior; Tr., trunk; V., vein; V.A., vertebral artery; Vel., velum.

FIGURE 2.4. A–D. Cerebellar

arteries, brainstem, and
cerebellar-brainstem fissures. A,
posterolateral view. The SCA
passes around the midbrain to
enter the cerebellomesencephalic
fissure, where it sends perforating
branches into the posterior
midbrain below a line between
the superior and inferior colliculi,
and down the superior peduncle
to the dentate nucleus. The AICA
loops around the flocculus and
the facial and vestibulocochlear
nerves. The left PICA passes
between the rootlets of the nerves
entering the jugular foramen and
turns caudally around the lower
pole of the left tonsil, which has
been removed, and then ascends
to form a cranial loop at the
upper pole of the tonsil bordering
the inferior half of the ventricular
roof. B, another specimen. The
left half of the cerebellum has
been removed. The SCA passes
around the midbrain below the
PCA in the lower part of the
ambient and quadrigeminal
cisterns, enters the
and loops over the posterior lip of
the fissure to supply the tentorial
surface. The PICA arises from the
vertebral artery, passes around
the medulla, crosses the inferior
cerebellar peduncle, and enters
the cerebellomedullary fissure,
where it passes along the inferior
half of the ventricular roof, and
exits the fissure to supply the
suboccipital surface. The AICA
passes laterally around the pons
and above the flocculus. C,
enlarged oblique view. The right
PICA loops around the caudal
and rostral poles of the tonsil. The left PICA dips below the level of the foramen magnum. D, posterior view after removing
all of the cerebellum except for the right tonsil and dentate nucleus. A., artery; A.I.C.A., anteroinferior cerebellar artery;
Caud., caudal; Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; Chor., choroid; CN, cranial nerve; Cran.,
cranial; Dent., dentate; Fiss., fissure; Flocc., flocculus; Inf., inferior; Mid., middle; Nucl., nucleus; P.C.A., posterior cerebral
artery; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; S.C.A., superior cerebellar artery; Sup.,
superior; Vent., ventricle; Vert., vertebral.
tion of the basilar artery is an important determinant of the alon, and low if it is anterior to the pons. The origin of the
initial course (47, 59). The level of the bifurcation of the basilar SCA is above the edge of the tentorium if the bifurcation is
artery is normal if the bifurcation occurs at the pontomesen- high, medial to the free edge if it is normal, and below the
cephalic junction, high if it occurs anterior to the mesenceph- tentorium if it is low. In our study, the bifurcation was in a

S34 Rhoton
FIGURE 2.4. E and F.

Cerebellar arteries, brainstem,
and cerebellar-brainstem fis-
sures. E, the SCA passes above
the trigeminal nerve and en-
ters the cerebellomesence-
phalic fissure, where it sends
branches down the superior
peduncle to the dentate
nucleus. The PICA passes
between the vagus and
accessory nerves and courses
on the inferior peduncle to
reach the cerebellomedullary
fissure. F, enlarged view of
the lateral recess. The
flocculus and choroid plexus
project laterally from the
margin of the foramen of
Luschka into the
cerebellopontine angle,
behind the glossopharyngeal
and vagus nerves and above
the PICA. The hypoglossal
rootlets arises from the me-
dulla in front of the glossopharyngeal and vagus nerves and cross the posterior surface of the vertebral artery. Some hy-
poglossal rootlets pass above and others below the PICA origin.
normal position in 18 of the 25 brains that we examined, high by the rostral trunk. The diameters of the rostral and caudal
in 6, and low in 1. Three of the six arteries with a high bifurcation trunks are approximately equal, but if one is smaller, it is
were associated with a fetal origin of the PCA (47). usually the caudal trunk. If one trunk is small, the other
The length of the basilar artery ranges from 20 to 40 mm supplies a larger area. The caudal trunk rarely sends branches
(average, 30) and its diameter is greater at its origin from the to the vermis.
vertebral arteries, range from 3 to 8 mm (average, 5–6 mm)
than at its apex (range, 3–7 mm; mean, 4–5 mm). The basilar
artery is usually straight or deviates a short distance off the Branches
midline, but a few will deviate laterally as far as the origin of
the abducens nerve or the facial and vestibulocochlear nerves Perforating arteries
(18, 19). These perforating branches are divided into a direct and
circumflex type (Fig. 2.7). The direct type pursues a straight
course to enter the brainstem. The circumflex type winds
Bifurcation around the brainstem before terminating in it. The circumflex
All of the SCAs that arise as a single vessel bifurcate into perforating arteries are subdivided into short and long types.
two major trunks, one rostral and one caudal (Fig. 2.10). This The short circumflex type travels 90 degrees or less around
bifurcation occurs between 0.6 and 34.0 mm (average, 19 mm) the circumference of the brainstem. The long circumflex type
from the origin, most commonly near the point of maximal travels a greater distance to reach the opposite surface. Both
caudal descent of the artery on the lateral side of the brain- types of circumflex arteries send branches into the brainstem
stem. Rostral and caudal trunks are present in nearly every along their course.
hemisphere as a result of either a duplicate origin or the Perforating branches arise from the great majority of main,
bifurcation of a main artery. The rostral and caudal trunks rostral, and caudal trunks. Most trunks give rise to two to five
formed by a duplicate origin, referred to as rostral and caudal perforating branches, although some may give rise to no
duplicate SCAs, have a distribution equivalent to that of the perforators and others to as many as 10. The most common
rostral and caudal trunks formed by the bifurcation of a type of perforating artery arising from the main trunk is the
solitary SCA. long circumflex type, but it also gives rise to direct and short
The rostral trunk terminates by supplying the vermis and a circumflex branches. In descending order, the main trunk
variable portion of the adjacent hemisphere. The caudal trunk branches terminate in the tegmentum in the region of the
supplies the hemispheric surface lateral to the area supplied junction between the superior and middle cerebellar pe-

FIGURE 2.5. A–D. Cerebellar arteries. Superior views. A, both SCAs arise as duplicate arteries at the midbrain level and
accompany the basal vein around the brainstem to enter the cerebellomesencephalic fissure. They pass below the oculomotor
and trochlear nerves and above the trigeminal nerves. The SCA trunks are intertwined with the trochlear nerve on the pos-
terolateral brainstem. B, the level of the brainstem section has been extended downward to the pons. The rostral and caudal
trunks of the duplicate SCAs arise directly from the side of the basilar artery and pass laterally above the trigeminal nerve.
C, the brainstem section has been extended downward to the midpons. The trigeminal, oculomotor, and trochlear nerves
have been divided so that the brainstem could be reflected backward to expose the AICA and the facial and vestibuloco-
chlear nerves. Both AICAs pass below the abducens nerves and loop laterally toward the internal acoustic meatus. The left
PICA loops upward in front of the pons between the facial and vestibulocochlear nerves and the AICA before turning down-
ward to encircle the medulla. D, enlarged view. The right AICA loops laterally into the porus of the internal acoustic meatus,
as occurs in approximately half of cases. The AICA has a premeatal segment that passes toward the meatus, a meatal segment
that loops into the porus in about half of cerebellopontine angles, and a postmeatal segment that loops back to the brain-
stem. The vestibulocochlear nerve has been retracted to expose the nervus intermedius, which arises at the brainstem along
the anterior surface of the vestibulocochlear nerve, has a free segment in the cerebellopontine angle, and joins the facial
nerve as it proceeds laterally toward the meatus. The AICA gives rise to a recurrent perforating branch to the brainstem. A.,
artery; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Bridg., bridging; Cer. Mes., cerebellomesencephalic; CN, cranial
nerve; Fiss., fissure; Flocc., flocculus; Intermed., intermedius; Meat., meatal; Mes., mesencephalic; Nerv., nervus; P.C.A., pos-
terior cerebral artery; Ped., peduncle; Perf., perforating; P.I.C.A., posteroinferior cerebellar artery; Premeat., premeatal; Rec.,
recurrent; S.C.A., superior cerebellar artery; Seg., segment; V., vein; Vent., ventrical; Vert., vertebral.
duncles, the interpeduncular fossa (usually the direct type), colliculi. In descending order, they terminate in the junction
the cerebral peduncle, and the collicular region. between the superior and middle cerebellar peduncles, the
The branches from the rostral and caudal trunk are most inferior colliculus, the cerebral peduncle, and the interpedun-
frequently circumflex. They course around the brainstem to cular fossa.
reach two main areas: the region of the junction of the supe- The basilar artery also gives rise to multiple perforating
rior and middle cerebellar peduncles and the quadrigeminal branches to the brainstem. Those arising near the origin of the
cistern below the sulcus between the superior and inferior SCA intermingle with the direct perforating branches arising

S36 Rhoton
FIGURE 2.5. E–H. Cerebellar arteries. E, enlarged view. The left AICA arises from the basilar artery and passes laterally
toward the porus of the internal acoustic meatus before turning medially between the facial and vestibulocochlear nerves.
The tortuous PICA loops upward between the AICA and the facial nerve before turning downward. F, the AICA and the
nerves entering the internal acoustic meatus have been divided. The PICA loops upward before turning caudally and passing
between the rootlets of the vagus and accessory nerves. The hypoglossal nerve arises from the brainstem in front of the olive.
One of the rootlets of the hypoglossal nerve loops upward around the origin of the PICA before descending to join the other
rootlets at the hypoglossal canal. A bridging vein passes from the medulla to the jugular bulb. G, the section has been
extended downward to the level of the medulla to show the perforating branches of the vertebral and basilar arteries enter-
ing the medullary pyramids and the lateral medulla. The glossopharyngeal, vagus, and accessory nerves arise dorsal to the
olives. The hypoglossal nerve arises ventral to the olives and passes behind the vertebral arteries. H, the medullary section
has been extended caudally. The level of the PICA origins from the vertebral arteries are asymmetric. The right PICA inter-
mingles with multiple rootlets of the hypoglossal nerve, while the left PICA, which arises at a higher level, has only the upper
hypoglossal rootlet stretched around it. The PICAs encircle the medulla and appear on the dorsal surface behind the fourth
ventricle. The left is larger than the right vertebral artery.
from the proximal SCA. Those arising above the origin of the cult. These precerebellar branches tether the distal parts of the
SCA enter the interpeduncular fossa. trunks and the proximal parts of the cortical arteries in the
fissure. The precerebellar arteries consist of a medial group of
small branches that pass between the superior medullary velum
Precerebellar branches and the central lobule and a lateral group of larger branches that
The precerebellar arteries arise from the trunks and cortical course between the superior and middle cerebellar peduncles
branches within the cerebellomesencephalic fissure (Figs. 2.7- and the wings of the central lobule. The cortical arteries supply-
2.9). As many as eight precerebellar arteries may arise within ing the hemispheric surface lateral to the vermis send precer-
the fissure and these, along with the trunks and cortical ebellar branches that reach the dentate and deep cerebellar nu-
branches and their sharp turns in the fissure, create a com- clei, and those terminating in the vermis send branches to the
plexity that makes arterial dissection and identification diffi- inferior colliculi and the superior medullary velum.

FIGURE 2.6. The SCA, cerebellomesencephalic fissure, and tentorial surface. Superior views. A, the SCAs pass around the
midbrain to enter the cerebellomesencephalic fissure and, after a series of hairpin turns in the fissure, loop over the posterior
lip of the fissure to reach the tentorial surface. The lower part of the quadrigeminal cistern extends in the cerebellomesence-
phalic fissure. The tentorial surface slopes downward from the apex just behind the fissure. B, anterosuperior view. The left
SCA arises on a duplicate artery. In their initial course, the SCAs loop laterally below the tentorial edge, but further posteri-
orly, they pass medially under the tentorial edge to enter the cerebellomesencephalic fissure. C, another cerebellum. The
SCAs loop into the cerebellomesencephalic fissure, where they undergo a series of hairpin turns before exiting the fissure to
supply the tentorial surface. D, the posterior lip of the fissure has been retracted to expose the branches of the SCA within
the fissure. Cer. Mes., cerebellomesencephalic; Cist., cistern; CN, cranial nerve; Coll., colliculus; Dup., duplicate; Fiss., fis-
sure; Inf., inferior; P.C.A., posterior cerebral artery; Pet., petrosal; Quad., quadrigeminal; S.C.A., superior cerebellar artery;
Str., straight; Sup., superior; Tent., tentorial; V., vein.
Cortical arteries the vermis is divided into medial and paramedian segments
and each hemisphere lateral to the vermis is divided into
The most constant cortical supply of the SCA is to the
medial, intermediate, and lateral segments, because the most
tentorial surface (Figs. 2.6-2.9). The cortical territory of the
frequent pattern includes two vermian arteries and three
SCA is more constant than that of the AICA and PICA, but is
hemispheric arteries corresponding to these segments.
reciprocal with them. The SCA usually supplies the majority
of the tentorial surface and frequently the adjacent upper part Hemispheric arteries
of the petrosal surface. The maximal field of supply includes
a full half of the tentorial surface with overlap onto the The hemispheric branches arise from the rostral and caudal
opposite half of the vermis, the superior part of the suboccip- trunks in the depths of the cerebellomesencephalic fissure.
ital surface, and the upper two-thirds of the petrosal surface, They give rise to the precerebellar arteries, which bind their
including both lips of the petrosal fissure. The smallest field of proximal parts within the cerebellomesencephalic fissure.
supply includes only the part of the tentorial surface that lies After leaving the fissure, the hemispheric branches proceed
anterior to the tentorial fissure. to supply the tentorial surface lateral to the vermis. The
The cortical branches are divided into hemispheric and rostral and caudal trunks together most commonly give rise
vermian groups (Fig. 2.7). The cortical surface of each half of to three, but sometimes as many as five, hemispheric

S38 Rhoton
FIGURE 2.7. Relationships of the

SCA. A, left lateral view of the
SCA with part of the cerebellum
removed to show the termination
of the superior cerebellar
peduncle in the dentate nucleus.
The main trunk of the SCA passes
below the oculomotor and
trochlear nerves and above the
trigeminal nerve and splits into
rostral and caudal trunks. The
optic tract and short circumflex
arteries pass around the
brainstem. The precerebellar
arteries arise in the
supply the adjoining cerebellum
and the inferior colliculus, and
send branches along the superior
cerebellar peduncle to the dentate
nucleus. The superior colliculus is
supplied predominantly by the
PICA. The rostral and caudal
trunks split into vermian and
lateral, medial, and intermediate
hemispheric arteries. B, superior
view with the superior lip of
cerebellomesencephalic fissure
removed to show branches within
the fissure. The circumflex
perforating arteries terminate in
the inferior colliculus and the
region of the junction of the
superior and middle cerebellar
peduncles. The precerebellar
branches pass along the superior
cerebellar peduncles to the dentate nucleus. The right half of the vermis is supplied by a large vermian artery and the
hemispheric surface is supplied by medial, intermediate, and lateral hemispheric arteries. (From, Hardy DG, Peace DA,
Rhoton AL Jr: Microsurgical anatomy of the superior cerebellar artery. Neurosurgery 6:10–28, 1980 [19].) A., artery; A.I.C.A.,
anteroinferior cerebellar artery; Ant., anterior; B., basilar; Bo., body; Ca., caudal; Cer., cerebellar; Circ., circumflex; Co.,
communicating; Coll., colliculus; Dent., dentate; Gen., geniculate; He., hemispheric; Inf., inferior; Int., intermediate; L., long;
Lat., lateral; Med., medial; Nucl., nucleus; O., optic; P., posterior; P.C.A., posterior cerebral artery; Ped., peduncle; Ro.,
rostral; S., short; Sup., superior; Tr., trunk; V., ventricle or vertebral; Ve., vermian.
branches. There is a reciprocal relationship between the medial hemispheric segment, and the marginal artery (to be
hemispheric arteries. If one is small, the adjacent ones are described later) overlaps the lateral hemispheric segment. The
large and supply the territory normally supplied by the whole tentorial hemispheric surface was supplied by a branch
more rudimentary vessel. of the caudal trunk in one hemisphere and by branches aris-
The most common pattern is three hemispheric branches: ing from the rostral trunk in one other hemisphere. On reach-
lateral, intermediate, and medial corresponding to the third of ing the tentorial surface, the hemispheric arteries split into
the hemispheric surface that they supply. Each branch sup- one to seven (average, three) sub-branches, which arborize
plies approximately one-third of the tentorial surface of the over the tentorial surface and terminate by disappearing be-
hemisphere. However, there are frequent exceptions in which tween the cerebellar folia.
the hemispheric areas are supplied by two branches or by
branches from the adjacent hemispheric segments. The medial
segment is most frequently supplied from the rostral trunk Vermian arteries
and the lateral segment is most often supplied from the caudal The vermian arteries arise from the rostral trunk within the
trunk. The vermian arteries occasionally overlap onto the cerebellomesencephalic fissure. The rostral trunk most com-

monly gives rise to two vermian arteries (maximum four). If Trochlear nerve
the vermian branches on one side are hypoplastic, their area is
The trochlear nerve arises below the inferior colliculus and
supplied by branches from the contralateral SCA. The most
passes forward in the cerebellomesencephalic fissure (Figs.
common pattern is two vermian arteries: one distributed to a
2.4, 2.5, and 2.10). It passes from the medial to the lateral side
medial strip bordering the midline and one distributed to a
of the branches of the rostral and caudal trunks as it passes
paramedian strip bordering the hemispheric surface. Anasto-
forward within the fissure. On reaching the lateral side of the
moses between vermian branches from the two sides are
brainstem, it courses between the lower surface of the tento-
frequent near the apex of the tentorial surface.
rium and the SCA. The nerve has points of contact with the SCA
trunks in almost all cases. This contact may involve the main,
Marginal branch rostral, or caudal trunk, or both the rostral and caudal trunks.
About half of the proximal SCA trunks give rise to a mar- The point of contact with the nerve averages 17 mm (range, 4–30
ginal branch to the adjacent petrosal surface (Figs. 2.9 and mm) from the origin of the nerve and 24 mm (range, 13–38 mm)
2.10). When present, the marginal branch is the first cortical from the origin of the SCA (18).
branch. It usually arises from the lateral pontomesencephalic
segment and does not enter the cerebellomesencephalic fis- Trigeminal nerve
sure, as do the other cortical branches, but passes from its The trigeminal nerve arises from the lateral part of the pons
origin to the cortical surface. It may also arise from the caudal and runs obliquely upward (Figs. 2.8 and 2.10). It exits the
or main trunk or from the basilar artery as a variant of a posterior cranial fossa by passing forward beneath the tento-
duplicate origin of the SCA. Its most constant supply is to the rial attachment to enter Meckel’s cave. The SCA encircles the
part of the petrosal surface adjoining the tentorial surface. Its brainstem above the trigeminal nerve, making a shallow cau-
largest area of supply includes the full extent of the superior dal loop on the lateral side of the pons (18). Contact occurs
part of the petrosal surface and both lips of the petrous fissure. between the SCA and the trigeminal nerve in those cases with
Its area of supply is inversely related to the size of the petrosal the most prominent caudally projecting loops. About half of
surface area supplied by the AICA. The AICA or its branches the SCAs have a point of contact with the SCA, which, de-
supply the majority of the petrosal fissure if the marginal artery pending on the site of bifurcation, may involve the main,
is small or absent. Anastomoses between the marginal ar- rostral, caudal or both the rostral and caudal trunks, or a
tery and the AICA are frequent and are most prominent if marginal hemispheric branch. The diameter of the vessel at
the marginal branch is large. Perforating branches arising the point of contact averages 1 to 2 mm, but may range from
from the marginal branch terminate in the region of the less than 2 to nearly 3 mm. The distance between the origin of
middle cerebellar peduncle. the vessel and the point of contact with the trigeminal nerve
varies from 15 to 33 mm (average, 21 mm). The separation
Relationship to the cranial nerves between the SCA and the 24 trigeminal nerves, without a
neurovascular contact ranges from less than 1 to 8 mm (aver-
The SCA passes near and frequently has points of contact age, 3 mm).
with the oculomotor, trochlear, or trigeminal nerves (Figs. 2.2, The point of contact with the SCA is usually on the superior
2.5, and 2.8). or superomedial aspect of the nerve. Often a few fascicles of
the nerve are indented or distorted by the vessel 3 to 4 mm,
Oculomotor nerve but as much as 12 mm peripheral to the point of entry into the
The proximal part of the SCA passes below and is sepa- pons. In 6 of the 50 specimens we examined, the contact was
rated from the PCA by the oculomotor nerve (Fig. 2.5). Nearly located at the pontine root entry zone, usually by a loop
two-thirds of SCAs have a point of contact with the oculomo- tucked into the axilla formed between the brainstem and the
tor nerve, usually on the inferior surface. The point of contact medial side of the trigeminal nerve. There is no correlation
usually involves the main trunk or, less commonly, the rostral between the configuration of the SCA at its origin and the
trunk if there is an early bifurcation. This is a contact on the presence or absence of loops impinging upon the trigeminal
superior surface of the nerve only if the SCA arises from nerve; however, the point of bifurcation of the SCA did affect
the PCA, as occurs infrequently. Sunderland suggests that the the caliber of the vessel that made contact with the nerve. The
oculomotor nerve may occasionally be constricted between contacting vessel is of a smaller caliber if there is an early SCA
the PCA and SCA (52). bifurcation. The significance of these contacts in trigeminal
The length of vessel between its origin and its point of neuralgia is reviewed in the chapter on the cerebellopontine
contact with the oculomotor nerve averages 4.5 mm (range, angle (7, 16, 22, 45).
1–9 mm) and the length of the nerve between its origin from
the midbrain and the point of contact with the SCA averages Relationship to the tentorium cerebelli
5 mm (range, 1–10 mm) (19). The diameter of the artery at the The tentorium incisura (notch), the opening through the
point of contact averages 2 mm (range, 1–3 mm). There is less tentorium cerebelli, is triangular with the base on the clivus
likely to be a point of contact with the oculomotor nerve if (Figs. 2.6, 2.8, and 2.9) (41). The other two limbs are formed by
there is a duplicate origin, a low origin from the basilar artery, the right and left free edges that join at an apex located
or a fetal configuration of the PCA. between the colliculi below the occipital lobes above.

S40 Rhoton
FIGURE 2.8. SCA relationships. A, the left SCA arises as a duplicate artery. The caudal duplicate trunk crosses the rostral
surface of the trigeminal nerve before entering the cerebellomesencephalic fissure. B, the right SCA does not divide into ros-
tral and caudal trunks until it reaches the anterior edge of the cerebellomesencephalic fissure. C, near its origin, the SCA
courses below the oculomotor nerve and distally, near its entrance into the cerebellomesencephalic fissure, passes under the
trochlear nerve. D, another SCA. A large trunk passes directly from the side of the brainstem to the hemispheric surface with-
out entering the fissure, although it does give off some smaller branches to the fissure. E, the posterior lip of the cerebel-
lomesencephalic fissure has been removed and the upper half of the roof of the fourth ventricle opened. The SCA gives rise

FIGURE 2.9. A, the right SCA arises from the basilar artery as a duplicate artery. The rostral duplicate trunk gives rise to ver-
mian branches that supply the vermis and the adjacent part of the hemisphere. The caudal duplicate trunk gives rise to hemi-
spheric branches. B, enlarged view. Care is required in occluding and dividing the superior petrosal veins around the trigemi-
nal nerve, because the branches of the SCA may be intertwined with the tributaries of the veins, as in this example. The
peduncular vein, which usually empties into the basal vein, joins the lateral mesencephalic vein, and empties into the supe-
rior petrosal sinus. C, the lip of the fissure has been retracted to expose the SCA trunks and branches. D, the posterior lip of
the cerebellomesencephalic fissure has been removed. Within the fissure, the SCA branches pass down the superior cerebel-
lar peduncle. Some SCA branches pass above and some below the trochlear nerve. The SCA gives rise to a marginal branch
that supplies some of the petrosal surface bordering the tentorial surface. Br., branch; Caud., caudal; Cer. Mes., cerebel-
lomesencephalic; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Lat., lateral; Marg., marginal; Mes., mesencephalic;
Ped., peduncle; Pet., petrosal; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial; Tr., trunk; V.,
vein; Verm., vermian.
The proximal portion of the SCA, usually the main trunk SCA loops caudally and passes beneath, sometimes contact-
unless there is a duplicate origin or an early bifurcation, ing the middle third of the free edge of the tentorium. The
courses medial to the anterior third of the free edge. The interval between the free edge and the SCA as the SCA
SCAs with a high origin arise superior to the level of the passes below the free edge averages 3 mm (range, 0–5 mm).
tentorial edge, but the initial course of all of these slopes The part nearest the lower surface of the free edge is the main
caudally. Nearly 20% of SCAs have a point of contact with trunk in most cases, but may be the rostral or caudal trunk if
the free edge of the anterior half of the tentorium. Distally, the there is an early bifurcation. Further distally, branches pass
Š
to perforating branches that pass down the superior cerebellar peduncle to supply the dentate nucleus. F, oblique posterior
view of the SCA branches within the cerebellomesencephalic fissure and the quadrigeminal cistern. The SCA supplies the cis-
ternal walls below the sulcus between the superior and inferior colliculi, and the PCA supplies the wall above this level.
A.I.C.A., anteroinferior cerebellar artery; Br., branch; Caud., caudal; Cer. Mes., cerebellomesencephalic; Cist., cistern; CN,
cranial nerve; Coll., colliculus; Fiss., fissure; Inf., inferior; Mid., middle; P.C.A., posterior cerebral artery; Ped., peduncle; Pet.,
petrosal; Quad., quadrigeminal; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial; Tr., trunk;
Vent., ventricle.

S42 Rhoton
FIGURE 2.10. SCA trunks. A, the main trunk of the SCA bifurcates above the trigeminal nerve into a rostral and caudal
trunk. The main trunk passes below the trochlear nerve and tentorial edge at the anterolateral brainstem, but distally the ros-
tral trunk passes above and the caudal trunk below the trochlear nerve and tentorial edge. B, view after removing the tento-
rial edge. The most common compression of the trigeminal nerve in trigeminal neuralgia is by the SCA at the junction of the
main with the rostral and caudal trunks, which in this case is located above the trigeminal nerve. Both trunks dip into the
cerebellomesencephalic fissure before reaching the tentorial surface. C, this superior petrosal vein has multiple tributaries
that have become entwined with the branches of the SCA. These veins often need to be coagulated and divided in reaching
the trigeminal nerve. The SCA could be obliterated in coagulating the tributaries of the superior petrosal vein unless care is
taken to carefully separate the arterial trunks from the venous tributaries. D, this SCA has a duplicate origin in which both
the rostral and caudal trunks arise directly from the basilar artery. Both trunks, at the anterolateral brainstem, pass below the
tentorial edge and trochlear nerve and above the trigeminal nerve. At the posterolateral margin of the brainstem, the rostral
trunk loops above the level of the trochlear nerve and tentorial edge. The caudal trunk rests against the posterior trigeminal

medial to the posterior third of the free edge as they enter and The SCA is important in both hemorrhagic and ischemic
exit the cerebellomesencephalic fissure. These branches re- cerebrovascular disease of the posterior fossa. The dentate
main caudal to the level of the free edge in the interval nucleus, the most common site of spontaneous cerebellar
between the colliculi and the occipital lobe, but distally, pass hemorrhage, is supplied by the precerebellar and the pene-
below the tentorium to reach the superior surface of the trating cortical branches of the SCA (8, 49). The area supplied
cerebellum. by the SCA is postulated to be the most vulnerable to damage
by decreased blood flow in the posterior fossa, because it
represents the distal borderline of the vertebral and basilar
DISCUSSION arteries (49). Infarcts may occur in the area supplied by the
The effects of occlusion of a cerebellar artery range from SCA in the absence of its occlusion, after occlusion of the
clinical silence to infarction of portions of the brainstem or vertebral or basilar arteries.
cerebellum with swelling, hemorrhage, and death (3, 18, 19, The SCA and its branches may be stretched against the
30). Occlusion of the SCA, although uncommon, produces a tentorial edge by expanding lesions in the posterior fossa that
distinctive clinical picture that results from infarction of the cause a rostral protrusion of the upper surface of the cerebel-
cerebellum, dentate nucleus, brachium conjunctivum, and lum through the tentorial opening. The surface of the vermis
long sensory pathways in the tegmentum of the rostral pons and adjacent parts of the lateral lobes are grooved by the free
(32). The onset is marked by vomiting, sudden dizziness, and edge of the tentorium, and branches of the SCA may thus be
the inability to stand or walk. Occlusion may result in cere- compressed. Symmetrical softening of the cerebellar cortex in
bellar dysfunction caused by involvement of the cerebellum the area of supply will result, and similar changes may be
and its deep nuclei and peduncles; ipsilateral intention tremor found in the dentate nuclei that are supplied by the deep
caused by involvement of the dentate nucleus and the supe- branches (46).
rior cerebellar peduncle; ipsilateral Horner’s syndrome
caused by involvement of the descending oculosympathetic
fibers; contralateral loss of pain and temperature sensation Operative exposure
caused by involvement of the lateral spinothalamic and quin- The SCA is exposed in dealing with neoplasms involving
tothalamic tracts; nystagmus caused by involvement of the the cerebellum, posterior cavernous sinus, tentorial incisura,
medial longitudinal fasciculus and cerebellar pathways; con- and cerebellopontine angle; with aneurysms arising at the
tralateral disturbance of hearing caused by involvement of the basilar apex, origin of the SCA and PCA, and, although rare,
crossed fibers of the lateral lemniscus; and loss of emotional on the distal SCA; less commonly in dealing with arterio-
expression on the analgesic side caused by damage to the venous malformations; during vascular decompression of the
involuntary mimetic pathways in the upper brainstem. Al- trigeminal nerve in trigeminal neuralgia; and during a revas-
though a specific clinical syndrome may result from an SCA cularization bypass procedure for posterior fossa ischemia.
occlusion, it is worth emphasizing that in the posterior fossa, Selecting an operative approach to a lesion involving the
a given area of parenchyma cannot be as predictably allotted SCA requires that the arterial segments involved be accu-
to a specific vessel as in the cerebral circulation, because of the rately defined. Lesions located at the front of the brainstem
extensive anastomoses over the cerebellum and the variation near the origin require a different approach from those lo-
in arterial distribution. cated on the back of the brainstem in the quadrigeminal
The recovery and survival of many patients after the inten- cistern or cerebellomesencephalic fissure. The only supraten-
tional occlusion of a major cerebellar artery is attributed to torial approach that provides exposures to the SCA origin,
adequacy of the collateral circulation. If the adjacent arteries anterior and lateral pontomesencephalic and cerebellomesen-
are unusually small and the artery occluded is large, the cephalic segments, and the proximal cortical branches is a
collateral circulation is likely to be poor, creating an unfavor- temporal craniotomy with elevation of the temporal and oc-
able and dangerous situation. Arterial spasm caused by me- cipital lobes combined with division and retraction of the
chanical irritation induced by brain retraction may render the tentorium. Extending this approach backward to the quadri-
collateral supply less effective. Acute occlusion of any one of geminal cistern often necessitates obliteration of some of the
the cerebellar arteries is frequently associated with vomiting, veins draining the lower surface of the temporal and occipital
dizziness, and the inability to stand or walk. lobes, with the risk of venous infarction and edema. A similar
Š
root as the nerve passes below the anterior edge of the tentorium to enter Meckel’s cave. E, another SCA. The main trunk
passes above the trigeminal nerve before bifurcating into rostral and caudal trunks. The main trunk courses below the troch-
lear nerve, but the rostral trunk loops upward medial to the nerve. The caudal trunk divides into a large hemispheric branch
that supplies the tentorial surface and a marginal branch, which supplies some of the upper part of the petrosal surface. F,
another SCA. The artery bifurcates below the oculomotor nerve. Both trunks pass below the trochlear nerve at the anterolat-
eral margin of the brainstem and above the trochlear nerve distally at the entrance into the cerebellomesencephalic fissure.
A., artery; Bas., basilar; Br., branch; Caud., caudal; Cer. Mes., cerebellomesencephalic; CN, cranial nerve; Fiss., fissure; Hem.,
hemispheric; Marg., marginal; Pet., petrosal; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial;
Tr., trunk; V., vein.

S44 Rhoton
or even greater exposure of the SCA is achieved with the lip of the cerebellopontine fissure and the adjoining part of the
supra-infratentorial presigmoid approach with tentorial split- petrosal surface, and the caudal trunk supplies the inferior
ting, but this is a much more extensive operation. When the part of the petrosal surface, including a part of the flocculus
tentorium is divided in either of the above approaches, care and the choroid plexus. The AICA gives rise to perforating
must be taken to prevent injury to the trochlear nerve that arteries to the brainstem, choroidal branches to the tela and
passes between the lateral pontomesencephalic segment and choroid plexus, and the nerve-related arteries, including the
the tentorial edge. The SCA origin, along with the basilar labyrinthine, recurrent perforating, and subarcuate arteries
apex, if located above the dorsum sellae, can be reached (34).
through a pterional craniotomy with opening of Liliequist’s
membrane. Exposing a low SCA origin by the pterional route Segments
may require that the dura roof of the cavernous sinus be The AICA is divided into four segments: anterior pontine,
opened, a so-called transcavernous approach, and that the lateral pontine, flocculonodular, and cortical. Each segment
posterior clinoid and upper part of the dorsum sellae be may include more than one trunk, depending on the level of
removed. Resecting the petrous apex in the subtemporal an- bifurcation of the artery (Fig. 2.1).
terior petrousectomy approach will also aid in exposing a low
SCA origin, if it cannot be exposed by dividing the tentorium. Anterior pontine segment
A lateral suboccipital craniectomy or, as this writer prefers, a This segment, located between the clivus and the belly of
craniotomy, done through a vertical lateral suboccipital inci- the pons, begins at the origin and ends at the level of a line
sion and extending to the edge of the transverse and sigmoid drawn through the long axis of the inferior olive and extend-
sinuses, provides excellent exposure of the SCA in the region ing upward on the pons. This segment usually lies in contact
of the trigeminal nerve and the anterior part of the cerebel- with the rootlets of the abducent nerve.
lomesencephalic fissure. This approach provides satisfac-
tory exposure of the lateral pontomesencephalic segment, Lateral pontine segment
but not of the origin or of other segments. An infratentorial-
This segment begins at the anterolateral margin of the pons
supracerebellar approach directed through a suboccipital
and passes through the cerebellopontine angle above, below,
craniectomy provides satisfactory exposure of the cortical
or between the facial and vestibulocochlear nerves and is
branches, but not those within the depths of the cerebellomes-
intimately related to the internal auditory meatus, the lateral
encephalic fissure or lateral to the brainstem. The occipital
recess, and the choroid plexus protruding from the foramen of
transtentorial approach provides a more favorable angle for
Luschka (Figs. 2.11 and 2.12). This segment gives rise to the
exposing the branches ipsilateral to the craniotomy near the
nerve-related branches that course near or within the internal
midline, below the pineal within the cerebellomesencephalic
acoustic meatus in close relationship to the facial and vestibu-
fissure, and in the posterior part of the ambient cistern.
locochlear nerves. This segment is divided into premeatal,
meatal, and postmeatal parts, depending on their relationship
ANTEROINFERIOR CEREBELLAR ARTERY to the porus of the internal acoustic meatus (Fig. 2.5). These
nerve-related branches are the labyrinth artery, which sup-
Overview plies the facial and vestibulocochlear nerves and vestibuloco-
chlear labyrinth; the recurrent perforating arteries, which pass
The AICA courses through the central part of the cerebel-
toward the meatus, but turn medially to supply the brain-
lopontine angle near the facial and vestibulocochlear nerve
stem; and the subarcuate artery, which enters the subarcuate
(Figs. 2.5 and 2.11). It or its branches may be exposed in
fossa. This segment not uncommonly dips below the pon-
surgical approaches to cerebellopontine angle, basilar or ver-
tomedullary junction, especially if it is tortuous.
tebral arteries, clivus, the fourth ventricle and cerebellum, and
during approaches directed through the temporal and occip- Flocculopeduncular segment
ital bones.
The AICA is intimately related to the pons, lateral recess, This segment begins where the artery passes rostral or
foramen of Luschka, cerebellopontine fissure, middle cerebel- caudal to the flocculus to reach the middle cerebellar pedun-
lar peduncle, and petrosal cerebellar surface (Figs. 2.1-2.3 and cle and the cerebellopontine fissure (Fig. 2.11). The trunks that
2.11). The AICA originates from the basilar artery, usually as course along the peduncle may be hidden beneath the floccu-
a single trunk, and encircles the pons near the abducent, lus or the lips of the cerebellopontine fissure.
facial, and vestibulocochlear nerves. After coursing near and Cortical segment
sending branches to the nerves entering the acoustic meatus
and to the choroid plexus protruding from the foramen of This segment supplies predominantly the petrosal surface.
Luschka, it passes around the flocculus on the middle cere-
bellar peduncle to supply the lips of the cerebellopontine Origin
fissure and the petrosal surface. It commonly bifurcates near The AICA usually originates from the basilar artery as a
the facial-vestibulocochlear nerve complex to form a rostral single vessel, but may also arise as two (duplicate) or three
and a caudal trunk. The rostral trunk sends its branches (triplicate) arteries (Figs. 2.2, 2.3, and 2.11). It can arise at any
laterally along the middle cerebellar peduncle to the superior point along the basilar artery, but most commonly arises from

FIGURE 2.11. AICA

relationships. A,
anterolateral view of the
brainstem and right
petrosal cerebellar surface.
The right AICA passes
below the abducens and
between the facial and
vestibulocochlear nerves
before reaching the
cerebellopontine fissure
and petrosal cerebellar
surface. B, the right AICA
arises just above the
vertebrobasilar junction
and passes below the pontomedullary junction before turning upward to reach the surface of the middle cerebellar peduncle.
It passes above the floccular and along the cerebellopontine fissure to reach the petrosal surface. C and D, the cerebellum
and brainstem have been removed to show the relationship of the AICAs to the cranial nerves and internal acoustic meatus.
C, the left AICA passes above the abducens nerve and below the facial and vestibulocochlear nerves, where it gives rise to a
recurrent perforating branch to the brainstem. The SCA passes above the posterior trigeminal root. D, the right AICA loops
into the porus of the meatus and between the facial and vestibulocochlear nerves. E, another brainstem and cerebellum. The
right vertebral artery is a duplicate artery and gives rise to duplicate PICAs. The AICAs arise from the lower part of the
basilar artery. The left AICA is larger than the right. The rostral duplicate PICA loops upward into the cerebellopontine angle.
The left vertebral artery loops upward into the left cerebellopontine angle. A., artery; A.I.C.A., anteroinferior cerebellar artery;
Ant., anterior; Bas., basilar; Caud., caudal; Cer. Pon., cerebellopontine; CN, cranial nerve; Dup., duplicate; Fiss., fissure; Flocc.,
flocculus; For., foramen; Mid., middle; P.C.A., posterior cerebral artery; Ped., peduncle; Perf., perforating; P.I.C.A., posteroinferior
cerebellar artery; Pon., pontine; Rec., recurrent; Rost., rostral; S.C.A., superior cerebellar artery; Sp., spinal; Tent., tentorial; Vert.,
vertebral.

S46 Rhoton
FIGURE 2.12. AICA relationships. A, anterior view. The clivus and adjacent part of the occipital and temporal bones have been
removed to expose the front of brainstem, vertebral and basilar arteries, facial and vestibulocochlear nerves in the right internal
acoustic meatus, and the hypoglossal nerve in the right hypoglossal canal. The left AICA loops into the porus of the meatus. B,
enlarged view of the right cerebellopontine angle. The AICA passes between the facial and vestibulocochlear nerves. The hypoglos-
sal nerves are stretched around the posterior surface of the vertebral artery. The vertebral artery kinks upward into the cerebel-
lopontine angle where the PICA arises in close relationship to the root exit zone of the facial nerve, a common finding in hemifa-
cial spasm. A labyrinthine artery arises from the AICA. C, another enlarged view of the right cerebellopontine angle. The
labyrinthine artery passes laterally with the facial nerve. The PICA loops upward and contacts the lower margin of the facial nerve.
The vein of the cerebellopontine fissure ascends to empty into the superior petrosal sinus. D, the left AICA passes below the abdu-
cens, facial, and vestibulocochlear nerves and loops into the porus where it gives off two labyrinthine branches. Some of the hypo-
glossal rootlets are stretched over the PICA. The posterior trigeminal nerve was divided behind Meckel’s cave. The proximal stump
arises from the midpons and the distal portion enters Meckel’s cave. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar
artery; Cer. Pon., cerebellopontine; CN, cranial nerve; Fiss., fissure; Labyr., labyrinthine; Pet., petrosal; P.I.C.A., posteroinferior cerebellar
artery; Prox., proximal; S.C.A., superior cerebellar artery; Sup., superior; V., vein; Vert., vertebral.
the lower half. There is frequent asymmetry in the level of Bifurcation

origin from side to side, with one arising significantly above
the level of the other. In our previous study, we found that of The AICAs arising as a single trunk usually bifurcate into a
50 AICAs 72% arose as a single trunk, 26% as two (duplicate) rostral and a caudal trunk. The duplicate AICAs referred to
arteries, and 2% as three (triplicate) arteries (34). From its origin, as rostral and caudal duplicate AICAs have a distribution
the AICA courses backward around the pons toward the CPA. similar to the distribution of the rostral and caudal trunks
Its proximal part lays in contact with either the dorsal or the formed by the bifurcation of a single AICA. Approximately
ventral aspect of the abducens nerve. After passing the abducens two-thirds bifurcated before and one-third bifurcated after
nerve, it proceeds to the CPA where one or more of its trunks crossing the facial and vestibulocochlear nerves. The segment
course in close relationship to the facial and vestibulocochlear proximal to the bifurcation is the main trunk, and the two
nerves and thus are said to be nerve-related. trunks formed by the bifurcation are the rostral and the cau-

dal trunks. If the bifurcation is proximal to the facial and directed toward or through the meatus. The medial segment
vestibulocochlear nerves, either the rostral trunk alone or both was located medial to the porus in about half of CPAs and
of the postbifurcation trunks may be nerve-related. The ros- formed a loop that reached the porus or protruded into the
tral duplicate AICAs give rise to nerve-related branches more canal in the other half. Sunderland and Mazzoni found the
often than the caudal duplicate AICAs. The main trunk of the meatal segment at the porus or within the canal in 64 and 67%
duplicate AICAs also commonly bifurcate to form rostral and of CPAs, respectively (36, 51). Mazzoni found that the meatal
caudal trunks that sent branches to the cerebellum. segment was medial to the porus in 33%, reached the porus in
After crossing the nerves, the rostral trunk usually courses 27%, and entered the canal in 40%, rarely going beyond the
laterally above the flocculus to reach the surface of the middle medial half of the canal (36).
cerebellar peduncle and the petrosal fissure to be distributed In the 50 CPAs examined, we found there were 59 nerve-
to the superior lip of the cerebellopontine fissure and the related meatal segments; 41 CPAs (82%) had one, and 9 (18%)
adjoining part of the petrosal surface. The caudal trunks are had two meatal segments. The majority of the meatal seg-
frequently related to the lateral portion of the fourth ventricle. ments coursed below or between the facial and vestibuloco-
If the bifurcation is proximal to the facial and vestibulocochlear nerves (Fig. 2.14). There were three more meatal seg-
chlear nerve, the caudal trunk courses caudal to the flocculus ments than premeatal segments, because in three CPAs, a
to supply the inferior part of the petrosal surface, including a premeatal segment bifurcated near the nerves to yield two
part of the flocculus and the choroid plexus. If the bifurcation nerve-related meatal segments. The majority of meatal loops
is distal to the nerves, the caudal trunk courses posteriorly in coursed in a horizontal plane above or below the nerves, but
the inferior limb of the cerebellopontine fissure near the fora- some, mostly those passing between the facial and vestibulo-
men of Luschka. The caudal trunks often enter the lateral cochlear nerves, coursed in a vertical or oblique plane.
portion of the cerebellomedullary fissure just below the lat-
eral recess before turning laterally to supply the inferior part Subarcuate loop
of the petrosal surface. The distal branches of the caudal trunk
often anastomose with the PICA, and those from the rostral In some CPAs, the nerve-related loop formed a second
trunk anastomose with the SCA. The AICA gives rise to perfo- laterally convex curve that gave the loop an “M” configura-
rating arteries to the brainstem, choroidal branches to the lateral tion. This second loop was called the subarcuate loop, because
segment of the choroid plexus, and the nerve-related arteries it was directed toward the subarcuate fossa, a small depres-
described above. sion in the bone superolateral to the meatus. This loop was
located either posterior, posteroinferior, or posterosuperior to
Nerve-related branches the vestibulocochlear nerve. The apex of the loop was occa-
sionally adherent to the dura over the subarcuate fossa at the
The nerve-related branches are those that course in or near
point where the subarcuate artery arose.
the porus of the meatus and by the facial and vestibuloco-
chlear nerves (Figs. 2.5 and 2.11-2.14) (34). Each nerve-related
segment is composed of one or two arterial trunks. One was Postmeatal segment
most common. The single nerve-related segments were This segment begins distal to the nerves and courses me-
formed from either the main or a rostral trunk, which arise, in dially to supply the brainstem and the cerebellum. The 59
decreasing order of frequency, from a solitary AICA, a rostral meatal segments found in our previous study of 50 CPAs gave
duplicate AICA, or a caudal duplicate AICA. The double rise to 60 postmeatal segments; 80% of the CPAs had one, and
segments result from the presence of one of two anatomic 10 (20%) had two postmeatal segments. There was one more
configurations: a) both the rostral and caudal trunks of a postmeatal segment than meatal segment, because one meatal
solitary AICA or of one duplicate AICA are nerve-related, or segment bifurcated to form two postmeatal segments. The
b) one trunk from each of duplicate AICAs or one trunk from postmeatal segments were most commonly posteroinferior,
two of three triplicate AICAs is nerve related. superior, or posterior to or between the nerves (Fig. 2.14);
none were anterior to the nerves. Each of the vessels forming
Premeatal segment
a double segment might pursue similar or separate courses in
This segment begins at the basilar artery and courses relation to the nerves.
around the brainstem to reach the facial and vestibulocochlear
nerves and the anterior edge of the meatus. The premeatal
segment is composed of one or two arterial trunks. In the 50
Branches of nerve-related AICAs
CPAs we examined, there were 56 nerve-related premeatal seg- In their course through the CPA, the nerve-related trunks
ments, 44 CPAs (88%) had solitary, and 6 (12%) had double gives off four branches (Figs. 2.12-2.14): 1) labyrinthine (inter-
premeatal segments (34). Most of the premeatal segments, 46 of nal auditory) arteries, which enter the internal auditory canal
the 56, were anteroinferior to the nerves. The remainder were and reached the inner ear; 2) recurrent perforating arteries,
anterior, inferior, or anterosuperior to the nerves (Fig. 2.14). which course medially from their origin to supply the brain-
stem; 3) subarcuate arteries, which passed through the subar-
Meatal segment cuate fossa to reach the subarcuate canal; and 4) cerebellosub-
This segment, located in the vicinity of the internal auditory arcuate arteries, which terminated by sending one branch to
meatus, often forms a laterally convex loop, the medial loop, the subarcuate canal and one to the cerebellum.

S48 Rhoton
FIGURE 2.13. A, AICA relationships in the right CPA by retrosigmoid approach. The AICA passes laterally between the facial
and vestibulocochlear nerves and turns medially to course along the middle cerebellar peduncle and cerebellopontine fissure.
A large superior petrosal vein with multiple tributaries, including the pontotrigeminal and transverse pontine veins and the
vein of the cerebellopontine fissure, passes behind the trigeminal nerve. The flocculus hides the junction of the facial and ves-
tibulocochlear nerves with the brainstem. B, the flocculus and choroid plexus, which protrudes from the foramen of Luschka,
have been elevated to expose the junction of the facial and vestibulocochlear nerves with the brainstem, where the facial

Labyrinthine (internal auditory) arteries

These arteries are the one or more branches of the AICA
that enter the internal auditory canal and send branches to the
bone and dura lining the internal auditory canal, to the nerves
within the canal, and terminate by giving rise to the vestibu-
lar, cochlear, and vestibulocochlear arteries that supply the
organs of the inner ear (Figs. 2.12-2.14) (34).
The labyrinthine arteries almost always arise from the
AICA or one of its branches, although a few have been re-
ported to arise from the basilar artery. In one study, as many
as 17% were found to arise from the basilar artery (40, 51, 56).
We believe that this discrepancy is explained by differences in
the definition of the internal auditory artery and the AICA
used in the various studies. In this study and those of Adachi
and Fisch, the trunk of origin on the basilar artery of an artery
sending a branch to the internal auditory canal was called an
AICA if it sent branches, although small, to the cerebellum.
The site of origin of the internal auditory artery was defined
as the point where the branch to the internal auditory canal
arose from the trunk of the AICA sending branches to the
FIGURE 2.14. Diagram showing the relationship of nerve- cerebellum (1, 13). On the other hand, Nager and Sunderland
related arteries to the nerves in the cerebellopontine angle. called a trunk arising from the basilar artery a labyrinthine
The nerves are oriented as shown in the central diagram of artery rather than an AICA if the branch entering the meatus
the right side of the brainstem. The trigeminal nerve arises was larger than the branch reaching the cerebellum (40, 51).
from the pons. The facial and vestibulocochlear nerves and Adachi and Fisch, who did not find a single internal auditory
the nervus intermedius are oriented as shown. The terms artery that arose from the basilar artery, were always able to
superior, anterosuperior, and so on, refer to the relationship find a cerebellar branch, although small, on the vessel enter-
of the arteries to the nerves. The number of arteries and ing the meatus (1, 13). Mazzoni reported that the internal
arterial segments found in 50 CPAs are listed according to auditory artery arose from the PICA in a few cases (36), a
their location in relationship to the nerves. The most com- finding not confirmed in our study or in the other studies
mon locations were premeatal segment, anteroinferior; mentioned above. In our study, there was one internal audi-
meatal segment, inferior; postmeatal segment, posteroinfe- tory artery in 30% of the CPAs, two in 54%, three in 14%, and
rior; internal auditory artery origin and course, inferior and four in 2%.
anteroinferior; recurrent perforating artery origin, inferior Of the 94 internal auditory arteries found in our study, in 50
and anteroinferior, and course, superior and between; and CPAs, 72 (77%) originated from the premeatal segment, 20
subarcuate artery origin, posterior, and course, posterosupe- (21%) from the meatal segment, and 2 (2%) from the post-
rior. (From, Martin RG, Grant JL, Peace DA, Theiss C, Rho- meatal segment (34). They arose proximal to the subarcuate
ton AL Jr: Microsurgical relationships of the anterior inferior loop in each CPA in which the latter loop was present. Fifty-
cerebellar artery and the facial-vestibulocochlear nerve com- four percent originated from a solitary AICA, 23% from a
plex. Neurosurgery 6:483–507, 1980 [34].) c., course; I.A.A., duplicate or triplicate AICA, and 23% from a recurrent per-
internal auditory artery; Mea., meatal; o., origin; R.P.A., forating artery. Mazzoni and Hansen also noted that the in-
recurrent perforating artery; S.A., subarcuate artery; Seg., ternal auditory artery may arise from the recurrent perforat-
segment. ing, subarcuate, or cerebellosubarcuate arteries (37).
Š
nerve is seen below the vestibulocochlear nerve. An AICA branch gives rise to both the subarcuate and labyrinthine arteries.
C, a dissector elevates the vestibulocochlear nerve to more clearly define the junction of the facial nerve with the brainstem.
The junction of the facial nerve with the brainstem is easier to expose below rather than above the vestibulocochlear nerve.
D, the posterior meatal wall has been removed to expose the dura lining the meatus. E, the meatal dura has been opened and
the vestibulocochlear nerve displaced downward to expose the facial nerve coursing anterior and superior within the meatus.
The nervus intermedius, which arises on the anterior surface of the vestibulocochlear nerve and passes laterally to join the
facial nerve, is composed of several rootlets, as is common. F, the cleavage plane between the superior and inferior vestibular
nerves has been developed. The cochlear nerve is located anterior to the inferior vestibular nerve. A., artery; A.I.C.A., antero-
inferior cerebellar artery; Cer. Mes., cerebellomesencephalic; Cer. Pon., cerebellopontine; Chor., choroid; CN, cranial nerve;
Coch., cochlear; Fiss., fissure; Flocc., flocculus; Inf., inferior; Intermed., intermedius; Labyr., labyrinthine; N., nerve; Nerv.,
nervus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; Pon., pontine; S.C.A., superior cerebellar
artery; Subarc., subarcuate; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein; Vest., vestibular.

S50 Rhoton
The internal auditory arteries are divided into two approx- originating anterior, inferior, or anteroinferior to the facial
imately equal-sized groups based on their relationship to the nerve crossed inferior to the facial and vestibulocochlear
meatus. One group originates medial to the porus and the nerves to reach the subarcuate fossa (Fig. 2.14).
other arises at the porus or within the auditory canal. Those Nager noted that the subarcuate artery is mentioned rarely
arising medial to the porus most commonly originate and in descriptions of the arteries in this area (40). This is probably
course anterior, anteroinferior, or inferior to the nerves. Fisch because the artery and its connection to the bone were de-
noted that the internal auditory arteries often entered the stroyed when the brain was removed from the skull. Nager
canal by crossing the anteroinferior rim of the porus (13). found that its most frequent site of origin was the labyrinthine
Those arising at the porus or within the canal most commonly artery rather than the AICA, a difference explained by the
originate inferior or anteroinferior to the nerves. difference in definitions of the AICA and the internal auditory
artery previously mentioned (40). He reported that the sub-
Recurrent perforating arteries arcuate artery may also have a double origin; one branch may
enter the subarcuate canal by penetrating the subarcuate fossa
These perforating arteries arise from the nerve-related ves-
and the other may penetrate the wall of the internal auditory
sels and often travel from their origin toward the meatus,
canal to reach the subarcuate canal.
occasionally looping into the meatus before taking a recurrent
course along the facial and vestibulocochlear nerves to reach Cerebellosubarcuate artery
the brainstem (Figs. 2.5 and 2.14). They send branches to these
nerves and to the brainstem surrounding the entry zone of The cerebellosubarcuate artery is a small branch of the
those nerves. They also send branches, in decreasing order of AICA that sends one branch to the subarcuate fossa and
frequency, to the middle cerebellar peduncle and the adjacent another to the cerebellum, as reported by Mazzoni (37). It
part of the pons, the pons around the entry zone of the usually originates proximal to the meatal loop, passing infe-
trigeminal nerve, the choroid plexus of the CPA, the supero- rior to the facial and vestibulocochlear nerves before coursing
lateral medulla, and the glossopharyngeal and vagus nerves. superolateral to reach the subarcuate fossa. At the fossa, it
The recurrent perforating arteries give rise to about one- gives rise to a subarcuate artery and turns medially to supply
fourth of the internal auditory arteries and 10% of subarcuate the cerebellum. A cerebellosubarcuate artery was present in
arteries. four of the CPAs we investigated (34). The artery originates
In our study, recurrent perforating arteries were present in anteroinferior or inferior to the nerves entering the meatus.
41 (82%) of the CPAs; one was present in 37 CPAs (74%), two The cerebellar branch terminates on the flocculus and on the
in 3 (6%), and three in 1 (2%) (34). Most arose from the adjacent cerebellar cortex below the flocculus.
premeatal segment, but they also arose from the meatal loop
and the postmeatal segment. There was marked variability in Cortical branches
their relationship to the facial and vestibulocochlear nerves. The most common pattern is for the AICA to supply the
Most originated inferior, anteroinferior or anterior to or be- majority of the petrosal surface, but the cortical area of the
tween the nerves and coursed medially between or above or supply is quite variable (Fig. 2.11). It can vary from a small
below the nerves (Fig. 2.14). area on the flocculus and adjacent part of the petrosal surface
to include the whole petrosal surface and adjacent part of the
Subarcuate artery tentorial and suboccipital surfaces. After crossing the nerves,
the rostral trunk usually courses above the flocculus to be
The subarcuate artery usually originates medial to the
distributed to the superior lip of the cerebellopontine fissure,
porus, penetrates the dura covering the subarcuate fossa, and
and the caudal trunks course caudal to the flocculus to supply
enters the subarcuate canal (Figs. 2.13 and 2.14). In a few cases,
the inferior part of the petrosal surface. If the PICA is absent,
it originates in the internal auditory canal. The subarcuate
the caudal trunk may supply almost all of the ipsilateral
arteries originating in the auditory canal take one of two
suboccipital hemisphere and vermis. Overlap of the SCA onto
courses to reach the subarcuate canal; some take a recurrent
the upper part of the petrosal surface and the PICA onto the
course through the porus to reach the subarcuate fossa, and
lateral part of the suboccipital surface in not uncommon.
others penetrated the meatal wall to reach the subarcuate
canal. The artery supplies the petrous bone in the region of the
semicircular canals (43). The subarcuate canal is recognized as DISCUSSION
a potential route of extension of infections from the mastoid Occlusion of the AICA results in syndromes related pre-
region to the meninges and the superior petrosal sinus (40). dominantly to softening of the lateral portions of the brain-
The AICA is adherent to the dura lining the subarcuate fossa stem and cerebellar peduncles, rather than to involvement of
at the site of origin of the subarcuate artery in a few CPAs. the cerebellar hemisphere, including palsies of the facial and
In our study, a subarcuate artery was present in 36 (72%) of vestibulocochlear nerves caused by involvement of the nerves
the 50 CPAs; 13 (26%) originated from the premeatal segment, and their nuclei; vertigo, nausea, vomiting, and nystagmus
2 (4%) from the meatal segment, and 21 (42%) from the caused by lesions of the vestibular nuclei and their connec-
postmeatal segment (34). When present, there was only one tions with the nuclei of the vagus nerves; ipsilateral loss of
subarcuate artery. Most originated posterior and coursed pos- pain and temperature sensation on the face and corneal hyp-
terosuperior to the nerves to reach the subarcuate fossa. Those esthesia caused by interruption of the spinal tract and nucleus

of the trigeminal nerve; Horner’s syndrome caused by inter- combined with a medial petrosectomy, may be selected for
ruption of the descending pupillodilator fibers in the lateral lesions in which the AICA has a high origin, or also involves
portion of the pons and medulla; cerebellar ataxia and asyn- the SCA and basilar arteries and is medial to the trigeminal
ergia ascribed to a lesion in the cerebellar peduncles; and nerve. In the middle fossa approach to the internal meatus,
an incomplete loss of pain and temperature sensation on only a short segment of the artery located near the meatus is
the contralateral half of the body (the absence of a complete exposed and sometimes only if the artery loops into the meatal
contralateral hypalgesia is caused by the extreme lateral and perus. The translabyrinthine approach exposes the AICA, at and
posterior position of the lesion, which spares a portion of the for a short distance proximal and distal to the internal acoustic
lateral spinothalamic tract) (2, 3). All of the syndromes caused meatus and along the anterior part of the petrosal surface. The
by its occlusion are not identical, because of the variability of supra-infratentorial presigmoid approaches with various de-
the AICA. The symptoms usually are sudden in onset and grees of resection of the semicircular canals, vestibule, and co-
unaccompanied by a loss of consciousness (2). The most chlea may be selected for lesions located deep in front of the
prominent symptom is vertigo, often associated with nausea brainstem, especially those located near the AICA origin. The
and vomiting, followed by a facial paralysis, deafness, sen- AICA origin may be exposed in the anterior approaches directly
through the clivus only if the origin is near the midline, but not
sory loss, and cerebellar disorders. Notable by their absence
if the origin is from a tortuous basilar artery that loops laterally
are signs of involvement of the corticospinal tract and medial
into the cerebellopontine angle lateral to the medial aspect of the
lemniscus, which are nourished from midline tributaries of
cavernous sinus and petrous carotid, which limit the lateral
the vertebral and basilar arteries.
extent of the anterior exposures of the prepontine cistern.
The recovery and survival of many patients after the inten-
tional occlusion of the AICA at operation is attributed to
adequacy of the collateral circulation from the other cerebellar
arteries (34). The size of the area of infarction after AICA POSTEROINFERIOR CEREBELLAR ARTERY
occlusion is inversely related to the size of the PICA and SCA
and to the size of the anastomoses with those arteries. If the Overview
PICA is unusually small and the AICA is large, the collateral The PICA has the most complex, tortuous, and variable
circulation is likely to be poor, creating an unfavorable and course and area of supply of the cerebellar arteries. It may be
dangerous situation in the event of AICA occlusion. Arterial exposed in surgical approaches to the foramen magnum,
spasm caused by mechanical irritation induced by the brain fourth ventricle, cerebellar hemisphere, brainstem, jugular fo-
retractor used during tumor removal may render the collat- ramen, cerebellopontine angle, petrous apex, and clivus (30).
eral supply less effective. The PICA is intimately related to the cerebellomedullary
fissure, the inferior half of the ventricular roof, the inferior
cerebellar peduncle, and the suboccipital surface (Figs. 2.1-
Operative exposure 2.5). The PICA, by definition, arises from the vertebral artery
near the inferior olive and passes posteriorly around the
The AICA is most commonly exposed in operations for medulla. At the anterolateral margin of the medulla, it passes
tumors of the cerebellopontine angle. Aneurysms involving rostral or caudal to or between the rootlets of the hypoglossal
the AICA are rare and if not located at the origin, are most nerve, and at the posterolateral margin of the medulla it
likely located at or near the internal acoustic meatus (25, 31). courses rostral to or between the fila of the glossopharyngeal,
The displacement and management of the nerve-related ar- vagus, and accessory nerves. After passing the latter nerves, it
teries with acoustic neuromas are reviewed in greater detail in courses around the cerebellar tonsil and enters the cerebel-
the chapter on the cerebellopontine angle. Arteriovenous mal- lomedullary fissure and passes posterior to the lower half of
formations located infratentorially are uncommon compared the roof of the fourth ventricle. On exiting the cerebellomed-
with those in supratentorial locations, and not infrequently ullary fissure, its branches are distributed to the vermis and
involve the other cerebellar arteries, in addition to the AICA hemisphere of the suboccipital surface. Its area of supply is
and the brainstem, thus increasing the management risk the most variable of the cerebellar arteries (26). Most PICAs
(9, 39, 44). Compression of the facial and vestibulocochlear bifurcate into a medial and a lateral trunk. The medial trunk
nerves by tortuous arteries is postulated to cause dysfunction supplies the vermis and adjacent part of the hemisphere, and
of these nerves, a concept that is reviewed in Chapter Four on the lateral trunk supplies the cortical surface of the tonsil and
the cerebellopontine angle (18, 19, 34). the hemisphere. The PICA gives off perforating, choroidal,
The AICA may be approached by a lateral suboccipital and cortical arteries. The cortical arteries are divided into
(retrosigmoid), middle fossa, translabyrinthine or combined vermian, tonsillar, and hemispheric groups.
supra-infratentorial presigmoid approach. The suboccipital
exposure is excellent for lesions involving the meatal and
postmeatal segments of the AICA, the lateral part of the mid- Segments
and lower brainstem below the trigeminal nerve, and the area The PICA is divided into five segments: 1) anterior medul-
near the internal acoustic meatus. A subtemporal middle lary, 2) lateral medullary, 3) tonsillomedullary 4) teloveloton-
fossa approach, with division of the tentorium and possibly sillar, and 5) cortical (Figs. 2.1 and 2.15). These segments are

S52 Rhoton
FIGURE 2.15. A and B. Segments

of the PICA. A, inferior view. The
left tonsil has been removed at the
level of the tonsillar peduncle, its
site of attachment to the remainder
of the hemisphere. The anterior
medullary segment (green) extends
from the origin at the vertebral
artery to the level of the inferior
olive. This segment courses rostral
or caudal to or between the
rootlets of the hypoglossal nerve.
The lateral medullary segment
(orange) extends from the level of
the most prominent part of the
olive to the level of the rootlets of
the glossopharyngeal, vagus, and
accessory nerves. The
tonsillomedullary segment (blue)
extends from the level of the latter
nerves around the caudal half of
the tonsil and often forms a
caudally convex loop. The
telovelotonsillar segment (yellow)
extends from the midlevel of the
tonsil to the exit from the cleft
located between the tela choroidea
and the inferior medullary velum
superiorly and the superior pole of
the tonsil inferiorly. The cortical
segment (red ) extends from where
the artery and its branches exit the
fissures between the tonsil, vermis,
and hemisphere to reach the
cortical surface. The bifurcation of
the main trunk into medial and
lateral trunks is often located at the
level of the tonsillomedullary or the
telovelotonsillar segments. The
medial trunk gives rise to median
and paramedian vermian arteries.
The lateral trunk gives rise to
lateral, intermediate, and medial
hemispheric and tonsillar arteries.
B, enlarged posterior view. The left
and part of the right halves of the
cerebellum was removed to show
the relationship of the PICA to the
roof of the fourth ventricle. The
dentate nucleus wraps around the
superior pole of the tonsil. The
telovelotonsillar fissure is below the
inferior half of the roof of the
fourth ventricle between the tonsil, tela choroidea, and inferior medullary velum. The caudal loop of the PICA is near the caudal
pole of the tonsil, and the cranial loop is above the rostral pole of the tonsil. A., artery; A.I.C.A., anteroinferior cerebellar artery;
Ant., anterior; B.A., basilar artery; Cer., cerebellar; Ch., choroid; Coll., colliculus; F., foramen; Fiss., fissure; He., hemispheric; Inf.,
inferior; Int., intermediate; Lat., lateral; Med., medial, medullary; Mid., middle; Nucl., nucleus; Paramed., paramedian; P.C.A.,
posterior cerebral artery; Ped., peduncle; Pl., plexus; S.C.A., superior cerebellar artery; Seg., segment; Sup., superior; Ton., tonsillar;
Tr., trunk; V.A., vertebral artery; Ve., vermian; Vel., velum.

FIGURE 2.15. C and D. Segments

of the PICA. C, lateral view. The
anterior medullary segment passes
rostral to the hypoglossal nerve.
The lateral medullary segment
passes between the accessory
rootlets. The tonsillomedullary
segment forms a cranially convex
loop near the inferior pole of the
tonsil. The telovelotonsillar segment
forms a cranially convex loop and
bifurcates into medial and lateral
trunks near its termination. The
cortical segment spreads across the
suboccipital surface. D, midsagittal
section. The tonsillomedullary and
telovelotonsillar segments send
choroidal branches into the choroid
plexus. The telovelotonsillar
segment ascends between the
nodule and uvula medially and the
tonsil laterally. (From, Lister JR,
Rhoton AL Jr, Matsushima T, Peace
DA: Microsurgical anatomy of the
posterior inferior cerebellar artery.
Neurosurgery 10:170–199, 1982
[30].)
the fourth ventricle. Each segment

may include more than one trunk,
depending on the level of bifurca-
tion of the artery.
Anterior medullary segment

This segment lies anterior to the
medulla. It begins at the origin of the
PICA anterior to the medulla and
extends backward past the hypo-
glossal rootlets to the level of a rostro-
caudal line through the most promi-
nent part of the inferior olive that
marks the boundary between the an-
terior and lateral surfaces of the me-
dulla. Those PICAs arising lateral
rather than anterior to the medulla do
not have an anterior medullary seg-
ment. An anterior medullary segment
is more likely to be present if the
PICA arises from the superior part
of the vertebral artery, because the
vertebral artery courses from the lat-
eral side of the medulla below to the
anterior surface of the medulla
often longer than the distance around the medulla or the above. An anterior medullary segment is present if the vertebral
tonsil because the PICA frequently has a tortuous course and artery at the level of origin of the PICA has passed to the anterior
forms complex loops on the side of the brainstem among the surface of the brainstem. From its origin, the PICA usually passed
lower cranial nerves, near the tonsil, and caudal to the roof of posteriorly around or between the hypoglossal rootlets, but occa-

S54 Rhoton
sionally loops upward, downward, laterally, or medially before of the glossopharyngeal, vagus, and accessory rootlets. This
passing posteriorly around or between the hypoglossal rootlets. segment is present in most PICAs. Its course varies from passing
directly posterior to reach the glossopharyngeal, vagal, and ac-
Lateral medullary segment cessory rootlets to ascending, descending, or passing laterally or
This segment begins where the artery passes the most prom- medially to form one or more complex loops in the cistern on the
inent point of the olive and ends at the level of the origin side of the brainstem before passing between these nerves.
FIGURE 2.16. PICA relationships. A, the PICA courses around the medulla, enters the cerebellomedullary fissure, and exits
the fissure to supply the suboccipital surface. The fissure extends upward between the cerebellar tonsils on one side and the
medulla and inferior half of the ventricle roof on the other side. The PICAs frequently form a caudal loop at the lower pole
of the cerebellar tonsils. B, enlarged view. The left tonsil has been removed to expose the course of the PICA within the cer-
ebellomedullary fissure. The PICAs often loop upward around the rostral pole of the tonsil, where they course between the
rostral pole of the tonsil on the lower side and the tela choroidea and inferior medullary velum on the upper side. C, both
tonsils and the adjacent part of the biventral lobule have been removed to expose the PICA trunks. The PICAs divide into a
medial trunk, which supplies the vermis and adjacent part of the hemisphere, and a caudal trunk, which loops around the
tonsil to supply the largest part of the hemispheric surface. Choroidal branches pass to the tela choroidea and choroid plexus
in the roof. The vein of the cerebellomedullary fissure crosses the tela and velum and passes above the flocculus to join the
veins in the cerebellopontine angle that empty into the superior petrosal sinus. D, another dissection showing the relationship
of the cranial loop of the PICA to the tonsils and inferior medullary velum. Both tonsils and the nodule and uvula have been
preserved. The inferior medullary velum has been preserved on the right side. The left half of the inferior medullary velum
has been removed to expose the supratonsillar loop of the PICA, which courses between the velum and the tonsil. The velum
stretches laterally from the nodule across the rostral pole of the tonsil to blend into the flocculus. A., artery; A.I.C.A., antero-
inferior cerebellar artery; Br., branch; Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; Chor., choroidal;
CN, cranial nerve; Fiss., fissure; Flocc., flocculus; Inf., inferior; Lat., lateral; Med., medial, medullary; Mes., mesencephalic;
P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Tr., trunk; V., vein; Vel., velum; Vent., ventricle;
Verm., vermian; Vert., vertebral.

Tonsillomedullary segment Cortical segment

This segment begins where the PICA passes posterior to the This segment begins where the trunks and branches leave
glossopharyngeal, vagus, and accessory nerves and extends the groove between the vermis medially and the tonsil and
medially across the posterior aspect of the medulla near the the hemisphere laterally, and includes the terminal cortical
caudal half of the tonsil (Figs. 2.3, 2.4, 2.15, and 2.16). It ends branches. The bifurcation of the PICA often occurs near the
where the artery ascends to the midlevel of the medial surface origin of this segment. The cortical branches radiate outward
of the tonsil. The proximal portion of this segment usually from the superior and lateral borders of the tonsil to the
courses near the lateral recess and then posteriorly to reach remainder of the vermis and hemisphere.
the inferior pole of the tonsil. This segment commonly passes
medially between the lower margin of the tonsil and the medulla
before turning rostrally along the medial surface of the tonsil. The PICA origin and the vertebral artery
The loop passing near the lower part of the tonsil, referred to as The PICA is defined here, in agreement with others, as the
the caudal or infratonsillar loop, has been reported to form a cerebellar artery that arises from the vertebral artery (Figs.
caudally convex loop that coincides with the caudal pole of the 2.19 and 2.20) (49, 55). The PICA is less commonly defined as
tonsil, but it may also course superior or inferior to the caudal the cerebellar artery that supplies the posteroinferior part of
pole of the tonsil without forming a loop. In some cases it dips the cerebellum and generally arises from the vertebral artery,
below the caudal margin of the tonsil and even below the level but may also arise from the basilar artery (4, 56).
of the foramen magnum. A caudally convex loop is not present Of 50 cerebellar hemispheres examined in our previous
if the PICA passes directly medial between the tonsil and me- study, all but 1 had vertebral arteries, and 42 of the 49 verte-
dulla, if the PICA ascends along the lateral surface of the tonsil bral arteries gave rise to PICAs (30). Both a vertebral artery
to reach the hemispheric surface, or if the artery has a low origin and the associated PICA were absent in a few hemispheres. If
from the vertebral artery and ascends posterior to the medulla to a PICA is present, it is the largest branch of the vertebral
reach the tonsil (Fig. 2.17). artery. It is rarely absent bilaterally, but may arise as a double
The relationships between the tonsillomedullary segment or duplicate PICA. Forty-one of the 42 PICAs arose as a single
and the cerebellar tonsil and foramen magnum varies (Fig. trunk and 1 arose as a duplicate trunk. The vertebral artery
2.17). In our previous study of 42 PICAs, the caudal limit of sometimes terminates in a PICA.
this segment was located superior to the caudal pole of the The vertebral artery enters the dura lateral to the cervi-
tonsil in 23, inferior in 8, and at the same level in 11 (30). This comedullary junction, courses superior, anterior, and medial
segment passed medially in a location 10.0 mm inferior to 13.0 to reach the front of the medulla and joins its mate from the
mm superior (average, 1.6 mm superior) to the caudal tip of opposite side at approximately the level of the pontomedul-
the tonsil. The caudal limit of this segment was superior to the lary junction to form the basilar artery. The site of the origin
foramen magnum in 37 PICAs, inferior in 4, and at the same of the PICA from the vertebral artery varies from below the
level in 1. It was located 7.0 mm inferior to 18.0 mm superior foramen magnum to the vertebrobasilar junction. A few of
(average, 6.9 mm superior) to the foramen magnum. the PICAs arising below the foramen magnum may arise from
the vertebral artery in an extradural location (Fig. 2.21) (12).
Thirty-five of the 42 PICAs examined in our previous study
Telovelotonsillar segment arose above the level of the foramen magnum, and 7 vessels
This is the most complex of the segments. It begins at the originated below. The origin was located 14.0 mm below to
midportion of the PICA’s ascent along the medial surface of 26.0 mm above the level of the foramen magnum (average, 8.6
the tonsil toward the roof of the fourth ventricle and ends mm above) (30). The origin was located 0 to 35.0 mm (average,
where it exits the fissures between the vermis, tonsil, and 16.9 mm) below the junction of the vertebral and basilar
hemisphere to reach the suboccipital surface (Figs. 2.15-2.18). arteries.
In most, but not all, hemispheres, this segment often forms a The PICA arises from the posterior or lateral surfaces of the
loop with a convex rostral curve, called the cranial loop (20, vertebral artery more often than from the medial or anterior
38, 57). This loop is located caudal to the fastigium between surfaces (Fig. 2.19). On leaving the parent vessel, the initial
the cerebellar tonsil below and the tela choroidea and poste- course of the PICA is posterior, lateral, or superior more often
rior medullary velum above. The apex of the cranial loop than anterior, medial, or inferior (Fig. 2.20). The vertebral artery’s
usually overlies the central part of the inferior medullary diameter is greater at its entrance through the dura (range,
velum, but its location varies from the superior to the inferior 1.8–6.2 mm; average, 4.4 mm) than at the PICA origin
margin and from the medial to the lateral extent of the infe- (range, 1.6–5.7 mm; average, 3.9 mm) or at its termination (range,
rior medullary velum. The apex of the cranial loop is inferior 1.7–5.5 mm; average, 3.7 mm). The diameter of the PICA at its
to the level of the fastigium of the fourth ventricle in most origin ranges from 0.5 to 3.4 mm (average, 2.0 mm). The origin
cases, but may also extend to the level of the fastigium. This was 1.0 mm or less in diameter in 4 cerebellae. The PICA has
segment gives rise to branches that supply the tela choroidea been reported to be hypoplastic in 5 to 16% of cerebellar hemi-
and choroid plexus of the fourth ventricle. spheres (33, 48).

S56 Rhoton
FIGURE 2.17. Locations of the PICA bifurcation, the caudal loops in relation to the tonsil and the foramen magnum, and the
cranial loops. A, site of the bifurcation in relation to the tonsil. The main trunk of the PICA may bifurcate at any site along
the margin of the tonsil. Inferolateral bifurcation (red ): the lateral trunk passes upward lateral to the tonsil to reach the
hemisphere, and the medial trunk passes along the anteromedial margin of the tonsil. Inferomedial bifurcation (green): the
lateral trunk passes superolateral over the posterior margin of the tonsil to reach the hemispheric surface, and the medial
trunk passes upward along the anteromedial margin of the tonsil. Superomedial bifurcation (blue): the lateral trunk passes
posteriorly over the medial surface of the tonsil, and the medial trunk ascends to supply the vermis. Superolateral bifurcation
(yellow): the lateral trunk passes out of the fissure between the tonsil and the hemisphere and proceeds to the hemispheric
surface, and the medial trunk ascends to supply the vermis. B, location of the caudal loop in relation to the tonsil. The tonsil-
lomedullary segment often formed a caudally convex loop (blue, orange, green) as it passed medially across the posterior sur-
face of the medulla. This caudal part of the tonsillomedullary segment was located between 10.0 mm inferior and 13.0 mm
superior (average, 1.6 mm superior) to the caudal tip of the tonsil. This loop could be found superior to (orange), inferior to
(green), or at the level of (blue) the caudal tip of the tonsil. In some cases (yellow), the PICA ascended from the vertebral
artery (V.A.) or took another course to reach the medial surface of the tonsil without forming a caudal loop. C, relation of
the caudal loop to the foramen magnum. Most caudal loops were superior to the foramen magnum (yellow), but they could
be inferior to (red ) or at the level of (green) the foramen magnum. The caudal loop was located between 7.0 mm inferior
and 18.0 mm superior (average, 6.9 mm superior) to the foramen magnum. D, relationship of the cranial loop (arrow) to the
superior pole of the tonsil and the trunks of the PICA. The right tonsil was removed at the level of the tonsillar peduncle to
expose the inferior medullary velum and the tela choroidea. The telovelotonsillar segment often formed a cranially convex
loop. below the fastigium. The cranially convex loop could be formed by either the main (green), medial (yellow), or lateral
(blue) trunk. On the left (blue), the lateral trunk (arrow) forms a cranially convex loop over the superior pole of the tonsil

FIGURE 2.18. PICA relationships. A, the right half of the cerebellum has been removed. The right PICA passes between the
rootlets of the vagus and accessory nerves to reach the surface of the inferior cerebellar peduncle. The left PICA, as it
courses around the rostral pole of the tonsil, is hidden by the remaining left half of the uvula. The SCA passes around the
brainstem below the oculomotor nerve and above the trigeminal nerve. B, the part of the uvula and nodule medial to the
tonsil has been removed to expose the PICAs passage through the cerebellomedullary fissure and around the tonsil. The artery
frequently forms a caudal loop at the lower margin of the tonsil and a cranial or supratonsillar loop that wraps around the rostral
pole of the tonsil. C, the tonsil has been removed to expose the PICA’s looping course through the cerebellomedullary fissure. D,
the inferior medullary velum, which stretches across the rostral pole of the tonsil, has been folded downward to expose the dentate
tubercle, a prominence near the fastigium that underlies the dentate nucleus. The lateral recess is also exposed. The telovelotonsil-
lar segment of the PICA courses in the cerebellomedullary fissure between the tela and velum on one side and the tonsil on the
other side. Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; CN, cranial nerve; Cran., cranial; Dent., dentate;
Fiss., fissure; Inf., inferior; Lat., lateral; Med., median, medullary; Mid., middle; Nucl., nucleus; Ped., peduncle; P.I.C.A., posteroinfe-
rior cerebellar artery; S.C.A., superior cerebellar artery; Sulc., sulcus; Sup., superior; Vel., velum.
Bifurcation adjacent part of the hemisphere and the lateral trunk supplies
most of the hemispheric and tonsillar parts of the suboccipital
Most PICAs bifurcate into a smaller medial and a larger surface. The PICAs that do not bifurcate are usually small and
lateral trunk; the trunk before the bifurcation is referred to as supply only a small area on the tonsil and adjacent part of the
the main trunk. The medial trunk supplies the vermis and vermis and hemisphere.
Š
and the medial trunk ascends straight to the vermis. In the center (yellow), the medial trunk (arrow) forms a cranially convex
loop at the superior pole of the tonsil and the lateral trunk courses around the medial surface of the tonsil. On the right
(green), the cranial loop is formed by the main trunk (arrow) and lies in the telovelotonsillar fissure anterior to the superior
pole of the tonsil. (From, Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical anatomy of the posterior inferior
cerebellar artery. Neurosurgery 10:170–199, 1982 [30].) Inf., inferior; Lat., lateral; Med., medial, medullary; Ped., peduncle;
Ton., tonsillar; Tr., trunk; V.A., vertebral artery; Vel., velum.

S58 Rhoton
FIGURE 2.19. Inferior view of the brainstem and cerebellum FIGURE 2.20. Anterosuperior (top) and anterior (bottom)
(top) shows the site on the circumference of the vertebral views of the pons, the medulla, and the vertebral and basilar
artery (lower right) of the origin of the 42 PICAs found in 50 arteries show the direction taken by the initial segment of
cerebellar hemispheres. The circle on the lower right corre- the PICA. Forty-two PICAs were found in the 50 cerebellar
sponds to the circumference of the vertebral artery. Eight of hemispheres we examined. The arrows are on and define the
the 50 cerebellar hemispheres did not have a PICA. The direction taken by the initial segment of the PICAs immedi-
PICA most commonly arose from the posterior, posterolat- ately distal to their origin. The abducens, facial, and vestibu-
eral, or lateral surface of the vertebral artery, but a few sites locochlear nerves arise at the level of the pontomedullary
of origin were located on the anterior or medial half of the junction. The glossopharyngeal, vagus, and accessory nerves
circumference of the artery. (From, Lister JR, Rhoton AL Jr, arise posterior to the inferior olives, and the hypoglossal
Matsushima T, Peace DA: Microsurgical anatomy of the pos- nerves arise anterior to the inferior olives. The initial seg-
terior inferior cerebellar artery. Neurosurgery 10:170–199, ment was most commonly directed posterior, lateral supe-
1982 [30].) rior, posterolateral, or posteromedial. A few PICAS were
directed superolateral, inferolateral, anterolateral, posteroin-
ferior, superomedial, inferomedial, or anterior. (From, Lister
JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical
The bifurcation usually occurs posterior to the brainstem as anatomy of the posterior inferior cerebellar artery. Neurosur-
the PICA courses around the tonsil (Figs. 2.16, 2.17, and 2.22). gery 10:170–199, 1982 [30].) Ant., anterior; B.A., basilar
The most common site of the bifurcation is in the teloveloton- artery; Inf., inferior; Lat., lateral; Med., medial; Post., poste-
sillar fissure as the artery courses around the rostral pole of rior; Sup., superior; V.A., vertebral artery.
the tonsil. The medial trunk usually ascends in the vermohe-
mispheric fissure to reach the vermis, and the lateral trunk
passes laterally out of the telovelotonsillar fissure to reach the rior surfaces of the tonsil. This division of the lateral trunk
hemispheric surface. If the bifurcation occurs at a more prox- into tonsillar and hemispheric branches may occur at various
imal site in relation to the tonsil, the medial trunk usually sites in relation to the tonsil, but is most commonly located
ascends along the medial tonsillar surface and through the near the posterior margin of the medial surface of the tonsil.
vermohemispheric fissure, and the lateral trunk passes poste- The trunks passing through the tonsillomedullary fissure
riorly over the tonsillar surface near the point of bifurcation to send branches to the medulla, and the trunks passing through
reach the hemispheric surface. If the bifurcation occurs prox- the telovelotonsillar fissure send ascending branches to the
imal to the lateral margin of the tonsil, the medial trunk dentate nucleus (55).
commonly pursues a course around the medial surface of the
tonsil to reach the vermohemispheric fissure, and the lateral
trunk passes directly to the hemispheric surface. Branches
The medial trunk terminates by sending branches over the The PICA gives rise to perforating branches to the medulla,
inferior part of the vermis and adjacent part of the tonsil and choroidal arteries that supply the tela choroidea and choroid
hemisphere. The lateral trunk divides into a larger hemispheric plexus, and cortical arteries. The cortical arteries are divided
trunk that gives off multiple branches to the hemisphere and into median and paramedian vermian; tonsillar; and medial,
smaller tonsillar branches that supply the posterior and infe- intermediate, and lateral hemispheric arteries. The cortical

FIGURE 2.21. Bilateral PICAs with an extradural origin. A, both PICAs arise outside the dura as the vertebral arteries course
behind the atlanto-occipital joints. The PICAs enter the dura at the level of the dorsolateral medulla and do not have an ante-
rior medullary or a full lateral medullary segment. The left PICA loops downward in front of the posterior arch of the atlas.
B, enlarged view. The left PICA gives off a posterior meningeal artery, penetrates the dura by passing through the dural cuff
around the vertebral artery, and loops downward behind the accessory nerve and the C1 and C2 roots before ascending to
enter the cerebellomedullary fissure. The right PICA passes through the dura and courses along the side of the medulla in
front of the rootlets of the accessory nerve. C, the left PICA penetrates the dural cuff with the vertebral artery and the C1
nerve root. The accessory nerve passes posterior to both the vertebral artery and the PICA. The rostral attachment of the
dentate ligament ascends between the PICA and the vertebral artery to attach to the dura at the level of the foramen mag-
num. D, the C1 nerve root passes through the dural cuff with the vertebral artery and the PICA. The accessory nerve ascends
posterior to both the vertebral artery and PICA. A small posterior spinal artery arises from the PICA and courses along the
dorsolateral aspect of the spinal cord. A., artery; Atl., atlanto; CN, cranial nerve; Dent., dentate; Lig., ligament; Men., menin-
geal; Occ., occipital; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Sp., spinal; Suboccip., suboccipital; Vert.,
vertebral.
branches arising near the superior pole of the tonsil send branches ing in it. The circumflex perforating arteries are divided into
upward to supply the dentate nucleus. short and long types. The short circumflex type does not
travel more than 90 degrees around the circumference of the
Perforating arteries brainstem. The long circumflex type travels a greater distance
The perforating arteries are small arteries that arise from to reach the opposite surface. Both types of circumflex arteries
the three medullary segments and terminate in the brainstem. send branches into the brainstem along their course. The
They are divided into direct and circumflex types. The direct perforating arteries have numerous branches and anastomo-
type pursues a straight course to enter the brainstem. The ses that create a plexiform pattern on the medullary surface.
circumflex type passes around the brainstem before terminat- In our previous study, the anterior medullary segments gave

S60 Rhoton
FIGURE 2.22. PICA relationships. A, the left PICA is larger than the right. Both PICAs enter the cerebellomedullary fissure,
pass around the tonsils, and exit the fissure to supply the suboccipital surface. The natural cleft between the right tonsil and
the biventral lobule has been opened. The tonsil is attached to the remainder of the cerebellum by the tonsillar peduncle, a
white matter bundle along its superolateral margin. All of the other margins of the tonsils are free margins. B, enlarged view.
The left biventral lobule has been elevated to expose the flocculus protruding from the margin of the lateral recess. C, the
tonsils have been retracted laterally to expose the PICAs coursing in the cerebellomedullary fissure. The right PICA bifurcates
into medial and lateral trunks before reaching the cerebellomedullary fissure. The left PICA bifurcates within the fissure. The
medial trunks supply the vermis and adjacent part of the hemisphere and the lateral trunks supply the remainder of the hemi-
sphere. D, the right tonsil has been removed to expose the lateral recess and bifurcation of the right PICA into medial and
lateral trunks. E, both tonsils and the tela have been removed to expose the ventricular floor and walls. The left PICA divides
into its trunks within the cerebellomedullary fissure. The inferior medullary velum has been preserved, but is a thin layer that

rise to 0 to 2 (average, 1.0) perforating branches per hemi- aspect of the tonsil. The largest area supplied by a PICA
sphere, which were most commonly of the short circumflex includes all of the ipsilateral half of the suboccipital surface
posterior type and supplied the anterior, lateral, or posterior with overlap onto the contralateral half of the suboccipital
surfaces of the medulla (30). The lateral medullary segments surface and the adjacent parts of the tentorial and petrosal sur-
gave rise to 0 to 5 (average, 1.8) branches per hemisphere that faces. The smallest area supplied by a PICA is confined to the
supplied the lateral or posterior medulla predominately as inferior part of the ipsilateral cerebellar tonsil. The cortical
short circumflex arteries. The tonsillomedullary segment gave area supplied by the PICA is more variable than that supplied
rise to more perforating branches than the other segments by the AICA and the SCA. If the PICA is absent on one side,
(range, 0–11 per hemisphere; average, 3.3). They were either the contralateral PICA or the ipsilateral AICA supplies most
of the direct or short circumflex type, but the former predom- of the area normally supplied by the absent PICA.
inated. They terminated in the lateral and posterior surfaces of The cortical branches are divided into hemispheric, ver-
the medulla. mian, and tonsillar groups. The vermian branches usually
The perforating branches of the PICA intermingle and over- arise from the medial trunk, and the hemispheric and tonsillar
lap with those arising from the vertebral artery (Fig. 2.5). The branches from the lateral trunk. Each half of the vermis is
segment of the vertebral artery distal to the origin of the PICA divided into median and paramedian segments, and the
more frequently gives rise to perforating arteries than the hemisphere lateral to the vermis is divided into medial, inter-
segment proximal to the PICA origin. The perforating mediate, and lateral segments. There is a reciprocal relation-
branches arising between the entrance of the vertebral artery ship with frequent overlap in the areas supplied by the ton-
into the dura mater and origin of the PICA are most com- sillar, hemispheric, and vermian branches.
monly of the short circumflex or direct type and terminate
predominately on the lateral side of the medulla. Those aris- Hemispheric branches
ing between the PICA origin and the vertebrobasilar junction The hemispheric branches most commonly arise from the
are predominately of the short circumflex type and terminate lateral trunk within or distal to the vermohemispheric fissure.
on the anterior and lateral surfaces of the medulla. The seg- They appear to radiate outward to the hemispheric surface
ment of the vertebral artery distal to the PICA origin also from the superior and lateral margin of the tonsil. In our
gives rise to a few branches that enter the choroid plexus previous study, the number of hemispheric branches given off
protruding from the foramen of Luschka. from a PICA ranged from 0 to 9 (average, 2.8). Four PICAs
had no hemispheric branches (30). A common pattern was for
Choroidal arteries
there to be three branches with an individual branch being
The PICA gives rise to branches that supply the tela cho- directed to the medial, intermediate, and lateral segments of
roidea and choroid plexus of the fourth ventricle, usually the suboccipital surface. The medial hemispheric segment is
supplying the choroid plexus near the midline of the roof of occasionally supplied by the medial trunk. The ipsilateral
the fourth ventricle and in the medial part of the lateral recess AICA often gives rise to branches that overlap onto the lateral
(Figs. 2.16 and 2.23) (15). This includes all of the medial hemispheric segment, and the SCA often overlaps onto the
segment and the adjacent part of the lateral segment of the superior part of the three hemispheric segments.
choroid plexus. More choroidal branches arise from the ton-
sillomedullary and telovelotonsillar segments than from the
Vermian arteries
lateral or anterior medullary segment. The AICA usually sup-
plies the portion of the choroid plexus not supplied by the The vermian arteries usually arise from the medial trunk in
PICA, commonly that part in the cerebellopontine angle and the vermohemispheric fissure. A common pattern is for there
the adjacent part of the lateral recess. to be one or two vermian branches. If two are present, they are
often directed to the median and paramedian segments. If no
Cortical arteries vermian branches are present, the vermian area is usually
The most constant area supplied by the PICA includes the supplied by the contralateral PICA.
majority of the ipsilateral half of the suboccipital surface of the
cerebellum (Figs. 2.15, 2.16, and 2.22). This includes the ma- Tonsillar branches
jority of the suboccipital surface of the ipsilateral hemisphere The tonsillar branches usually arise from the lateral trunk
and tonsil, the ipsilateral half of the vermis, and the anterior and most commonly supply the medial, posterior, inferior,
Š
can be opened, if needed, to increase the exposure of the fourth ventricle. F, enlarged view showing the relationship of the
PICAs to the fourth ventricle. The PICAs, after passing between the rootlets of the accessory rootlets course along the cau-
dolateral margin of the fourth ventricle on the inferior cerebellar peduncle before entering the cerebellomedullary fissure.
The left PICA has been reflected laterally. The facial colliculus is in the upper and hypoglossal and vagal nuclei are in the
lower part of the floor. Bivent., biventral; Br., branch; Cer. Med., cerebellomedullary; CN, cranial nerve; Coll., colliculus;
Fiss., fissure; Flocc., flocculus; Hem., hemispheric; Hypogl., hypoglossal; Inf., inferior; Lat., lateral; Med., medial, medullary;
Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Suboccip., suboccipital; Tr., trunk; Trig., trigeminal; V., vein; Vel.,
velum; Vent., ventricle; Verm., vermian.

S62 Rhoton
FIGURE 2.23A

and part of the anterior surfaces of the tonsil. If there are no lets with the medulla (Fig. 2.24). The PICAs that arise superior
branches directed predominately to the tonsil, the tonsil is or inferior to the hypoglossal rootlets usually course supe-
supplied by the adjacent hemispheric and vermian branches. rior or inferior to, rather than between, the hypoglossal root-
lets. The hypoglossal rootlets are frequently stretched around
Relationship to the cranial nerves the origin and initial segment of the PICAs that arise at the
The PICA has the most complex relationship to the cranial level of the caudal two-thirds of the olive, in addition to being
nerves of any artery (27, 30, 52). The vertebral artery courses stretched posteriorly by the vertebral artery. About half of the
anterior to glossopharyngeal, vagus, accessory, and hypoglos- PICA origins are located anterior to and half posterior to or at
sal nerves, and the proximal part of the PICA passes around the level of the rostrocaudal line drawn through the exits of
or between and often stretches or distorts the rootlets of these the hypoglossal rootlets from the medulla. The vertebral
and adjacent nerves. artery courses from the lateral side of the inferior part of
The inferior olive protrudes from the anterolateral surface the medulla to the anterior surface of the superior part of the
of the medulla near the vertebral artery and the origin of the medulla. Those PICAs arising inferior to the olive, arise pos-
PICA (Fig. 2.24). The hypoglossal nerve joins the brainstem on terior to the level of the hypoglossal rootlets if the vertebral
its anterior border and the glossopharyngeal, vagus, and ac- artery at the site of origin of the PICA has not coursed far
cessory nerves on its posterior border. Most PICAs arise at the enough anterior to reach the level of the hypoglossal rootlets.
level of the olive, but some will arise rostral or caudal to The PICA origin is anterior to the hypoglossal rootlets if
that level. The PICA origins at the level of the olive are either the vertebral artery, on reaching the hypoglossal rootlets, was
lateral or anterior to the olive. The PICA origin is anterior to anterior to the olive. The PICA origin is located at the level of
the olive if the vertebral artery pursues its usual course ante- or posterior to the hypoglossal rootlets if the vertebral artery
rior to the olive, but if the vertebral artery is tortuous and at the site of origin of the PICA courses lateral to the olive and
kinked posteriorly, the PICA origin is lateral to the olive. stretches the hypoglossal rootlets posteriorly.
The initial segment of the PICA has a variable course in
Hypoglossal rootlets relation to the hypoglossal rootlets. The most common course
is for the PICA to arise from the vertebral artery and pass
The hypoglossal nerve arises as a line of rootlets that exits
directly posteriorly around or between the hypoglossal root-
the brainstem along the anterior margin of the caudal two-
lets. However, some PICAs will loop upward, downward, or
thirds of the olive in the preolivary sulcus, a groove between
laterally in front of the hypoglossal rootlets before passing
the olive and the medullary pyramid (Fig. 2.24). The hypo-
posteriorly between or around them.
glossal rootlets, in their course from the preolivary sulcus to
the hypoglossal canal, pass posterior to the vertebral artery,
except in the rare instance in which they pass anterior to the Glossopharyngeal, vagus, and accessory nerves
artery. If the vertebral artery is elongated or tortuous and After coursing posterior to the hypoglossal rootlets, the
courses lateral to the olive, it stretches the hypoglossal rootlets PICA encounters the rootlets of the glossopharyngeal, vagus, and
dorsally over its posterior surface. Some tortuous vertebral accessory nerves (Fig. 2.25). The glossopharyngeal, vagus, and
arteries stretch the hypoglossal rootlets so far posteriorly that accessory nerves arise as a line of rootlets, then exit the
they intermingle with the glossopharyngeal, vagus, and ac- brainstem along the posterior edge of the olive in the retro-
cessory nerves. olivary sulcus, a shallow groove between the olive and the
The relation of the origin and proximal part of the PICA to posterolateral surface of the medulla. The glossopharyngeal
the hypoglossal rootlets varies markedly. The PICA arises nerve arises as one or rarely two rootlets posterior to the
either rostral or caudal or at the level of the hypoglossal superior third of the olive, just inferior to the pontomedullary
rootlets. The majority of the PICAs arise at the level of the junction and anterior to the foramen of Luschka and the
hypoglossal rootlets near the junction of the hypoglossal root- rhomboid lip of the lateral recess of the fourth ventricle. The
Š
FIGURE 2.23. A. Schematic illustration of choroidal arteries in the posterior fossa. Upper: Posterior or suboccipital view. The
choroid plexus is composed of two medial and two lateral segments. Each medial segment is divided into a rostral, or nodu-
lar, and a caudal, or tonsillar, part. Each lateral segment is divided into a medial, or peduncular, and a lateral, or floccular,
part. The medulla, fourth ventricle, vertebral arteries, and origin of the PICAs are below. The choroidal arteries arise from
the PICA, SCA, and AICA. The choroid plexus is attached to the tela choroidea, which is attached to the taenia along the bor-
der of the floor of the fourth ventricle. Lower: Anterolateral view. The choroid plexus is seen through the brainstem. The
AICA arises from the basilar artery and sends branches that enter the choroid plexus near the flocculus. The SCA may also
send choroidal branches to the floccular part of the choroid plexus. Right Center: Diagram showing subdivision of the cho-
roid plexus into medial and lateral segments. The medial segments have nodular and tonsillar parts and the lateral segments
have peduncular and floccular parts. The floccular parts protrude through the foramina of Luschka, and the tonsillar parts
extend through the foramen of Magendie. A., artery; A.I.C.A., anteroinferior cerebellar artery; B.A., basilar artery; Ch., cho-
roidal; F., foramen; fl., floccular; He., hemispheric; L., lateral; M., medial; Med., medulla; no., nodular; pe., peduncular;
P.I.C.A., posteroinferior cerebellar artery; Pl., plexus; S.C.A., superior cerebellar artery; to., tonsillar; To., tonsillo; V.A., verte-
bral artery; Ve., vermian.

S64 Rhoton
FIGURE 2.23B.

vagus nerve arises inferior to the glossopharyngeal nerve as a PICA is included in the occlusion. Occlusion of the PICA is
line of tightly packed rootlets posterior to the superior third of usually the result of thrombosis of a preexisting atheroscle-
the olive. The accessory nerve arises as a widely separated rotic stenosis and is less commonly caused by embolization
series of rootlets that originates from the medulla and upper (5).
cervical cord, inferior to the vagus nerve below the level of the Occlusion of the PICA causes an infarct in the lateral me-
junction of the upper and middle third of the olive. The dulla, dorsal to the inferior olivary nucleus. The syndrome of
glossopharyngeal and vagus nerves arise rostral to the level of occlusion of the PICA, referred to as the lateral medullary
origin of the hypoglossal rootlets. The accessory rootlets arise syndrome, includes ipsilateral numbness of the face caused
at both the level of and inferior to the origin of the hypoglos- by injury to the spinal tract of the trigeminal nerve; loss of
sal rootlets. pain and temperature on the contralateral half of the body
The PICA commonly passes from the lateral to the posterior caused by damage to the spinothalamic tract; dysphagia, dys-
aspect of the medulla by passing between the rootlets of the arthria, and hoarseness as a result of homolateral weak-
glossopharyngeal, vagus, and accessory nerves. The PICA ness of the palate, pharynx, vocal cord, and occasionally the
may be ascending, descending, or passing laterally, or medi- sternoclinoid muscle caused by a lesion in the nucleus am-
ally or be involved in a complex loop that stretches and biguis; ataxia, dizziness, vertigo, nystagmus, and homolat-
distorts these nerves as it passes between them. Of the 42 eral cerebellar signs caused by damage to the vestibular
PICAs found in 50 cerebellae in a previous study, 16 passed nuclei, cerebellar tracts in the brainstem, and the cerebel-
between the rootlets of the accessory nerve, 10 passed be- lum; an ipsilateral Horner’s syndrome caused by disrup-
tween the rootlets of the vagus nerve, 13 passed between the tion of the oculosympathetic fibers in the lateral medullary
vagus and accessory nerves, 2 passed above the glossopha- reticular substance; and vomiting caused by involvement of
ryngeal nerve between the latter nerve and the vestibuloco- the nucleus and tractus solitarius. Other less common ac-
chlear nerve, and 1 passed between the glossopharyngeal and companiments include nystagmus and diplopia caused by
vagus nerves (30). a lesion in the dorsal medulla and the medial longitudinal
fasciculus; and facial weakness caused by damage to the
Facial and vestibulocochlear nerves
facial motor nucleus (10, 14, 17).
The facial and vestibulocochlear nerves arise superior to The syndrome associated with lateral medullary infarction
the glossopharyngeal nerve at the level of the pontomedullary may be caused by occlusion of either the PICA or the vertebral
junction. The proximal part of the PICA usually passes artery, but it is most commonly attributable to vertebral artery
around the brainstem inferior to the facial and vestibuloco- occlusion (14, 17). Fisher et al. noted that 75% of cases of
chlear nerves. However, in some cerebellopontine angles, the lateral medullary syndrome were associated with a vertebral
proximal part of the PICA, after coursing posterior to the level artery occlusion and that only 12% had a PICA occlusion (14).
of the hypoglossal rootlets, loops superiorly toward, even The site of the infarct with a PICA occlusion does not differ
compressing, the facial and vestibulocochlear nerves before significantly from that with a vertebral artery occlusion.
descending to pass between the glossopharyngeal, vagus, and Symptoms, if present with the other manifestation of the
accessory rootlets (Figs. 2.11 and 2.12). lateral medullary syndrome, suggest vertebral artery rather
than PICA occlusion include paresis of the trunk, limb, and
DISCUSSION tongue muscles, crossed sensory loss with dysphagia, visual
loss suggesting calcarine cortex involvement, diplopia with an
Occlusion abducens nerve palsy, loss of hearing, or a facial palsy.
The consequences of a PICA occlusion vary and may be Occlusion of the branches of the PICA distal to the medul-
overshadowed by the effects of occlusion of the parent verte- lary branches produces a syndrome resembling labyrinthitis
bral artery. The effects range from a clinically silent occlusion and includes rotatory dizziness, nausea, vomiting, inability to
to infarction of portions of the brainstem or cerebellum with stand or walk unaided, and nystagmus without appendicular
swelling, hemorrhage, and death (53). Nearly all occlusions of dysmetria. The dizziness, unsteadiness, and nystagmus are
the PICA, but only slightly more than half of occlusions of the postulated to caused by involvement of the flocculonodular
vertebral artery, result in medullary or cerebellar infarction (5, complex. The lack of brainstem signs in this syndrome indi-
11). The incidence of medullary and cerebellar infarction in cates that the occlusion is distal to the medullary branches of
vertebral artery occlusion increases greatly if the origin of the the PICA. Branch occlusions are usually caused by emboli and
Š
FIGURE 2.23. B. Schematic illustrations of the choroid plexus of the posterior fossa showing the different patterns of blood
supply. Upper: Orienting diagram. The PICA and its plexal area of supply are shown in blue, the AICA in red, and the SCA in
green. The PICA divides into vermian and tonsillohemispheric branches. Lower diagrams (A--D): The size of the area supplied
by the arteries arising from the AICA, PICA, and SCA is shown. Each half of the schematic diagrams shows a different pat-
tern. Colors used to show plexal areas of supply of the different cerebellar arteries are as follows: red: ipsilateral AICA;
orange: contralateral AICA; blue: ipsilateral PICA; yellow: contralateral PICA; and green: ipsilateral SCA. (From, Fujii K, Len-
key C, Rhoton AL Jr: Microsurgical anatomy of the choroidal arteries: Fourth ventricle and cerebellopontine angles. J Neuro-
surg 52:504–524, 1980 [15].)

S66 Rhoton
FIGURE 2.24. Lateral view of the right side of the brainstem

shows the site of origin of the PICA in relation to the inferior
olive and the rootlets of the hypoglossal nerve. Forty-two PICAs
were found in the 50 cerebellar hemispheres we examined. The FIGURE 2.25. Relationship of the PICA to the rootlets of
rootlets of the glossopharyngeal, vagus, and accessory nerves the glossopharyngeal, vagus, and accessory nerves. A,
arose posterior to the olive. The glossopharyngeal and vagus orientation of illustrations B through F. The inset shows
nerves arose at the level of the upper third of the olive. The the site of the scalp flap and the craniectomy. The large
accessory rootlets arose at the level of the lower two-thirds of illustration shows the cerebellum retracted and the facial,
the olive and below. The rootlets of the hypoglossal nerve arose vestibulocochlear, glossopharyngeal, vagus, accessory, and
anterior to and slightly below the lower two-thirds of the olive. hypoglossal nerves. The glossopharyngeal, vagal, and
Two PICAS arose at the level of the rostral third of the olive, 12 accessory rootlets arise posterior to the olive, and the
arose at the level of the middle third, 16 arose at the level of hypoglossal rootlets arise anterior to the olive. The
the caudal third, and 12 arose below the olive. Twenty arose choroid plexus and the flocculus project into the
anterior to the olive, and 22 arose beside the olive. The verte- cerebellopontine angle posterior to the glossopharyngeal
bral arteries and PICA origins located beside the olive stretched and vagus nerves. The PICA arises from the vertebral
the hypoglossal rootlets posteriorly because the hypoglossal artery and passes inferior (B and C ), superior (E and F ), or
rootlets always pass posterior to the vertebral artery. (From, between (D) the rootlets of the hypoglossal nerve. Of the
Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical 42 PICAs found in 50 cerebellar hemispheres, 16 passed
anatomy of the posterior inferior cerebellar artery. Neurosur- between the rootlets of the accessory nerve (B ), 13
gery 10:170–199, 1982 [30].) passed between the vagus and accessory nerves (C ),
10 passed between the rootlets of the vagus nerve (D),
result in infarction of the suboccipital portion of the cerebellar 2 passed between the glossopharyngeal and
hemisphere and vermis. Massive acute cerebellar infarction is vestibulocochlear nerves (E ), and 1 passed between the
most frequently caused by PICA or vertebral artery occlusion, glossopharyngeal and vagus nerves (F ). A tortuous PICA may
with the most common site of cerebellar infarction being in ascend anterior to the glossopharyngeal and vagus nerves
the PICA territory (53). and compress and distort the facial and vestibulocochlear
nerves before passing posteriorly between the
glossopharyngeal, vagus, and accessory nerves (E and F ).
Operative exposure
(From, Lister JR, Rhoton AL Jr, Matsushima T, Peace DA:
The PICA is exposed in dealing with neoplasms involving Microsurgical anatomy of the posterior inferior cerebellar
the cerebellopontine angle, foramen magnum, cervicocranial artery. Neurosurgery 10:170–199, 1982 [30].)
junction, clivus, jugular foramen, fourth ventricle, and cere-
bellum; aneurysms arising at the PICA origin, the most com- cervical junction, like the Chiari malformation and osseous
mon site in the posterior fossa below the basilar apex, and less deformities; and dysfunction of the lower cranial nerves like
frequently from the distal segments (30); arterial dissections at glossopharyngeal neuralgia (21, 23, 24, 29, 42).
the PICA-vertebral junction (54, 58); arteriovenous malforma- The PICA can arise outside the dura, and at any point from
tions, which also commonly involve the other cerebellar ar- along the intradural course of the vertebral artery. The origin
teries and the brainstem as well as the cerebellum (6); poste- can be located along the lateral side of the medulla, if the
rior fossa ischemia requiring bypass because of the PICAs artery arises near the passage of the vertebral artery through
easy accessibility through a suboccipital craniotomy and the the dura, or in front of the brainstem, if the origin is high near
proximity to the occipital artery (28); anomalies at the cranio- the vertebrobasilar junction. Exposing a low-lying PICA ori-

gin, either extra- or immediately intradurally, at the level of 12. Fine AD, Cardoso A, Rhoton AL Jr: Microsurgical anatomy of the
the foramen magnum can be achieved by a midline suboccip- extracranial-extradural origin of the posterior inferior cerebellar
ital or a far-lateral approach. If an artery with a low-lying artery. J Neurosurg 91:645–652, 1999.
origin has to be followed upward into the cerebellopontine 13. Fisch U: The surgical anatomy of the so-called internal auditory artery,
angle or there is a need to mobilize the site of the vertebral in Proceedings of the Tenth Nobel Symposium on Disorders of the Skull Base
Region. Stockholm, Almqvist and Wiksell, pp 121–130, 1968.
artery’s passage through the dura, a far-lateral or transcon-
14. Fisher CM, Karnes WE, Kubik CS: Lateral medullary infarction:
dylar modification approach are to be considered. A retrosig-
The pattern of vascular occlusion. J Neuropathol Exp Neurol
moid craniotomy may be sufficient to expose a PICA arising 20:323–379, 1961.
from the midportion of the vertebral artery on the lateral side 15. Fujii K, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the
of the brainstem in the lower part of the cerebellopontine choroidal arteries: Fourth ventricle and cerebellopontine angles.
angle. If there is a need to expose the origin deep in the J Neurosurg 52:504–524, 1980.
midline near the vertebrobasilar junction, a supra- 16. Gardner WJ: Concerning the mechanism of trigeminal neuralgia
infratentorial presigmoid approach with some added degree and hemifacial spasm. J Neurosurg 19:947–958, 1962.
of labyrinth resection may be required, depending on the 17. Goodhart SP, Davison C: Syndrome of the posterior inferior and
depth of the PICA origin and the pathology. A midline sub- anterior inferior cerebellar arteries and their branches. Arch
occipital craniectomy, possibly combined with removal of the Neurol Psychiatry 35:501–524, 1936.
18. Hardy DG, Rhoton AL Jr: Microsurgical relationships of the su-
posterior atlantal arch, is usually sufficient to expose pathol-
perior cerebellar artery and the trigeminal nerve. J Neurosurg
ogy involving the tonsillomedullary and telovelotonsillar seg-
49:669–678, 1978.
ments of the artery. Lesions involving the PICA in the walls in 19. Hardy DG, Peace DA, Rhoton AL Jr: Microsurgical anatomy of
the fourth ventricle, vermis, and paravermian areas are usu- the superior cerebellar artery. Neurosurgery 6:10–28, 1980.
ally exposed by a midline suboccipital approach. Lesions 20. Huang YP, Wolf BS: Angiographic features of fourth ventricle
involving the hemispheric branch can be exposed through a tumors with special reference to the posterior inferior cerebellar
vertical suboccipital incision and craniotomy centered over artery. AJR Am J Roentgenol 107:543–564, 1969.
the pathology. The anatomy of PICA compression of the 21. Jannetta PJ: Neurovascular cross-compression in patients with
lower cranial nerves and medulla is reviewed in the section hyperactive dysfunction symptoms of the eighth cranial nerve.
on the cerebellopontine angle. Surg Forum 26:467–469, 1975.
22. Jannetta PJ: Microsurgical approach to the trigeminal nerve for tic
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro- douloureux. Prog Neurol Surg 7:180–200, 1976.
logical Surgery, University of Florida Brain Institute, P.O. Box 100265, 23. Jannetta PJ, Gendell HM: Clinical observations on etiology of
100 South Newell Drive, Building 59, L2-100, Gainesville, FL essential hypertension. Surg Forum 30:431–432, 1979.
32610-0265. 24. Jannetta PJ, Abbassy M, Maroon JC, Ramos FM, Albin MS: Etiol-
ogy and definitive microsurgical treatment of hemifacial spasm:
Operative techniques and results in 47 patients. J Neurosurg
47:321–328, 1977.
REFERENCES
25. Johnson JH, Kline DG: Anterior inferior cerebellar artery aneu-
1. Adachi B: Das Artieriensystem der Japaner. Kyoto, Kaiserlich- rysms: Case report. J Neurosurg 48:455–460, 1978.
Japanische Universität, 1928, vol I, p 123. 26. Kaplan HA, Ford DH: Arteria cerebelli inferior posterior, in The
2. Adams RD: Occlusion of the anterior inferior cerebellar artery. Brain Vascular System. Amsterdam, Elsevier, 1966, pp 93–95.
Arch Neurol Psychiatry 49:765–770, 1943. 27. Katsuta T, Rhoton AL Jr, Matsushima T: The jugular foramen:
3. Atkinson WJ: The anterior inferior cerebellar artery. J Neurol Microsurgical anatomy and operative approaches. Neurosurgery
Neurosurg Psychiatry 12:137–151, 1949. 41:149–202, 1997.
4. Burns JB, Hoffman JC, Brylski JR: Posterior inferior cerebellar 28. Khodadad G, Singh RS, Olinger CP: Possible prevention of brain
artery in fourth ventricular dilatation. Acta Radiol Diagn stem stroke by microvascular anastomosis in the vertebrobasilar
(Stockh) 13:58–65, 1972. system. Stroke 8:316–321, 1977.
5. Castaigne P, Lhermitte F, Gautier JC, Escourolle R, Derouesné C, 29. Laha RK, Jannetta PJ: Glossopharyngeal neuralgia. J Neurosurg
Der Agopian P, Popa C: Arterial occlusions in the vertebro-basilar 47:316–320, 1977.
system: A study of 44 patients with post-mortem data. Brain 30. Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical
96:133–154, 1973. anatomy of the posterior inferior cerebellar artery. Neurosurgery
6. Chou SN, Erickson DL, Ortiz-Suarez HJ: Surgical treatment of 10:170–199, 1982.
vascular lesions in the brain stem. J Neurosurg 42:23–31, 1975. 31. Locksley HB: Report on the cooperative study of intracranial aneurysms
7. Dandy WE: Concerning the cause of trigeminal neuralgia. Am J and subarachnoid hemorrhage: Section V, Part II—Natural history of
Surg 24:447–455, 1934. subarachnoid hemorrhage, intracranial aneurysms and arteriovenous
8. Dinsdale H, Logue V: Ruptured posterior fossa aneurysms and malformations. J Neurosurg 25:321–368, 1966.
their surgical treatment. J Neurol Neurosurg Psychiatry 22:202– 32. Luhan JA, Pollack SL: Occlusion of the superior cerebellar artery.
217, 1959. Neurology 3:77–89, 1953.
9. Drake CG: Surgical removal of arteriovenous malformations from 33. Margolis MT, Newton TH: The posterior inferior cerebellar artery, in
the brain stem and cerebellopontine angle. J Neurosurg 43:661– Newton TH, Potts DG (eds): Radiology of the Skull and Brain, Angiog-
670, 1975. raphy. St. Louis, C.V. Mosby, 1974, vol 2, book 2, pp 1710–1774.
10. Duncan GW, Parker SW, Fisher CM: Acute cerebellar infarction in 34. Martin RG, Grant JL, Peace DA, Theiss C, Rhoton AL Jr: Microsurgical
the PICA territory. Arch Neurol 32:364–368, 1975. relationships of the anterior inferior cerebellar artery and the facial-
11. Feely MP: Cerebellar infarction. Neurosurgery 4:7–11, 1979. vestibulocochlear nerve complex. Neurosurgery 6:483–507, 1980.

S68 Rhoton
35. Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the 46. Russel DS, Rubinstein LJ: Pathology of Tumors of the Nervous Sys-
fourth ventricle: Part I—Microsurgical anatomy. Neurosurgery tem. Baltimore, Williams & Wilkins, 1977, p 368.
11:631–667, 1982. 47. Saeki N, Rhoton AL Jr: Microsurgical anatomy of the upper
36. Mazzoni A: Internal auditory canal: Arterial relations at the porus basilar artery and the posterior circle of Willis. J Neurosurg
acusticus. Ann Otol Rhinol Laryngol 78:797–814, 1969. 46:563–578, 1977.
37. Mazzoni A, Hansen CC: Surgical anatomy of the arteries of the 48. Salamon G, Huang YP: Radiologic Anatomy of the Brain. Berlin,
internal auditory canal. Arch Otolaryngol 91:128–135, 1970. Springer-Verlag, 1976, pp 305–306.
38. Megret M: A landmark for the choroidal arteries of the fourth 49. Stephens RB, Stilwell DL: Arteries and Veins of the Human Brain.
ventricle: Branches of the posterior inferior cerebellar artery. Springfield, Charles C Thomas, 1969, pp 72–73, 95–96.
Neuroradiology 5:85–90, 1973. 50. Stopford JSB: The arteries of the pons and medulla oblongata.
39. Mount LA: Arteriovenous angioma derived from the anterior J Anat 50:131–164, 1916.
inferior cerebellar artery: Its diagnosis and treatment. J Neuro- 51. Sunderland S: The arterial relations of the internal auditory me-
surg 22:612–615, 1965. atus. Brain 68:23–27, 1945.
40. Nager GT: Origins and relations of the internal auditory artery and 52. Sunderland S: Neurovascular relations and anomalies at the base
the subarcuate artery. Ann Otol Rhinol Laryngol 63:51–61, 1954. of the brain. J Neurol Neurosurg Psychiatry 2:243–257, 1948.
41. Ono M, Ono M, Rhoton AL Jr, Barry M: Microsurgical anatomy of 53. Sypert GW, Alvord EC Jr: Cerebellar infarction: A clinicopatho-
the region of the tentorial incisura. J Neurosurg 60:365–399, 1984. logical study. Arch Neurol 32:357–363, 1975.
42. Ouaknine GE, Robert F, Molina-Negro P, Hardy J: Geniculate 54. Waga S, Fujimoto K, Morooka Y: Dissecting aneurysm of the
neuralgia and audio-vestibular disturbances due to compression vertebral artery. Surg Neurol 10:237–239, 1978.
of the intermediate and eighth nerves by the postero-inferior 55. Warwick R, Williams PL: Gray’s Anatomy. Philadelphia, W.B.
cerebellar artery. Surg Neurol 13:147–150, 1980. Saunders Co., 1973, ed 35, pp 643–644.
43. Pait TG, Zeal A, Harris FS, Paullus WS, Rhoton AL Jr: Microsur- 56. Watt JC, McKillop AN: Relation of arteries to roots of nerves in
gical anatomy and dissection of the temporal bone. Surg Neurol posterior cranial fossa in man. Arch Surg 30:336–345, 1935.
8:363–391, 1977. 57. Wolf BS, Newman CM, Khilnani MT: The posterior inferior cer-
44. Perret G, Nishioka H: Report on the cooperative study of intra- ebellar artery on vertebral angiography. AJR Am J Roentgenol
cranial aneurysms and subarachnoid hemorrhage: Section VI— 87:322–337, 1962.
Arteriovenous malformations. J Neurosurg 25:467–490, 1966. 58. Yonas H, Agamanolis D, Takaoka Y, White RJ: Dissecting intra-
45. Rhoton AL Jr: Microsurgical anatomy of posterior fossa cranial cranial aneurysms. Surg Neurol 8:407–415, 1977.
nerves, in Barrow DL (ed): Surgery of the Cranial Nerves of the Posterior 59. Zeal AA, Rhoton AL Jr: Microsurgical anatomy of the posterior
Fossa: Neurosurgical Topics. Chicago, AANS, 1993, pp 1–103. cerebral artery. J Neurosurg 48:534–559, 1978.
Cranial floor, cerebellum, and brain

stem, from, Andreas Vesalius, De
Humani Corporis Fabrica. Basel,
Ex officina Ioannis Oporini, 1543.
Courtesy, Rare Book Room, Norris
Medical Library, Keck School Of
Medicine, Los Angeles, California.
(Also see pages S27, S209, and S285.)

CHAPTER 3
The Posterior Fossa Veins

Key words: Anatomic study, Brainstem, Cerebellum, Posterior fossa, Veins
T
he veins of the posterior fossa are divided into four Deep veins
groups: superficial, deep, brainstem, and bridging
The deep veins course in the three deep fissures between
veins. The superficial veins are divided on the basis of
the cerebellum and brainstem near the roof and walls of the
which of the three cortical surfaces they drain; the tentorial
fourth ventricle and on the three cerebellar peduncles that
surface is drained by the superior hemispheric and superior course within these fissures. The vein of the cerebellomesen-
vermian veins, the suboccipital surface is drained by the cephalic fissure arises in the cerebellomesencephalic fissure
inferior hemispheric and inferior vermian veins; and the and is intimately related to the superior half of the roof; the
petrosal surface is drained by the anterior hemispheric veins vein of the cerebellomedullary fissure courses in the cerebel-
(15, 16). The deep veins course in the three fissures between lomedullary fissure, and is intimately related to the inferior
the cerebellum and the brainstem and on the three cerebellar half of the roof; and the vein of the cerebellopontine fissure
peduncles. The major deep veins in the fissures between the courses in the cerebellopontine fissure is intimately related to
cerebellum and brainstem are the veins of the cerebellomes- the lateral recess and lateral walls of the fourth ventricle.
encephalic, cerebellomedullary, and cerebellopontine fissures, The major veins on the surface of the three cerebellar pe-
and those on the cerebellar peduncles are the veins of the duncles also course within these fissures. The vein of the
superior, middle, and inferior cerebellar peduncles. The veins superior cerebellar peduncle courses on the posterior surface
of the brainstem are named on the basis of whether they drain of the superior cerebellar peduncle in the cerebellomesence-
the midbrain, pons, or medulla and course transversely or phalic fissure; the vein of the inferior cerebellar peduncle
horizontally. The veins of the posterior fossa terminate as ascends on the posterior surface of the inferior cerebellar
bridging veins, which collect into three groups: a galenic peduncle in the cerebellomedullary fissure; and the vein of
group that drains into the vein of Galen; a petrosal group that the middle cerebellar peduncle ascends on the lateral surface
drains into the petrosal sinuses; and a tentorial group of the middle cerebellar peduncle in the anterior part of the
that drains into the tentorial sinuses, which empty into the trans- cerebellopontine fissure. The deep tonsillar veins are also
verse, straight, or superior petrosal sinus (Figs. 3.1 and 3.2). included in this group.
Veins of the brainstem

THE POSTERIOR FOSSA VEINS The veins of the brainstem are named on the basis of three
characteristics: the subdivision of the brainstem drained (mes-
Superficial veins encephalon, pons, or medulla); the surface of the brainstem
drained (median anterior, lateral anterior, etc.); and the direc-
The superficial veins drain the cortical surfaces of the cer- tion in which they course (transverse or longitudinal).
ebellum. They are divided on the basis of whether they drain The longitudinally oriented veins are the median anterior
the tentorial, petrosal, or suboccipital surface and whether pontomesencephalic and the median anterior medullary veins,
they drain the hemisphere or vermis. The tentorial surface is which course in the midline; the lateral anterior pontomesence-
drained by the superior hemispheric and the superior ver- phalic and the lateral anterior medullary veins, which course on
mian veins; the suboccipital surface is drained by the inferior the anterolateral surface of the brainstem; and the lateral med-
hemispheric and the inferior vermian veins; and the petrosal ullary and the lateral mesencephalic veins, which course on the
surface is drained by the anterior hemispheric veins. In addi- lateral surface of the brainstem. The transversely oriented veins
tion, selected cortical veins may be named on the basis of the running in the sulci at the junctions of the pons and mesenceph-
vermian or hemispheric lobule that they drain, or on the basis alon and the pons and medulla are the veins of the pontomes-
of the fissure in which they course. The superficial tonsillar encephalic and the pontomedullary sulci. The transverse pontine
veins are also included in this group. and transverse medullary veins course across the anterior and

S70 Rhoton
FIGURE 3.1. Drainage patterns of the cerebellar surfaces. A,

tentorial surface. The tentorial surface is drained by the supe-
rior hemispheric and superior vermian veins, which are divided
into an anterior and a posterior group. The anterior group and
the veins from the cerebellomesencephalic fissure empty pre-
dominantly into the vein of Galen and its tributaries. The poste-
rior group drains the posterior part of the tentorial surface and
empties into the tentorial sinuses, which are tributaries of the
straight, transverse, or superior petrosal sinus, or the torcula.
Some of the inferior hemispheric veins from the suboccipital
surface pass forward under the transverse sinus and cross the
posterior part of the tentorial surface to empty into the tentorial
sinuses. B, suboccipital surface. The suboccipital surface is
drained by the inferior hemispheric and inferior vermian veins,
which ascend toward the transverse sinus, but then turn for-
ward below the sinus and commonly empty into the tentorial
sinuses. Some of the inferior hemispheric veins from the suboc-
cipital surface empty into the inferior vermian veins, which in
turn empty into the tentorial sinuses. C, petrosal surface and
anterior surface of the brainstem. The anterior hemispheric
veins, which drain the petrosal surface, and the veins from the
brainstem commonly unite to form the superior petrosal veins
that empty into the superior petrosal sinus. Ant., anterior; Cer.
Mes., cerebellomesencephalic; Fiss., fissure; Hem., hemispheric;
Inf., inferior; Pet., petrosal; Post., posterior; Sup., superior;
Trans., transverse; V., vein; Ve., vermian.
2. Superior hemispheric veins

B. Suboccipital surface
1. Inferior vermian veins
2. Inferior hemispheric veins
3. Retrotonsillar veins
4. Medial and lateral tonsillar veins
C. Petrosal surface
1. Anterior hemispheric veins
II. Deep Veins
A. Cerebellomesencephalic fissure
1. Vein of superior cerebellar peduncle
2. Vein of cerebellomesencephalic fissure
3. Pontotrigeminal vein
lateral surfaces of the pons and medulla, and the peduncular 4. Tectal veins
veins pass around the cerebral peduncles. B. Cerebellomedullary fissure
1. Vein of cerebellomedullary fissure
Bridging veins and major draining groups 2. Vein of inferior cerebellar peduncle
3. Supratonsillar veins
The terminal ends of veins draining the brainstem and
4. Choroidal veins
cerebellum form bridging veins that cross the subarachnoid
C. Cerebellopontine fissure
and subdural spaces to reach the venous sinuses in the dura
1. Vein of cerebellopontine fissure
(3, 6, 20, 21, 25). These bridging veins collect into three groups:
2. Vein of middle cerebellar peduncle
a superior or galenic group that drains into the vein of Galen;
III. Veins of the Brainstem
an anterior or petrosal group that drains into the petrosal si-
A. Longitudinal veins
nuses; and a posterior or tentorial group that drains into the
1. Midline
sinuses converging on the torcula.
a. Median anterior pontomesencephalic vein
An outline of the veins is as follows (Fig. 3.3):
b. Median anterior medullary vein
I. Superficial Veins 2. Anterolateral
A. Tentorial surface a. Lateral anterior pontomesencephalic vein
1. Superior vermian veins b. Lateral anterior medullary vein

Posterior Fossa Veins S71
FIGURE 3.2. A–D. Venous drainage of the posterior fossa. A, superior surface of the tentorium. Some of the tentorial sinuses can be seen
through the tentorial surface. Veins from both the cerebrum and cerebellum empty into the tentorial sinuses. The veins in the quadrigem-
inal cistern and the cerebellomesencephalic fissure empty into the vein of Galen and its tributaries. B, the left half of the tentorium has
been removed while preserving the tentorial edge. The inferior hemispheric veins from the suboccipital surface cross the posterior part of
the tentorial surface to empty into one of the tentorial sinuses with some of the superior hemispheric veins. Two veins from the right pos-
terior temporal lobe empty into the transverse sinus. C, superolateral view of the tentorium. A complex and variable group of venous
sinuses course within the tentorium and empty into the straight, transverse, and superior petrosal sinuses. The veins draining the suboc-
cipital surface and posterior part of the tentorial surface empty into the tentorial sinuses. The majority of veins from the upper part of the
tentorial surface drain toward the cerebellomesencephalic fissure and empty into tributaries of the vein of Galen. Some veins from the
lateral part of the tentorial surface may empty into the superior petrosal sinus. D, lateral cerebral and cerebellar surfaces. The sinuses in
the tentorium receive drainage from both the cerebrum and cerebellum. Veins from the lateral and inferior surfaces of the cerebral hemi-
sphere pass toward, but often turn medially above the transverse sinus to join the tentorium sinuses that empty into the transverse sinus.
The inferior hemispheric veins from the suboccipital surface ascend toward, but often pass below the transverse sinus to empty into the
tentorial sinuses. A mastoidectomy has been completed to expose the sigmoid sinus and jugular bulb. Cer., cerebellar; Cer. Mes., cerebel-
lomesencephalic; Cist., cistern; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Inf., inferior; Int., internal; Jug., jugular; Occip., occipi-
tal; Ped., peduncle; Pet., petrosal; Quad., quadrigeminal; S.C.A., superior cerebellar artery; Sig., sigmoid; Str., straight; Sup., superior;
Temp., temporal; Tent., tentorial; Trans., transverse; V., vein.
3. Lateral 5. Vein of pontomedullary sulcus

a. Lateral mesencephalic vein 6. Transverse medullary vein
b. Lateral medullary and retro-olivary veins IV. Bridging Veins (Major Draining Groups)
B. Transverse Veins A. Galenic group (to vein of Galen)
1. Peduncular vein B. Tentorial group (to torcula and tentorial
2. Posterior communicating vein sinuses)
3. Vein of pontomesencephalic sulcus C. Petrosal group (to petrosal sinuses)
4. Transverse pontine veins D. Other bridging veins

S72 Rhoton
FIGURE 3.2. E–H. Venous drainage of the posterior fossa. E, the temporal lobe has been elevated to show a group of veins
that pass from the lower surface of the cerebral hemisphere to the tentorial sinuses. Two large lateral cerebral veins empty
into the right transverse sinus, but the more medial veins exposed by eliminating the temporal lobe empty into tentorial
sinuses. F, the posterior part of the right temporal lobe has been elevated to show the complex of veins on the inferior sur-
face of the hemisphere that empty into the tentorial sinuses. G, the right half of the tentorium has been opened while pre-
serving a large tentorial sinus, which receives drainage from the cerebrum and cerebellum. The temporal and occipital lobes
have been preserved on the left side. H, the posterior lip of the cerebellomesencephalic fissure has been removed. The paired
veins of the superior cerebellar peduncle ascend to join and form the vein of the cerebellomesencephalic fissure, which emp-
ties into the vein of Galen.
SUPERFICIAL VEINS fissures on the tentorial surface overlap onto the superior part
of the petrosal surface, and those on the suboccipital surface
The superficial veins drain the tentorial, suboccipital, and petro-
overlap onto the inferior part of the petrosal surface.
sal surfaces. Each surface has the vermis in the midline and the
The cortical surfaces are drained by a mixture of longitudi-
hemispheres laterally, and is divided by a major fissure named
nal and transverse veins. On some surfaces the predominant
on the basis of the surface that it divides (Figs. 3.1 and 3.3).
drainage is transversely oriented along the interfolial fissures,
The three surfaces are separated by borders that are parallel
and on others the major drainage is longitudinally oriented at
to the major venous sinuses surrounding the cerebellum. The
right angles to these fissures. The veins within the interfolial
tentorial and petrosal surfaces are separated by a border that
fissures may not be visible on the cortical surface.
parallels the superior petrosal sinus; the tentorial and suboc-
cipital surfaces are separated by a border that parallels the
Tentorial surface
transverse sinus; and the suboccipital and petrosal surfaces
are separated by a border that parallels the sigmoid sinus. The The tentorial surface drained by the superior hemispheric
veins from adjoining surfaces frequently join near these bor- and superior vermian veins, conforms to the lower surface of
ders to form common trunks that terminate in a dural sinus. the tentorium (Figs. 3.1-3.5).
The veins from adjoining surfaces often anastomose across
these borders. These anastomoses often take place in the Superior vermian veins
fissures between the folia, which are continuous from one The veins that drain the vermian part of the tentorial sur-
surface to the other. The hemispheric lobules and interfolial face are divided into an anterior group, which ascends toward

FIGURE 3.3. A and B. Veins of

the posterior fossa. The veins
in the posterior are divided
into three groups: a galenic
group (green) that drains into
the vein of Galen; a petrosal
group (blue) that drains into
the petrosal sinuses; and a ten-
torial group (brown) that
drains into the sinuses near the
torcula. A, tentorial surface,
superior view. The tentorium
has been removed except in
the area of the tentorial
sinuses. B, suboccipital surface,
posterior view. The right tonsil
and the medial part of the
biventral lobule have been
removed to expose the struc-
tures on the ventral wall of the
cerebellomedullary fissure. A.,
artery; Ant., anterior; Bas.,
basilar; Br., bridging; Car.,
carotid; Cav., cavernous;
Cer., cerebellar, cerebello,
cerebral; Cer. Mes., cerebel-
lomesencephalic; Ch., choroi-
dal; Com., communicating;
Con., condylar; Em., emissary;
Fiss., fissure; He., hemispheric;
Inf., inferior; Int., internal;
Jug., jugular; Lat., lateral; Lig.,
ligament; Marg., marginal;
Med., medial, medullary; Mes.,
mesencephalic; Mid., mid, mid-
dle; N., nerve; Occ., occipital;
Olf., olfactory; Ped., peduncle;
Pon., pontine; Post., posterior;
Retroton., retrotonsillar; Sag.,
sagittal; Sig., sigmoid; Str.,
straight; Sulc., sulcus; Sup.,
superior; Supraculm., supracul-
minate; Supraton., supratonsil-
lar; Tent., tentorial; Ton., ton-
sillar; Trans., transverse; Trig.,
trigeminal; V., vein; Ve., ver-
mian; Vel., velum; Vert.,
vertebral.
the vein of Galen, and a posterior group, which descends The posterior, or descending, superior vermian veins origi-
toward the torcula (Figs. 3.3-3.5). The anterior, or ascending, nate in or near the tentorial fissure, course posteriorly, and
veins originate near the tentorial fissure and join near the apex drain alone or after joining the inferior vermian veins into the
of the cerebellum to form the superior vermian vein that torcula or a tentorial sinus.
crosses the quadrigeminal cistern to reach the vein of Galen.
The major tributaries of the superior vermian veins are the
vein of the cerebellomesencephalic fissure, to be described Superior hemispheric veins
later; the tectal veins from the quadrigeminal plate; and the These veins are divided into larger anterior and posterior
hemispheric branches from the medial part of the hemisphere. groups and a smaller lateral group (Figs. 3.3-3.5). The veins in

S74 Rhoton
FIGURE 3.3. C and D. Veins of

the posterior fossa. C, petrosal
surface and left side of the
brainstem, anterolateral view.
D, deep cerebellum and fourth
ventricle, posterior view. The
right cerebellar hemisphere and
the part of the left cerebellar
hemisphere posterior to the
dentate nucleus and tonsil have
been removed to show the roof
of the fourth ventricle and the
cerebellomesencephalic
and cerebellomedullary fissures.
the torcula or the superior

petrosal, transverse, or tentorial
sinuses. The veins in the
smaller lateral group originate
on the lateral part of the tento-
rial surface and drain directly
into the superior petrosal si-
nus or one of its tributaries.
Suboccipital surface
The suboccipital surface,
drained by the inferior hemi-
spheric and inferior vermian
veins and the superficial group
of tonsillar veins, conforms to
the part of the inner surface of
the occipital bone located be-
tween the sigmoid sinuses (Figs.
3.3 and 3.6-3.8). The superficial
group of tonsillar veins is com-
posed of the retrotonsillar and
the lateral and medial tonsillar
veins that converge on the pos-
terior surface of the tonsil and
join to form the inferior ver-
mian vein. There is also a deep
group of tonsillar veins, the su-
pratonsillar veins, which course
in the cerebellomedullary fis-
sure along the inferior part of
the roof of the fourth ventricle
and join the vein of the cerebel-
lomedullary fissure.
the anterior group drain the anterior part of the hemispheric Inferior vermian veins
surface and join the superior vermian vein or the veins in the
cerebellomesencephalic fissure. The other veins in the anterior The inferior vermian veins drain the vermis and the adja-
group cross the anteromedial margin of the cerebellum and cent portion of the hemisphere, including part of the tonsil
dip into and join the veins coursing in the cerebellomesence- (Figs. 3.3 and 3.6-3.8). These paired veins are usually formed
phalic fissure. The veins in the posterior group drain the by the union of the retrotonsillar veins. They ascend along the
posterior part of the tentorial surface. They usually join and vermohemispheric fissures and terminate in the straight or
form a common trunk with the inferior hemispheric veins transverse sinuses or the torcula, either directly or through a
from the suboccipital surface to form bridging veins that enter short tentorial sinus. They may course on the vermis or the

adjacent part of the hemisphere before reaching the vermo- sillar vein and other tributaries from lateral and medial ton-
hemispheric fissure. In a few cases, one inferior vermian vein sillar surfaces.
will cross the vermis to terminate in the inferior vermian vein on
the opposite side. There is often an anastomotic vein that Medial and lateral tonsillar veins
crosses obliquely or transversely from one inferior vermian
The medial tonsillar veins originate on the tonsillar surface
vein to the other. Some interconnect the veins after they leave
facing the other tonsil, and the lateral tonsillar veins arise on
the surface of the cerebellum to form bridging veins (24). The
the lateral side of the tonsil fissure between the tonsil and
tributaries of the inferior vermian vein, beginning caudally,
biventral lobule (Fig. 3.3). These veins usually course posteri-
include veins from the tonsil (the superior and inferior retro-
orly and drain into the superior or inferior retrotonsillar or the
tonsillar and the medial and the lateral tonsillar veins), the
inferior vermian veins.
adjacent part of the vermis and hemisphere, and the postero-
medial part of the tentorial surface.
Petrosal surface
Inferior hemispheric veins This surface, drained by the anterior hemispheric veins,
faces the posterior surface of the petrous bone (Figs. 3.3 and
The inferior hemispheric veins are oriented longitudinally 3.9).
or transversely on the suboccipital surface (Figs. 3.3, 3.6, and
3.7). The majority of the longitudinal veins ascend and cross
the margin between the suboccipital and tentorial surfaces to
Anterior hemispheric veins
join the posterior group of superior hemispheric veins before These veins arise near the border that separates the petrosal
emptying into a sinus in the tentorium. Some join the lower surface from the suboccipital and tentorial surfaces, and pass
part of the inferior vermian vein. The transversely oriented anteriorly to converge on the cerebellopontine fissure and the
veins course along the fissures between the folia and predom- middle cerebellar peduncle. They are divided into supe-
inantly empty into the inferior vermian vein medially, but a rior, middle, and inferior groups. The veins in the inferior
few join the anterior hemisphere veins laterally. group arise on the inferior part of the petrosal surface and
The inferior hemispheric veins are divided into four converge on the caudal part of the cerebellopontine fissure to
groups: the superomedial, inferomedial, superolateral, and form a common trunk. The vein of the cerebellomedullary
inferolateral veins, based on the part of the suboccipital sur- fissure, if it passes dorsal to the flocculus, joins the common
face that they drain. The veins in the superomedial group are trunk of the inferior group. The veins in the middle group
the largest. The major veins in this group usually run longi- drain the middle portion of the petrosal surface and converge
tudinally and drain into the torcular, a tentorial sinus, or the on the apex of the cerebellopontine fissure. The common
inferior vermian vein. Transversely oriented veins in this trunk of the inferior group joins the common trunk of the
group, if well developed, drain into the torcula or the inferior middle group near the flocculus to form the vein of the
vermian vein. The inferomedial group consists of small veins cerebellopontine fissure, which passes to the superior petrosal
that originate and course inferiorly on the biventral lobule to sinus. In a few cases, the common trunk of the middle group
join the inferior retrotonsillar or the inferior vermian veins. does not join the common trunk of the inferior group, but
The veins in the superolateral group usually pass superolat- ascends to drain directly into the superior petrosal sinus. The
erally across the posterior margin of the hemisphere and superior group, the smallest of the three groups, drains the
drain either directly or through a tentorial sinus into the rostral edge of the petrosal surface. These veins course ante-
superior petrosal or transverse sinuses, but some smaller riorly or posteriorly to join either the vein of the cerebellopon-
members of this group may course around the lateral margin tine fissure, the anterolateral marginal vein that courses along
of the hemisphere to join the anterior hemispheric veins on the junction of the tentorial and petrosal surfaces, or one of the
the petrosal surface. The veins in the inferolateral group drain superior hemispheric veins.
the lateral part of the biventral lobule and pass around the
inferior margin of the hemisphere to join the anterior hemi-
spheric veins. DEEP VEINS
The deep veins course in the fissures between the brain-
stem and the cerebellum near the roof and lateral walls of the
Retrotonsillar veins fourth ventricle (Fig. 3.3). The veins most intimately related to
The superior and inferior retrotonsillar veins drain the supe- the superior part of the roof are those that course in the
rior and inferior poles and the posterior surface of the tonsils cerebellomesencephalic fissure; the veins most intimately re-
(Figs. 3.3 and 3.8). They receive tributaries from the medial lated to the inferior part of the roof are those that course in the
and lateral tonsillar surfaces and the adjacent part of the cerebellomedullary fissure; and those most intimately related
vermis and hemisphere. The superior retrotonsillar vein arises to the lateral wall and cerebellopontine angle are those that
near the superior pole and courses posteriorly to join the course in the cerebellopontine fissure. The structures ventral
inferior retrotonsillar vein to form the inferior vermian vein. to the floor of the fourth ventricle are drained by the veins of
The inferior retrotonsillar vein arises near the caudal pole of the brainstem, which are considered in the section on the
the tonsil and courses superiorly to join the superior retroton- veins of the brainstem in this chapter.

S76 Rhoton
FIGURE 3.3. E and F. Veins of

the posterior fossa. E,
midsagittal section of
cerebellum and fourth
ventricle. Left lateral view.
The left half of the cerebellum
has been removed to expose
the fourth ventricle. F,
brainstem. Anterior view. The
part of the tentorium between
the temporal lobe and the
cerebellum has been
preserved. A–F, the inferior
sagittal sinus joins the straight
sinus at the apex of the
tentorium. The superior
sagittal sinus joins the straight
sinus at the torcula. The
superior petrosal sinus passes
along the petrous ridge and
joins the junction of the lateral
(referred to here as the
transverse sinus) and sigmoid
sinuses posteriorly and the
cavernous sinus anteriorly.
The veins converging on the
tentorium join to form
tentorial sinuses that drain
into the straight, lateral, and
superior petrosal sinuses and
the torcula. The marginal sinus
courses in the dura at the level
of the foramen magnum above
the rostral attachment of the
dentate ligament. The emissary
vein passing through the
condylar foramen joins the
sigmoid sinus. The vertebral
venous plexus anastomoses
with the internal jugular vein.
Bridging veins pass from the
surface of the cerebellum and
brainstem to the dural sinuses.
The superior hemispheric
veins are divided into three
groups: an anterior group that
drains toward the vein of
Galen; a posterior group that
drains into the veins
converging on the straight sinus, torcula, and medial part of the lateral sinus; and a lateral group that drains into the superior
petrosal sinus, the anterolateral marginal vein, and the lateral part of the lateral sinus. The superior vermian veins drain the
tentorial part of the vermis. The veins on the superior part of the tentorial surface of the vermis ascend toward the superior
vermian vein and those on the inferior part of the tentorial surface of the vermis descend toward the torcula. The tributary of
the superior vermian vein draining the tentorial surface of the culmen has been called the supraculminate vein. The declival
vein drains the declive and joins the inferior vermian vein or the torcula. The vein of the postclival fissure courses in the
postclival fissure. The superior petrosal veins are divided into medial, intermediate, and lateral groups, depending on whether
they enter the middle, intermediate, or lateral third of the superior petrosal sinus. The inferior hemispheric veins drain the
hemispheric part of the suboccipital surface, and the inferior vermian veins drain the vermian part of the suboccipital

Cerebellomesencephalic fissure peduncles and then upward on the peduncles, just lateral to
the lingula. They join near the rostral tip of the lingula to form
The major veins in the cerebellomesencephalic fissure are
a single trunk, the vein of the cerebellomesencephalic fissure.
the veins of the cerebellomesencephalic fissure and the supe-
In a few cases, the paired veins do not join but form two
rior cerebellar peduncle, and the pontotrigeminal and lateral
separate veins of the cerebellomesencephalic fissure. Each
mesencephalic veins (Figs. 3.2-3.5 and 3.10).
nerve of the superior cerebellar peduncle anastomoses with
the pontotrigeminal and lateral mesencephalic vein.
Vein of the superior cerebellar peduncle
The paired veins of the superior cerebellar peduncle orig-
inate deep in the cerebellomesencephalic fissure near the cau- Vein of the cerebellomesencephalic fissure
dolateral margin of the superior cerebellar peduncles from This vein, also referred to as the precentral cerebellar vein,
tributaries draining the dentate nuclei, superior cerebellar arises deep in the cerebellomesencephalic fissure from the
peduncles, and the walls of the cerebellomesencephalic fis- union of the veins of the superior cerebellar peduncle. It
sure (Figs. 3.3 and 3.4). They first course medially across the crosses the quadrigeminal cistern anterior to the central lobule
Š
surface. The inferior vermian veins drain toward the tentorium and enter the torcula or a tentorial sinus. The inferior hemi-
spheric veins cross the posterior margin of the cerebellum to reach the tentorial surface, where they often join the superior
hemispheric veins before terminating in the tentorial, lateral, or superior petrosal sinuses or the torcula. The inferior vermian
vein is formed on the posterior surface of the tonsil by the union of the superior and inferior retrotonsillar veins. The medial
and lateral tonsillar veins pass to the retrotonsillar or the inferior vermian veins. The vein of the petrosal fissure passes along
the petrosal fissure. The anterior hemispheric veins that drain the petrosal surface of the cerebellum and are divided into
superior, middle, and inferior groups, depending on whether they drain the superior, inferior, or middle third of the petrosal
surface. The anterior hemispheric veins converge on the lateral cerebellar incisura and join to form the vein of the cerebel-
lopontine fissure that ascends to enter the superior petrosal sinus. The major veins related to the superior half of the roof of
the fourth ventricle are the veins of the cerebellomesencephalic fissure and the superior cerebellar peduncle; the major veins
related to the inferior part of the roof are the veins of the cerebellomedullary fissure and the inferior cerebellar peduncle;
and the major veins in the region of the lateral recesses and lateral walls are the veins of the cerebellopontine fissure and the
middle cerebellar peduncle. In the cerebellomesencephalic fissure, the paired veins of the superior cerebellar peduncle
ascend lateral to the lingula and the superior medullary velum and join to form the vein of the cerebellomedullary fissure,
which ascends to join the superior vermian vein. The internal cerebral, basal, and superior vermian veins enter the vein of
Galen. The lateral mesencephalic and the pontotrigeminal veins course in the cerebellomesencephalic fissure. The lateral
mesencephalic vein courses in the lateral mesencephalic sulcus. The pontotrigeminal vein arises on the superior and middle
cerebellar peduncles and passes rostral to the trigeminal nerve. The tectal veins arise in the region of the colliculi. The vein
of the cerebellomedullary fissure arises on the lateral side of the uvula and nodule and passes laterally through the cerebel-
lomedullary fissure, either dorsal or ventral to the flocculus, to join one of the veins in the cerebellopontine angle. The vein
of the cerebellomedullary fissure receives the medial and lateral supratonsillar veins, which pass along the medial and lateral
edge of the inferior medullary velum above the superior pole of the tonsil. The dentate nucleus is drained by the supratonsil-
lar veins and the vein of the cerebellomedullary fissure. The median posterior medullary vein ascends on the posterior
medulla and divides just below the obex into the paired veins of the inferior cerebellar peduncle. The veins of the inferior
cerebellar peduncle ascend on the inferior cerebellar peduncles and join the lateral medullary veins. The choroidal veins
draining the tela choroidea and choroid plexus are tributaries of the veins of the inferior cerebellar peduncle and the cerebel-
lomedullary fissure. The peduncular veins arise in the interpeduncular fossa and pass laterally to join the basal veins. The pos-
terior communicating vein interconnects the medial ends of the peduncular veins. The longitudinally oriented veins in the
midline on the anterior surface of the brainstem are the median anterior medullary vein, which ascends on the medulla, and
the median anterior pontomesencephalic vein that ascends in the midline on the pons and midbrain. The median anterior
pontomesencephalic vein does not usually extend the full length of the pons. The ends adjoining the absent segment often
join the transverse pontine veins. The transversely oriented veins coursing in the sulci between the subdivisions of the brain-
stem are the veins of the pontomesencephalic and the pontomedullary sulci. Each vein of the middle cerebellar peduncle
arises in the region of the foramen of Luschka near the flocculus and ascends on the middle cerebellar peduncle to join the
vein of the cerebellopontine fissure or one of the superior petrosal veins. The lateral anterior medullary vein courses along
the preolivary sulcus near the hypoglossal nerve. The lateral anterior pontomesencephalic vein passes along the anterolateral
margin of the pons and medulla. The transverse medullary veins pass transversely across the medulla. The retro-olivary vein
courses along the posterior margin of the olive, and the lateral medullary vein courses slightly dorsal to the olive, along the
origin of the rootlets arising from the dorsolateral surface of the medulla. There are diffuse anastomoses between the veins
ventral to the diencephalon and third ventricle and those draining the midbrain. The deep middle cerebral and the anterior
cerebral veins join the basal vein in the region of the anterior perforated substance. (From, Matsushima T, Rhoton AL Jr, de
Oliveira E, Peace D: Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 59:63–105, 1983 [15].)

S78 Rhoton
FIGURE 3.4. Tentorial surface and cerebellomesencephalic fissure. A, the left half of the tentorium has been removed while
preserving a laterally placed tentorial sinus. A large sinus is seen through the right tentorial surface. B, the right half of the
tentorium has been removed to expose a large inferior hemispheric vein from the suboccipital surface and a smaller superior
hemispheric vein from the tentorial surface emptying into the large tentorial sinus. The superior hemispheric veins, which
drain the tentorial surface, are divided into an anterior group, which empties into the Galenic system, and a posterior group,
like the vein shown, which empties into the tentorial sinuses. Smaller veins from both the left tentorial and suboccipital sur-
faces join the laterally placed tentorial sinus near the junction of the left transverse and superior petrosal sinuses. C, the
straight and tentorial sinuses have been removed. The anterior group drains toward the cerebellomesencephalic fissure and
the vein of Galen, and the posterior group passes backward to empty into the tentorial sinuses. D, the posterior lip of the
cerebellomesencephalic fissure has been removed to expose the veins of the superior cerebellar peduncle, which ascend to
unite and form the vein of the cerebellomesencephalic fissure that empties into the vein of Galen. A transverse pontine vein
and the vein of the cerebellopontine fissure join to form a superior petrosal vein that empties into the superior petrosal sinus.

FIGURE 3.5. Tentorial surface and cerebellomesencephalic fissure. A, the left half of the tentorium has been removed
while preserving the tentorial sinuses. The anterior group of superior vermian and superior hemispheric veins arise on
the upper part of the tentorial surface and ascend to reach the veins exiting the cerebellomesencephalic fissure, which
empty into the vein of Galen. The posterior group of superior vermian and superior hemispheric veins arise on the pos-
terior part of the tentorial surface and descend to empty into tentorial sinuses. The inferior hemispheric veins, which
arise on the suboccipital surface, also empty into the tentorial sinuses. B, both halves of the tentorium have been
removed while preserving the large tentorial sinuses. The superior hemispheric veins from the posterior part of the ten-
torial surface and the inferior hemispheric veins from the suboccipital surface drain into the paired large tentorial sinus
that join the torcula. The veins draining the anterior part of the tentorial surface empty into the tributaries of the vein
of Galen. C, lateral view of the cerebellomesencephalic fissure. The largest vein in the fissure is the vein of the cerebel-
lomesencephalic fissure. The internal cerebral veins pass above the pineal to join the vein of Galen. D, the veins drain-
ing the walls of the cerebellomesencephalic fissure join the vein of Galen, as do the internal cerebral and basal veins. A
pineal vein also joins the Galenic group. Ant., anterior; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Fiss., fissure;
Hem., hemispheric; Inf., inferior; Int., internal; Occip., occipital; Post., posterior; S.C.A., superior cerebellar artery; Str.,
straight; Sup., superior; Temp., temporal; Tent., tentorial; V., vein; Ve., vermian.
Š
E–F, cerebellomesencephalic fissure from another hemisphere. E, the posterior lip of the cerebellomesencephalic fissure has been
removed to expose the tributaries of the vein of the cerebellomesencephalic fissure and the branches of the SCA. The paired veins
of the superior cerebellar peduncle unite to form the vein of the cerebellomesencephalic fissure that empties into the vein of
Galen. F, the branches of the SCA within the cerebellomesencephalic fissure have been removed. The paired veins of the superior
cerebellar peduncle ascend on the superior cerebellar peduncles and join to form the vein of the cerebellomesencephalic fissure.
The veins on the surface of the middle cerebellar peduncle course laterally to join the veins emptying into the superior petrosal
sinus. A., artery; Ant., anterior; Cer., cerebral; Cer. Mes., cerebellomesencephalic; CN., cranial nerve; Fiss., fissure; Hem., hemi-
spheric; Inf., inferior; Int., internal; Mid., middle; N., nerve; Ped., peduncle; Post., posterior; Str., straight; Sup., superior; Tent., ten-
torial; Trans., transverse; V., vein; Ve., vermian.

S80 Rhoton
FIGURE 3.6. Suboccipital surface. A, the falx cerebelli, which fits into the posterior cerebellar incisura in which the vermis is partially
buried, has been preserved. The inferior hemispheric veins drain the hemispheric portion of the suboccipital surface. A large left inferior
hemispheric vein ascends toward a tentorial sinus. A large right inferior hemispheric vein descends medially to join an inferior vermian
vein, which ascends to empty into the sinuses in the tentorium. The occipital sinus courses within the falx cerebelli and joins the torcula
above and the sigmoid sinus below. B, the falx cerebelli has been removed to expose the inferior vermian veins, which ascend and pass
below the transverse sinus to empty into the tentorial sinuses. The retrotonsillar veins and other veins around the superior pole of the
tonsils ascend to join the inferior vermian veins. C and D, another cerebellum. C, the branches of the PICA supplying the left hemisphere
have been removed, but those on the right have been preserved. The inferior vermian and hemispheric veins on both halves of the suboc-
cipital surface ascend and pass below the transverse sinus to empty into the sinuses in the tentorium. D, enlarged view of the inferior ver-
mian veins that ascend to empty into sinuses in the tentorium. E, another cerebellum. A large right inferior hemispheric vein joins an infe-
rior vermian vein that crosses the upper edge of the suboccipital surface and courses for a short distance on the tentorial surface before
emptying into a tentorial sinus. F, enlarged view of another cerebellum. The large right inferior vermian vein passes forward to join the
sinuses in the tentorium. A superior hemispheric vein from the tentorial surface descends to join a tentorial sinus. In the midline, a supe-
rior and inferior vermian join to empty into a tentorial sinus. A., artery; Cer., cerebellar; Hem., hemispheric; Inf., inferior; Occip., occipi-
tal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Retroton., retrotonsillar; Sig., sigmoid; Sup., superior; Tent., tentorial; Trans.,
transverse; V., vein; Ve., vermian; Vert., vertebral.

FIGURE 3.7. Suboccipital surface and cerebellomedullary fissure. A, the veins from the region of the tonsil empty into the
inferior vermian veins that ascend toward the sinuses in the tentorium. B, gentle retraction of the cerebellar tonsils exposes
the veins of the cerebellomedullary fissure crossing the inferior medullary velum. C, the cerebellar tonsils have been
removed. The tela on the left side has been removed. The veins of the cerebellomesencephalic fissure cross the inferior med-
ullary velum to join the veins in the cerebellopontine angles, which empty into the superior petrosal veins. The medial end of
the veins of the cerebellomedullary fissure anastomose with the veins around the tonsil. D, a portion of the left half of the
cerebellum has been removed. The inferior hemispheric veins from the suboccipital surface ascend and cross the junction of
the suboccipital and tentorial surfaces to course on the posterior part of the tentorial surface, where they often form com-
mon stems with the superior hemispheric veins from the posterior part of the tentorial surface before emptying into the ten-
torial sinuses. A., artery; Cer., cerebellar; Cer. Med., cerebellomedullary; Fiss., fissure; Hem., hemispheric; Inf., inferior; Med.,
medullary; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Retrotons., retrotonsillar; Sup., superior; V., vein; Ve.,
vermian; Vel., velum; Vert., vertebral.
to drain either directly or through the superior vermian vein hemispheric and transverse pontine veins may drain into the
into the vein of Galen (Figs. 3.2-3.5 and 3.10). Its tributaries are pontotrigeminal vein.
from the posterior aspect of the midbrain and the walls of the
cerebellomesencephalic fissure, and occasionally include the Tectal veins
tectal and preculminate veins. The small tectal veins originate on or near the superior and
inferior colliculi and course upward in the quadrigeminal cistern
Pontotrigeminal vein to drain into the vein of the cerebellomesencephalic fissure, the
This vein arises on the surface of the middle cerebellar superior vermian or internal cerebral vein, or the vein of Galen.
peduncle near the interpeduncular sulcus located between the These veins often anastomose with the vein of the superior cerebel-
superior and middle peduncles, passes above the trigeminal lar peduncle and the pineal, lateral mesencephalic, and basal veins.
nerve, and drains directly into the superior petrosal sinus or
its tributaries (Figs. 3.10 and 3.11). Its proximal end frequently Cerebellomedullary fissure
anastomoses with the vein of the superior cerebellar peduncle The major veins in the cerebellomedullary fissure are the
and the lateral mesencephalic vein. Some of the superior veins of the cerebellomedullary fissure and the inferior cerebellar

S82 Rhoton
FIGURE 3.8. Suboccipital surface and the cerebellomedullary fissure. A, the retrotonsillar veins pass upward in the fissure
between the tonsil and biventral lobule and empty into the inferior vermian veins. B, the tonsils have been removed to
expose the veins of the cerebellomedullary fissure, which pass laterally on the inferior medullary velum and across the lateral
recesses to join the veins in the cerebellopontine angles. The medial end of the veins of the cerebellomedullary fissure anasto-
mose with the veins around the tonsil. C, another specimen. The tonsils and part of the biventral lobules have been removed
to expose the paired veins of the cerebellomedullary fissure, which cross the inferior medullary velum to empty into the veins
in the cerebellopontine angles. D, the cerebellar hemispheres, except for the right tonsil, have been removed. The right retro-
tonsillar vein courses along the posterior surface of the tonsil and empties into an inferior vermian vein. The left vein of the
cerebellomedullary fissure passes through the lateral recess to join the vein of the middle cerebellar peduncle, which ascends
to empty into a superior petrosal vein. The paired veins of the superior cerebellar peduncle ascend on the peduncle and join
to form the vein of the cerebellomesencephalic fissure. An interpeduncular vein courses between the superior and middle
cerebellar peduncles. A., artery; Bivent., biventral; Cer., cerebellar; Cer. Med., cerebellomedullary; CN, cranial nerve; Fiss.,
fissure; Inf., inferior; Interped., interpeduncular; Lat., lateral; Med., medullary; Mid., middle; Ped., peduncle; Pet., petrosal;
P.I.C.A., posteroinferior cerebellar artery; Retrotons., retrotonsillar; Sup., superior; Tons., tonsillar; V., vein; Ve., vermian;
Vent., ventricle; Vert., vertebral.
peduncle (Figs. 3.3, 3.7-3.9) (2). Both of these veins drain into the anterior hemispheric veins or in the vein of the cerebellopon-
cerebellopontine angle through the communication between tine fissure. If it courses ventral to the flocculus, it passes
the cerebellomedullary and cerebellopontine fissures. between the flocculus and the foramen of Luschka and joins
the lateral medullary vein or the vein of the inferior cerebellar
Vein of the cerebellomedullary fissure peduncle or the pontomedullary sulcus to form the vein of the
This vein originates on the lateral edge of the nodule and middle cerebellar peduncle. The vein of the cerebellomedul-
uvula, courses laterally near the junction of the inferior med- lary fissure frequently connects with its mate on the opposite
ullary velum and tela choroidea, and passes dorsal or ventral side through a transverse vein crossing the nodule or uvula
to the flocculus to reach the cerebellopontine angle (Figs. and/or with the inferior vermian vein. The medial part of the
3.7-3.9). If it courses dorsal to the flocculus, it terminates in the vein of the cerebellomedullary fissure is sometimes hypoplas-

tic or absent. Its tributaries drain the inferior medullary ve- Vein of the cerebellopontine fissure
lum, tela choroidea and attached choroid plexus, periven-
This is the largest vein draining the petrosal surface. It is
tricular white matter, dentate nuclei, anteroinferior surface of
formed just rostral or caudal to the flocculus by the union of
the biventral lobule, and the inferior vermis.
the stems of the anterior hemispheric veins (Figs. 3.9-3.11). It
Vein of the inferior cerebellar peduncle courses in or near the superior limb of the cerebellopontine
fissure, or on the superior part of the petrosal surface near the
This vein courses on the peduncle parallel and several anterolateral margin. It crosses the subarachnoid space rostral
millimeters caudal to the curved inferolateral margin of the to the facial, vestibulocochlear, and trigeminal nerves, and
fourth ventricle (Figs. 3.3, 3.7, and 3.9). Its caudal part is visible drains into the superior petrosal sinus either directly or after
on the posterior surface of the medulla lateral to Magendie’s forming a common stem with other veins draining into the
foramen, but its superior portion is hidden in the cerebellomed- superior petrosal sinus. The vein of the middle cerebellar
ullary fissure. Inferiorly, the veins from each side join below the peduncle and the pontotrigeminal vein often join the vein of
obex to form a single channel, the median posterior medullary the cerebellopontine fissure to form one of the trunks that
vein. Superiorly, it passes below the lateral recesses and joins drain into the superior petrosal sinus near the trigeminal
the vein of the pontomedullary sulcus, either directly or by nerve. The vein of the cerebellomedullary fissure, if it passes
first connecting with the lateral medullary vein. It often re- dorsal to the flocculus, may drain into the vein of the cerebel-
ceives the vein of the cerebellomedullary fissure near the lopontine fissure.
lateral end of the pontomedullary sulcus. These veins, con-
verging on the lateral end of the pontomedullary sulcus, join
to form the vein of the middle cerebellar peduncle. The vein of Vein of the middle cerebellar peduncle
the inferior cerebellar peduncle drains the posterior and lat-
eral aspects of the medulla, the tela choroidea, choroid plexus, This vein originates in the fossette above the inferior olive
the inferior part of the floor of the fourth ventricle, the lateral by the union of the vein of the pontomedullary sulcus with
recess, and the glossopharyngeal and vagus nerves. This ros- the lateral medullary vein or the vein of the inferior cerebellar
tral part of the vein of the inferior cerebellar peduncle often peduncle (Figs. 3.8-3.11). It ascends on the lateral surface of
anastomoses with the sinuses converging on the jugular fora- the middle cerebellar peduncle near the base of the cerebel-
men through a bridging vein that passes along the nerves that lopontine fissure to reach the area posterior to the origin of the
pass through the jugular foramen. trigeminal nerve. It drains directly into the superior petrosal
sinus or joins other veins to form one of the common trunks
Supratonsillar veins that drain into the superior petrosal sinus. Its initial part
passes either between the flocculus and the origin of the
The supratonsillar veins course in the cerebellomedullary
vestibulocochlear nerve or between the origins of the vestibu-
fissure near the superior pole of the tonsil (Fig. 3.3) (9). The
locochlear and the facial nerves.
name “supratonsillar” suggests that these veins drain the
The vein of the middle cerebellar peduncle receives the
tonsil; however, they course on and drain the opposite side of
drainage of the rostral half of the medulla, the inferior half of
the cerebellomedullary fissure from the tonsil. They originate
the fourth ventricle, and the lateral surface of the pons. It often
in the deep nuclei and white matter of the cerebellum and
receives the drainage of the veins of the cerebellomedullary
drain the inferior half of the roof of the fourth ventricle rather
fissure and inferior cerebellar peduncle, some of the trans-
than the tonsil. They course along the inferior medullary
verse pontine veins, and the veins draining the origins of the
velum and drain into the vein of the cerebellomedullary fis-
facial and the vestibulocochlear nerves. It is large if the vein of
sure or the inferior vermian vein.
the cerebellomedullary fissure courses ventral to the flocculus
Choroidal veins to join it rather than passing dorsal to the flocculus to join the
anterior hemispheric veins or the vein of the cerebellopontine
The choroidal veins drain the tela choroidea and the at- fissure.
tached choroid plexus, and are tributaries of the veins of the
cerebellomedullary fissure and the inferior cerebellar pedun-
cle. The medial half of the vein of the cerebellomedullary
fissure drains the rostral part of the medial segment and the VEINS OF THE BRAINSTEM
medial part of the lateral segment of the choroid plexus. The The veins of the brainstem are divided into two groups
lateral half of the vein of the cerebellomedullary fissure, and based on whether they course longitudinally or transversely
the rostral part of the vein of the inferior cerebellar peduncle (Figs. 3.3 and 3.9-3.11). The longitudinal veins are the median
drain the lateral part of the lateral segment. The caudal part of anterior pontomesencephalic, median anterior medullary, lat-
the vein of the inferior cerebellar peduncle receives the drain- eral anterior pontomesencephalic, lateral anterior medullary
age of the caudal part of the medial segment (Fig. 3.3). (preolivary), lateral mesencephalic, lateral medullary, and
retro-olivary veins. The transverse veins are the veins of the
Cerebellopontine fissure pontomesencephalic and the pontomedullary sulci, and the
The major veins arising in this region are the veins of the transverse pontine, transverse medullary, peduncular, and
cerebellopontine fissure and the middle cerebellar peduncle. posterior communicating veins.

S84 Rhoton
FIGURE 3.9. Brainstem and petrosal surface. A, the vertebral and basilar arteries and their branches course superficial to the
veins. The veins on the anterior surface of the pons and medulla and the petrosal surface drain predominantly into the superior
petrosal veins, which empty into the superior petrosal sinuses. B, the arteries have been removed. The median anterior pontomes-
encephalic and median anterior medullary veins ascend on the front of the brainstem. The transverse pontine and transverse med-
ullary veins run transversely across the pons and medulla surfaces. The anterior hemispheric veins drain the petrosal surface and
commonly empty into the vein of the cerebellopontine fissure, which ascends to join the superior petrosal veins. The vein of the
pontomedullary sulcus passes across the pontomedullary junction. C, enlarged view of the right petrosal surface. The anterior
hemispheric veins drain the petrosal surface and pass forward to empty into the vein of the cerebellopontine fissure or a superior
petrosal vein. The vein of the cerebellopontine fissure arises at the lateral apex of the cerebellopontine fissure and crosses the mid-
dle cerebellar peduncle, where it is joined by a large transverse pontine vein. D, enlarged view of the left petrosal surface. The vein
of the cerebellopontine fissure arises from the union of the anterior hemispheric veins at the apex of the cerebellopontine fissure

Longitudinal veins and the vein of the pontomedullary sulcus at the pontomed-
ullary junction and inferiorly with the anterior spinal vein. It
Median anterior pontomesencephalic vein may join the lateral anterior pontomesencephalic vein ros-
This vein runs in or near the midline on the anterior surface trally if the inferior part of the median anterior pontomesen-
of the mesencephalon and the pons (Figs. 3.9-3.11). It has a cephalic vein is absent. A bridging vein may connect the
mesencephalic segment that courses in the interpeduncular median anterior medullary vein with the sinuses around the
fossa, and a pontine segment that runs in or adjacent to the jugular foramen.
basilar sulcus. The mesencephalic segment of this vein is
usually composed of the two veins, which are frequently Lateral anterior pontomesencephalic vein
asymmetrical in size and course near the oculomotor nerves This vein on the anterolateral aspect of the brainstem is
on the lateral walls of the interpeduncular fossa. They usually rarely continuous from the midbrain to the lower pons (Fig.
anastomose rostrally with the medial end of the peduncular 3.3). At the mesencephalic level it may anastomose with the
veins and the lateral ends of the posterior communicating basal and peduncular veins and the vein of the pontomesen-
vein. The small veins exiting the posterior perforated sub- cephalic sulcus, and at the pontine level it anastomoses with
stance often join this confluence. A bridging vein may arise in the transverse pontine veins. Caudally, it joins the vein of the
the interpeduncular fossa and pass to the tentorial edge. The pontomedullary sulcus near the abducens nerve. It deviates
paired mesencephalic segments join several millimeters be- medially to connect with the median anterior pontomesence-
low the pontomesencephalic sulcus on the upper surface of phalic or the median anterior medullary veins, if the lower
the pons to form the pontine segment. If the superior part of part of the median anterior pontomesencephalic vein is ab-
the pontine segment is absent, the mesencephalic segment sent. It may give rise to a bridging vein to the inferior petrosal
divides to connect inferiorly with the lateral anterior pon- sinus.
tomesencephalic vein or the vein of the pontomesencephalic
sulcus. Lateral anterior medullary vein (preolivary vein)
The pontine segment, which connects caudally with the This vein courses in the anterolateral sulcus between the
median anterior medullary vein and the vein of the pon- pyramid and the olive, and is partly hidden by the roots of the
tomedullary sulcus, is subdivided into superior, middle, and hypoglossal nerve (Fig. 3.3). A segment along the lateral bor-
inferior parts. One of the three parts is usually absent. If the der of the pyramid may be absent. It connects superiorly with
superior portion is absent, the middle portion anastomoses the vein of the pontomedullary sulcus and inferiorly with the
superiorly with a transverse pontine vein, and the caudal part lateral medullary or transverse medullary vein. The median
is continuous inferiorly with the median anterior medullary and lateral anterior medullary veins are linked together by the
vein. If the middle part is absent, the caudal end of the transverse medullary veins that cross the pyramids at various
superior part and the cranial end of the inferior part anasto- levels.
mose with the transverse pontine or the lateral anterior pon-
tomesencephalic veins. The pontine segment may deviate to Lateral mesencephalic vein
one side away from the basilar sulcus, especially if the trans- This vein runs in or adjacent to the lateral mesencephalic
verse pontine vein gives rise to a large bridging vein to a sulcus and usually drains into the basal vein near the medial
petrosal sinus. geniculate body (Fig. 3.3). It drains the posterolateral aspect of
the midbrain and sometimes receives a branch from the quad-
Median anterior medullary vein rigeminal plate. Its inferior end anastomoses with the ponto-
This vein courses in the median anterior medullary fissure trigeminal vein and the vein of the pontomesencephalic sul-
between the medullary pyramids (Figs. 3.9-3.11). It connects cus. It sometimes receives a superior hemispheric or tectal
superiorly with the median anterior pontomesencephalic vein vein (1, 9, 26).
Š
and ascends to be joined by a superior hemispheric vein from the lateral part of the tentorial surface before emptying into
the superior petrosal sinus. E, the cerebellum has been removed to expose the veins of the superior, inferior, and middle cer-
ebellar peduncles. The vein of the superior cerebellar peduncle ascends to join the vein of the cerebellomesencephalic fis-
sure. The vein of the inferior cerebellar peduncle crosses the peduncle at the inferolateral margin of the fourth ventricle and
passes around the lateral recess to join the veins in the cerebellopontine angle. The veins of the cerebellopontine fissure and
middle cerebellar peduncle and a transverse pontine vein join to form a superior petrosal vein. The vein of the cerebellomed-
ullary fissure empties into the vein of the middle cerebellar peduncle. F, posterior view of the right cerebellopontine angle.
The vein of the cerebellomedullary fissure passes laterally across the lateral recess and empties into the vein of the middle
cerebellar peduncle. The latter vein and the vein of the cerebellopontine fissure join to form a large superior petrosal vein. A
large anterior hemispheric vein ascends along the petrosal surface. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant.,
anterior; Cer., cerebellar, cerebral; Cer. Med., cerebellomedullary; Cer. Pon., cerebellopontine; CN, cranial nerve; Fiss., fis-
sure; Hem., hemispheric; Inf., inferior; Med., median, medullary; Mid., middle; Ped., peduncle; Pet., petrosal; P.I.C.A., pos-
teroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary; Pon. Mes., pontomesencephalic; Pon. Trig., pontotri-
geminal; S.C.A., superior cerebellar artery; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein; Vert., vertebral.

S86 Rhoton
FIGURE 3.10. Upper brainstem. A, the veins on the anterior surface of the pons and medulla and the veins of the cerebellopontine
fissure and their tributaries empty into the superior petrosal veins. The median anterior medullary vein and median anterior pon-
tomesencephalic veins course in the midline, but often do not extend along the full length of the pons and medulla. The vein of the
pontomesencephalic sulcus and the transverse pontine veins are transversely oriented. The veins of the cerebellomedullary fissure
join the veins of the middle cerebellar peduncle, which ascends to join the veins of the cerebellopontine fissure. B, the veins in the
crural and ambient cistern join the basal vein, which empties into the vein of Galen in the quadrigeminal cistern. The basal vein
also drains the walls of the temporal horn, which has been opened on the right. An internal occipital vein passes from the calcar-
ine sulcus and occipital lobe to the vein of Galen. C, enlarged view of the basal cisterns. The inferior ventricular vein from the
temporal horn and the lateral atrial vein join the basal vein, which also drains the walls of the crural and ambient cisterns. The cer-
ebellomesencephalic fissure, an inferior extension of the quadrigeminal cistern, is drained by tributaries of the vein of Galen. D,
lateral view of the cerebellomesencephalic fissure. The veins in the medial portion of the cerebellomesencephalic fissure empty
into the vein of Galen and those from the lateral part may join the superior petrosal veins. In this case, the vein of the cerebel-
lomesencephalic fissure is small, resulting in most of the fissure’s drainage being directed laterally through a pontotrigeminal vein,
which passes above the trigeminal nerve to empty into a superior petrosal vein formed by a superior hemispheric and transverse pontine
vein and the vein of the cerebellopontine fissure. Ant., anterior; Atr., atrial; Cer., cerebellar; Cer. Med., cerebellomedullary; Cer. Mes.,
cerebellomesencephalic; Cist., cistern; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Int., internal; Lat., lateral; Med., median, med-
ullary; Mes., mesencephalic; Mid., middle; Occip., occipital; Ped., peduncle; Pet., petrosal; Pon., pontine, ponto; Quad., quadrigeminal;
Str., straight; Sulc., sulcus; Sup., superior; Temp., temporal; Trans., transverse; Trig., trigeminal; V., vein; Vent., ventricle.

Lateral medullary and retro-olivary veins may anastomose with the lateral end of this vein near the
confluence of the pontomesencephalic, lateral mesencephalic,
There are usually two longitudinal veins between the lat-
and interpeduncular sulci.
eral border of the olive and the foramen of Luschka (Fig. 3.3):
a smaller ventral vein (the retro-olivary vein), and a larger Transverse pontine veins
dorsal vein (the lateral medullary vein). The lateral medullary
vein courses slightly dorsal to the retro-olivary sulcus along This is a group of veins that cross the anterior surface of the
the rootlets of the accessory, vagus, and glossopharyngeal pons at various levels (Figs. 3.9-3.11). They interconnect the
nerves. It receives the retro-olivary vein from its ventral side median anterior pontomesencephalic vein and the veins on
and the vein of the inferior cerebellar peduncle from its dorsal the lateral surface of the pons. The most prominent transverse
side, and joins the vein of the pontomedullary sulcus to form pontine veins are located at the midpons. Those on the upper
the vein of the middle cerebellar peduncle. This vein and the and lower thirds of the pons are usually small and only
vein of the inferior cerebellar peduncle often give rise to an infrequently transverse the full width of the pons. Those on
inferior petrosal bridging vein near the foramen of Luschka, the midpons are usually present bilaterally and anastomose
which courses along the rootlets of the nerves entering the medially with the median anterior pontomesencephalic vein.
jugular foramen to join the venous sinuses near the jugular They course laterally above or below the trigeminal nerve to
bulb. drain into the superior petrosal sinus, the pontotrigeminal
The retro-olivary vein usually courses along the rostral vein, or the vein of the cerebellopontine fissure or the middle
two-thirds of the retro-olivary sulcus slightly ventral to the cerebellar peduncle. They sometimes give rise to a bridging
lateral medullary vein. Although small, it may rarely replace vein to the inferior petrosal sinus. If the middle third of the
the lateral medullary vein. It often anastomoses near the median anterior pontomesencephalic vein is absent, the ends
lower edge of the olive with the caudal part of the lateral adjoining the absent segments drain into the transverse pon-
medullary vein and above the olive with either the vein of the tine veins.
pontomedullary sulcus or the rostral end of the lateral med-
Vein of the pontomedullary sulcus
ullary vein.
This vein courses in or near the pontomedullary sulcus and
Transversely oriented veins connects with the longitudinally oriented veins on the ante-
rior aspect of the pons and medulla (Figs. 3.3 and 3.9). It joins
Peduncular vein the lateral medullary or retro-olivary veins or the vein of the
This vein arises in the interpeduncular fossa and courses inferior cerebellar peduncle above the olive to form the vein of
laterally around the cerebral peduncle below the optic tract the middle cerebellar peduncle. It may give rise to a bridging
toward the basal vein (Figs. 3.3, 3.9, and 3.10). It anastomoses vein to the sinuses around the jugular foramen.
medially with the posterior communicating vein, which links
the medial ends of the peduncular veins, and with the upper
Transverse medullary veins
end of the median anterior pontomesencephalic vein. Its me- These veins cross the anterior and lateral surfaces of the
dial end is located on the superomedial surface of the origin of medulla at the level of the medullary pyramid or below (Fig.
the oculomotor nerve. The lateral end of the vein drains into 3.9). They interconnect the median anterior medullary vein
the basal vein or one of its tributaries. In a few cases it drains with the veins on the lateral surface of the medulla. They
through a bridging vein into a sinus in the edge of the rarely cross the full distance from the median anterior med-
tentorium. ullary vein to the lateral medullary vein, but usually consist of
one or two shorter veins passing transversely across the med-
Posterior communicating vein ullary pyramid or the olive. The largest transverse medullary
This vein courses transversely across the interpeduncular veins are usually situated at the level of the middle third
fossa on the superomedial surface of the oculomotor nerves, of the pyramid. They sometimes give rise to a bridging vein to
interconnecting the medial ends of the peduncular veins and the sigmoid or marginal sinuses.
the rostral ends of the median anterior pontomesencephalic
veins (Fig. 3.3). It usually courses in the interpeduncular cis- MAJOR DRAINING GROUPS
tern, bridging over rather than coursing on the floor of the The terminal end of the veins draining the brainstem and
interpeduncular fossa. Small veins exiting the interpeduncu- cerebellum form bridging veins that collect into three groups:
lar fossa frequently join the posterior communicating vein. 1) a galenic group that drains into the vein of Galen; 2) a
petrosal group that drains into the petrosal sinuses; and 3)
Vein of the pontomesencephalic sulcus a tentorial group that drains into the sinuses converging on
This vein is usually small, and does not extend the entire the torcula (Fig. 3.3). The galenic group drains the tentorial
length of the pontomesencephalic sulcus from the midline to surface, the cerebellomesencephalic fissure, and the superior
the lateral mesencephalic sulcus (Fig. 3.3 and 3.10). It passes half of the roof of the fourth ventricle; the petrosal group
below the oculomotor nerves and anastomoses with the me- drains the petrosal surface, the cerebellomedullary and cer-
dian and lateral anterior pontomesencephalic veins in most ebellopontine fissures, the inferior half of the roof of the
cases. The lateral mesencephalic and pontotrigeminal veins fourth ventricle and the lateral recesses, and the anterior and

S88 Rhoton
FIGURE 3.11. Superior petrosal veins. A, the superior petrosal veins drain the anterior and lateral surfaces of the brainstem, the
petrosal surface, and some of the lateral part of the tentorial and suboccipital surfaces. The veins of the middle cerebellar peduncle
ascend on the middle cerebellar peduncles and join the veins of the cerebellopontine fissure and the transverse pontine veins to
form superior petrosal veins that empty into the superior petrosal sinuses. B, lateral view of a large superior petrosal vein formed
by the union of the transverse pontine, pontotrigeminal, and anterior hemispheric veins and the vein of the cerebellopontine fis-
sure. A large branch of the superior cerebellar artery and the trigeminal nerve are enmeshed in the tributaries of this superior

lateral sides of the pons and medulla; and the tentorial group The tentorial sinuses can course directly medially to drain into
drains the suboccipital surface. Other less frequent bridging the midportion of the straight sinus, posteromedially to drain
veins pass to the cavernous, marginal, basilar, and sigmoid into the torcula or the straight or lateral sinus near the torcula,
sinuses and the jugular bulb. immediately posteriorly to drain into the middle third of the
lateral sinus, or posterolaterally to drain into the lateral and
superior petrosal sinuses at or near the confluence of the two
Galenic draining group
sinuses. Some sinuses are formed by the union of veins drain-
This group, formed by the veins converging on the vein of ing the tentorium itself.
Galen, includes the superficial veins that drain the tentorial
surface, the deep veins that drain the superior part of the roof
Petrosal draining group
of the fourth ventricle and the cerebellomesencephalic fissure,
and the brainstem veins that drain the midbrain. Most of these The petrosal draining group includes the veins draining
veins drain through the superior vermian and basal veins to into the petrosal sinuses (Figs. 3.1, 3.11, and 3.12) (9, 26). This
reach the vein of Galen (Figs. 3.2-3.5). The superficial group draining group includes the superficial veins that drain the
includes the superior vermian vein and the anterior group of lateral part of the cerebellar hemisphere; a deep group that
the superior hemispheric veins; the deep group includes the drains the cerebellopontine and cerebellomedullary and the
vein of the cerebellomesencephalic fissure and the paired lateral part of the cerebellomesencephalic fissures, and the
veins of the superior cerebellar peduncle; and the brainstem inferior part of the roof and the lateral wall of the fourth
group includes the peduncular, posterior communicating, ventricle; and a brainstem group that drains much of the
and tectal veins and the rostral portions of the medial and brainstem.
lateral anterior pontomesencephalic and the lateral mesence- The petrosal veins are divided into superior and inferior
phalic veins. All of these brainstem veins, except for the tectal petrosal veins based on whether they enter the superior or
vein, join the basal vein that drains into the vein of Galen. The inferior petrosal sinus. The superior petrosal veins are among
tectal veins join the superior vermian vein or the vein of the the largest and most frequent veins in the posterior fossa. The
cerebellomesencephalic fissure. inferior petrosal veins are represented by a few small bridging
veins. The superior petrosal veins may be formed by the
terminal segment of a single vein or by the common stem
Tentorial draining group formed by the union of several veins. The most common
The tentorial draining group includes the veins that drain tributaries of the superior petrosal veins are the transverse
into the straight and lateral sinuses and the torcula, either pontine and pontotrigeminal veins, the common stem of the
directly or through a tentorial sinus (Figs. 3.2-3.6). It is lateral group of the superior hemispheric veins, and the veins
composed of the superficial veins draining the suboccipital of the cerebellopontine fissure and the middle cerebellar pe-
surface and the posterior part of the tentorial surface. The duncle. The superior petrosal veins are subdivided into a
veins from the suboccipital surface include the inferior lateral, intermediate, and medial group based on the relation-
vermian veins and inferior hemispheric veins. The veins ship of their site of entry into the superior petrosal sinus to the
from the tentorial surface include the posterior groups of internal acoustic meatus. The intermediate group drains into
superior hemispheric and superior vermian veins. The in- the sinus above the internal acoustic meatus, the medial
ferior hemispheric veins and the posterior group of the group drains into the sinus medial to the meatus, and the
superior hemispheric veins often join before entering the lateral group drains into the sinus lateral to the meatus. Of 20
tentorial sinuses, which drain into the torcula or into the superior petrosal sinuses examined in our previous study, 8
straight or lateral sinuses near the torcula. received one superior petrosal vein, 10 received two, and
The tentorial sinuses also receive the inferior cerebral veins, 2 received three (15). Of the 34 superior petrosal veins, 22
the vein of Labbé, and the bridging veins to the tentorial edge. (64.7%) were of the medial type, 3 (8.8%) were of the inter-
Š
petrosal vein. Care is required to avoid occluding the superior cerebellar artery when occluding a multipronged petrosal vein.
C, retrosigmoid view. The right cerebellopontine angle is drained by a superior petrosal vein formed by the pontotrigeminal
and transverse pontine veins and the vein of the cerebellopontine fissure. D, the tributaries of this superior petrosal vein
include the transverse pontine, pontotrigeminal, and anterior hemispheric veins and the vein of the cerebellopontine fissure.
E, superior petrosal vein with multiple tributaries. The vestibulocochlear nerve has been depressed to expose the facial nerve.
F, the segment of the superior petrosal sinus, which crosses above the trigeminal nerve and receives the superior petrosal
veins, has been removed. The posterior trigeminal nerve passes forward below the tentorial edge and the superior petro-
sal sinus to enter Meckel’s cave. The superior petrosal sinus extends medially through the upper edge of the porus of Meck-
el’s cave and above the trigeminal nerve to join the cavernous sinus. Some superior petrosal veins may join the sinus on the
medial side of the trigeminal nerve. A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Cer., cerebellar; Cer. Pon., cer-
ebellopontine; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Med., median, medullary; Mid., middle; P.C.A., posterior
cerebral artery; Ped., peduncle; Pet., petrosal; Pon., pontine; Pon. Mes., pontomesencephalic; Pon. Trig., pontotrigeminal;
S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial; Trans., transverse; V., vein.

S90 Rhoton
FIGURE 3.12. Inferior petrosal sinus and veins. A, posterior view of the anterior portion of the posterior fossa with the
brainstem and cerebellum removed. The inferior petrosal and sigmoid sinuses can be seen through the dura. B, the dural roof
of the basilar, inferior petrosal, and sigmoid sinuses have been removed. The inferior petrosal sinuses extend from the basilar
sinus above to the jugular bulbs below. The inferior petrosal veins arise on the brainstem and empty into the lower part of
the inferior petrosal sinus, jugular bulb, or distal sigmoid sinus. C–E, posterior views into cerebellopontine angle. C, an infe-
rior petrosal vein passes from the medulla between the glossopharyngeal and vagus nerves to the jugular bulb. It receives the
drainage of the vein of the inferior cerebellar peduncle, which crosses the peduncle just below the lateral recess. D, an infe-
rior petrosal nerve passes behind the glossopharyngeal and vagus nerves to empty into the terminal part of the sigmoid sinus.
E, an inferior petrosal vein crosses behind the nerves entering the jugular foramen to reach the sigmoid sinus. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Cer., cerebellar; Cer. Med., cerebellomedullary; CN, cranial nerve;
Fiss., fissure; Inf., inferior; Jug., jugular; Lat., lateral; Med., median, medullary; Ped., peduncle; Pet., petrosal; P.I.C.A., pos-
teroinferior cerebellar artery; Post., posterior; Sig., sigmoid; V., vein; Vert., vertebral.
mediate type, and 9 (26.5%) were of the lateral type. Nineteen Other bridging veins
of 20 (95%) sinuses examined had veins of the medial type, 3
(15%) had veins of the intermediate type, and 9 (45%) had The major bridging veins have been discussed above. Other
veins of the lateral type. The medial group of superior petro- less frequent bridging veins run from the basal vein to a sinus
sal veins is usually a common trunk formed by the union of coursing in the tentorial edge; from the peduncular vein to a
two or three of the following veins: transverse pontine veins, sinus in the tentorial edge or the cavernous sinus; from the
pontotrigeminal veins, and the veins of the cerebellopontine lateral or medial anterior pontomesencephalic or a transverse
fissure and the middle cerebellar peduncle. The latter veins pontine vein to the posterior portion of the cavernous or the
may also enter the sinus without joining another vein. Two of adjoining part of the inferior petrosal sinuses just below
the three intermediate superior petrosal veins were formed by Meckel’s cave; from the veins of the pontomedullary sulcus
a single vein, the vein of the cerebellopontine fissure. The and the inferior cerebellar peduncle or the lateral medullary
most common veins in the lateral group are the common stem vein to the sigmoid and inferior petrosal sinuses near the
formed by the union of superior and inferior hemispheric jugular foramen or jugular bulb; from the vein of the pon-
veins and the vein of the cerebellopontine fissure. tomedullary sulcus, and the lateral anterior, lateral, and trans-

verse medullary veins to a marginal sinus at the level of the the tumor during the later stages of the removal of a large
foramen magnum or to the veins in the hypoglossal canal, which tumor. Smaller tumors can often be removed without sacri-
communicates with the marginal sinuses (Fig. 3.12) (13, 15). ficing a petrosal vein. The large vein encountered around the
superior pole of an acoustic neuroma is the vein of the cer-
ebellopontine fissure, which passes from the petrosal surface
DISCUSSION and cerebellopontine fissure above the facial and vestibuloco-
The infrequent reports of adverse sequelae after the intra- chlear nerves to the area above the trigeminal nerve. This vein
operative occlusion of veins in the posterior fossa is caused by has been occluded during acoustic neuroma removal without
the diffuse anastomosis between the veins. It is not surprising causing a deficit (14).
that more severe sequelae have occurred after occlusion of Compression of the trigeminal nerve by the surrounding veins
bridging veins than after occlusion of veins on the surface of is postulated to be a cause of trigeminal neuralgia (8, 11). In 411
the cerebellum, since the bridging veins are formed by the operations for trigeminal neuralgia, Jannetta found veins com-
terminal end of numerous surface veins. The veins crossing pressing the nerve in 153; however, none of these veins involved
the cerebellopontine angle to reach the petrosal sinuses are the in this compression was listed by name (11). Compression of the
ones most frequently occluded in the course of operations in facial and glossopharyngeal nerves by veins has also been pos-
the posterior fossa. Bridging veins are more frequently ex- tulated to be a cause of hemifacial spasm and glossopharyngeal
posed and sacrificed in the rostral part of the cerebellopontine neuralgia (12). The venous relationships of the trigeminal nerve
angle during operations near the trigeminal nerve than dur- where numerous bridging veins converge on and cross the sub-
ing operations in the central or caudal part near the nerves arachnoid space near the posterior root is distinctly different
entering the internal acoustic meatus and the jugular foramen. from those in the region of the facial and vestibulocochlear
Exposure of the trigeminal nerve through a suboccipital crani- nerves, where the predominant veins are on the side of the
ectomy commonly requires the sacrifice of one or more bridg- brainstem and in contact with the nerves at their junction with
ing veins, while exposure of the nerves entering the internal the brainstem. The veins coursing on or near the junction of the
acoustic meatus infrequently requires sacrifice of even a sin- facial and vestibulocochlear nerves with the brainstem are
gle bridging vein. the veins of the middle cerebellar peduncle, the cerebellomed-
In 1929, Dandy pointed out that the petrosal vein should ullary fissure, and the pontomedullary sulcus. There are no large
receive special attention during posterior fossa operations on the veins intermingling with the nerves at or within the acoustic
trigeminal nerve (4). His illustration showed a vein that coursed meatus, as occurs with the arteries. The major veins near the
in the cerebellopontine angle near the rostral aspect of the tri- glossopharyngeal and vagus nerves also course near the origin
geminal nerve to drain into the superior petrosal sinus. Later, of the nerves on the surface of the brainstem, although there are
this common stem came to be known either as the superior small bridging veins that course along these nerves to the ve-
petrosal vein or simply as the petrosal vein (4, 5, 23). No con- nous sinuses near the jugular bulb. The lateral medullary, retro-
sideration has been given in the surgical literature to the identi- olivary, and transverse medullary veins and the vein of the
fication of the trunks that unite to form the petrosal veins, and to inferior cerebellar peduncle course near the origin of the rootlets
the size of the area drained by their tributaries. The veins con- of the glossopharyngeal and vagus nerves.
verging on the trigeminal nerve to form the superior petrosal Bridging veins are more frequently encountered in expos-
veins are the transverse pontine and the pontotrigeminal veins, ing the tentorial surface of the cerebellum than in exposing the
and the veins of the cerebellopontine fissure and the middle suboccipital or petrosal surfaces of the cerebellum. The bridg-
cerebellar peduncle. The largest vein contributing to the forma- ing veins from the suboccipital surface are often encountered
tion of the petrosal vein near the trigeminal nerve is the vein of on the posterior part of the tentorial surface because the
the cerebellopontine fissure, which drains most of the petrosal hemispheric veins from the suboccipital surface uniformly
surface of the cerebellum and much of the lower brainstem ascend to the tentorial surface before forming bridging veins
and the cerebellopontine and cerebellomedullary fissures. Al- that pass to the venous sinuses in the tentorium. Most of the
though superior petrosal veins can be located at any point along veins from the petrosal surface pass to the vein of the cerebel-
the superior petrosal sinus, most are located just lateral to the lopontine fissure and not directly to a venous sinus. The veins
trigeminal nerve. Adverse sequelae only infrequently follow from the tentorial and suboccipital surface that enter the
occlusion of this medial group of superior petrosal veins; how- sinuses in the tentorium are obstacles in the supracerebellar
ever, we have seen two patients with a transient cerebellar approaches. In the infratentorial supracerebellar approach to
disturbance caused by a venous infarction with hemorrhagic the pineal region, it may be necessary to divide numerous
edema after the intraoperative occlusion of these veins lateral to bridging veins entering the torcula and the tentorial sinuses,
the trigeminal nerve. including some of the superior and inferior hemispheric and
The exposure of lesions such as acoustic neuromas in the vermian veins, and the vein of the cerebellomesencephalic
central part of the cerebellopontine angle near the lateral fissure. These veins have commonly been sacrificed without
recess, by retracting the petrosal surface of the hemisphere adverse effect to open the quadrigeminal region and the in-
away from the sigmoid sinus, can usually be completed with- cisura (18, 22, 27). However cerebellar swelling followed tran-
out sacrificing a single bridging vein. If a vein is obliterated section of one of the bridging veins by Page (17).
during acoustic tumor removal, it is usually one of the supe- Bridging veins infrequently cross from the suboccipital sur-
rior petrosal veins that is sacrificed near the superior pole of face, tonsils, and medulla to the venous sinuses in the dura

S92 Rhoton
overlying the suboccipital surface. In a few cases, an inferior 2. Braun JP, Tournade A: The veins of the lateral recess of the 4th
vermian or hemispheric vein will give rise to a bridging vein ventricle. Neuroradiology 7:9–13, 1974.
that drains into the occipital sinuses below the torcula, and 3. Browder J, Kaplan HA, Krieger AJ: Anatomical features of the
the veins on the posterior and lateral surfaces of the medulla straight sinus and its tributaries: Clinical correlations. J Neuro-
will give rise to bridging veins to the marginal or the occipital surg 44:55–61, 1976.
4. Dandy WE: An operation for the cure of tic douloureux: Partial
sinuses (7, 19). In approaching the fourth ventricle, the veins
section of the sensory root at the pons. Arch Surg 18:687–734, 1929.
around the tonsils, on the lower vermis, and near the inferior 5. Dandy WE: Concerning the cause of trigeminal neuralgia. Am J
part of the roof may be sacrificed. These veins, including the Surg 24:447–455, 1934.
vein of the cerebellomedullary fissure, have been occluded 6. Das AC, Hasan M: The occipital sinus. J Neurosurg 33:307–311, 1970.
repeatedly without sequelae. 7. Duvernoy HM: Human Brainstem Vessels. New York, Springer-
It may be necessary to divide part of the tentorium in either Verlag, 1977, pp 6–24.
the occipital transtentorial or the infratentorial supracerebellar 8. Haines SJ, Jannetta PJ, Zorub DS: Microvascular relations of the
approaches (10). In the occipital transtentorial approach, the trigeminal nerve: An anatomical study with clinical correlation.
occipital lobe can often be retracted away from the falx and J Neurosurg 52:381–386, 1980.
tentorium adjoining the straight sinus without sacrificing any 9. Huang YP, Wolf BS: Veins of the posterior fossa, in Newton TH,
Potts DG (eds): Radiology of the Skull and Brain. St Louis, C.V.
veins, because only infrequently are there bridging veins from
Mosby, 1974, vol II, Book 3, pp 2155–2216.
the occipital lobe near the straight sinus to the torcula, lateral, 10. Jamieson KG: Excision of pineal tumors. J Neurosurg 35:550–553, 1971.
straight, and superior sagittal sinuses. The posterior 5 cm of the 11. Jannetta PJ: Vascular decompression in trigeminal neuralgia, in
superior sagittal sinus is frequently devoid of bridging veins. Samii M, Jannetta PJ (eds): The Cranial Nerves: Anatomy-Pathology-
The vein of Labbé, which drains into the lateral portion of the Diagnosis-Treatment. New York, Springer-Verlag, 1981, pp 331–340.
lateral sinus, is usually lateral to this exposure, and the internal 12. Jannetta PJ, Abbasy M, Maroon JC, Ramos FM, Albin MS: Etiology and
occipital vein, which must be divided to reach the pineal region, definitive microsurgical treatment of hemifacial spasm: Operative tech-
drains not into a dural sinus, but into the internal cerebral or niques and results in 47 patients. J Neurosurg 47:321–328, 1977.
great vein in the quadrigeminal cistern. In the transtentorial 13. Katsuta T, Rhoton AL Jr, Matsushima T: The jugular foramen:
approach the tentorium is divided adjacent to and parallel to the Microsurgical anatomy and operative approaches. Neurosurgery
41:149–202, 1997.
straight sinus beginning at the free edge and extending posteri-
14. Kempe LG: Posterior Fossa, Spinal Cord and Peripheral Nerve Disease:
orly (20). The tentorial sinuses in the anterior part of the tento- Operative Neurosurgery. New York, Springer-Verlag, 1970, vol 2,
rium are smaller and less frequent than those in the posterior pp 34–45.
part of the tentorium. Most of the tentorial sinuses found in the 15. Matsushima T, Rhoton AL Jr, de Oliveira E, Peace D: Microsur-
posterior third of the tentorium are formed by the cerebellar gical anatomy of the veins of the posterior fossa. J Neurosurg
veins. The veins draining the lower portion of the temporal and 59:63–105, 1983.
occipital lobes empty into the more anteriorly situated tentorial 16. Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the
sinuses that drain into the superior petrosal or adjacent part of fourth ventricle: Part 1—Microsurgical anatomy. Neurosurgery
the transverse sinus. The tentorial sinuses formed by the veins 11:631–667, 1982.
draining the cerebrum commonly course posteromedially, pos- 17. Page LK: The infratentorial-supracerebellar exposure of tumors in
the pineal area. Neurosurgery 1:36–40, 1977.
terolaterally, or straight posteriorly from their origin. The sinus
18. Pendl G: Infratentorial approach to mesencephalic tumors, in
in the anterior part of the tentorium usually receives only small Koos WT, Böck FW, Spetzler RF (eds): Clinical Microneurosurgery.
bridging veins from the midbrain, but in rare cases, the basal Stuttgart, Georg Thieme, 1976, pp 143–150.
vein may terminate as a large bridging vein that enters the 19. Perese DM: Superficial veins of the brain from a surgical point of
anterior part of the tentorium. The anteromedial edge of the view. J Neurosurg 17:402–412, 1960.
tentorium posterior to the superior petrosal sinus may be sec- 20. Rhoton AL Jr, Yamamoto I, Peace DA: Microsurgery of the third
tioned through a subtemporal craniectomy to expose the trigem- ventricle: Part 2—Operative approaches. Neurosurgery 8:357–
inal nerve and the surrounding superior petrosal venous com- 373, 1981.
plex from their superolateral side. This provides excellent 21. Saxena RC, Beg MAQ, Das AC: The straight sinus. J Neurosurg
exposure of the pontotrigeminal and transverse pontine veins 41:724–727, 1974.
22. Stein BM: The infratentorial supracerebellar approach to pineal
passing above the trigeminal nerve, but some of the transverse
lesions. J Neurosurg 35:197–202, 1971.
pontine and bridging veins may be hidden below or medial to 23. Takahashi M, Wilson G, Hanafee W: The significance of the
the nerve in this exposure. petrosal vein in the diagnosis of cerebellopontine angle tumors.
Radiology 89:834–840, 1967.
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro- 24. Wackenheim A, Braun JP: The Veins of the Posterior Fossa: Normal
logical Surgery, University of Florida Brain Institute, P.O. Box 100265, and Pathologic Findings. New York, Springer-Verlag, 1978, pp 1–23.
100 South Newell Drive, Building 59, L2-100, Gainesville, FL 32610-0265. 25. Waltner JG: Anatomic variations of the lateral and sigmoid si-
nuses. Arch Otolaryngol 39:307–312, 1944.
26. Wolf BS, Huang YP, Newman CM: The lateral anastomotic mes-
REFERENCES encephalic vein and other variations in drainage of the basal
cerebral brain. AJR Am J Roentgenol 89:411–422, 1963.
1. Billewicz O: The normal and pathological radioanatomy of the 27. Yamamoto I, Kageyama N: Microsurgical anatomy of the pineal
lateral mesencephalic vein. Neuroradiology 8:295–299, 1975. region. J Neurosurg 53:205–221, 1980.

CHAPTER 4
The Cerebellopontine Angle and Posterior Fossa Cranial

Nerves by the Retrosigmoid Approach

Key words: Acoustic neuroma, Cerebellopontine angle, Cranial nerves, Hemifacial spasm, Microsurgery, Microsurgical anatomy, Surgical ap-
proach, Trigeminal neuralgia
T
he cerebellopontine angle is located between the supe- Trigeminal root anatomy
rior and inferior limbs of the angular cerebellopontine
The fibers from the third division remain in a caudolateral
fissure formed by the petrosal cerebellar surface folding
position in the posterior root throughout the interval from the
around the pons and middle cerebellar peduncle (Fig. 4.1).
ganglion to the pons, the first division rostromedial, with
The cerebellopontine fissure opens medially and has superior
second-division fibers in an intermediate position (Figs. 4.2
and inferior limbs that meet at a lateral apex. The fourth
and 4.3). Conclusions that the third-division fibers remain
through the eleventh cranial nerves are located near or within
caudolateral and that the first-division fibers remain rostro-
the angular space between the two limbs commonly referred
medial from the pons to the ganglion agree with data from
to as the cerebellopontine angle (Fig. 4.1). The trochlear and
clinical and laboratory studies (5, 8, 31). There are anastomo-
trigeminal nerves are located near the fissure’s superior limb
ses between the fibers from each division in the area posterior
and the glossopharyngeal, vagus, and accessory nerves are
to the ganglion (Fig. 4.2). Results of selective rhizotomy of the
located near the inferior limb. The abducens nerve is located
posterior root indicate that somatotopic localization with the
near the base of the fissure, along a line connecting the ante-
rior ends of the superior and inferior limbs. third division inferolaterally and the ophthalmic division dor-
This description of the cranial nerves and operative ap- somedially is well maintained posterior to, and despite, the
proaches to the cerebellopontine angle is organized around prominent retrogasserian anastomoses (5).
the three neurovascular complexes, defined in the chapter on A cross section of the sensory root between the pons and
the cerebellar arteries, and focuses on the retrosigmoid ap- the petrous apex is elliptical. In most nerves, the angle be-
proach, which is the most frequently selected approach for tween the longest diameter of this cross section and the long
lesions in the angle. The microsurgical anatomy of acoustic axis of the body is 40 to 50 degrees; the angle, however, can
neuromas, vascular compression syndromes, and other disor- vary from 10 to 80 degrees (Fig. 4.4) (12). An angle of 80
ders involving the nerves in the cerebellopontine angle are the degrees places the third-division fibers almost directly lateral
subjects of this section. to those of the first division; but an angle of 10 degrees places
the third-division fibers almost directly caudal to those of the
first division. The variability in the degree of rotation of the
sensory root entering the pons may explain some differences
UPPER NEUROVASCULAR COMPLEX in the quantity of sensation retained after partial section of the
The most common operation directed to the upper neuro- nerve in the posterior cranial fossa. The most frequent pattern
vascular complex is the exposure of the posterior root of the is for the third-division fibers to be caudolateral to the first-
trigeminal nerve. The posterior trigeminal root joins the brain- division fibers; some nerves, however, are rotated so that
stem about halfway between the lower and upper borders of third-division fibers will be almost directly lateral to the first
the pons (Fig. 4.2). Frequently, a lip of cerebellum projects division; others are rotated nearly 70 degrees away from this
forward and obscures the junction of the posterior root with so that the third-division fibers will be directly caudal to those
the pons. In its intradural course, the trigeminal nerve uni- of the first division. Cutting into the nerve partially from a
formly runs obliquely upward from the lateral part of the caudolateral direction would give a significantly different
pons toward the petrous apex. It exits the posterior fossa to pattern of sensory loss if the nerve is rotated with the third
enter the middle cranial fossa by passing forward beneath the division lateral to the first, than if the third division is almost
tentorial attachment to enter Meckel’s cave, which sits in the directly caudal to the first division.
trigeminal impression on the upper surface of the petrous part At the junction of the nerve with the pons, as many as
of the temporal bone. 15 separate nerve rootlets may be spread around the rostral

S94 Rhoton
FIGURE 4.1. Retrosigmoid

exposure of the nerves in the
right cerebellopontine angle. A,
the vestibulocochlear nerve
enters the internal acoustic
meatus with a labyrinthine
branch of the AICA. The PICA
courses around the
glossopharyngeal, vagus, and
accessory nerves. The abducens
nerve ascends in front of the
pons. A subarcuate artery enters
the subarcuate fossa
superolateral to the porus of the
meatus. Choroid plexus
protrudes into the
cerebellopontine angle behind
the glossopharyngeal and vagus
nerves. B, the posterior wall of
the internal acoustic meatus has
been removed. The cleavage
plane between the upper bundle,
formed by the superior
vestibular nerve, and the lower
bundle, formed by the inferior
vestibular and cochlear nerves,
was begun laterally where the
nerves have separated near the
meatal fundus and extended
medially. The nervus intermedius
arises on the anterior surface of
the vestibulocochlear nerve, has
a free segment in the cistern
and/or meatus, and joins the
facial nerve distally. The facial
nerve is located anterior to the
superior vestibular nerve and the
cochlear nerve is anterior to
the inferior vestibular nerve.
C, the cleavage plane between
the cochlear and inferior
vestibular nerves, which is well
developed in the lateral end of the internal acoustic meatus, has been extended medially. Within the cerebellopontine angle,
the superior vestibular nerve is posterior and superior, the facial nerve anterior and superior, the inferior vestibular nerve
posterior and inferior, and the cochlear nerve anterior and inferior. D, the superior and inferior vestibular nerves have been
divided to expose the facial and cochlear nerves. A labyrinthine branch of the PICA enters the internal meatus. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Chor. Plex., choroid plexus; CN, cranial nerve; Coch., cochlear; Flocc., flocculus;
Inf., inferior; Intermed., intermedius; Labyr., labyrinth; N., nerve; Nerv., nervus; Pet., petrosal; P.I.C.A., posteroinferior
cerebellar artery; Subarc., subarcuate; Sup., superior; V., vein; Vest., vestibular.
half of the site where the main sensory cone enters the pons Those arising rostral to the sensory root most frequently enter
(12). These rootlets are either motor or aberrant sensory root- the first division, and those arising more caudally enter the
lets. The aberrant sensory fibers are small rootlets that pene- second or third division. No aberrant rootlets originate
trate the pons outside the main sensory root (Figs. 4.2, 4.5, and around the caudal third of the sensory root. Of 66 aberrant
4.6). The aberrant rootlets arise around the rostral two-thirds rootlets found in our study of 50 trigeminal nerves, 49 went
of the nerve and usually join the root a short distance from the into the first division, 10 into the second division, and 7 into
brainstem. There may be as many as eight aberrant roots. the third division (12). The findings that aberrant rootlets are

Cerebellopontine Angle S95
FIGURE 4.2. Lateral views, right trigeminal nerve. A,

Meckel’s cave, the cistern, which extends forward from the
posterior fossa along the posterior trigeminal root to the
level of the mid portion of the ganglion, has been exposed
by removing the lateral dural wall of the cave. The motor
root arises rostral to the sensory root and passes through
Meckel’s cave on the medial side of the posterior sensory
root and ganglion. B, the dura has been removed to expose
the posterior root and ganglion and the three trigeminal
divisions. There are diffuse anastomoses between the
rootlets posterior to the ganglion. C, enlarged view of the
diffuse anastomosis in the region of Meckel’s cave. D, four
motor rootlets, which arise around the rostral margin of the
sensory root, have been elevated to expose the anastomoses
between the motor and sensory roots. The cerebellar lip
projects forward and may hide the junction of the sensory root with the pons in the retrosigmoid approach. E, a cleavage
plane has been started anteriorly and extended backward to the level of the posterior root. The first-division fibers are
rostromedial within the posterior root and the third-division fibers caudolateral with the second division being in an
intermediate location. Cav., cavernous; Cereb., cerebellar; CN, cranial nerve; Gang., ganglion; Post., posterior; V., vein.
most commonly related to the first division agree with Motor rootlets also arise around the rostral part of the
Dandy’s conclusion that when the accessory fibers are spared, nerve; however, they tend to arise further from the main
sensation in the first division tends to be spared (5). The sensory cone than do the accessory sensory rootlets. The
aberrant rootlets appear to be nonspecific sensory fibers sep- motor root may be composed of 4 to 14 separate rootlets, each
arated from the root by transverse pontine fibers (12, 43). having a separate exit from the pons (Figs. 4.2, 4.3, and 4.7)
Aberrant roots contribute mainly to the first division and (12). The aberrant sensory fibers usually arise closer to the
probably do not convey a specific sensory modality from all main sensory root than to the motor fibers. Some aberrant
three divisions. sensory fibers, however, will arise further from the main

S96 Rhoton
FIGURE 4.3. Diagrams of 12 trigeminal nerves showing

the relationship of the trigeminal sensory root, motor
rootlets, and aberrant sensory rootlets at the site of entry
into the pons. The central diagrams are for orientation and
show the elliptical cross section of the sensory root. The
large ovals (A–F ) represent the sensory root and are
oriented in the same manner as the sensory root in the
central diagram. The sites of origin of the motor rootlets
are black. Upper: Nerves on the right. Only 5 motor
rootlets are present in B, but 13 are seen in F. The
aberrant sensory rootlets are shown by the dark outline
with clear center. None are present in D and F. In C and
E, some aberrant rootlets arise farther from the sensory
root than some of the motor rootlets. Lower, nerves on
the left. Only 4 motor rootlets are present in A, but there
are 10 in B and C. Aberrant sensory rootlets are shown by
the dark outline with clear center. None are present in B
and C. In A, D, E, and F, some aberrant rootlets arise
farther from the sensory root than some of the motor
rootlets. Lines through the oval representing the main
sensory root show portions of the nerve from each of the
three divisions. In all diagrams, the rostromedial portion is
from the first division, the caudolateral portion is from the
third division, and the second division is in an
intermediate position. In all these nerves, except A and B
in the left nerve, the second division fibers make up a
greater portion of the medial than the lateral portion of
the sensory root. Small arteries or veins coursing between
the rootlets at the level of entry into the pons are shown
in all diagrams of both nerves, except D in the right nerve
(upper). (From, Gudmundsson K, Rhoton AL Jr, Rushton
JG: Detailed anatomy of Surgical approach, the
intracranial portion of the trigeminal nerve. J Neurosurg
35:592–600, 1971 [12].)
sensory root than does the origin of some motor filaments; for the posterior root, because anastomotic rootlets are present
this reason, it is easy to confuse aberrant sensory fibers and throughout the interval from the pons to the ganglion. Aber-
motor filaments at the nerve/pons junction. rant sensory roots are present in only half of the nerves. They
Anastomoses between the motor and sensory roots are provide another explanation for the preservation of sensation
present in most nerves (Fig. 4.2). Those sensory fibers associ- after section of the main sensory root.
ated with the motor root from the pons to just proximal to the
ganglion, where they anastomose with the sensory root,
would be spared with a rhizotomy in the posterior fossa. Anatomy of vascular compression in the upper
Horsley et al. (15) suspected that there were sensory fibers in neurovascular complex
the trigeminal motor root, suggesting that the motor root be In 1934, Dandy postulated that arterial compression and
sectioned if trigeminal neuralgia recurred after the complete distortion of the trigeminal nerve might be the cause of tri-
section of the sensory root. Our studies offer two explanations geminal neuralgia (6). He described the superior cerebellar
for the accidental preservation of sensation after posterior artery (SCA) as affecting the nerve in 30.7% of his 215 cases
rhizotomy: 1) sparing of the aberrant sensory rootlets, and 2) of trigeminal neuralgia. The vascular compression theory
sparing of the anastomotic sensory fibers that run with the failed to gain acceptance at the time, but it awaited the better
motor root at the level of the rhizotomy (12). Anastomosis is demonstration of these pathological changes at surgery by
a more likely explanation for the accidental sensory preserva- Jannetta (17, 21) using magnification provided by the operat-
tion and recurrence of trigeminal neuralgia after the section of ing microscope.

FIGURE 4.5. Lateral view of the left trigeminal nerve. A

nerve hook is between the large aberrant sensory rootlet and
the main sensory root. An aberrant rootlet arises from the
pons directly lateral to the sensory root and joins the sensory
root about 1 cm from the brainstem. Four motor rootlets are
seen above the sensory root. (From, Gudmundsson K, Rhoton
AL Jr, Rushton JG: Detailed anatomy of the intracranial por-
tion of the trigeminal nerve. J Neurosurg 35:592–600, 1971
[12].)
bridging petrosal vein, which commonly blocks access to the

trigeminal nerve, is coagulated with gentle bipolar coagula-
tion and divided nearer its junction with the brain than to the
superior petrosal sinus. Unexpected bleeding encountered as
FIGURE 4.4. Variability of the longest axis of the elliptical the superolateral margin of the cerebellum is elevated, if
cross section of the trigeminal nerve at the pons (broken venous in appearance, is usually related to stretching and
line) to the longitudinal axis of the body (solid line). The long tearing of the petrosal veins that pass from the superior
axis of most nerves makes a 40- to 50-degree angle with the surface of the cerebellum to the venous sinus in the tentorium
longitudinal axis of the body (A); however, this can vary or, if arterial in appearance, to tearing of the subarcuate
from 10 degrees (C ) to 80 degrees (B ). In B, the third divi- branch of the anteroinferior cerebellar artery (AICA) behind
sion is almost directly lateral to the first division, and in C, it the internal auditory canal at its site of penetration of the dura
is almost directly caudal. (From, Gudmundsson K, Rhoton AL covering the subarcuate fossa. The trochlear nerve is identi-
Jr, Rushton JG: Detailed anatomy of the intracranial portion fied before opening the arachnoid behind the trigeminal
of the trigeminal nerve. J Neurosurg 35:592–600, 1971 [12].) nerve, because it may be difficult to see the nerve after the
arachnoid has been opened and shrinks into thick white
This upper neurovascular complex, for a vascular decom- clumps that may hide the nerve. Usually, the trochlear nerve
pression operation, is approached using a vertical scalp inci- is several millimeters above the trigeminal nerve; it may be
sion crossing the asterion, which usually overlies the junction carried downward, however, if it is adherent to a segment of
of the lower half of the transverse and sigmoid sinuses (Fig. the SCA that has looped into the axilla of the trigeminal nerve.
4.8). The bone opening, a small craniotomy, located behind The overhanging lip of the cerebellomesencephalic fissure
the upper half of the sigmoid sinus, exposes the edge of the must be retracted gently to expose the junction of the nerve
junction of the transverse and sigmoid sinuses in its supero- with the pons.
lateral margin. The cerebellum is relaxed by opening the The most common finding at a vascular decompression
arachnoid and removing cerebrospinal fluid, a maneuver operation for trigeminal neuralgia is a segment of the SCA
made safer by the use of the operating microscope. A narrow compressing the trigeminal nerve (13, 18). Normally, the
brain spatula, commonly 3 mm at the tip, is introduced par- SCA encircles the brainstem well above the trigeminal nerve.
allel and just below the superior petrosal sinus to elevate the In adults, the SCA commonly makes a shallow, caudal loop
superolateral margin of the cerebellum (Fig. 4.9) (36). The use and courses inferiorly for a variable distance on the lateral
of a wider spatula or a lower entry point along the lateral side of the pons (Figs. 4.8 and 4.10-4.12). In those cases with
cerebellum risks damaging the vestibulocochlear nerve. A the most prominent caudally projecting loop, contact be-

S98 Rhoton
FIGURE 4.6. Origin of the aberrant sensory rootlets in rela-

tion to the main sensory root. The large, clear oval repre-
sents a cross section of the sensory root at the level of entry
into the pons. Origin of aberrant rootlets is in solid black. All
nerves to the left of the solid line are from the right side and
are oriented the same as the nerves shown in Figure 4.3
(upper). Those to the right of the line are from the left side
and are oriented as shown in Figure 4.3 (lower). The rootlet
origin shown with the arrow below F (right) goes with sen-
sory root G, and the rootlet origin shown with the arrow FIGURE 4.7. A, lateral view of the right trigeminal nerve
below M (left) goes with sensory root O. The rostral margin near its junction with the pons. The arrow points to the
of the root is superior and the caudal margin is inferior on intermediate group of fibers between the motor rootlet and
the diagrams. No aberrant sensory root originates caudal to the sensory root. B, the same trigeminal nerve. The arrow
the main sensory root. (From, Gudmundsson K, Rhoton AL Jr, points to the intermediate group of fibers that proved to be a
Rushton JG: Detailed anatomy of the intracranial portion of motor rootlet when traced distally. This illustrates the difficulty
the trigeminal nerve. J Neurosurg 35:592–600, 1971 [12].) in telling whether an intermediate group of fibers is motor or
sensory unless the nerve bundles can be separated and exam-
tween the artery and the trigeminal nerve occurs. The point of
ined individually. (From, Gudmundsson K, Rhoton AL Jr, Rush-
contact with the SCA is usually on the superior or superome-
ton JG: Detailed anatomy of the intracranial portion of the tri-
dial aspect of the nerve; and often a few fascicles of the nerve
geminal nerve. J Neurosurg 35:592–600, 1971 [12].)
are distorted by an SCA that has looped down into the axilla
between the medial side of the nerve and the pons (Figs. 4.8
and 4.12). An arterial loop in the axilla may not be visible from superior surfaces of the nerve to reach the cerebellomesence-
the retrosigmoid view behind the trigeminal nerve if the SCA phalic fissure. The medial axilla of the nerve must be carefully
courses around the brainstem directly in front of the nerve. explored before concluding that there is no arterial loop in the
The loop of the SCA also may be difficult to see if the artery axilla of the nerve. It is important to remember that the trunks
passes over the rostral aspect of the nerve very close to the do not pass directly from the side of the brainstem to the
brainstem, where it may be hidden by the overhanging lip of superior surface of the cerebellum; they dip into the deep
the cerebellomesencephalic fissure. The loop of the SCA may fissure between the cerebellum and midbrain at the posterior
be seen dangling below the lower margin of the nerve, even margin of the trigeminal nerve. The SCA gives off perforating
though it is not visible above the nerve. These loops of the arteries that may limit the degree of repositioning of the artery
SCA, however, always pass rostrally along the medial and achievable in a microvascular decompression operation.

FIGURE 4.8. Retrosigmoid approach

to the trigeminal nerve for a
microvascular decompression
operation. A, (upper left), the patient
is positioned in the three-quarter
prone position. The surgeon is seated
at the head of the table. The table is
tilted so that the feet are lower than
the heart. B, the vertical paramedian
incision crosses the asterion. The
superolateral margin of the
craniotomy is positioned at the
junction of the transverse and sigmoid
sinuses. C, the superolateral margin of
the cerebellum is gently elevated
using a brain spatula tapered from 10
mm at the base to 3 or 5 mm at the
tip to expose the site at which the
trigeminal nerve enters the pons. The
brain spatula is advanced and aligned
parallel to the superior petrosal sinus.
The trochlear nerve is at the superior
margin of the exposure and the facial
and vestibulocochlear nerves are at
the lower margin. The dura is tacked
up to the adjacent muscles to
maximize the exposure along the
cerebellum. The main trunk of the
SCA loops down into the axilla of the
trigeminal nerve. (From, Rhoton AL
Jr: Microsurgical anatomy of
decompression operations on the
trigeminal nerve, in Rovit RL, Murali
R, Jannetta PJ (eds): Trigeminal
Neuralgia. Baltimore, Williams &
Wilkins, 1990, pp 165–200 [34].)
S.C.A., superior cerebellar artery; Sig.,
sigmoid; Sup., superior; Trans.,
transverse.
The most common site of compression of the trigeminal caliber if the SCA bifurcates before reaching the trigeminal
nerve on the SCA is at the junction of the main trunk with the nerve.
origin of the rostral and caudal trunks (Figs. 4.11 and 4.12) A less frequent source of compression of the trigeminal
(34). However, other sites of compression are seen, depending nerve is by the AICA (Figs. 4.11 and 4.12). Normally, the AICA
on how far distal the artery bifurcates in relation to the passes around the pons below the trigeminal nerve with the
trigeminal nerve. If the SCA bifurcates near the basilar artery facial and vestibulocochlear nerves. The AICA, however, may
or if there is a duplicate configuration in which the rostral and have a high origin and loop upward to indent the medial or
caudal trunks arise directly from the basilar artery, both lower surface of the trigeminal nerve before passing down-
trunks may loop down into the axilla and compress the nerve. ward to course with the facial and vestibulocochlear nerves. A
Alternatively, if the artery bifurcates before reaching the serpentine basilar artery also may wander laterally and com-
nerve, the caudal trunk may compress the nerve and the press the medial side of the trigeminal nerve (43). This type of
rostral trunk may course well above the nerve. If the artery basilar artery often is elongated and has a fusiform configu-
bifurcates distal to the nerve, only the main trunk will be ration. More than one artery may compress the nerve. In a few
involved in the compression. The point of bifurcation of the cases, the SCA will compress the rostral surface of the nerve
SCA does affect the caliber of the vessel that makes contact and the AICA will compress the caudal surface. Infrequently,
with the nerve. The contacting vessel will be of a smaller the posteroinferior cerebellar artery (PICA) may reach and

S100 Rhoton
FIGURE 4.9. Direction of the

application of brain spatulas for
surgery in the various
compartments of the
cerebellopontine angle. A,
lateral exposure for a lesion in
the midportion of the
cerebellopontine angle, such as
an acoustic neuroma. The site of
the craniotomy below the
transverse sinus and medial to
the sigmoid sinus is shown for
removing an acoustic neuroma
or other lesion involving
multiple neurovascular
complexes. The spatula protects
the lateral surface of the
cerebellum after the cerebellum relaxes after the opening of the cisterns and removing cerebrospinal fluid. A brain spatula
tapered from 20 or 25 mm at the base to 15 or 20 mm at the tip is commonly used during the removal of large tumors, and
a spatula tapered from 15 mm at the base to 10 mm at the tip is used for small tumors. B, spatula application for exposing
the upper neurovascular complex for a microvascular decompression operation for trigeminal neuralgia. A spatula tapered
from 10 mm at the base to 3 or 5 mm at the tip is commonly selected. The spatula is placed parallel to the superior petrosal
sinus. C, retractor application for the exposure of the lower neurovascular complex. This approach also is used in hemifacial
spasm because the facial nerve root exit zone is located only a few millimeters above the glossopharyngeal nerve and the
PICA is commonly a compressing vessel. A brain spatula tapered from 10 mm at the base to 3 or 5 mm at the tip is
commonly used for operations for hemifacial spasm. (From, Rhoton AL Jr: Instrumentation, in Apuzzo MLJ (ed): Brain
Surgery: Complication Avoidance and Management. New York, Churchill-Livingstone, 1993, vol 2, pp 1647–1670 [36].)
groove the undersurface of the trigeminal nerve. The trigem- zone, both of which are postulated as a prerequisite for the
inal nerve also may be compressed by a large pontine branch production of trigeminal neuralgia (18).
of the basilar artery (Figs. 4.11 and 4.12). Normally, these
pontine branches pass around and penetrate the pons before
reaching the trigeminal nerve. A large pontine artery, how- Venous relationships
ever, may indent the medial surface of the trigeminal nerve Compression and distortion of the trigeminal nerve by the
and then course rostral or caudal to the nerve to supply the surrounding veins, although less frequent than arterial com-
pons behind the nerve. pression, also is found in trigeminal neuralgia (Figs. 4.13 and
In a previous study of 50 cadaveric trigeminal nerves, we 4.14) (2, 18, 26). It is the superior petrosal veins that empty
found that 26 had a point of contact with the SCA in the into the superior petrosal sinus that are most frequently en-
posterior cranial fossa (14). In the 26 nerves having a point of countered in operative approaches to the trigeminal nerve
contact with the SCA, the segment of the SCA involved was and that most commonly compress the trigeminal nerve.
the main trunk before its bifurcation in 8, the caudal trunk The superior petrosal veins are among the largest and most
distal to the bifurcation in 11, the rostral trunk in 2, both the frequently encountered veins in the posterior fossa. The su-
rostral and caudal trunk in 4, and a hemispheric branch of the perior petrosal veins may be formed by the terminal segment
caudal trunk in 1. In that study, the site of vascular contact of a single vein or by the common stem formed by the union
was commonly a few millimeters peripheral to the point of of several veins. The most common tributaries of the superior
entry of the nerve into the pons (average, 3.7 mm) rather than petrosal veins are the transverse pontine and pontotrigeminal
at the root entry zone, as is seen in most of our cases with veins, the veins of the cerebellopontine fissure and the middle
trigeminal neuralgia. In one cadaveric specimen, the vascular cerebellar peduncle, and the common stem of the veins drain-
contact was more than 1 cm from the pons. In 6 of the 50 ing the lateral part of the cerebellar hemisphere. The trans-
cadaveric nerves, the contact occurred at the pontine sensory verse pontine veins, which pass near the trigeminal nerve to
root entry zone of the trigeminal nerve. The main trunk of the reach the bridging veins entering the superior petrosal sinus,
AICA also impinged on 4 of the 50 cadaveric trigeminal are the most frequent veins to compress the trigeminal nerve.
nerves that were examined, and in 3 of these, there was also They may course medially in the axilla of the nerve or they
a point of contact between the nerve and the SCA. One nerve also may pass above, below, or lateral to the nerve and may
also was contacted on its superior surface by the SCA and on indent any of its surfaces. The vein of the middle cerebellar
its inferior surface by both trunks of a duplicated AICA. Not peduncle may compress the lateral or medial surface of the
all of these contacts seen in our anatomic studies produced trigeminal nerve before joining the petrosal veins as it ascends
distortion of the nerve or occurred at the sensory root entry in the pons. The vein of the cerebellopontine fissure may

FIGURE 4.10. Trigeminal nerve and SCA relationships. A, the trigeminal posterior root, ganglion, and three divisions have
been exposed by removing the dura from the lateral wall of Meckel’s cave and the cavernous sinus. The posterior root enters
the midpons below the SCA and is intertwined with the branches of the superior petrosal vein. B, the SCA loops downward
and, at the junction of the rostral and caudal trunks, contacts the posterior trigeminal root at the pontine junction. The cere-
bellar lip projects forward and may block access to the junction of the trigeminal nerve and pons in the retrosigmoid
approach. C, SCA with an early bifurcation. The rostral trunk loops downward and indents the upper surface of the trigemi-
nal nerve. D, another SCA passes around the pons and bifurcates into its rostral and caudal trunks above the trigeminal root
entry zone. A., artery; A.I.C.A., anteroinferior cerebellar artery; Car., carotid; Caud., caudal; Cav., cavernous; Cereb., cere-
bellar; CN, cranial nerve; Pet., petrosal; Post., posterior; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tr.,
trunk; V., vein.
indent the lateral margin of the trigeminal nerve as it ascends and the prepontine cistern medial to the trigeminal nerve (Figs.
toward the superior petrosal sinus, and the pontotrigeminal 4.15 and 4.16). Removal of the suprameatal tubercle increases
vein may indent the upper margin of the nerve. access to the region of the upper neurovascular complex around
The junction of these veins, which converge and form a the trigeminal nerve, and may possibly avoid the need for a
single trunk before entering the superior petrosal sinus, usu- supratentorial craniotomy in exposing tumors that are located
ally is lateral to the trigeminal nerve. This junction, however, predominantly in the cerebellopontine angle but also extend into
may be located medial to the trigeminal nerve, in which case the posterior part of the middle fossa in the region of Meckel’s
the common trunk must pass around the trigeminal nerve cave (42). The tubercle, the most prominent bony elevation
before reaching the superior petrosal sinus. These common around the circumference of the internal acoustic meatus, is
trunks also may compress the trigeminal nerve. defined below by the internal acoustic meatus, above by the
petrous ridge, laterally by a vertical line crossing the posterior
Suprameatal extension of the retrosigmoid approach edge of the porus of the internal acoustic meatus, and medially
The part of the posterior surface of the temporal bone that by a vertical line crossing the medial edge of the trigeminal
forms the superior lip of the porus of the internal acoustic notch, a depression in the petrous ridge located below the porus
meatus is the site of a prominence, the suprameatal tubercle, of Meckel’s cave. Above and medial to the suprameatal tubercle,
that blocks access to the lateral margin of the trigeminal nerve the posteromedial part of the floor of the middle cranial fossa is

S102 Rhoton
FIGURE 4.11. Sites of arterial

compression of the trigeminal
nerve. Orientation as shown in the
central diagram. A, central
diagram. The right trigeminal nerve
is compressed by a tortuous basilar
artery and the left trigeminal nerve
is compressed by the main trunk of
the SCA. B, the SCA bifurcates into
rostral and caudal trunks before
reaching the trigeminal nerve. The
nerve is compressed by the caudal
trunk. C, the SCA bifurcates
distally to the nerve. The nerve is
compressed by the main trunk. D,
the SCA bifurcates before reaching
the nerve. The nerve is compressed
by both the rostral and caudal
trunks. E, the nerve is compressed
by a large pontine artery. F, the
nerve is compressed by an AICA
that has a high origin and loops
upward into the medial surface of
the nerve. The SCA passes around
the brainstem above the nerve.
(From, Rhoton AL Jr: Microsurgical
anatomy of decompression
operations on the trigeminal nerve,
in Rovit RL, Murali R, Jannetta PJ
(eds): Trigeminal Neuralgia.
Baltimore, Williams & Wilkins,
1990, pp 165–200 [34].) A., artery;
artery; Bas., basilar; Ca., caudal;
Ro., rostral; S.C.A., superior
cerebellar artery; Tr., tract; V.,
vein.
the site of the depression underlying Meckel’s cave in which the The intraosseous structures, which limit the extent of the
posterior trigeminal root sits. The most prominent posterior drilling if they are to be preserved, are the posterior part of the
projection of the tubercle is located above the lateral half of the superior semicircular canal, the upper part of the posterior
porus of the internal acoustic meatus. semicircular canal, and the common crus of the two canals.
The neural structures that surround and limit access to the After removal of the suprameatal tubercle, the drilling can be
suprameatal tubercle are the cerebellum posteriorly, the facial extended below Meckel’s cave to the edge of the petroclival
and vestibulocochlear nerves below, the trigeminal nerve fissure just in front of the inferior petrosal sinus and imme-
above and medial, and the abducens nerve medially. The cer- diately lateral to the abducens nerve. Removing the bone in
ebellopontine cistern opens through the porus into Meckel’s this area provides access, on average, to the posterior 10.3 mm
cave. Meckel’s segment of the trigeminal nerve, which begins at (range, 8.0–13.0 mm) of Meckel’s cave and the enclosed por-
the porus and extends to the trigeminal ganglion, is differenti- tion of the trigeminal nerve, and opens a 180-degree window
ated from the cavernous segment in the wall of the cavernous around the lateral and lower surface of the posterior trigem-
sinus. Meckel’s segment is narrower adjacent to the porus and inal root, which may be used for accessing the posterior part
fans out as it approaches the posterior edge of the gasserian of the middle fossa (Figs. 4.15 and 4.16).
ganglion, which is embedded in the dura just anterior to the The size of the area created by removing the suprameatal
anterior edge of Meckel’s cave. tubercle and adjacent part of the petrous apex by the retrosig-


nerve as seen through a
suboccipital craniotomy. A,
central diagram. The site of the
skin incision (solid line) and the
craniotomy (interrupted line) are
shown in the insert. The
cerebellum is gently retracted to
expose the trigeminal nerve and
the SCA. The brain spatula is
advanced parallel to the superior
petrosal sinus. The trochlear
nerve is at the superior margin
of the exposure and the facial
and vestibulocochlear nerves are
at the lower margin. The
trigeminal nerve is compressed
by a loop of the SCA that
dangles down into the axilla of
the nerve. The site of
compression on the artery is at
the junction of the main trunk
with the rostral and caudal
trunks. B, the nerve is
compressed by the caudal trunk.
C, the nerve is compressed by
the main trunk. D, compression
by both the rostral and caudal
trunks. E, compression by a
pontine branch of the basilar
artery. F, compression by the
AICA. G, compression by a
tortuous basilar artery. A.,
artery; A.I.C.A., anteroinferior
cerebellar artery; Bas., basilar;
Ca., caudal; Ro., rostral; S.C.A.,
superior cerebellar artery; Sup.,
superior; Tr., trunk; V., vein.
(From, Rhoton AL Jr:
Microsurgical anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds):
Trigeminal Neuralgia. Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].)
moid route is limited superiorly by the superior petrosal sinus 10.3 mm) anterior to what could be achieved using the ret-
and the dura covering the upper surface of the petrous bone. rosigmoid approach alone (42). The extent to which the bone
The superior petrosal sinus can be divided, and Meckel’s cave in the region of the suprameatal tubercle could be removed
and the tentorium lateral to the porus of Meckel’s cave can be using the retrosigmoid approach is defined and limited by the
opened to provide intradural access to the posteromedial part neural and bony structures in the region. The cerebellum,
of the middle fossa, but cannot be extended forward to the with gentle retraction, limits the angle at which the su-
horizontal portion of the petrous carotid. prameatal tubercle can be drilled, although when combined
The suprameatal extension of the retrosigmoid approach with evacuation of cerebrospinal fluid, it provides a space to
may permit removal of some tumors that are located mainly adequately visualize and remove lesions medial to the su-
in the posterior fossa but that extend into the middle fossa in prameatal tubercle. A portion of this bone is commonly re-
the region of Meckel’s cave. The space created after drilling moved in approaching tumors extending into the internal
the suprameatal tubercle and the bone medial to the internal acoustic meatus. It is possible to remove approximately 270
auditory canal and below the trigeminal nerve was enough to degrees of the circumference of the wall of the internal acous-
extend the retrosigmoid approach as far as 13.0 mm (average, tic meatus when using the retrosigmoid approach; however,

S104 Rhoton
FIGURE 4.13. Sites of venous

nerve. A, central diagram.
Anterior view. The veins that
commonly compress the
trigeminal nerve are tributaries of
the superior petrosal vein. The
tributaries that converge on and
may compress the nerve are the
transverse pontine and
pontotrigeminal veins and the
veins of the cerebellopontine
fissure and middle cerebellar
peduncle. The transverse pontine
veins course transversely across
the pons. The vein of the middle
cerebellar peduncle arises in the
region of the facial and
vestibulocochlear nerves and
ascends on the pons. The vein of
the cerebellopontine fissure arises
along the cleft between the pons
and the cerebellum and ascends
behind the trigeminal nerve. The
pontotrigeminal vein arises on the
upper pons and passes above the
trigeminal nerve. B, a transverse
pontine vein compresses the
lateral side of the nerve and joins
the veins of the middle cerebellar
peduncle and cerebellopontine
fissure to empty into a superior
petrosal vein. C, the medial side
of the nerve is compressed by a
tortuous transverse pontine vein.
D, the lateral side of the nerve is
compressed by the junction of
the transverse pontine vein with
the veins of the middle cerebellar
peduncle and the
cerebellopontine fissure. E, the
nerve is compressed on the
medial side by the vein of the middle cerebellar peduncle and on the lateral side by the vein of the cerebellopontine fissure.
F, the lateral side of the nerve is compressed by the vein of the cerebellopontine fissure. (From, Rhoton AL Jr: Microsurgical
anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal Neuralgia.
Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].) Cer., cerebellar; Cer. Pon., cerebellopontine; Fiss., fissure; Mid.,
middle; Ped., peduncle; Pon., pontine; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein.
with the approach described herein, only the bone in the prameatal tubercle often requires that the superior petrosal
region of the suprameatal tubercle is removed. The drilling on veins be obliterated and divided. This allows the drilling to be
the lateral side of the tubercle should avoid the posterior directed medially along the lateral and lower margin of the
semicircular canal and common crus of the posterior and porus of Meckel’s cave. The dura along the lower and lateral
superior canals if hearing is to be preserved, but on the medial margin of the porus of Meckel’s cave and the tentorium lateral to
side, it can extend through the petrous apex into the side of the porus trigeminus can then be opened to expose the trigem-
the clivus. inal nerve in the posterior part of Meckel’s cave and the middle
Often, the subarcuate branch of the AICA must be obliter- cranial fossa. Care is taken to protect the trochlear nerve if the
ated to access the suprameatal tubercle. Accessing the su- tentorial incision is to be extended through the free edge.

FIGURE 4.14. Sites of venous

nerve as seen through a
retrosigmoid craniotomy. A, the
insert shows the site of the scalp
incision (solid line) and the
craniotomy (interrupted line). The
cerebellum has been elevated to
expose the junction of the
trigeminal nerve with the pons.
The superior petrosal veins empty
into the superior petrosal sinus.
The trochlear nerve is at the
superior margin and the facial and
vestibulocochlear nerves are at
the lower margin of the exposure.
The craniotomy exposes the
junction of the sigmoid and
transverse sinuses. The trigeminal
nerve is compressed by the
junction of a transverse pontine
vein and the vein of the middle
cerebellar peduncle with the
superior petrosal vein. The vein of
the cerebellopontine fissure
ascends behind the nerve and the
pontotrigeminal vein passes above
the nerve. B, the trigeminal nerve
is compressed on its medial side
by a transverse pontine vein and
on its lateral side by the vein of
the middle cerebellar peduncle. C,
the lateral side of the nerve is
compressed by a transverse
pontine vein. D, the medial side
of the nerve is compressed by the
junction of a transverse pontine
vein with the veins of the middle
cerebellar peduncle and
cerebellopontine fissure. E, the
lateral side of the nerve is
compressed by the junction of the transverse pontine vein with the veins of the middle cerebellar peduncle and
cerebellopontine fissure. F, the medial side of the nerve is compressed by the vein of the middle cerebellar peduncle. G, the
lateral side of the nerve is compressed by the vein of the cerebellopontine fissure. (From, Rhoton AL Jr: Microsurgical
anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal Neuralgia.
Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].) Cer., cerebellar; Cer. Pon., cerebellopontine; Fiss., fissure; Mid.,
middle; Ped., peduncle; Pon., pontine; Sig., sigmoid; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein.
MIDDLE NEUROVASCULAR COMPLEX surface of the cerebellum. Operations directed to the middle
complex are for the removal of acoustic neuromas and other
The middle complex includes the AICA, pons, middle cer- tumors and for the relief of hemifacial spasm. The considerations
ebellar peduncle, cerebellopontine fissure, petrosal surface of related to acoustic neuromas will be dealt with first.
the cerebellum, and the abducens, facial, and vestibuloco-
chlear nerves (Figs. 4.1 and 4.17). The AICA arises at the
pontine level and courses in relationship to the abducens, Anatomy of acoustic neuromas
facial, and vestibulocochlear nerves to reach the surface of the Acoustic neuromas, as they expand, may involve a majority
middle cerebellar peduncle, where it courses along the cer- of the cranial nerves, cerebellar arteries, and parts of the
ebellopontine fissure and terminates by supplying the petrosal brainstem. On the lateral side, in the meatus, they com-

S106 Rhoton
FIGURE 4.15. Suprameatal

variant of the retrosigmoid
approach. A, the cerebellum
has been elevated to expose
the nerves in the
cerebellopontine angle. A
large petrosal vein blocks
access to the suprameatal
area. B, the superior petrosal
vein has been divided to
expose the suprameatal
tubercle located above the
porus of the internal acoustic
meatus and lateral to the
trigeminal nerve. C, the dura
over the suprameatal
tubercle has been removed
in preparation for drilling.
D, removing the
suprameatal bone, including
the tubercle, extends the
exposure along the posterior
trigeminal root by
approximately 1 cm and
increases access to the front
of the brainstem and clivus.
A.I.C.A., anteroinferior
cerebellar artery; CN, cranial
nerve; Flocc., flocculus; Pet.,
petrosal; S.C.A., superior
cerebellar artery;
Sup., superior; Suprameat.,
suprameatal; V., vein.
monly expand by enlarging the meatus, but infrequently of the facial nerve distal to the tumor at the lateral part of
erode into the vestibule and cochlea. On the medial side, the internal acoustic canal. Less attention has been directed
they compress the pons, medulla, and cerebellum. An un- to identification at the brainstem on the medial side of the
derstanding of microsurgical anatomy is especially impor- tumor. These anatomic considerations are divided into sec-
tant in preserving the facial and adjacent cranial nerves, tions dealing with the relationships at the lateral end of the
which are the neural structures at greatest risk during tumor in the meatus and those on the medial end of the tumor
acoustic neuroma removal. A widely accepted operative at the brainstem, which follow in this chapter (33, 35, 37).
precept is that a nerve involved by a tumor should be
identified proximal or distal to the tumor, where its dis- Meatal relationships
placement and distortion is the least, before the tumor is
removed from the involved segment of the nerve. Consid- The nerves in the lateral part of the internal acoustic meatus
erable attention has been directed to the early identification are the facial, cochlear, and inferior and superior vestibular

FIGURE 4.16. Suprameatal approach to the posterior part of Meckel’s cave. A, right cerebellopontine angle. The suprameatal
tubercle is located above the porus of the internal meatus. A large inferior petrosal vein passes behind the vagus nerve. B, the
suprameatal tubercle has been removed and the dura extending anteriorly toward Meckel’s cave has been opened to provide
1 cm of additional exposure along the posterior trigeminal root. In addition, access to the side of the clivus is improved. C,
superior view of the suprameatal tubercle. The tubercle is located lateral to the trigeminal nerve, below the superior petrosal
vein, and above the internal acoustic meatus and the facial and vestibulocochlear nerves. D, lateral view after removal of the
suprameatal tubercle and the segment of the superior petrosal sinus passing above the porus of Meckel’s cave. This improves
the length of the posterior trigeminal root exposed by 8 to 10 mm, compared with the exposure before drilling the tubercle.
Bridg., bridging; CN, cranial nerve; Flocc., flocculus; P.C.A., posterior cerebral artery; Pet., petrosal; P.I.C.A., posteroinferior
cerebellar artery; S.C.A., superior cerebellar artery; Sup., superior; Suprameat., suprameatal; Tent., tentorium; V., vein.
nerves (Figs. 4.1 and 4.18) (30, 38). The position of the nerves The facial nerve is anterior to the superior vestibular nerve
is most constant in the lateral portion of the meatus, which is and is separated from it at the lateral end of the meatus by a
divided into a superior and an inferior portion by a horizontal vertical ridge of bone, called the vertical crest. The vertical
ridge, called either the transverse or falciform crest. The facial crest is also called “Bill’s bar” in recognition of William
and the superior vestibular nerves are superior to the crest. House’s role in focusing on the importance of this crest in

S108 Rhoton
FIGURE 4.17. Left

retrosigmoid exposure. A, the
cerebellum has been
elevated. A large AICA loops
into the porus of the internal
meatus. The junction of the
facial nerve with the
brainstem is located below
and slightly in front of the
vestibulocochlear nerve. B,
the vestibulocochlear nerve
has been elevated to provide
additional exposure of the
facial nerve. C, choroid
plexus protrudes from the
foramen of Luschka into the
cerebellopontine angle
behind the glossopharyngeal
and vagus nerves. A nerve
hook has been placed inside
the rhomboid lip, a pouch of
neural tissue attached along
the anterior margin of the
lateral recess and extending
laterally behind the
glossopharyngeal and vagus
nerves. D, enlarged view of
the rhomboid lip. A.I.C.A.,
anteroinferior cerebellar
artery; Chor. Plex., choroid
plexus; CN, cranial nerve;
Flocc., flocculus; Pet.,
petrosal; Sup., superior; V.,
vein.
identifying the facial nerve in the lateral end of the canal (16). and middle fossa approaches are reviewed in the chapter on
The cochlear and inferior vestibular nerves run below the the temporal bone.
transverse crest with the cochlear nerve located anteriorly. Retrosigmoid approach. The retrosigmoid approach to the
Thus, the lateral meatus can be considered to be divided into meatus is directed through a vertical scalp incision that
four portions, with the facial nerve being anterosuperior, the crosses the asterion. A burr hole is placed below the asterion
cochlear nerve anteroinferior, the superior vestibular nerve and a craniotomy is performed exposing the lower margin of
posteroinferior. The anatomy of the region offers the oppor- the transverse sinus superiorly, the posterior margin of the
tunity for three basic approaches to the tumor in the meatus sigmoid sinus laterally, and the inferior portion of the squa-
and cerebellopontine angle. One is directed through the mid- mous part of the occipital bone inferiorly. The intradural
dle cranial fossa and the roof of the meatus. Another is di- exposure is directed down the plane between the posterior
rected through the labyrinth and posterior surface of the face of the temporal bone and the petrosal cerebellar surface
temporal bone. The third is directed through the posterior (Figs. 4.1, 4.17, and 4.18) (35–37). The petrosal cerebellar sur-
cranial fossa and posterior meatal lip. The translabyrinthine face usually relaxes away from the temporal bone after the

FIGURE 4.18. A–F. Left cerebellopontine angle. A, the AICA passes between the facial and vestibulocochlear nerves. A dural sep-
tum separates the glossopharyngeal and vagus nerves at the jugular foramen. B, the vestibulocochlear nerve and the flocculus have
been elevated to expose the junction of the facial nerve with the brainstem. In the retrosigmoid approach, the facial nerve junction
with the brainstem can be exposed below the vestibulocochlear nerve. C, the posterior wall of the internal acoustic meatus has
been removed. The cleavage plane between the superior and inferior vestibular nerves is especially prominent. D, the dura lining
the internal acoustic meatus has been opened. The transverse crest separates the superior vestibular and facial nerves above
from the inferior vestibular and cochlear nerves below. E, enlarged view of the nerves within the meatus. The cochlear nerve is
partially hidden anterior to the inferior vestibular nerve. F, the cleavage plane between the superior and inferior vestibular and
cochlear nerves has been started laterally and extended medially to expose the individual nerve bundles. A., artery; A.I.C.A.,
anteroinferior cerebellar artery; Arc., arcuate; CN, cranial nerve; Coch., cochlear; Emin., eminence; Endolymph., endolymphatic;
Flocc., flocculus; Inf., inferior; Intermed., intermedius; Jug., jugular; Labyr., labyrinth; N., nerve; Nerv., nervus; P.I.C.A., posteroinfe-
rior cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Subarc., subarcuate; Sup., superior; Trans., transverse;
Vert., vertebral; Vest., vestibular.

S110 Rhoton
FIGURE 4.18. G–J. Left cerebellopontine angle. G, the vertical and transverse crest are exposed at the meatal fundus. The
common crus and adjacent part of the superior and posterior canals have been exposed. The endolymphatic duct and sac are
situated inferolateral to the internal acoustic meatus. H, another dissection showing the relationships of the junction of the
posterior and superior canals and common crus to the meatus. The endolymphatic duct extends downward and backward
from the vestibule and opens into the endolymphatic sac, which sits under the dura in the area below and lateral to the
meatus. The jugular bulb can be seen through the bone medial to the endolymphatic sac. I, fundus of the left internal acous-
tic meatus. The transverse crest separates the superior vestibular area and facial canal above from the inferior vestibular and
cochlear areas below. The vertical crest separates the superior vestibular area from the entrance into the facial canal. The
multiple cochlear nerve filaments penetrating the tiny openings in the lamina cribrosa at the meatal fundus can easily be torn
with traction on the nerve from lateral to medial, therefore, we try to direct the strokes of dissection from medial to lateral
when there is an opportunity to preserve hearing. J, closure after removing the posterior wall of the internal acoustic meatus. Bone
wax on a microdissector is carefully placed into open air cells in the posterior meatal lip and then a pledget of crushed subcutane-
ous abdominal fat is laid over the drilled meatal area. This has prevented cerebrospinal fluid leaks after removal of the posterior
wall of the internal acoustic meatus in more than 200 consecutive operations for acoustic neuroma by the author.
arachnoid membrane over the cisterna magna has been The posterior semicircular canal and its common crus with
opened and the cerebrospinal fluid allowed to escape. When the superior canal, both of which are situated just lateral to the
removing the posterior meatal wall, it often is necessary to posterior meatal lip, should be preserved when removing
sacrifice the subarcuate artery because it passes through the the posterior meatal wall if there is the possibility of preserv-
dura on the posterior meatal wall to reach the subarcuate ing hearing, since hearing may be lost if damage occurs (Fig.
fossa (Figs. 4.1 and 4.18) (25). This artery usually has a suffi- 4.18). Care also is required to avoid injury to the vestibular
ciently long stem that its obliteration does not risk damage to aqueduct, which is situated inferolateral to the meatal lip,
the AICA from which it arises. In a few cases, however, the and the endolymphatic sac, which expands under the dura on
subarcuate artery and the segment of the AICA from which it the posterior surface of the temporal bone inferolateral to the
arises will be incorporated into the dura covering the subar- meatal porus (Fig. 4.18). The endolymphatic sac may be en-
cuate fossa. In this case, the dura and the artery will have to tered in removing the dura from the posterior meatal lip.
be separated together from the posterior meatal lip wall in There is little danger of encountering the cochlear canaliculus,
preparation for opening the meatus. which has a more medial course below the internal auditory

FIGURE 4.19. View of right internal acoustic meatus with the posterior lip removed to show variable direction of facial
nerve displacement by acoustic neuroma. A, normal neural relationships with the eighth nerve dividing into its three parts in
the lateral meatus. The facial and superior vestibular nerves are above the transverse crest and the cochlear and inferior ves-
tibular nerves are below. The facial nerve occupies the anterosuperior quadrant of the lateral meatus. B, the facial nerve is
displaced directly anteriorly. This is a frequent direction of displacement with acoustic neuroma. C, another frequent direc-
tion of displacement of the facial nerve is anterior and superior. D, the facial nerve is displaced anteriorly and inferiorly by
tumor, which erodes the superior wall of the meatus above the nerves and grows into the area above the nerves, displacing
them inferiorly. (From, Rhoton AL Jr: Microsurgery of the Internal Acoustic Meatus. Surg Neurol 2:311–318, 1974 [32].)
canal. An unusually high projection of the jugular bulb into tibulocochlear nerve should be directed from medial to lateral
the posterior wall of the meatus presents an anomaly that may rather than from lateral to medial, because traction medially
block access to the posterior meatal lip. Mastoid air cells may tear the tiny filaments of the cochlear nerve at the site
commonly are encountered in the posterior meatal lip. where these filaments penetrate the lateral end of the meatus
After removing the posterior wall of the meatus, the dura to enter the modiolus of the cochlea (Fig. 4.18).
lining the meatus is opened to expose its contents (Figs. 4.18
and 4.19). The facial nerve is identified near the origin of the Brainstem relationships
facial canal at the anterosuperior quadrant of the meatus A consistent set of neural, arterial, and venous relationships
rather than in a more medial location where the direction of at the brainstem facilitates the identification of the nerves on the
displacement is variable. If the tumor extends into the vesti- medial side of an acoustic neuroma (Figs. 4.20-4.22) (33, 37, 38).
bule, the latter can easily be exposed by drilling and removing Neural relationships. The landmarks on the medial or
the posterior wall of the vestibule lateral to the meatal fundus. brainstem side of structures that are helpful in guiding the
The strokes of the fine dissecting instruments along the ves- surgeon to the junction of the facial nerve with the brainstem

S112 Rhoton
FIGURE 4.20. Neurovascular relation-

ships on the brainstem side of an acous-
tic neuroma. Anterolateral view of the
right cerebellopontine angle. A, neural
relationships. The facial and vestibuloco-
chlear nerves arise from the brainstem
near the lateral end of the pontomedul-
lary sulcus, anterosuperior to the choroid
plexus protruding from the foramen of
Luschka, anterior to the flocculus, rostral
to a line drawn along the junction of the
rootlets of the glossopharyngeal, vagus,
and accessory nerves with the brainstem,
and slightly posterior to the rostral pole
of the inferior olive. The cerebellopon-
tine fissure formed by the cerebellum
wrapping around the lateral side of the
pons and middle cerebellar peduncle has
a superior limb that passes above the
trigeminal nerve and an inferior limb
that extends below the foramen of Lus-
chka. The cerebellomedullary fissure,
which extends superiorly between the
medulla and cerebellum, communicates
in the region of the foramen of Luschka
with the cerebellopontine fissure. B, arte-
rial relationships. The AICA arises from
the basilar artery and divides into rostral
and caudal trunks. The rostral trunk,
which is usually the larger of the two
trunks, courses below the facial and ves-
tibulocochlear nerves, and then above
the flocculus to reach the surface of the
middle cerebellar peduncle. The PICA
arises from the vertebral artery and
passes first between the hypoglossal
rootlets, and then between the vagus
and accessory nerves on its way to the
cerebellar hemisphere. The SCA passes
above the trigeminal nerve. The cerebel-
lar arteries give rise to hemispheric
branches. C, venous relationships. The
veins that converge on the junction of the facial and vestibulocochlear nerves with the brainstem are the veins of the pontomedullary
sulcus, cerebellomedullary fissure, middle cerebellar peduncle, and the retro-olivary and lateral medullary veins. The vein of the cerebel-
lopontine fissure, which passes above the flocculus on the middle cerebellar peduncle, is formed by the anterior hemispheric veins that
arise on the cerebellum. Transverse pontine and transverse medullary veins cross the pons and medulla. The median anterior medullary
and median anterior pontomesencephalic veins ascend on the anterior surface of the medulla and pons. The veins of the middle cerebel-
lar peduncle and the cerebellopontine fissure and a transverse pontine vein join to form a superior petrosal vein, which empties into the
superior petrosal sinus. A bridging vein passes below the vagal rootlets toward the jugular foramen. D, neurovascular relationships of an
acoustic neuroma. The tumor arises from the vestibulocochlear nerve and displaces the facial nerve anteriorly, the trigeminal nerve supe-
riorly, and the vagus and glossopharyngeal nerves inferiorly. The facial nerve, even though displaced by the tumor, enters the brainstem
along the lateral margin of the pontomedullary sulcus, rostral to the glossopharyngeal and vagus nerves, anterior to the flocculus, and
rostral to the choroid plexus protruding from the foramen of Luschka. The rostral trunk of the AICA, after passing below the tumor,
returns to the surface of the middle cerebellar peduncle above the flocculus. The veins displaced around the medial side of the tumor are
the veins of the middle cerebellar peduncle, cerebellomedullary fissure, cerebellopontine fissure, and pontomedullary sulcus, and the
retro-olivary and lateral medullary veins. (From, Rhoton AL Jr: Microsurgical anatomy of the brainstem surface facing an acoustic neu-
roma. Surg Neurol 25:326–339, 1986 [33].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Br., bridging;
Ca., caudal; Cer., cerebellar; Cer. Pon., cerebellopontine; Chor., choroid; F., foramen; Fiss., fissure; Hem., hemispheric; Lat., lateral; Med.,
medial, medullary; Mid., middle; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary;
Pon. Mes., pontomesencephalic; Ro., rostral; S.C.A., superior cerebellar artery; Sulc., sulcus; Sup., superior; Tr., trunk; Trans., transverse;
V., vein; Vert., vertebral.

FIGURE 4.21. Relationship of the

foramen of Luschka and the lateral
recess of the fourth ventricle to
the junction of the facial and
vestibulocochlear nerves with the
brainstem, as seen through a
suboccipital craniotomy. A, the
orientation, skin incision (solid
line), and craniotomy (interrupted
line) are shown in the insert. The
foramen of Luschka opens into the
cerebellopontine angle behind the
nerves. The choroid plexus
protrudes from the foramen of
Luschka, slightly below and behind
nerves, and behind to the
nerves. The flocculus protrudes
into the cerebellopontine angle
above the foramen of Luschka. The
accessory nerve arises below the
vagus nerve. The hypoglossal
rootlets arise ventral to the olive.
The trigeminal nerve crosses in the
upper part of the exposure. B, the
right cerebellar tonsil has been
removed by dividing the tonsillar
peduncle to show the relationship
of the lateral recess to the facial
and vestibulocochlear nerves. The
flocculus and choroid plexus
protrude in the cerebellopontine
angle behind the junction of the
facial and vestibulocochlear nerves
with the brainstem. The inferior
medullary velum stretches from
the lateral side of the vermis to the
flocculus and is all that remains of
the connection between the
flocculus and the nodulus, which form the flocculonodular lobe of the cerebellum. The inferior medullary velum stretches
laterally to form the peduncle of the flocculus. The tela choroidea forms the caudal part of the roof of the fourth ventricle
and has the choroid plexus attached to its inner surface. The facial and vestibulocochlear nerves enter the brainstem at the
lateral end of the pontomedullary sulcus. C, the tela choroidea has been opened, but the choroid plexus, which arises on the
inner surface of the tela in the fourth ventricle, has been preserved. The fringelike choroid plexus extends through the
foramen of Luschka slightly below and behind the junction of the facial and vestibulocochlear nerves with the brainstem. The
inferior cerebellar peduncle ascends on the dorsolateral margin of the medulla. D, relationships of an acoustic neuroma. The
facial nerve is displaced anteriorly and superiorly in the cerebellopontine angle and enters the brainstem at the lateral end of
the pontomedullary sulcus, anterosuperior to the choroid plexus protruding from the foramen of Luschka, and near where the
flocculus is attached along the margin of the lateral recess. The tumor displaces the trigeminal nerve upward and the
glossopharyngeal and vagus nerves downward. The AICA gives rise to a subarcuate artery, which enters the subarcuate fossa
in the posterior wall of the internal acoustic meatus and bifurcates into a rostral and a caudal trunk. The rostral trunk
courses above the flocculus to reach the surface of the middle cerebellar peduncle. (From, Rhoton AL Jr: Microsurgical
anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol 25:326–339, 1986 [33].) Br., bridging; Ca.,
caudal; Cer. Med., cerebellomedullary; Cer. Pon., cerebellopontine; Chor. choroid; F., foramen; Fiss., fissure; Inf., inferior;
Jug., jugular; Lat., lateral; Med., medial, medullary; Mid., middle; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery;
Pon. Med., pontomedullary; Ro., rostral; Subarc., subarcuate; Sulc., sulcus; Tr., trunk; V., vein; Vel., velum.

S114 Rhoton
FIGURE 4.22. Neurovascular rela-

tionships on the brainstem side of an
acoustic neuroma. Anterosuperior
views. A, neural relationships. The
cerebrum and tentorium cerebelli
have been removed, and the trigemi-
nal, trochlear, and oculomotor nerves
have been divided to allow the brain-
stem to be displaced posteriorly to
expose the cerebellopontine angle
from above. The facial and vestibulo-
cochlear nerves arise at the lateral
end of the pontomedullary sulcus
anterior to the flocculus, rostral to the
glossopharyngeal, vagus, and acces-
sory nerves, and anterosuperior to the
choroid plexus protruding from the
foramen of Luschka. The cerebel-
lopontine fissure, formed where the
cerebellum wraps around the lateral
side of the pons and middle cerebellar
peduncle, has superior and inferior
limbs. The foramen of Luschka opens
into the inferior limb near the facial
and vestibulocochlear nerves. B, arte-
rial relationships. The AICA arises
from the basilar artery, passes below
nerves, gives rise to the subarcuate
artery, and divides into a rostral and a
caudal trunk. The rostral trunk passes
above the flocculus to course on the
middle cerebellar peduncle, and the
caudal trunk supplies the area below the flocculus. C, venous relationships. The veins converging on the junction of the facial
nerve with the brainstem are the lateral medullary and retro-olivary veins, and the veins of the pontomedullary sulcus, cerebel-
lomedullary fissure, and middle cerebellar peduncle. The median anterior pontomesencephalic vein ascends on the anterior surface
of the brainstem, and the transverse pontine and transverse medullary veins cross the pons and medulla. The vein of the cerebel-
lopontine fissure passes above the flocculus. The transverse pontine vein and the veins of the middle cerebellar peduncle and cer-
ebellopontine fissure join to form one of the superior petrosal veins that empty into the superior petrosal sinus. A bridging vein
passes from the side of the brainstem to the jugular foramen. The anterolateral marginal vein crosses the anterolateral margin of
the cerebellum. The vein of the pontomesencephalic sulcus courses in the pontomesencephalic sulcus below the oculomotor nerve.
D, neurovascular relationships of an acoustic neuroma. The tumor arises from the vestibulocochlear nerve and displaces the facial
nerve anteriorly, the trigeminal nerve superiorly, and the glossopharyngeal and vagus nerves inferiorly. The vestibulocochlear nerve
disappears into the tumor. The facial nerve enters the brainstem along the lateral margin of the pontomedullary sulcus, rostral to
the glossopharyngeal nerve, anterior to the flocculus, and rostral to the choroid plexus protruding from the foramen of Luschka.
The AICA is usually displaced around the lower margin of the tumor. The veins displaced around the medial side of the tumor are
the veins of the pontomedullary sulcus, middle cerebellar peduncle, and cerebellomedullary fissure, and the lateral medullary and
retro-olivary veins. (From, Rhoton AL Jr: Microsurgical anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol
25:326–339, 1986 [33].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Br., bridging; Ca., caudal;
Cer., cerebellar; Cer. Pon., cerebellopontine; Chor., choroid; F., foramen; Fiss., fissure; Inf., inferior; Jug., jugular; Lat., lateral;
Marg., marginal; Med., medial, medullary; Mid., middle; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Pon., pontine;
Pon. Med., pontomedullary; Pon. Mes., pontomesencephalic; Ro., rostral; S.C.A., superior cerebellar artery; Subarc., subarcuate;
Sulc., sulcus; Sup., superior; Tr., trunk; Trans., transverse; V., vein; Vert., vertebral.
are the pontomedullary sulcus; the junction of the glossopha- lateral end of the pontomedullary sulcus 1 to 2 mm anterior to
ryngeal, vagus, and spinal accessory nerves with the medulla; the point at which the vestibulocochlear nerve joins the brain-
the foramen of Luschka and its choroid plexus; and the floc- stem at the lateral end of the sulcus. The interval between the
culus. The facial nerve arises from the brainstem near the vestibulocochlear and facial nerves is greatest at the level of

the pontomedullary sulcus and decreases as these nerves with resulting lateral pontine, tegmental, and medullary in-
approach the meatus. farction in the area supplied by the AICA and death. He noted
The facial nerve enjoys a consistent relationship to the that the blood pressure rose at or near the time of occlusion of
junction of the glossopharyngeal, vagus, and spinal accessory the artery, although the hypertension often subsided by the
nerves with the medulla (Figs. 4.20-4.22). The facial nerve end of the operation. These tumors may also displace the
arises 2 to 3 mm above the most rostral rootlet contributing to PICA and insinuate themselves between the basilar artery and
these nerves. A helpful way of visualizing the point where the the pons, stretching the perforating branches of the basilar ar-
facial nerve will exit from the brain stern, even when dis- tery. The labyrinthine, recurrent perforating, and subarcuate
placed by a tumor, is to project an imaginary line along the branches arise from the AICA near the facial and vestibulo-
medullary junction of the rootlets forming the glossopharyn- cochlear nerves and are frequently stretched around a cerebel-
geal, vagus, and spinal accessory nerves upward through the lopontine angle tumor.
pontomedullary junction. This line, at a point 2 to 3 mm above Venous relationships. The veins on the side of the brain-
the junction of the glossopharyngeal nerve with the medulla, stem that have a predictable relationship to the facial and
will pass through the pontomedullary junction at the site vestibulocochlear nerves are the vein of the pontomedullary
where the facial nerve exits from the brainstem. The filaments sulcus, the veins of the cerebellomedullary fissure, middle
of the nervus intermedius also are stretched around an acous- cerebellar peduncle, and cerebellopontine fissure (Figs. 4.20-
tic neuroma. 4.22) (26). The identification of any of these veins during the
The structures related to the lateral recess of the fourth removal of the tumor makes it easier to identify the site of
ventricle that have a consistent relationship to the facial and the junction of the facial and vestibulocochlear nerves with
vestibulocochlear nerves are the foramen of Luschka and its the brainstem. The exposure of an acoustic neuroma in the
choroid plexus, and the flocculus (Figs. 4.20-4.22) (10, 27). The central part of the cerebellopontine angle near the lateral
foramen of Luschka is situated at the lateral margin of the recess usually can be completed without sacrificing a bridging
pontomedullary sulcus, just behind the junction of the glos- vein. If a vein is obliterated during acoustic tumor removal, it
sopharyngeal nerve with the brainstem, and immediately pos- is usually one of the superior petrosal veins, which is sacri-
teroinferior to the junction of the facial and vestibulocochlear ficed near the superior pole of the tumor during the later
nerves with the brainstem. The foramen of Luschka is infre- stages of the removal of a large tumor. Small acoustic neuromas
quently well visualized. A consistently identifiable tuft of cho- usually are removed without sacrificing a petrosal vein. The
roid plexus, however, hangs out of the foramen of Luschka and
largest vein encountered around the superior pole of an
sits on the posterior surface of the glossopharyngeal and vagus
acoustic neuroma is the vein of the cerebellopontine fissure.
nerves just inferior to the junction of the facial and vestibuloco-
chlear nerves with the brainstem. Another structure related to
the lateral recess, the flocculus, projects from the margin of the Summary: Anatomy of acoustic neuromas
lateral recess and foramen of Luschka into the cerebellopontine
angle, just posterior to where the facial and vestibulocochlear Because acoustic neuromas most frequently arise in the
nerves join the pontomedullary sulcus. posteriorly placed vestibular nerves, they usually displace
Arterial relationships. The arteries crossing the cerebel- the facial and cochlear nerves anteriorly (Figs. 4.19 and 4.24).
lopontine angle, especially the AICA, enjoy a consistent rela- The facial nerve is stretched around the anterior half of the
tionship to the facial and vestibulocochlear nerves, the fora- tumor capsule. Variability in the direction of the growth of
men of Luschka, and the flocculus as described elsewhere in the tumor arising from the vestibular nerves may result in the
this volume (13, 14, 24, 25). In a previous study, the author’s facial nerve being displaced, not only directly anteriorly, but
group found that the AICA formed a loop that reached the also anterosuperiorly or anteroinferiorly. The nerve infre-
porus or protruded into the canal in 54% of the cases (25). quently is found on the posterior surface of the tumor. Be-
When opening the meatus by the middle fossa, translabyrin- cause the facial nerve always enters the facial canal at the
thine, or posterior approaches, care is required to avoid injury anterosuperior quadrant of the meatal fundus, it usually is
to the AICA if it is located at or protrudes through the porus. easiest to locate it here, rather than at a more medial location
In most cases, the AICA passes below the facial and ves- where the degree of displacement of the nerve is more vari-
tibulocochlear nerves as it encircles the brainstem, but it able. The cochlear nerve also lies anterior to the vestibular
also may pass above or between these nerves in its course nerve and is stretched most frequently around the anterior
around the brainstem (Fig. 4.23). In the most common case, in half of the tumor. The strokes of the fine dissecting instru-
which the artery passes below the nerves, the tumor would ments used in removing the tumor should be directed along
displace the artery inferiorly. If the artery courses between the the vestibulocochlear nerve from medial to lateral rather than
facial and vestibulocochlear nerves, a tumor arising in the latter from lateral to medial, because traction medially may tear the
nerve will displace the artery forward. Tumor growth would tiny filaments of the cochlear nerve at the site where these
displace the artery superiorly if it passes above the nerves. filaments penetrate the lateral end of the meatus to enter the
Atkinson pointed out that those cases of acoustic neuroma cochlea (Figs. 4.18 and 4.25).
appearing at necropsy after operation frequently had occlu- The operation for a cerebellopontine angle tumor should be
sion of the AICA (3). In three cases presented by Atkinson, an planned so that the tumor surface is allowed to settle away
arterial branch coursing over the tumor capsule was ligated from the neural tissue rather than the neural structures being

S116 Rhoton
FIGURE 4.23. Posterior views

of the direction of
displacement of the AICA
around an acoustic neuroma.
Top left, the insert shows the
direction of view. Both the
premeatal and the postmeatal
segments are in their most
common locations around the
lower margin of the tumor.
The premeatal segment
approaches the meatus from
anteroinferior, and the
postmeatal segment passes
posteroinferior to the tumor.
The SCA and the trigeminal
nerve are above the tumor,
and the PICA and the
spinal accessory nerves are
below the tumor. The choroid
plexus protrudes into the
cerebellopontine angle medial
to the tumor. The posterior
wall of the internal acoustic
canal has been removed to
expose the transverse crest and
the superior vestibular and
inferior vestibular nerves. The
vestibular nerves disappear
into the tumor; however, the
cochlear and facial nerves are
displaced around the anterior
margin of the tumor. A
subarcuate artery arises from
the premeatal segment, and a
recurrent perforating artery
arises from the postmeatal
segment. Center right, in a less
common pattern of
displacement of the AICA, the
premeatal and postmeatal
segments are above the tumor.
The internal auditory arteries arise from the meatal segment. Bottom left, both the premeatal and the postmeatal segments
are displaced anteriorly to the tumor. This occurs if the AICA courses between the vestibulocochlear and facial nerves. The
tumor arises in the vestibular nerves, and tumor growth displaces both the premeatal and the postmeatal segments anteriorly.
(From, Martin RG, Grant JL, Peace DA, Theiss C, Rhoton AL Jr: Microsurgical relationships of the anterior inferior cerebellar
artery and the facial-vestibulocochlear nerve complex. Neurosurgery 6:483–507, 1980 [25].) Ch. Pl., choroid plexus; Co.,
cochlear; I.A.A., internal auditory (labyrinthine) artery; I.V., inferior vestibular; Mea., meatal; P.I.C.A., posteroinferior
cerebellar artery; Post., posterior; R.P.A., recurrent perforating artery; S.A., subarcuate artery; S.V., superior vestibular;
S.C.A., superior cerebellar artery; Seg., segment; Tent., tentorium.
retracted away from the tumor (Fig. 4.25). No attempt is made for the tumor appearing to be tightly adherent to the neural
to see the whole tumor upon initial exposure. The surface of structures is not adhesions between the capsule and sur-
the tumor then is opened and the intracapsular contents are rounding tissue, but, rather, the residual tumor within the
removed. As the intracapsular contents are evacuated, the capsule wedging the tumor into position. As the intracapsular
tumor shifts laterally, allowing more of the tumor to be re- contents are removed, the tumor capsule folds laterally, re-
moved through the small exposure. The most common reason vealing the structures on the brainstem side of the tumor.

FIGURE 4.24. Neurovascular

relationships on the brainstem side
of an acoustic neuroma. Posterior
view through a retrosigmoid
craniotomy. A, neural relationships.
The orientation, skin incision (solid
line), and craniotomy site
(interrupted line) are shown in the
insert. The retractor is on the
petrosal surface of the cerebellum.
The facial and vestibulocochlear
nerves arise at the lateral end of the
pontomedullary sulcus, anterior to
the flocculus, rostral to the
accessory nerves, and anterosuperior
to the choroid plexus protruding
from the foramen of Luschka. The
cerebellopontine fissure, formed
where the cerebellum wraps around
the lateral side of the pons and
middle cerebellar peduncle, has
superior and inferior limbs. B,
arterial relationships. The AICA
arises from the basilar artery and
divides into a rostral trunk, which
passes above the flocculus to reach
the surface of the middle cerebellar
peduncle, and a caudal trunk, which
supplies the area below the
flocculus. The PICA arises from the
vertebral artery and passes dorsally
between the vagus and accessory
nerves. The SCA courses above the
trigeminal nerve. C, venous
relationships. The veins that join
near the junction of the facial and
brainstem are the lateral medullary
veins and the veins of the
cerebellomedullary fissure,
pontomedullary sulcus, and middle
cerebellar peduncle. The vein of the cerebellopontine fissure passes above the flocculus along the superior limb of the cerebel-
lopontine fissure and joins the vein of the middle cerebellar peduncle and a transverse pontine vein to form a superior petrosal
vein, which empties into the superior petrosal sinus. A bridging vein passes behind the vagus nerve. The lateral anterior pontomes-
encephalic vein ascends on the pons. D, neurovascular relationships of an acoustic neuroma. The tumor arises from the vestibulo-
cochlear nerve and displaces the facial nerve anteriorly, the trigeminal nerve superiorly, and the glossopharyngeal and vagus nerves
inferiorly. The vestibulocochlear nerve disappears into the tumor. The facial nerve enters the brainstem at the lateral margin of the
pontomedullary sulcus anterior to the flocculus and rostral to the choroid plexus protruding from the foramen of Luschka. The ros-
tral trunk of the AICA courses below the tumor and above the flocculus to reach the surface of the middle cerebellar peduncle.
The veins displaced around the medial side of the tumor are the lateral medullary veins and the veins of the middle cerebellar pe-
duncle, cerebellomedullary fissure, and pontomedullary sulcus. The vein of the cerebellopontine fissure passes above the tumor. A
recurrent perforating branch of the AICA passes across the tumor and supplies the brainstem. (From, Rhoton AL Jr: Microsurgical
anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol 25:326–339, 1986 [33].) A., artery; A.I.C.A., anteroinfe-
rior cerebellar artery; Ant., anterior; Bas., basilar; Br., bridging; Ca., caudal; Cer., cerebellar; Cer. Pon., cerebellopontine; Chor.,
choroid; F., foramen; Fiss., fissure; Lat., lateral; Med., medial, medulla; Mid., middle; Ped., peduncle; Perf., perforating; P.I.C.A.,
posteroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary; Rec., recurrent; Ro., rostral; S.C.A., superior cerebellar
artery; Sulc., sulcus; Sup., superior; Tr., trunk; V., vein; Vert., vertebral.

S118 Rhoton
arachnoid space and the mastoid air cells that will require
careful closure to prevent a cerebrospinal fluid leak. Laying a
small pledget of crushed fat over the drilled meatal area has
been successful in minimizing this complication (Fig. 4.25).
The retrosigmoid approach is used by this author for most
acoustic neuromas, because it is suitable for the removal of
both small and large tumors. Unlike the translabyrinthine
approach, described in the section on the temporal bone,
which is directed through the vestibule and semicircular ca-
nals, the retrosigmoid approach is not necessarily associated
with hearing loss. The retrosigmoid approach provides a
broader exposure of the small tumor than does the middle
FIGURE 4.25. A. Retrosigmoid approach for removal of fossa approach. Also, once the nerves are identified lateral to
small or medium-size acoustic neuromas. A, the patient is the tumor, there are advantages to being able to separate the
positioned in the three-quarter prone position with the sur- tumor capsule off the nerves beginning medially, because this
geon behind the head. The insert (right) shows the site of the more often results in preservation of hearing than dissection
scalp incision (continuous line) and the bony opening (inter- starting laterally. Compared with the middle fossa approach,
rupted line). it has the advantage that the facial nerve is usually deep to the
tumor and often is protected by a thin veil of vestibuloco-
The landmarks that are helpful in identifying the facial and chlear nerve, thus increasing the opportunity for facial nerve
vestibulocochlear nerves at the brainstem on the medial side preservation. In the middle fossa approach, the facial nerve is
of the tumor have been reviewed (Figs. 4.20-4.24) (33). These often in the upper part of the exposure, stretched over the
nerves, although distorted by the tumor, usually can be iden- upper half of the tumor, and much of the dissection is directly
tified on the brainstem side of the tumor at the lateral end of on the surface of the nerve, which increases the risk of facial
the pontomedullary sulcus, just rostral to the glossopharyn- dysfunction after surgery.
geal nerve and just anterosuperior to the foramen of Luschka,
the flocculus, and the choroid plexus protruding from the
foramen of Luschka. After the facial and vestibulocochlear Anatomy of vascular compression in the middle
nerves are identified on the medial and lateral sides of the neurovascular complex
tumor, the final remnants of the tumor are separated from the Compression of the facial and vestibulocochlear nerves by
intervening segment of the nerves using fine dissecting in- tortuous arteries is postulated to cause dysfunction of these
struments (Fig. 4.25). It is especially important to preserve the nerves, and cases in which surgical liberation of the vessels
segment of the cerebellar arteries adherent to the tumor cap- from these nerves has relieved the symptoms provide support
sule because a major cause of operative mortality and mor- for a vascular compressive etiology (Figs. 4.1 and 4.20) (11, 20,
bidity is the loss of perforating arteries and branches of the 38). Ectasia and elongation of the arteries are important in
cerebellar arteries that may be adherent to and displaced by forcing the arteries into the nerves. Gardner was the first to
the tumor. Any vessel that stands above or is stretched treat hemifacial spasm by removing a compressive arterial
around the tumor capsule should be dealt with initially as if it loop from the facial nerve (11). Jannetta et al., using the
were an artery that runs over the tumor surface to supply the suboccipital approach to the cerebellopontine angle, found
brain. After the tumor has been removed from within the mechanical compression and distortion of the root exit zone of
capsule, an attempt should be made to displace the vessel off the facial nerve in all of 47 patients with hemifacial spasm
the tumor capsule. When dissected free of the capsule, vessels (20). The distorting vessel not only was the AICA and its
that initially appeared to be adherent to the capsule often branches, but in some cases was found to be the PICA, the
prove to be neural vessels. The number of veins sacrificed vertebral or basilar artery, veins, or an arteriovenous malfor-
should be kept to a minimum because of the undesirable mation (Fig. 4.26) (20). It is expected that the AICA would be
consequences of their loss. Obliteration of the petrosal veins, the compressing vessel in most cases because the facial nerve
which pass from the surface of the cerebellum and the brain- is located in the middle neurovascular complex. However, a
stem to the superior petrosal sinus, is inescapable when reach- tortuous PICA is an equally frequent offending vessel in
ing and removing some cerebellopontine angle tumors. Oc- hemifacial spasm, followed in order by the vertebral artery,
clusion of these veins, which drain much of the cerebellum basilar artery, veins, and a combination of these vessels (Figs.
and the brainstem, infrequently may cause hemorrhagic 4.26 and 4.27). The proximal part of the PICA usually passes
edema of the cerebellum and the brainstem. Some of these around the brainstem below the facial and vestibulocochlear
veins may need to be sacrificed if the tumor extends into the nerves. In some cerebellopontine angles, however, the proxi-
area above the internal acoustic meatus. Small acoustic neu- mal part of the PICA, after coursing posteriorly to the level of
romas and other tumors in the lower part of the cerebellopon- the hypoglossal rootlets, will loop superiorly toward the facial
tine angle, however, frequently may be removed without and vestibulocochlear nerves before descending to pass be-
sacrificing a petrosal vein. In removing the posterior meatal tween the glossopharyngeal, vagus, and spinal accessory
lip, a communication may be established between the sub- nerves.

FIGURE 4.25. B–E. Retrosigmoid approach for

the removal of small or medium-size acoustic
neuromas. B, the posterior wall of the internal
auditory canal is removed using an irrigating
drill. The AICA courses around the lower margin
of the tumor. C, the intracapsular contents of
the tumor have been removed. The capsule
of the tumor is being separated from the pons
and the posterior surface of the part of the
facial and vestibulocochlear nerves adjacent to
the brainstem. The superior and inferior
vestibular nerves are seen at the lateral end of
the internal auditory canal. The trigeminal nerve
and SCA are above the tumor and the
glossopharyngeal and vagus nerves and the PICA
are below the tumor. D, the dissection along the
eighth nerve is done in a medial to lateral
direction (arrows) to avoid tearing the tiny
filaments of the cochlear nerve in the lateral end
of the canal where they pass through the lamina
cribrosa. The transverse crest separates the
superior and inferior vestibular nerves in the
lateral end of the canal. E, cerebellopontine
angle and internal auditory canal after tumor
removal. The facial and vestibulocochlear nerves have been preserved. A.I.C.A., anteroinferior cerebellar artery; Inf., inferior;
Int., internal; N., nerve; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Sup., superior; Vest.,
vestibular. (From, Rhoton AL Jr: Microsurgical anatomy of acoustic neuromas, in Sekhar LN, Janecka IP (eds): Surgery of
Cranial Base Tumors. New York, Raven Press, 1993, pp 687–713 [37].)
The offending arterial loop may be located on either the surface of the glossopharyngeal and vagus nerves. Com-
superior or the inferior aspect of the facial nerve at its exit monly, the flocculus is seen protruding behind the nerves and
from the brainstem. In the most common type of hemifacial blocks their visualization at the junction with the brainstem. It
spasm, that beginning in the orbicularis oculi muscle and also may be difficult to see the facial nerve that is hidden in
gradually spreading downward to involve the lower face, the front of the vestibulocochlear nerve. At this time, it is impor-
anteroinferior aspect of the nerve root exit zone will com- tant to recall that the facial nerve root exits the brainstem 2 to
monly be compressed. Atypical hemifacial spasm, a much less 3 mm rostral to the point at which the glossopharyngeal nerve
common entity, beginning in the lower or midface and enters the brainstem. To expose the nerve’s exit zone, it may
spreading upward to involve the frontalis muscle, will be be necessary to gently separate the choroid plexus from the
caused by the compression of the posterosuperior aspect of posterior margin of the glossopharyngeal nerve so that its
the facial nerve at the brainstem. Jannetta and others thought junction with the brainstem can be seen. The brain spatula is
that the arteries frequently seen coursing around or between advanced upwards to elevate the choroid plexus away from
the facial and vestibulocochlear nerves in the interval between
the posterior margin of the glossopharyngeal nerve. The ex-
the brainstem and porus acusticus, as found by Gardner (11),
posure is then directed several millimeters above the glosso-
were not the cause of hemifacial spasm, but that cross-
pharyngeal nerve to where the facial nerve will be seen join-
compression of the facial nerve by the same arteries coursing
ing the brainstem below and in front of the vestibulocochlear
at right angles to the nerve at the root exit zone was the
essential element (20). The craniotomy for hemifacial spasm is nerve. The spatula often needs to be positioned so that it
positioned behind the lower half of the sigmoid sinus. elevates the lower margin of the flocculus. Care must be taken
The operation for hemifacial spasm is directed along the to avoid damage to the vestibulocochlear nerve, which may
inferolateral margin of the cerebellum (Figs. 4.28 and 4.29). be adherent to the flocculus. In the experience of this author,
The craniotomy is located medial to the lower half of the the most common offending artery is a PICA that loops up-
sigmoid sinus (Figs. 4.9, 4.28, and 4.29). It is not necessary to ward before passing between the glossopharyngeal, vagus,
extend the bone opening downward to the foramen magnum and spinal accessory nerves. After looping into the facial
or upward to the transverse sinus. The inferolateral margin of nerve exit zone, the PICA then passes distally between the
the cerebellum is elevated with a small brain spatula and the rootlets of the lower cranial nerves. The compressing artery
arachnoid behind the glossopharyngeal and vagus nerves is may also be the premeatal or postmeatal segments of the
opened. This will expose the tuft of choroid plexus protruding AICA or a tortuous vertebral or basilar artery. Care is taken to
from the foramen of Luschka, which sits on the posterior explore the interval between the facial and vestibulocochlear

S120 Rhoton

compression of the facial
nerve in hemifacial spasm. A,
anterosuperior view. The facial
and vestibulocochlear nerves
are distorted at their junction
with the brainstem by the right
premeatal and the left
postmeatal segments of the
AICAs. B, anterior view. The
junction of the right facial and
vestibulocochlear nerves with
the brainstem is compressed
by a tortuous vertebral artery.
The nerves on the left side are
compressed by the PICA.
(From, Martin RG, Grant JL,
Peace DA, Theiss C, Rhoton
AL Jr: Microsurgical
relationships of the anterior
inferior cerebellar artery and
the facial-vestibulocochlear
nerve complex. Neurosurgery
6:483–507, 1980 [25].)
A.I.C.A., anteroinferior
cerebellar artery; Ch. Pl.,
choroid plexus; Mea., meatal;
P.C.A., posterior cerebral
artery; P.I.C.A., posteroinferior
cerebellar artery; Post.,
posterior; S.C.A., superior
cerebellar artery; Seg.,
segment; V.A., vertebral
artery.
nerves because it would be easy to miss a vessel compressing Cochlear and vestibular nerve compression syndromes
the facial nerve in this location.
Vascular compression has been reported as a cause of co-
Venous compression is less commonly encountered. The
most common venous compression is by the vein of the chlear and vestibular nerve dysfunction manifested by tinni-
pontomedullary sulcus, the retro-olivary vein, or the vein of tus, hearing loss, dysequilibrium, and disabling positional
the middle cerebral peduncle (26). The vein of the pontomed- vertigo (21, 28, 29). The site of the compressive lesion with
ullary sulcus and the retro-olivary vein commonly join in the vestibulocochlear nerve dysfunction has been reported to be
region of the facial nerve to form the vein of the middle more peripheral along the nerve rather than at the junction
cerebellar peduncle, which ascends on the middle cerebral with the brainstem, as commonly seen in trigeminal neuralgia
peduncle toward the superior petrosal sinus. The vein of the and hemifacial spasm. Jannetta and others have restricted the
middle cerebral peduncle commonly passes between the fa- use of the operation for vestibulocochlear nerve symptoms to
cial and vestibulocochlear nerves. It is not uncommon to those patients who are disabled and have documented uni-
encounter a bridging vein that passes from the lateral side of lateral disease on neuro-otologic testing. Jannetta et al. (21)
the medulla to the jugular bulb. At the time of elevating the and Gardner (11) have postulated that vascular compression
cerebellum, it is best to obliterate this vein with gentle bipolar of a cranial nerve is more likely to be symptomatic when it is
coagulation. located on the nerve proximal to the Obersteiner-Redlich zone

FIGURE 4.27. A, the PICA arises from the

vertebral artery, passes between the rootlets of the
hypoglossal nerve, and loops superiorly under the
glossopharyngeal and vagus nerves before passing posteroinferiorly between the rootlets of the vagus and spinal accessory
nerves. The vertebral artery stretches the rootlets of the hypoglossal nerve posteriorly. The AICA loops posterior to the facial
and vestibulocochlear nerves. B, a tortuous PICA arises from the vertebral artery and passes rostrally toward the
vestibulocochlear and facial nerves. At the level of the vestibulocochlear nerve, it loops inferiorly and descends anterior to
the glossopharyngeal and vagus nerves, and passes between the vagus and spinal accessory nerves. The PICA compresses the
medulla anterior to the origin of the glossopharyngeal and vagus nerves. The choroid plexus protrudes from the foramen of
Luschka posterior to the glossopharyngeal nerve. The cerebellar peduncles are above the lateral recess of the fourth ventricle.
C, the vertebral artery displaces and stretches the hypoglossal rootlets so far posteriorly that they intermingle with the
rootlets of the spinal accessory nerve. The PICA descends between the rootlets of the spinal accessory nerve. (From, Lister JR,
Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10:
170–199, 1982 [24].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Cer., cerebellar; Ch. Pl., choroid plexus; F.,
foramen; Lat., lateral; Ped., peduncle; Perf., perforating; P.I.C.A., posteroinferior cerebellar artery; V.A., vertebral artery.
where the axons are insulated by central myelin produced by small nerve that is hidden between the vestibulocochlear and
oligodendroglia. It is proximal to this glial-neurilemmal junc- facial nerves (Figs. 4.1 and 4.30) (40). The nervus intermedius
tion that the compression causes transaxonal excitement be- usually is described as a component of the facial nerve. Rel-
tween the afferent and efferent fibers. This glial-neurilemmal atively little note has been taken of the fact that it may be
junction on the facial and trigeminal nerves is situated at the closely bound to the vestibulocochlear nerve for a variable
nerve root junction with the brainstem, but the entire intra- distance before it enters the brainstem, and that in the cer-
cranial portion of the vestibulocochlear nerve is sensitive to ebellopontine angle, it may consist of as many as four rootlets.
compression because the glial-neurilemmal junction is located The nervus intermedius is found divisible into three parts: a
at or in the internal acoustic meatus (21). medial segment that adheres closely to the vestibulocochlear
Compression by veins is less common around the facial and nerve, an intermediate segment that lies freely between the
vestibulocochlear nerves than in the region of the trigeminal
acoustic nerve and the motor root of the facial nerve, and a
nerve because the veins around the facial and vestibuloco-
distal segment that joins the motor root to form the facial
chlear nerves tend to be smaller. Because no large bridging
nerve (40). Twenty-two percent of the nerves were adherent to
veins cross the subarachnoid space around the facial and
the acoustic nerve for 14 mm or more (the entire course of the
vestibulocochlear nerves, as are seen frequently around the
nerve in the posterior cranial fossa) and could be found as a
trigeminal nerve, any vascular cross-compression of facial
and vestibulocochlear nerves peripheral to the brainstem is separate structure only after opening the internal acoustic
likely to be caused by arteries that loop through the cerebel- meatus. In most instances, the nerve was a single trunk, but in
lopontine angle and even into the meatus. The veins at the some cases, it was composed of as many as four rootlets. A
level of the junction of the facial and vestibulocochlear nerves single large root most frequently arises at the brainstem an-
with the brainstem tightly hug the pontomedullary junction terior to the superior vestibular nerve and, in the meatus, lies
where they are adhere to the pial membrane, as described anterior to the superior vestibular nerve. When multiple root-
earlier in the section on the middle neurovascular complex. lets are present, they may arise along the whole anterior
surface of the vestibulocochlear nerve; however, they usually
Geniculate neuralgia converge immediately proximal to the junction with the facial
Sectioning the nervus intermedius for geniculate neuralgia motor root to form a single bundle that lies anterior to the
requires an understanding of the complex anatomy of this superior vestibular nerve.

S122 Rhoton
FIGURE 4.28. Facial nerve expo-

sure in hemifacial spasm. A, the
insert shows the approach along
the inferolateral margin of the cere-
bellum. The cerebellum has been
elevated to expose the right cer-
ebellopontine angle. The facial
nerve exit zone from the brainstem
is seen along the lower margin of
the vestibulocochlear nerve. The
AICA passes between the facial and
vestibulocochlear nerve. A large
tortuous PICA loops upward ante-
rior to the facial and vestibuloco-
chlear nerves and behind the tri-
geminal nerve, before turning
downward to reach the medulla.
The flocculus and the choroid
plexus protruding from the foramen
Luschka often hide the junction of
nerves with brainstem. In this case,
the flocculus has been gently ele-
vated to expose the junction of
these nerves with the brainstem. B,
enlarged view. Exposing the facial
nerve exit zone from the brainstem
is facilitated by directing the expo-
sure along the inferolateral margin
of the cerebellum in the area above
the glossopharyngeal nerve and be-
low the lower edge of the floccu-
lus. C, the vestibulocochlear nerve
has been depressed. This exposes
the distal segment of the facial
nerve, but does not provide access
to the junction of the facial nerve
with the brainstem, which should
be visualized in dealing with hemi-
facial spasm. D, the vestibuloco-
chlear nerve has been gently ele-
vated. This exposes both the rostral
and caudal margins of the facial
nerve at the brainstem. A rootlet of
the nervus intermedius is also ex-
posed. The vein of the middle cere-
bellar peduncle passes between the
facial and vestibulocochlear nerve.
A., artery; A.I.C.A., anteroinferior
cerebellar artery; Cer., cerebellar;
Chor. Plex., choroid plexus; CN, cranial nerve; Flocc., flocculus; Inf., inferior; Intermed., intermedius; Mid., middle; Nerv.,
nervus; Ped., peduncle; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; V., vein; Vert., vertebral.
It is the free segment between the facial and vestibuloco- dius is composed of a single rootlet. If the nervus intermedius
chlear nerve that is divided in geniculate neuralgia. This is composed of more than one rootlet, however, there may be
segment, where the nervus intermedius is free of both the free segments both in the cerebellopontine angle and in the
facial and vestibulocochlear nerves, may be located in the meatus. Geniculate neuralgia with or without vestibuloco-
cerebellopontine angle or in the meatus if the nervus interme- chlear dysfunction also has been postulated to be caused by

FIGURE 4.29. A–F, arterial

compression of the facial nerve in
hemifacial spasm as viewed through
a retrosigmoid craniotomy
performed with the patient in the
three-quarter prone position. A, the
upper drawing shows the site of the
incision (straight line) and the
location of the craniotomy (broken
line). The lower drawing shows the
surgical exposure obtained with this
approach. The AICA and the facial
and vestibulocochlear nerves are in
the midportion of the exposure. The
vertebral artery, PICA, and the
glossopharyngeal, vagus, and spinal
accessory nerves are below. B, the
cerebellum is elevated to expose the
facial and vestibulocochlear nerves
and the premeatal, meatal, and
postmeatal segments of the AICA.
The flocculus and the choroid
plexus block the view of the
junction of the facial and
brainstem. C, the flocculus and the
choroid plexus have been elevated
to expose the root entry/exit zone of
nerves. The premeatal segment
compresses the nerves at the
junction with the pons and the
medulla. D, the nerve root entry/
exit zone is compressed by the
postmeatal segment. E, a tortuous
PICA loops upward to compress the
nerves at their junction with the
brainstem before turning inferiorly
to pass between the
glossopharyngeal and vagus nerves.
F, a tortuous vertebral artery
compresses the nerve root entry/exit
zone. A., artery; A.I.C.A.,
anteroinferior cerebellar artery;
Chor. Plex., choroid plexus;
Labyrin., labyrinthine; Mea., meatal;
P.I.C.A., posteroinferior cerebellar
artery; Post., posterior; Seg.,
segment; Subarc., subarcuate; Vert.,
vertebral.
vascular compression of the nervus intermedius or vestibulo- fissure, suboccipital surface of the cerebellum, and the glos-
cochlear nerve (21, 29). sopharyngeal, vagus, spinal accessory, and hypoglossal
nerves (Figs. 4.1, 4.17, and 4.27). The PICA arises at the med-
LOWER NEUROVASCULAR COMPLEX ullary level, encircles the medulla, passing in relationship to
The lower complex, which is related to the PICA, includes the glossopharyngeal, vagus, spinal accessory, and hypoglos-
the medulla, inferior cerebellar peduncle, cerebellomedullary sal nerves to reach the surface of the inferior cerebellar pe-

S124 Rhoton
FIGURE 4.31. A, lateral view of the left side of the brain-

stem as outlined by the broken line. B, note the ventral and
dorsal rootlets of the glossopharyngeal and vagus nerves.
FIGURE 4.30. View of the cerebellopontine angle from One ventral glossopharyngeal and two ventral vagal rootlets
above to show the relationship of the nervus intermedius to are seen. (From, Rhoton AL Jr, Buza R: Microsurgical anat-
the facial and vestibulocochlear nerves. A, most common omy of the jugular foramen. J Neurosurg 42:541–550, 1975
relationship. The nervus intermedius is joined to the ventral [39].)
surface of the vestibulocochlear nerve for a few millimeters
adjacent to the brainstem, then has a free segment in the
cerebellopontine angle as it courses to join the facial motor inferior two-thirds of the olive and from the lower medulla
root. B, pattern present in 20% of the nerves studied. The and the upper segments of the cervical spinal cord. The glos-
free segment is entirely in the meatus. C, the nervus interme- sopharyngeal and vagus nerves arise rostral to the level of
dius consists of three free segments: two are the angle and origin of the hypoglossal rootlets.
one is in the meatus. The nervus intermedius in A could be The glossopharyngeal nerve arises as one or rarely two
exposed in the angle without drilling off the posterior lip of rootlets from the upper medulla, posterior to the olive, just
the meatus. In B, the free segment could not be found in the caudal to the origin of the facial nerve. It courses ventral to the
angle but only in the meatus. (From, Rhoton AL Jr: Microsur- choroid plexus protruding from the foramen of Luschka on its
gical anatomy of acoustic neuromas, in Jackler RK (ed): Oto- way to the jugular foramen. Frequently, a larger dorsal and a
laryngologic Clinics of North America. Philadelphia, W.B. smaller ventral component can be seen at the junction with
Saunders Co., 1992, pp 257–294 [35].) the brainstem (22, 39). The smaller ventral rootlets have been
demonstrated to be motor and the larger main bundle to be
duncle, where it dips into the cerebellomedullary fissure and sensory (7, 44). The larger dorsal component usually arises
terminates by supplying the suboccipital surface of the from the medulla as one root, except in a few cases in which
cerebellum. it will originate as two rootlets. The two rootlets may remain
separate throughout their course to the dura (Figs. 4.31 and
4.32).
Neural relationships The vagus nerve arises below the glossopharyngeal nerve
The glossopharyngeal, vagus, spinal accessory, and hypo- as a line of tightly packed rootlets along a line 2 to 5.5 mm in
glossal nerves arise from the medulla along the margin of the length posterior to the superior third of the olive (Figs. 4.1,
inferior olive. The glossopharyngeal, vagus, and spinal acces- 4.27, and 4.32). The most rostral vagal fibers arise adjacent to
sory nerves arise as a line of rootlets that exit the brainstem the glossopharyngeal origin, from which they are sometimes
along the posterior edge of the olive in the post-olivary sulcus, separated by as much as 2 mm. The vagus is composed of
a shallow groove between the olive and posterolateral surface multiple combinations of large and small rootlets that pass
of the medulla (Figs. 4.1, 4.17, 4.31, and 4.32). The hypoglossal ventral to the choroid plexus protruding from the foramen of
nerve arises as a line of rootlets that exit the brainstem along Luschka on its way to the jugular foramen. Occasionally,
the anterior margin of the lower two-thirds of the olive in the several small rootlets are found originating ventral to the
preolivary sulcus, a groove between the olive and the med- majority of the vagal rootlets (Figs. 4.31 and 4.32). These small
ullary pyramid. The glossopharyngeal and vagus nerves arise ventral rootlets are considered to be motor (7).
at the level of the superior third of the olive. The spinal The accessory nerve arises as a widely separated series of
accessory rootlets arise along the posterior margin of the rootlets that originated from the medulla at the level of the

FIGURE 4.32. The broken line on the drawing of the lateral surface of the brainstem outlines the area shown in each dia-
gram, demonstrating the brainstem origin and variations of the rootlet size of the glossopharyngeal, vagus, and spinal acces-
sory nerves. The large ovoid structure is the inferior olive. The broken-line circles outline the origin of the facial and vestibu-
locochlear nerves. The most cephalad, shaded circles indicate glossopharyngeal rootlet origins, intermediate, open circles
indicate vagal rootlet origins, and caudal, black circles outline spinal accessory rootlet origins. The glossopharyngeal nerve
usually originates as one large rootlet, the vagus as a series of large and small rootlets, and the spinal accessory as a series of
small rootlets. Top, note the small ventral rootlets of the glossopharyngeal nerve in A, B, and C and the small ventral rootlet
between the glossopharyngeal and vagus nerves in A. The glossopharyngeal rootlet is larger than the rostral rootlet of the
vagus nerve in all except D, in which the rostral vagal rootlet is larger than the glossopharyngeal nerve. Bottom, note the
wide separation of the origin of the glossopharyngeal and vagus nerves in C, the small ventral rootlet of the glossopharyngeal
nerve in C, and the small ventral rootlets of the glossopharyngeal and vagus nerves in A. The glossopharyngeal nerve is
smaller than the upper vagal rootlet in A and D. (From, Rhoton AL Jr, Buza R: Microsurgical anatomy of the jugular foramen.
J Neurosurg 42:541–550, 1975 [39].)
lower two-thirds of the olive and from the upper cervical deep to the hypoglossal triangle in the floor of the fourth
cord. The cranial rootlets of the accessory nerve arise as a line ventricle, and exit the medulla along the anterior margin of
of rootlets ranging in diameter from 0.1 to 1 mm just caudal to the caudal two-thirds of the olive. The hypoglossal rootlets
the vagal fibers (Figs. 4.1, 4.17, 4.27, and 4.32). The cranial course anterolateral through the subarachnoid space and pass
rootlets of the accessory nerve are more properly regarded as behind the vertebral artery to reach the hypoglossal canal. If
inferior vagal rootlets, since they arise from vagal nuclei (22, the vertebral artery is short and straight, it may not contact or
39). It may be difficult to separate the lower vagal fibers from distort the hypoglossal rootlets, but if the artery is tortuous it
the upper accessory rootlets because the vagal and cranial may stretch the hypoglossal rootlets posteriorly over its dor-
accessory fibers usually enter the vagal meatus as a single sal surface (38). Infrequently, the vertebral artery passes be-
bundle. tween the rootlets of the hypoglossal nerve (24). Before enter-
The upper rootlets of the spinal portion of the accessory ing the hypoglossal canal, the rootlets collect into two
nerve originate several millimeters caudal to the lowest cra- bundles, and in some cases, the canal is divided by a bony
nial accessory fibers and either course to join the cranial septum that separates the two bundles. After passing through
accessory bundle or enter the lower border of the vagal me- the canal, the bundles unite and the nerve lies medial to the
atus separate from the cranial accessory rootlets. The spinal internal jugular vein, and the glossopharyngeal, vagus, and
accessory fibers pass superolateral from their origin to reach accessory nerves.
the jugular foramen. Although the cranial and spinal portion
of the accessory nerve most frequently enter the vagal meatus
together, they may infrequently be separated by a dural Anatomy of glossopharyngeal neuralgia
septum. Dandy (4) described endocranial sectioning of the glosso-
The rootlets forming the hypoglossal nerve arise from the pharyngeal nerve for neuralgia, but because this alone did not
medulla along a line that is continuous inferiorly with the line adequately control the neuralgia, he later advocated the ad-
along which the ventral spinal roots arise (Figs. 4.1, 4.17, and ditional sectioning of “perhaps 1/8 to 1/6 of the vagus” (Figs.
4.27). These rootlets arise in a nucleus whose rostral part sits 4.1, 4.17, 4.27, and 4.32). Tarlov (44, 45) sectioned the cephalic

S126 Rhoton
FIGURE 4.33. A and B. Tumors involving multiple neurovascular complexes. A, routes that can be taken between the cranial
nerves to expose and remove a tumor situated medial to and involving multiple cranial nerves. The patient is positioned in
the three-quarter prone position. The insert (upper left) shows the site of the vertical scalp incision and craniotomy. The
approach to pathology located medial to the nerves can be directed (arrows) between the trochlear nerve above and trigemi-
nal nerve below; between the trigeminal nerve above and the facial and vestibulocochlear nerves below; between the facial
and vestibulocochlear nerves above and the glossopharyngeal nerve below; between the glossopharyngeal and vagus nerves;
between the vagus nerve and accessory rootlets; and between the widely separated rootlets of the accessory nerve. A tumor
located medial to the nerves will often widen the intervals between the nerves, depending on the site of origin of the tumor.
Choroid plexus protrudes from the foramen of Luschka. B, meningioma attached lateral to the trigeminal nerve in the region
of the superior petrosal sinus. The trochlear nerve is elevated, the trigeminal nerve is pushed medially, and the facial and ves-
tibulocochlear nerves are stretched below the tumor. A., artery; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Ch.
Plex., choroid plexus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Sig., sigmoid;
Sup., superior; Tent., tentorium; Vert., vertebral.
FIGURE 4.33. C and D. Tumors involving multiple neurovascular complexes. C, the tumor has been removed. The thin dis-
torted nerves have been preserved, and the remaining dural attachment is removed or cauterized with bipolar coagulation.
The basilar artery and abducens nerve are exposed. D, a large meningioma arising from the clivus in the region of the inferior
petrosal sinus with involvement of the fourth through the eleventh nerves. The nerves are displaced laterally around the
tumor. The tumor is removed by working through the intervals between the nerves.
third of the vagal-spinal accessory group and produced anal- soft palate, pharynx, and larynx. In our study, the structure
gesia of the epiglottis but only hypalgesia over the mucosa of of the vagus nerve was variable, being composed of all large
the lower pharynx and larynx. In his second case, he sectioned or all small rootlets or any combination of the two. It is
the cephalic half of the vagal-spinal accessory complex; this suggested that fewer of the rostral rootlets be cut if the diam-
caused both analgesia and transient paralysis of the ipsilateral eters of the upper rootlets are large rather than small; the

FIGURE 4.33. E and F. Tumors involving multiple neurovascular complexes. E, the meningioma has been removed. The dural
attachment has been partially removed and the base is being cauterized. F, meningioma arising medial to the jugular bulb in
the region of the jugular tubercle and involving the lower cranial nerves.
FIGURE 4.33. G and H. Tumors involving multiple neurovascular complexes. G, the tumor was removed by operating
through the intervals between the facial and vestibulocochlear nerves above and the glossopharyngeal nerve below and
between the glossopharyngeal and vagus nerves (round insert). H, a large epidermoid tumor being removed by working
through the intervals between the nerves.
diameter of the largest rootlet is 1.5 mm and the smallest is The only location where the glossopharyngeal nerve can
0.1 mm (39). consistently be distinguished from the vagus is just proximal
A large glossopharyngeal nerve diameter might be associ- to the dural meati where a dural septum separates the glos-
ated with a small diameter of the upper rootlets of the vagus sopharyngeal and vagus nerves (39). This septum varies in
nerve, or a large vagus nerve might be associated with a small width from 0.5 to 4.9 mm and serves to differentiate the
glossopharyngeal nerve, because the two nerves arise from glossopharyngeal nerve from the vagus nerve. The close med-
the same nuclei and have a similar function (7). This idea that ullary origin of the glossopharyngeal and vagus nerves and
more fibers might be distributed to one nerve, leaving the the frequent arachnoid adhesions between the two makes
other smaller, was not confirmed in our studies (39). When the separation difficult in their course through the subarachnoid
diameter of the dorsal root of the glossopharyngeal nerve is space or adjacent to the brainstem, except in the few cases in
compared with the mean of the upper rootlets of the vagus which there will be a 1- to 2-mm separation between their
nerve, no significant correlation is found (39). A smaller di- origin at the medulla.
ameter of the glossopharyngeal nerve is not commonly asso- The superior glossopharyngeal and vagal ganglia may be
ciated with a large mean diameter of the upper rootlets of the visible intracranially (22). In glossopharyngeal neuralgia, Ad-
vagus, nor is a large glossopharyngeal nerve diameter asso- son (1) noted the need to section the glossopharyngeal nerve
ciated with a small diameter of the vagal rootlets. proximal to the superior ganglion. The superior ganglion was

S128 Rhoton
separation of the arteries and nerves (23). The adverse cardio-

vascular effects of mobilization of these nerves and the risk to
causing swallowing and vocal cord defects have led some to
conclude that rhizotomy of the glossopharyngeal nerve and
upper vagal rootlets is a reasonable alternative to vascular
mobilization along the lateral medulla (19, 20, 21, 29, 41).
Jannetta has proposed that compression of the left side of
the medulla by the PICA or the vertebral artery may be a
cause of hypertension and that diabetes mellitus may result
from right lateral medullary compression as a result of vagal
effects on pancreatic islet cell secretion (9, 19). The fact that
hypertension is a component of the Cushing response to
lateral medullary compression has been well established and
that hypertension has been relieved after decompression of
the left side of the medulla supports this concept. The rela-
tionship of vascular compression to diabetes mellitus awaits
FIGURE 4.33. I. Tumors involving multiple neurovascular further elucidation.
complexes. I, distorted nerves after the removal of the epi-
dermoid tumor.
Tumors involving multiple neurovascular complexes
intracranial in 32% of 50 jugular foramina that we examined
Tumors in the cerebellopontine angle commonly involve
and within or extracranial to the foramen in 68% (39). The
more than one of the neurovascular complexes (Fig. 4.33) (38).
superior ganglion of the vagus could be seen intracranially in
An especially difficult challenge is exposing and removing the
only 14% of the cases.
tumors that are situated medial to the nerves. In this case,
the operation must be directed through the interval between
Vascular relationships the neurovascular complexes, because these tumors often will
The vertebral artery courses anterior to the nerves in the widen these intervals. Lesions in the upper cerebellopontine
lower neurovascular complex. The hypoglossal rootlets usu- angle may be exposed through the interval between the lower
ally pass behind the vertebral artery, however, some hypo- margin of the tentorium and the upper edge of the trigeminal
glossal rootlets infrequently pass anterior to the artery. If the nerve. Care is needed to protect the trochlear nerve and the
vertebral artery is elongated or tortuous and courses laterally SCA in this area. Further inferiorly, the medially placed tumor
to the olive, it will stretch the hypoglossal rootless over its may be approached through the interval between the trigem-
posterior surface. Some tortuous vertebral arteries will stretch inal nerve above and the facial and vestibulocochlear nerves
the hypoglossal rootlets so far posterior that they intermingle below. If the tumor has an even lower attachment near the
with the glossopharyngeal, vagus, and spinal accessory jugular foramen, it can be approached through the interval
nerves. The PICA has a much more complex relationship to between the lower margin of the nerves entering the internal
these nerves (Fig. 4.27). The proximal part of the PICA passes meatus and the upper margin of the glossopharyngeal nerve,
around or between and often stretches or distorts the rootlets or through the interval between the lower rootlets of the
of the nerves in the lower complex. At the anterolateral me- vagus nerve and the upper rootlets of the spinal accessory
dulla, the PICA passes around or between the rootlets of the nerve. The intervals between the glossopharyngeal and va-
hypoglossal nerve. At the posterolateral margin of the me- gus nerves and between the individual vagal rootless usually
dulla, it passes between the fila of the glossopharyngeal, are too narrow to work through unless they have been opened
vagus, and spinal accessory nerves. The PICA may be ascend- by the tumor; however, the interval between the lower of the
ing, descending, or passing laterally or medially, or may be cranial accessory rootlets may provide access to lesions in
involved in a complex loop that stretches and distorts these the area. The role of procedures involving resection of parts
nerves as it passes between them (Fig. 4.27). The relationships of the temporal bone in accessing lesions in this area is re-
of the PICA and vertebral artery to these nerves are reviewed viewed in the chapter on the temporal bone.
in greater detail in the chapter on the cerebellar arteries.
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro-
logical Surgery, University of Florida Brain Institute, P.O. Box 100265,
Vascular compression in the lower
100 South Newell Drive, Building 59, L2-100, Gainesville, FL
neurovascular complex 32610-0265.
The close relationship of the PICA and the vertebral artery
to the glossopharyngeal and vagus nerves makes it logical to
explore these relationships in glossopharyngeal neuralgia (23,
REFERENCES
46). Both the glossopharyngeal and vagus nerves have been
found to be compressed at their junction with the brainstem 1. Adson AW: The surgical treatment of glossopharyngeal neural-
by the PICA or the vertebral artery, or both, with relief after gia. Arch Neurol Psychiatry 12:487–506, 1924.

2. Apfelbaum RI: Microvascular decompression for tic douloureux 25. Martin RG, Grant JL, Peace DA, Theiss C, Rhoton AL Jr: Microsurgical
results, in Brackmann DE (ed): Neurological Surgery of the Ear and relationships of the anterior inferior cerebellar artery and the facial-
Skull Base. New York, Raven Press, 1982, pp 175–180. vestibulocochlear nerve complex. Neurosurgery 6:483–507, 1980.
3. Atkinson WJ: The anterior inferior cerebellar artery: Its variations, 26. Matsushima T, Rhoton AL Jr, de Oliveira E, Peace DA: Microsur-
pontine distribution, and significance in the surgery of cerebello- gical anatomy of the veins of the posterior fossa. J Neurosurg
pontine angle tumours. J Neurol Neurosurg Psychiatry 12:137– 59:63–105, 1983.
151, 1949. 27. Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the
4. Dandy WE: Glossopharyngeal neuralgia (tic douloureux): Its di- fourth ventricle: Part I—Microsurgical anatomy. Neurosurgery
agnosis and treatment. Arch Surg 15:198–214, 1927. 11:631–667, 1982.
5. Dandy WE: An operation for the cure of tic douloureux: Partial 28. Møller MB, Møller AR, Jannetta PJ, Sekhar L: Diagnosis and
section of the sensory root at the pons. Arch Surg 18:687–734, 1929. surgical treatment of disabling positional vertigo. J Neurosurg
6. Dandy WE: Concerning the cause of trigeminal neuralgia. Am J 64:21–28, 1986.
Surg 24:447–455, 1934. 29. Ouaknine GE, Robert F, Molina-Negro P, Hardy J: Geniculate
7. DuBois FS, Foley JO: Experimental studies on the vagus and neuralgia and audio-vestibular disturbances due to compression
spinal accessory nerves in the cat. Anat Rec 64:285–307, 1936. of the intermediate and eighth nerves by the postero-inferior
8. Emmons WF, Rhoton AL Jr: Subdivision of the trigeminal sensory root: cerebellar artery. Surg Neurol 13:147–150, 1980.
Experimental study in the monkey. J Neurosurg 35:585–591, 1971. 30. Pait TG, Zeal A, Harris FS, Paullus WS, Rhoton AL Jr: Microsur-
9. Fein JM, Frishman W: Neurogenic hypertension related to vascular gical anatomy and dissection of the temporal bone. Surg Neurol
compression of the lateral medulla. Neurosurgery 6:615–622, 1980. 8:363–391, 1977.
10. Fujii K, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the 31. Pelletier V, Poulos DA, Lende RA: Localization in the trigeminal
choroidal arteries: Fourth ventricle and cerebellopontine angles. root. Presented at the American Association of Neurological Sur-
J Neurosurg 52:504–524, 1980. geons, Washington, DC, 1970.
11. Gardner WJ: Concerning the mechanism of trigeminal neuralgia 32. Rhoton AL Jr: Microsurgery of the internal acoustic meatus. Surg
and hemifacial spasm. J Neurosurg 19:947–958, 1962. Neurol 2:311–318, 1974.
33. Rhoton AL Jr: Microsurgical anatomy of the brainstem surface
12. Gudmundsson K, Rhoton AL Jr, Rushton JG: Detailed anatomy of
facing an acoustic neuroma. Surg Neurol 25:326–339, 1986.
the intracranial portion of the trigeminal nerve. J Neurosurg
34. Rhoton AL Jr: Microsurgical anatomy of decompression operations on
35:592–600, 1971.
the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal
13. Hardy DG, Rhoton AL Jr: Microsurgical relationships of the su-
Neuralgia. Baltimore, Williams & Wilkins, 1990, pp 165–200.
perior cerebellar artery and the trigeminal nerve. J Neurosurg
35. Rhoton AL Jr: Microsurgical anatomy of acoustic neuromas, in
49:669–678, 1978.
Jackler RK (ed): Otolaryngologic Clinics of North America. Philadel-
14. Hardy DG, Peace DA, Rhoton AL Jr: Microsurgical anatomy of
phia, W.B. Saunders Co., 1992, pp 257–294.
the superior cerebellar artery. Neurosurgery 6:10–28, 1980.
36. Rhoton AL Jr: Instrumentation, in Apuzzo MLJ (ed): Brain Surgery:
15. Horsley V, Taylor J, Coleman WS: Remarks on the various surgical
Complication, Avoidance and Management. New York, Churchill
procedures devised for the relief or cure of trigeminal neuralgia (tic
Livingstone, 1993, pp 1647–1670.
douloureux). Br Med J 2:1139–1143, 1191–1193, 1249–1252, 1891.
37. Rhoton AL Jr: Microsurgical anatomy of acoustic neuromas, in
16. House WF: Translabyrinthine approach, in House WF, Luetje CM
Sekhar LN, Janecka IP (eds): Surgery of Cranial Base Tumors. New
(eds): Acoustic Tumors: II—Management. Baltimore, University
York, Raven Press, 1993, pp 687–713.
Park Press, 1979, pp 43–87. 38. Rhoton AL Jr: Microsurgical anatomy of posterior fossa cranial nerves,
17. Jannetta PJ: Arterial compression of the trigeminal nerve at the pons in Barrow DL (ed): Surgery of the Cranial Nerves of the Posterior Fossa:
in patients with trigeminal neuralgia. J Neurosurg 26:159–162, 1967. Neurosurgical Topics. Park Ridge, AANS, 1993, pp 1–103.
18. Jannetta PJ: Vascular decompression in trigeminal neuralgia, in 39. Rhoton AL Jr, Buza R: Microsurgical anatomy of the jugular
Samii M, Jannetta PJ (eds): The Cranial Nerves: Anatomy, Pathology, foramen. J Neurosurg 42:541–550, 1975.
Pathophysiology, Diagnosis, Treatment. New York, Springer-Verlag, 40. Rhoton AL Jr, Kobayashi S, Hollingshead WH: Nervus interme-
1981, pp 331–340. dius. J Neurosurg 29:609–618, 1968.
19. Jannetta PJ, Gendell HM: Clinical observations on etiology essen- 41. Segal R, Gendell HM, Canfield D, Dujovny M, Jannetta PJ: Car-
tial hypertension. Surg Forum 30:431–432, 1979. diovascular response to pulsatile pressure applied to ventrolat-
20. Jannetta PJ, Abbasy M, Maroon JC, Ramos FM, Albin MS: Etiol- eral medulla. Surg Forum 30:433–435, 1979.
ogy and definitive microsurgical treatment of hemifacial spasm: 42. Seoane ER, Rhoton AL Jr: Suprameatal extension of the
Operative techniques and results in 47 patients. J Neurosurg retrosigmoid approach: Microsurgical anatomy. Neurosurgery
47:321–328, 1977. 44:553–560, 1999.
21. Jannetta PJ, Møller MB, Møller AR, Sekhar LN: Neurosurgical 43. Sunderland S: Neurovascular relationships and anomalies at the base of
treatment of vertigo by microvascular decompression of the the brain. J Neurol Neurosurg Psychiatry 11:243–257, 1948.
eighth cranial nerve. Clin Neurosurg 33:645–665, 1986. 44. Tarlov IM: Structure of the nerve root: Part II—Differentiation of
22. Katsuta T, Rhoton AL Jr, Matsushima T: The jugular foramen: sensory from motor roots: Observations on identification of func-
Microsurgical anatomy and operative approaches. Neurosurgery tion in roots of mixed cranial nerves. Arch Neurol Psychiatry
41:149–202, 1997. 37:1338–1355, 1937.
23. Laha RK, Jannetta PJ: Glossopharyngeal neuralgia. J Neurosurg 45. Tarlov IM: Section of the cephalic third of the vagus-spinal acces-
47:316–320, 1977. sory complex: Clinical and histologic results. Arch Neurol Psy-
24. Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical chiatry 47:141–148, 1942.
anatomy of the posterior inferior cerebellar artery. Neurosurgery 46. Watt JC, McKillop AN: Relation of arteries to roots of nerves in
10:170–199, 1982. posterior cranial fossa in man. Arch Surg 30:336–345, 1935.

Anterior superficial neural complexes, from, Bartolommeo Eustachio, Tabulae anatomicae. Rome, Sumptibus Laurentii & Thomae
Pagliarini, 1728. Courtesy, Rare Book Room, Norris Medical Library, Keck School of Medicine, Los Angeles, California.
(Also see pages S2, S28, S154, S194, and S298.)
CHAPTER 5
Tentorial Incisura

Key words: Anatomic study, Anatomy, Circle of Willis, Incisura, Midbrain, Neurovascular, Tentorium
T
he tentorial incisura provides the only communication The anterior end of each free edge is attached to the petrous
between the supratentorial and infratentorial spaces apex and the anterior and posterior clinoid processes (Figs.
(17) (Fig. 5.1). The area between the upper brainstem 5.1–5.3). The attachment to the petrous apex and the clinoid
and the incisural edges is divided into the anterior, middle, processes forms three dural folds: the anterior and posterior
and posterior incisural spaces (Fig. 5.2). The anterior incisural petroclinoid folds and the interclinoid fold. Between these
space is located anterior to the brainstem and extends upward folds is located the oculomotor trigone, a shallow depressed
around the optic chiasm to the subcallosal area; the middle area over the posterior part of the roof of the cavernous sinus,
incisural space is located lateral to the brainstem and is inti- through which the oculomotor and trochlear nerves enter the
mately related to the hippocampal formation in the medial sinus. The posterior petroclinoid fold extends from the pe-
part of the temporal lobe; and the posterior incisural space is trous apex to the posterior clinoid process; the anterior pet-
located posterior to the midbrain and corresponds to the region roclinoid fold extends from the petrous apex to the anterior
of the pineal gland and vein of Galen. The arterial relationships clinoid process; and the interclinoid fold covers the ligament
in the anterior incisural space and the venous relationships in the extending from the anterior to the posterior clinoid process.
posterior incisural space are extremely complex, since the ante- The oculomotor nerve penetrates the dura in the central part
rior incisural space contains all of the components of the circle of of this triangle, the oculomotor triangle, and the trochlear
Willis and the bifurcation of the internal carotid and basilar nerve enters the dura at the posterolateral edge of this trian-
arteries, and the posterior incisural space contains the conver- gle. The petrosphenoid ligament passes between the leaves
gence of the internal cerebral and basal veins and many of their of the posterior petroclinoid fold from the petrous apex to
tributaries on the vein of Galen. The incisura is intimately related the lateral border of the dorsum sellae, just below the
to the depths of the cerebrum and cerebellum, the first six cranial
posterior clinoid process. The abducens nerve passes below
nerves, and the upper brainstem. Some part of the incisura is
the petrosphenoid ligament to enter the cavernous sinus.
commonly exposed during the operations for aneurysms, deep
The dura forming the roof of the oculomotor trigones ex-
tumors and arteriovenous malformations, trigeminal neuralgia,
tends medially across the sella to form the diaphragma
and epilepsy. Much attention has been focused on the distortions
sellae, which covers the pituitary gland and contains an
of this anatomy by herniation of the brain through the incisural
opening for the infundibulum.
space.
Anterolateral to the diaphragma are two orifices: a bone
orifice, the optic canal (through which the optic nerve enters
the orbit), and a dural orifice through which the internal
ANATOMY OF THE TENTORIUM carotid artery exits the cavernous sinus (Fig. 5.3). From the
The tentorium covers the cerebellum, supports the cere- anterior part of the free edge, the dura mater slopes steeply
brum, and forms a collar around the brainstem (Figs. 5.2 and downward to form the lateral wall of the cavernous sinus and
5.3). The tentorium slopes downward from its apex, located at to cover the middle cranial fossa. Plaut reported that the
the posterior edge of the incisura, to its attachment to the attachment of the anterior end of the free edge to the petrous
temporal, occipital, and sphenoid bones. All of the tentorial apex may be situated as much as 10 mm lateral and 8 mm
margins, except the free edges bordering the incisura, are below the level of the clinoid processes and that the low
rigidly attached to the cranium. The anterior border is at- position of the free edge may facilitate descending tentorial
tached to the petrous ridge and divides to enclose the superior herniations (20).
petrosal sinus. The lateral and posterior borders, which divide The falx cerebri fuses into the dorsal surface of the tento-
to enclose the transverse sinus and the torcula, are attached to rium in the midline behind the apex (Fig. 5.1). The straight
the inner surface of the occipital and temporal bones along the sinus, which is enclosed in the falcotentorial junction, begins
internal occipital protuberance and to the edges of the shallow at the tentorial apex, where it receives the vein of Galen and
osseous groove for the transverse sinus. the inferior sagittal sinus, and terminates in the torcular.

S132 Rhoton
FIGURE 5.1. Tentorial incisura. A, the left cerebral

hemisphere has been removed. The tentorial incisura is
located between the tentorial edges and is the only site of
communication behind the supra and infratentorial spaces.
The tentorial apex is located at the junction of the vein of
Galen and the straight sinus. The tentorial edges slope
downward from the apex. The free edge passes along the side
of the brainstem and anteriorly blends into the dura covering
the petrous apex and the anterior and posterior clinoid
processes. The incisura, in relation to the midbrain, is divided
into anterior, middle, and posterior spaces. The anterior
incisural space extends above the optic chiasm to the lamina
terminalis and below the chiasm and third ventricular floor to
the interpeduncular fossa. The middle incisural space is
located between the midbrain and tentorial edge, opens
upward into the ambient and crural cisterns, and extends
inferiorly into the anterior part of the cerebellomesencephalic
fissure. The posterior incisural space, located between the
posterior midbrain and the tentorial apex, encompasses the
quadrigeminal cistern, which extends into the
cerebellomesencephalic fissure and along the outer surface of
the upper part of the fourth ventricular roof. The anterior
incisural space, located below the frontal horn, contains the
basilar bifurcation. The PCA and SCA arise in the anterior and
pass around the brainstem to reach the middle and posterior
incisural spaces. The branches of the PCA and SCA pass
through the lateral part of the posterior incisural space, and
the large venous structures converging on the vein of Galen
course in the medial part of the posterior incisural space. B, part of the left central hemisphere and all of the left thalamus
have been removed, while preserving the fornix and choroid plexus. The frontal horn and anterior part of the third ventricle
is located above the anterior incisural space. The middle incisural space is located medial to the temporal horn, between the
temporal lobe and midbrain. The posterior incisural space is located between the tentorial apex and posterior midbrain
surface. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Chor., choroid; CN, cranial
nerve; Front., frontal; Gyr., gyrus; Incis., incisural; Mid., middle; Parahippo., parahippocampal; Ped., peduncle; Plex., plexus;
Post., posterior; Temp., temporal; Tent., tentorial; V., vein; Vent., ventricle.
TENTORIAL INCISURA brainstem; paired middle incisural spaces situated lateral to

the brainstem; and a posterior incisural space located be-
The incisura is roughly triangular and has its anterior edge or
hind the brainstem (Figs. 5.1–5.4). The description of each
base on the dorsum sellae and its apex dorsal to the midbrain,
incisural space is divided into sections on neural, cisternal,
just posterior to the pineal gland (Fig. 5.2). The incisura, when
ventricular, cranial nerve, arterial, and venous relationships.
viewed from above after removal of the cerebral hemispheres, is
filled by the midbrain, pons, and cerebellum, and the free edges
skirt the cerebral peduncles, either touching or being separated
from them by a variable distance (Fig. 5.2). The amount of ANTERIOR INCISURAL SPACE
cerebellar cortex visible between the midbrain and the free edge
varies from none when the free edge hugs the tectum to a large Neural relationships
amount when the incisura extends far posteriorly. When viewed The anterior incisural space is located anterior to the mid-
from below after removal of the cerebellum, the incisura is filled brain and pons. It extends inferiorly between the brainstem
by the midbrain and the uncus and parahippocampal gyrus (Fig. and clivus and obliquely forward and upward around the
5.4). The amount of parahippocampal gyrus visible from below optic chiasm to the subcallosal area. It opens laterally into
varies from none when the free edge hugs the tectum to a large the medial part of the Sylvian fissure, and posteriorly be-
amount when the incisura is very wide. The width of the inci- tween the uncus and the brainstem into the middle incisural
sura varies from 26 to 35 mm (average, 29.6 mm) and the space (Figs. 5.3 and 5.4).
anteroposterior diameter varies from 46 to 75 mm (average, 52.0 The part of the anterior incisural space located below the
mm) (17). optic chiasm has posterolateral and posterior walls. The pos-
The area between the brainstem and the free edges is di- terolateral wall is formed by the bulbous prominence of the
vided into: an anterior incisural space located in front of the anterior third of the uncus, which hangs over the anterior part

Tentorial Incisura S133
FIGURE 5.2. Tentorial incisura,

superior views. A, the left
cerebrum, above the level of the
cerebral peduncle, has been
removed to expose the anterior,
middle, and posterior incisural
spaces. The thalamus, which forms
the floor of the body of the lateral
ventricle, sits directly above the
central part of the tentorial
incisura. The right lateral ventricle
and the lower wall of the sylvian
fissure have been preserved. The
left half of the tentorium, except
the edge, has been removed to
expose the tentorial cerebellar
surface. The frontal horn is
located above the anterior
incisural space. Structures located
in the anterior incisural space
below the frontal horn include the
optic nerves and chiasm, internal
carotid arteries, and the upper
part of the basilar artery and its
branches. The middle incisural
space, located between the
midbrain and tentorial edge,
opens upward into the crural and
ambient cisterns and downward
into the anterior part of the
cerebellomesencephalic fissure.
The posterior incisural space,
located between the midbrain and
the tentorial apex, includes the
area of the quadrigeminal cistern
and opens into the central part of
the cerebellomesencephalic
fissure. The atrium of the lateral
ventricle is situated lateral to the posterior incisural space. B, view of the tentorial incisura after removing the cerebrum. The
tentorial edges sweep along the lateral margin of the cerebral peduncle. The oculomotor nerve passes medial to the anterior
edge of the tentorium and enters the cavernous sinus by passing through a triangular patch of dura called the oculomotor
trigone. C, superior view of the tentorial incisura before removing the left temporal lobe. The crural cistern is located
between the cerebral peduncle and uncus. The ambient cistern opens upward between the midbrain and the medial surface
of the temporal lobe formed by the parahippocampal and dentate gyri. The thalamus and the genu of the internal capsule are
located above the central part of the tentorial incisura. D, enlarged view after removing the temporal lobe. The internal
capsule and the lentiform nucleus are located above the middle incisural space. The genu of the internal capsule abuts on the
lateral ventricular wall at the level of the foramen of Monro. A., artery; Ant., anterior; Cap., capsule; Car., carotid; Caud.,
caudate; Cist., cistern; CN, cranial nerve; For., foramen; Front., frontal; Incis., incisural; Int., internal; Lent., lentiform; Mid.,
middle; Nucl., nucleus; P.C.A., posterior cerebral artery; Ped., peduncle; Post., posterior; Quad., quadrigeminal; Tent.,
tentorial; Trig., trigone.
of the free edge above the oculomotor trigone (Fig. 5.2). The teriorly by the lamina terminalis, and laterally by the part of the
posterior wall is formed by the pons and cerebral peduncles. The medial surfaces of the frontal lobes located below the rostrum.
infundibulum of the pituitary gland crosses the anterior incisural The anterior incisural space opens laterally into the part of
space to reach the opening in the diaphragma sellae. The part of the Sylvian fissure situated below the anterior perforated
the anterior incisural space situated above the optic chiasm is substance (Fig. 5.4). The anterior limb of the internal capsule,
limited superiorly by the rostrum of the corpus callosum, pos- the head of the caudate nucleus, and the anterior part of the

S134 Rhoton
FIGURE 5.3. Stepwise dissection of the neural structures above the tentorial incisura. A, the coronal section of the right
hemisphere crosses vertically through the thalamus and lateral geniculate body and the transverse section crosses the cere-
bral peduncle. The right temporal horn has been opened to expose the hippocampus and amygdaloid nucleus. The floor of
the third ventricle is exposed in the midline. The coronal section of the left hemisphere crosses anterior to the thalamus near
the foramen of Monro and genu of the internal capsule. The anterior incisural space extends from the interpeduncular fossa,
around the chiasm, and into the suprachiasmatic area. B, the right thalamus has been removed while preserving the fornix,
which wraps around the thalamus to form the outer edge of the choroidal fissure situated between the thalamus and fornix.
The middle incisural space extends upward into the ambient and crural cisterns. The crural cistern is located between the
uncus and the cerebral peduncle. The ambient cistern in located between the parahippocampal and dentate gyri and the fim-
bria of the fornix laterally and the midbrain medially. The posterior part of the tentorial edge is exposed. The quadrigeminal
cistern is located in the posterior incisural space between the tentorial apex and the pineal. The atrium is located lateral to
the quadrigeminal cistern and posterior incisural space. C, enlarged view. The coronal section through the left hemisphere
has been extended backward to the level of the thalamus and posterior limb of the internal capsule. The left temporal horn is

lentiform nucleus are located above the anterior perforated From the chiasm, the optic tract continues in a posterolateral
substance (Fig. 5.2). direction around the cerebral peduncle to enter the middle
incisural space (Fig. 5.4). The oculomotor nerve emerges from
the midbrain on the medial surface of the cerebral peduncle.
Cisternal relationships
It crosses the anterior incisural space between the posterior
The interpeduncular cistern, which sits in the posterior part cerebral artery (PCA) and the superior cerebellar artery (SCA)
of the anterior incisural space between the cerebral peduncles and passes inferomedial to the uncus to enter the roof of the
and the dorsum sellae, communicates laterally with the Syl- cavernous sinus through the oculomotor trigone. The abdu-
vian cistern below the anterior perforated substance and an- cens nerve ascends from deep within the infratentorial part of
teriorly with the chiasmatic cistern located below the optic chi- the anterior incisural space. It emerges from the pontomedul-
asm. The interpeduncular and chiasmatic cisterns are separated lary sulcus, ascends in the prepontine cistern to pierce the
by Liliequist’s membrane, an arachnoidal sheet extending from dura covering the clivus, and passes below the petrosphenoid
the dorsum sellae to the anterior edge of the mammillary bodies ligament to enter the cavernous sinus.
(14, 35, 36). The chiasmatic cistern communicates around the
optic chiasm with the cisterna laminae terminalis, which lies
anterior to the lamina terminalis. Arterial relationships
The arterial relationships of the anterior incisural space are
Ventricular relationships complex because it contains all of the components of the circle
The anterior part of the third ventricle projects into the of Willis (4, 5, 7, 18, 19, 27, 37). The internal carotid artery
anterior incisural space in the medial plane, dividing it into enters the anterior incisural space by passing along the medial
supra and infra chiasmatic portions. The frontal horns of the surface of the anterior clinoid process and bifurcates below
lateral ventricles are located above the anterior incisural space the anterior perforated substance (Figs. 5.5 and 5.6). The pos-
(Figs. 5.1–5.3). The tip of the temporal horn is separated from terior communicating artery arises from the posteromedial
the uncal surface, forming the posterolateral wall of the ante- aspect of the carotid artery and courses superomedial to the
rior incisural space, by the amygdaloid nucleus. oculomotor nerve to join the PCA in the anterior incisural
space. The anterior choroidal artery originates from the pos-
terior surface of the carotid artery 0.1 to 3.0 mm distal to the
Cranial nerves origin of the posterior communicating artery and courses below
The optic and oculomotor nerves and the posterior part of the optic tract before passing between the uncus and the cerebral
the olfactory tracts pass through the anterior incisural space. peduncle to enter the middle incisural space (3, 24).
Each olfactory tract runs posteriorly, and splits just above the The proximal part of the anterior cerebral artery also
anterior clinoid process to form the medial and the lateral courses in the anterior incisural space (Fig. 5.6). It arises below
olfactory striae, which course along the anterior margin of the the anterior perforated substance and courses anteromedially
anterior perforated substance (Fig. 5.4). above the optic chiasm, where it is joined to its mate from the
The optic nerves and chiasm and the anterior part of the opposite side by the anterior communicating artery. It then
optic tracts cross the anterior incisural space (Fig. 5.3). The courses upward in front of the lamina terminalis. The middle
optic nerves emerge from the optic canal medial to the attach- cerebral artery courses laterally from its origin below the
ment of the free edge to the anterior clinoid processes, and are anterior perforated substance. The major bifurcation of the
directed posteriorly, superiorly, and medially toward the op- middle cerebral artery is usually located in the lateral part of
tic chiasm. The optic chiasm is usually located above the the anterior incisural space.
diaphragma sellae, but it may be prefixed and lie over the The basilar artery ascends and gives rise to the PCA and
tuberculum sellae or postfixed and lie over the dorsum sellae. SCA in the posterior part of the anterior incisural space be-
Š
exposed below the basal ganglia. The optic nerves, chiasm, and tracts, and the oculomotor nerves cross the anterior incisural
space. The middle incisural space extends into the ambient and crural cisterns, and the posterior incisural space, located in
front of the tentorial apex, contains the quadrigeminal cistern. D, the upper parts of the anterior and middle incisural spaces
have been exposed by removing the thalami on both sides. The tentorial edges extend forward from the apex, located at the
posterior margin of the pineal region, along the side of the midbrain to attach to the petrous ridge and clinoid processes. E,
the temporal lobe has been sectioned in a coronal plane and the third ventricular floor has been removed. The lateral wall of
the ambient cistern is formed by the parahippocampal and dentate gyri and the fimbria of the fornix. F, enlarged view. The
rounded medial edge of the parahippocampal gyrus, the site of the subiculum, which blends into the hippocampus, joins the
dentate gyri and fimbria to form the lateral wall of the ambient cistern. The fimbria arises on the hippocampal surface. A.,
artery; Amyg., amygdaloid; Ant., anterior; Cap., capsule; Car., carotid; Chor., choroid; Cist., cistern; CN, cranial nerve; Coll.,
colliculus; Dent., dentate; Front., frontal; Gen., geniculate; Gyr., gyrus; Incis., incisural; Int., internal; Lat., lateral; Lent., lenti-
form; Nucl., nucleus; Parahippo., parahippocampal; Ped., peduncle; Plex., plexus; Quad., quadrigeminal; Sulc., sulcus; Temp.,
temporal; Tent., tentorial; Vent., ventricle.

S136 Rhoton
FIGURE 5.4. Neural relationships

above the tentorial incisura.
Stepwise dissection viewed from
below. A, the anterior incisural
space extends forward from the
interpeduncular fossa below the
floor of the third ventricle and
around the optic chiasm to the
lamina terminalis. The middle
incisural space extends upward
into the crural cistern located
between the uncus and cerebral
peduncle and the ambient cisterns
located between the lateral
midbrain and the temporal lobe.
The posterior incisural space is
located behind the midbrain and
includes the quadrigeminal cistern
and pineal region. The anterior
part of the tentorial edge has
grooved the uncus. B, the medial
edge of the parahippocampal
gyrus has been removed to expose
the roof of the ambient cistern
formed by the lower surface of
the thalamus and the geniculate
bodies. The optic tract extends
posteriorly in the roof of the
crural cistern and terminates in
the lateral geniculate body
located in the anterior part of the
roof of the ambient cisterns. The
dentate gyrus and the fimbria of
the fornix are located in the
lateral margin of the ambient
cistern above the
parahippocampal gyrus. C, the
part of the parahippocampal gyrus
below the temporal horn has been
removed while preserving the
fimbria of the fornix. The choroid
plexus in the temporal horn is
attached along the choroidal
fissure located between the
fimbria and the thalamus. D, all but the upper part of the left temporal lobe and fimbria has been removed. The optic tract
extends posteriorly through the crural cistern to the anterior part of the ambient cistern where it terminates in the lateral
geniculate body. The posterior incisural space between the midbrain and the tentorial apex borders the atrium laterally.
Amyg., amygdaloid; Ant., anterior; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Dent., dentate; Fiss., fissure; Gen.,
geniculate; Gyr., gyrus; Interped., interpeduncular; Lat., lateral; Med., medial; Nucl., nucleus; Olf., olfactory; Parahippo.,
parahippocampal; Ped., peduncle; Perf., perforated; Pit., pituitary; Plex., plexus; Quad., quadrigeminal; Subst., substance; Temp.,
temporal; Tent., tentorial; Tr., trunk.
tween the posterior perforated substance and the clivus (Fig. incisural space by coursing between the uncus and the cere-
5.7). The position of the basilar tip and bifurcation varies from bral peduncle. The SCA originates in the anterior incisural
as far caudal as 1.3 mm below the pontomesencephalic sulcus space below the PCA and courses laterally below the oculo-
to as far rostral as the mammillary bodies (17). The PCA motor nerve (Fig. 5.7). The origin is usually just rostral to the
courses laterally around the cerebral peduncle, above the level of the free edge. It dips below the tentorium to reach the
oculomotor nerve. It exits the anterior and enters the middle superior surface of the cerebellum at the junction of the ante-

FIGURE 5.5. Tentorial incisura. A,

view from below of the cisterns
bordering the tentorial incisura.
The middle incisural space opens
upward into the crural cistern
located between the uncus and
peduncle and the ambient cistern
located between the
parahippocampal gyrus and the
lateral surface of the brainstem.
The PCAs course through the
crural and ambient cisterns to
reach the posterior incisural
space, the site of the
quadrigeminal cistern. The basal
vein accompanies the PCA in the
upper part of the crural and
ambient cisterns and empties into
the vein of Galen in the
quadrigeminal cistern. The medial
posterior choroidal arteries course
around the brainstem on the
medial side of the PCAs with the
long circumflex perforating
branches. B, the medial part of
the right temporal lobe has been
removed to expose the temporal
horn. The fimbria of the fornix,
which arises on the upper surface
of the hippocampus and forms the
lower margin of the choroidal
fissure, has been preserved. The
thalamus, geniculate bodies, and
optic tract are in the roof of the
crural and ambient cisterns. C, the right PCA has been removed. The basal vein passes backward above the PCA and empties
into the vein of Galen with the internal cerebral and internal occipital veins. The lower surface of the thalamus, the
geniculate bodies, and the optic tract form the roof of the crural and ambient cisterns. The anterior choroidal artery passes
posteriorly above the uncus and through the choroidal fissure to supply the choroid plexus in the temporal horn. D, both
PCAs have been removed to expose the roof of the middle incisural space on both sides and the basal veins, which drain the
neural structures in the region. A., artery; Ant., anterior; Car., carotid; Cer., cerebral; Chor., choroid, choroidal; Cist., cistern;
CN, cranial nerve; Fiss., fissure; Gen., geniculate; Gyr., gyrus; Incis., incisural; Int., internal; Lat., lateral; Med., medial; Mid.,
middle; Occip., occipital; Parahippo., parahippocampal; P.C.A., posterior cerebral artery; Plex., plexus; Post., posterior;
Quad., quadrigeminal; Temp., temporal; V., vein.
rior and middle incisural spaces. The structures in the walls of MIDDLE INCISURAL SPACE
the anterior incisural space receive perforating branches from
all of the above arteries. Neural relationships
The middle incisural space is located lateral to the brain-
Venous relationships stem (Figs. 5.3 and 5.4). This narrow space extends upward
The main venous trunk related to the anterior incisural between the temporal lobe and the midbrain and down-
space is the basal vein (Figs. 5.5 and 5.6) (16). It courses ward between the cerebellum and the upper brainstem. It has
through the anterior, middle, and posterior incisural spaces to medial and lateral walls and a roof. The medial wall, formed
empty into the vein of Galen. It originates below the anterior by the lateral surface of the midbrain and upper pons, is divided
perforated substance, courses posterolaterally around the ce- by the pontomesencephalic sulcus, which lies at the level of the
rebral peduncle, below the optic tract and medial to the un- free edge. The surface of the midbrain facing the middle inci-
cus, to enter the middle incisural space. sural space is divided into a larger anterior part formed by the

S138 Rhoton
FIGURE 5.6. Superior views of

the anterior, middle, and posterior
incisural spaces. A and B are from
one specimen and C is from
another. A, the basal cisterns in
the region of the tentorial incisura
have been exposed by removing
the thalamus and all of the left
cerebral hemisphere except the
occipital and temporal lobes. The
roof of the temporal horn has
been removed. The structures
related to the anterior incisural
space, located between the
tuberculum sellae anteriorly, the
midbrain posteriorly, and the
anterior tentorial edge laterally,
includes the optic nerve and
chiasm, and the internal carotid,
basilar, superior cerebellar, and
PCAs. The anterior incisural space
opens posteriorly into the middle
incisural space, which extends
into the crural and ambient
cisterns. The crural cistern is located between the cerebral peduncle and the
uncus, and the ambient cistern is located between the lateral midbrain and
the medial surface of the temporal lobe. The ambient cistern opens posteriorly
into the posterior incisural space, which contains the quadrigeminal cistern.
The basal vein and the PCA and SCA pass around the midbrain in the middle
incisural space to reach the posterior incisural space and quadrigeminal
cistern. B, enlarged view. The preserved tentorial edge is exposed between the
basal vein and trochlear nerve. C, superior view of the middle and posterior
incisural space in another specimen. The basal vein courses through the crural
and ambient cisterns. The upper lip of the calcarine sulcus has been removed
but the lower lip of the sulcus has been preserved. The calcarine branch of
the PCA loops laterally into the calcarine sulcus, which extends so deeply
into the medial part of the hemisphere that it forms a prominence, the calcar
avis, in the lower part of the medial wall of the atrium. A., artery; A.C.A.,
anterior cerebral artery; Ant., anterior; Car., carotid; Calc., calcarine; Cer.,
cerebral; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Comm.,
communicating; Gyr., gyrus; Incis., incisural; Int., internal; Interped.,
interpeduncular; M.C.A., middle cerebral artery; Mid., middle; Parahippo.,
parahippocampal; P.C.A., posterior cerebral artery; Plex., plexus; Post.,
posterior; Quad., quadrigeminal; Sulc., sulcus; Temp., temporal; Tent.,
tentorial; V., vein.
cerebral peduncle and a smaller posterior part formed by the wider posterior part formed by the inferior surface of the
tegmental surface. The optic tract forms a smooth white band at thalamus (Fig. 5.4). The lateral geniculate body protrudes
the upper edge of the cerebral peduncle that stands in sharp from the lower surface of the thalamus just behind the uncus.
contrast to the vertically striated surface of the peduncle. The The medial geniculate body bulges into the roof posterome-
peduncular and tegmental surfaces are separated by the lateral dial to the lateral geniculate body just behind the lateral
mesencephalic sulcus, a vertical groove that extends from the mesencephalic sulcus.
pulvinar above to the pontomesencephalic sulcus below. The lateral wall of the supratentorial part of the middle
The roof of the middle incisural space has a narrow anterior incisural space is composed of the hippocampal formation on
part formed by the posterior part of the optic tract that is the medial surface of the temporal lobe (Figs. 5.3 and 5.4). The
flattened between the cerebral peduncle and the uncus, and a uncus and parahippocampal gyri, the most inferior structures

FIGURE 5.7. A–D. Anterior and middle incisural space. A, the right temporal lobe has been elevated. The middle incisural
space, located between the lateral surface of the midbrain and the tentorial edge, opens upward into the ambient cistern
where the PCA and basal vein course. The internal carotid artery is exposed in front of the midbrain in the anterior incisural space.
B, enlarged view of the junction of the anterior and middle incisural space. The internal carotid artery, optic nerves, and basilar
bifurcation are located in the anterior incisural space. The oculomotor nerve passes forward between the PCA and SCA.
C, the inferior temporal and fusiform gyri have been removed to expose the lateral edge of the parahippocampal gyrus
above the middle incisural space. The opening into the temporal horn exposes the choroid plexus attached along the
choroidal fissure. The veins draining the roof of the temporal horn empty into the basal vein. D, the choroidal fissure
has been opened by detaching the choroid plexus from the fimbria of the fornix. Opening the fissure exposes the upper
part of the ambient cistern and the branches of the PCA and basal vein. A., artery; Ant., anterior; Bas., basilar; Br.,
branch; Car., carotid; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Comm., communicating; Coll., collicu-
lus; Fiss., fissure; Gen., geniculate; Gyr., gyrus; Inf., inferior; Lat., lateral; Med., medial; Mes., mesencephalic; Para-
hippo., parahippocampal; P.C.A., posterior cerebral artery; Ped., peduncle; Plex., plexus; Post., posterior; S.C.A., supe-
rior cerebellar artery; Sup., superior; Temp., temporal; Tent., tentorial; V., vein; Vent., ventricular.
in this part of the lateral wall, form a curved border around our specimens, these grooves were commonly present on the
the middle incisural space. The uncus bulges medially at the uncus and adjacent part of the parahippocampal gyrus without
anterior end of the parahippocampal gyrus. The amygdaloid being observed on the posterior part of the parahippocampal
nucleus is situated just lateral to the medial surface of the gyrus, but they were only rarely present posteriorly, and not
uncus and just anterior to the tip of the temporal horn. anteriorly (17). The distance from the most medial point of the
The uncus commonly prolapses into the incisura anteriorly uncus to this groove varied from 2 to 8.6 mm (average, 4.4 mm).
and has a groove along its undersurface marking the free edge Howell reported that these grooves may measure up to 15 mm
(Fig. 5.4). This groove usually disappears at the lateral margin in length and lie as far as 10 mm from the medial tip of the uncus
of the peduncle, because the free edge often hugs the pedun- (10). Klintworth (12, 13) noted unilateral uncal grooving in 88.4%
cle at this site, but it may reappear posterior to the peduncle of brains and bilateral grooving in 80%.
on the lower surface of the parahippocampal gyrus as the Posterior to the uncus, the surface of the temporal lobe
space between the brainstem and the free edge increases. In facing the middle incisural space is formed by three longitu-

S140 Rhoton
FIGURE 5.7. E–H. E, anterior and middle incisural space, enlarged view. The opening through the choroidal fissure exposes
the basal vein and branches of the PCA in the upper part of the ambient cistern. The PCA gives off numerous branches to the
choroid plexus, including a large lateral posterior choroidal artery. F, the hippocampus and the medial part of the temporal
lobe, including the parahippocampal gyrus, have been removed to expose the upper part of the middle incisural space. The
PCA and basal vein course through the middle incisural space on the medial side of the parahippocampal gyrus, which has
been removed. The choroid plexus remains attached along the choroidal fissure located between the fimbria and the lower
surface of the thalamus. The inferior ventricular veins drain the roof of the temporal horn and empty into the basal vein. G,
the branches of the PCA have been removed to expose the basal vein, which originates below the anterior perforated sub-
stance and courses posteriorly through the middle incisural space to gain access to the posterior incisural space and the
quadrigeminal cistern. The pulvinar and lower surface of the thalamus, including the geniculate bodies, are in the upper mar-
gin of the exposure. H, the basal vein has been removed. This exposes the lateral aspect of the cerebral peduncle and the teg-
mental part of the midbrain, which are separated by the lateral mesencephalic sulcus. The medial and lateral geniculate bod-
ies protrude downward from the lower surface of the thalamus.
dinal strips of neural tissue, one located above the other, phalic fissure, located between the anterosuperior part of the
which are interlocked with the hippocampal formation to cerebellum and the lateral surface of the tegmentum.
make an important part of the limbic system (Figs. 5.3 and
5.4). The most inferior strip is formed by the rounded medial
edge of the parahippocampal gyrus; the middle strip is Cisternal relationships
formed by the dentate gyrus, a serrated or beaded strip of The supratentorial part of the middle incisural space con-
gray matter located on the medial surface of the hippocampal tains the crural and ambient cisterns (Figs. 5.2–5.6). The crural
formation; and the superior strip is formed by the fimbria cistern, located between the cerebral peduncle and the uncus,
of the fornix, a white band formed by the fibers emanating is a posterolateral extension of the interpeduncular cistern. The
from the hippocampal formation that are directed posteriorly crural cistern opens posteriorly into the ambient cistern, demar-
into the crus of the fornix. cated medially by the midbrain, above by the pulvinar, and
The middle incisural space extends below the tentorium to laterally by the parahippocampal and dentate gyri and fim-
communicate with the anterior part of the cerebellomesence- bria of the fornix. The ambient cistern is continuous pos-

teriorly with the quadrigeminal cistern, the major cistern in central part of the incisura. They sit on and are separated from
the posterior incisural space. The ambient cistern extends the central part of the incisura by the thalamus.
below the free edge into the part of the cerebellomesence-
phalic fissure located above the origin of the trigeminal nerve.
Cranial nerves
The trochlear and trigeminal nerves are related to the middle
Ventricular relationships incisural space (Fig. 5.8). The trochlear nerve has the longest
The temporal horn extends into the medial part of the course within the incisura of any nerve and is the cranial nerve
temporal lobe lateral to the middle incisural space and ends most intimately related to the free edge. The trochlear nerve arises
approximately 3 cm from the temporal pole (Figs. 5.2–5.7). The below the inferior colliculus in the posterior incisural space
choroidal fissure, located between the fimbria of the fornix and passes forward through the middle incisural space be-
and the lower surface of the thalamus, is the site of attach- tween the PCA and SCA. Its initial course around the mid-
ment of the choroid plexus in the temporal horn. The paired brain is medial to the free edge in the space between the
bodies of the lateral ventricles are located directly above the tectum and cerebellum. It reaches the lower margin of the free
FIGURE 5.8. Anterior and middle subtemporal exposure of the anterior and adjacent part of the middle incisural space. A,
the craniotomy flap and dural opening exposes the temporal lobe and the floor of the middle cranial fossa. The insert shows
the site of the scalp incision. B, the temporal lobe has been elevated to expose the PCA and SCA in the anterior and middle
incisural space. The PCA passes above and the SCA below the oculomotor nerve. The SCA branches course with the trochlear
nerve around the side of the brainstem. C, the PCA has been depressed to expose the basilar artery. The anterior choroidal
artery arises in the anterior incisural space and passes between the cerebral peduncle and uncus to enter the crural cistern in
the middle incisural space. D, the tentorium has been divided behind the petrous ridge to expose the SCA and the trigeminal
and trochlear nerves in the region of the middle incisural space. The SCA sends branches above the trigeminal nerve and into
the anterior part of the cerebellomesencephalic fissure. The medial posterior choroidal artery also passes around the lateral
side of the brainstem. A., artery; Ant., anterior; Bas., basilar; Br., branch; Car., carotid; Chor., choroidal, CN, cranial nerve;
Comm., communicating; Fiss., fissure; M.C.A., middle cerebral artery; Med., medial; P.C.A., posterior cerebral artery; Ped.,
peduncle; Post., posterior; S.C.A., superior cerebellar artery; Temp., temporal; Tent., tentorial.

S142 Rhoton
edge at the posterior edge of the cerebral peduncle. It pierces inar to reach the posterior incisural space. It may infrequently
the free edge in the posterior part of the oculomotor trigone terminate in a tentorial sinus in the free edge at this level.
and runs for a short distance in the anterior petroclinoid fold
before entering the lateral wall of the cavernous sinus. POSTERIOR INCISURAL SPACE
The trigeminal nerve courses in the infratentorial part of the
middle incisural compartment. It arises on the anterolateral Neural relationships
aspect of the mid pons and passes above the petrous apex to
The posterior incisural space lies posterior to the midbrain
enter Meckel’s cave (the arachnoidal and dural cavern) where
and corresponds to the pineal region (Figs. 5.1–5.4) (33). It has
it separates into the three sensory divisions (6). The medial
a roof, floor, and anterior and lateral walls, and extends
edge of the posterior trigeminal root is observed just medial to
backward to the level of the tentorial apex. The quadrigeminal
the tentorial edge if one looks from straight superior through the
plate is located at the center of the anterior wall. The anterior
incisura with the cerebrum removed, but it is hidden below
wall rostral to the colliculi is formed by the pineal body. The
the free edge in the lateral view provided by the subtemporal
habenular commissure forms the upper half and the posterior
operative exposure.
commissure forms the lower half of the attachment of the pineal
body to the posterior part of the third ventricle. The part of the
Arterial relationships anterior wall below the colliculi is formed in the midline by the
The major arteries in the middle incisural space, the ante- lingula of the vermis and laterally by the superior cerebellar
rior choroidal, PCA, and SCA, arise in the anterior incisural peduncles as they ascend beside the lingula.
space and reach the middle incisural space by coursing The roof of the posterior incisural space is formed by the
around the brainstem parallel to the free edge (Figs. 5.5–5.8). lower surface of the splenium, the terminal part of the crura of
The anterior choroidal artery enters the superior part of the the fornices, and the hippocampal commissure (Figs. 5.1 and
middle incisural space below the optic tract and passes 5.4). Each crus arises as a continuation of the fimbria, passes
through the choroidal fissure near the inferior choroidal point around the posterior margin of the pulvinar, and blends into
to supply the choroid plexus in the temporal horn. the lower margin of the splenium. The hippocampal commis-
The PCA enters the middle incisural space between the sure is an oblique band of fibers that courses below the
cerebral peduncle and uncus and passes straight posteriorly splenium between the medial margins of the crura. The floor
between the tegmentum and subiculum (Figs. 5.6 and 5.8). It of the posterior incisural space is formed by the anterosuperior
gives off several cortical branches, which cross the free edge to part of the cerebellum and consists of the culmen of the vermis
reach the inferior surface of the temporal and occipital lobes, in the midline and the quadrangular lobules of the hemispheres
and the lateral posterior choroidal and thalamogeniculate ar- laterally. The posterior incisural space extends inferiorly into the
teries, which course medial to the free edge. The lateral pos- cerebellomesencephalic fissure.
terior choroidal arteries, arising in the middle incisural space, Each lateral wall is formed by the pulvinar, crus of the
course superolaterally through the choroidal fissure and fornix, and the medial surface of the cerebral hemisphere.
around the pulvinar to reach the choroid plexus in the tem- The anterior part of the lateral wall is formed by the part
poral horn and atrium (Fig. 5.7). The medial posterior choroi- of the pulvinar located just lateral to the pineal body. The
dal artery arises from the proximal part of the PCA in the lateral wall, posterior to the pulvinar, is formed by the seg-
anterior incisural space and courses parallel and medial to ment of the crus of the fornix that wraps around the posterior
the PCA through the middle incisural space to reach the margin of the pulvinar (Fig. 5.1). The posterior part of the
posterior incisural space (Fig. 5.5). The thalamogeniculate lateral walls is formed by the cortical areas located below
branches arise below the pulvinar and pass upward through the splenium on the medial surface of the hemisphere. These
the geniculate bodies to reach the thalamus and internal areas include the posterior part of the parahippocampal and
capsule. dentate gyri. The posterior part of the parahippocampal gyrus
The SCA usually passes below the level of the free edge and usually extends medially above the posterior part of the free
bifurcates into rostral and caudal trunks as it passes around edge and may have shallow grooves from the free edge on its
the lateral margin of the cerebral peduncle to enter the middle lower surface.
incisural spaces (Figs. 5.7 and 5.8). It passes above the trigem-
inal nerve and enters the cerebellomesencephalic fissure in Cisternal relationships
the anterior part of the middle incisural space. The walls
The quadrigeminal cistern, situated posterior to the quad-
of the supratentorial part of the middle incisural space are
rigeminal plate, is the major cistern in the posterior incisural
supplied by the perforating branches of the anterior choroidal
space (Figs. 5.1–5.4). The quadrigeminal cistern communicates
and PCA, and the walls in the infratentorial part are supplied
above with the posterior pericallosal cistern; inferiorly into
by the SCA.
the cerebellomesencephalic fissure; inferolaterally into the
posterior part of the ambient cistern located between the
Venous relationships midbrain and the parahippocampal gyrus; and laterally into
The venous relationships in the middle incisural space are the retrothalamic areas medial to where the crus of the fornix
relatively simple (Figs. 5.5–5.7). The basal vein courses along wraps the posterior part of the pulvinar. The quadrigeminal
the upper part of the cerebral peduncle and below the pulv- cistern may communicate with the velum interpositum, a

space that extends forward into the roof of the third ventricle phalic fissure, originates from the union of the paired veins of
between the splenium above and the pineal body below. the superior cerebellar peduncle.
Ventricular relationships Tentorial arteries

The posterior portion of the third ventricle and the cerebral The tentorial arteries arise from three sources (8). The
aqueduct are anterior and the atria and occipital horns of the first source, the cavernous segment of the carotid artery,
lateral ventricles are lateral to the posterior incisural space provides two arteries: the basal tentorial artery (the artery of
(Figs. 5.2–5.4). The aqueduct passes ventral to the anterior Bernasconi-Cassinari) from the meningohypophyseal trunk,
wall of the posterior incisural space. The atrium is separated and the marginal tentorial artery from the artery from the
from the posterior incisural space by the crus of the fornix as inferolateral trunk (also called the artery of the inferior cav-
it passes posterior to the pulvinar and by the cortical gyri ernous sinus). The basal tentorial artery arises from the me-
located in the lateral wall of the posterior incisural space. ningohypophyseal trunk and courses posterolaterally along
the medial part of the tentorial attachment to the petrous
ridge. The marginal tentorial artery arises from the inferolat-
Arterial relationships
eral trunk, passes laterally over the abducens nerve, then
The trunks and branches of the PCA and SCA enter the superoposteriorly near the trochlear nerve to enter the tento-
posterior incisural space from anteriorly (Figs. 5.5 and 5.6). rial edge. If this artery is absent, a branch from the meningo-
The PCA courses through the lateral part of the posterior hypophyseal artery may replace it (8, 28, 32).
incisural space and bifurcates into the calcarine and parieto- The second source of tentorial arteries is from the SCA. The
occipital arteries near where it crosses above the free edge. meningeal branch originates from the main or rostral trunk
The medial posterior choroidal arteries enter the posterior near where the artery passes under the tentorium, and it
incisural space from anteriorly, turn forward beside the pineal enters the free edge in the middle incisural space. In our
body, and enter the velum interpositum to supply the choroid specimens, 28% of the SCAs gave rise to a tentorial branch,
plexus in the roof of the third ventricle and the body of the and such a vessel may be encountered when the tentorium is
lateral ventricle. The lateral posterior choroidal arteries that divided through a subtemporal approach (17).
arise in the posterior incisural space pass around the postero- The third source is the proximal part of the PCA. The
medial surface of the pulvinar and through the choroidal tentorial branch of the PCA arises as a long circumflex artery
fissure to supply the choroid plexus in the atrium, giving that courses around the brainstem and below the free edge to
branches to the thalamus along the way. enter the tentorium near the apex (17, 37). This artery may
The SCA is coursing within the cerebellomesencephalic also give branches to the superior vermis and inferior
fissure when it reaches the posterior incisural space. These colliculi.
branches, upon exiting the cerebellomesencephalic fissure, are
anterior to the free edge, but they pass below the free edge to
DISCUSSION
supply the tentorial surface of the cerebellum (Fig. 5.2).
The perforating branches of the PCA and SCA, and the Tentorial herniation
medial posterior choroidal arteries supply the walls of the
posterior incisural space. The PCAs supply the structures Tentorial herniation is the most common and most impor-
above the level of the lower margin of the superior colliculi tant form of brain herniation (10, 12, 15). In descending her-
and the SCAs supply the structures below the upper margin niation caused by supratentorial mass lesions, the uncus and
of the inferior colliculus. parahippocampal gyri herniate downward through the inci-
sura, and in ascending herniation resulting from infratentorial
masses, the superior part of the cerebellum may herniate
Venous relationships upward through the incisura. These brain herniations may
The posterior incisural space has the most complex venous cause combinations of direct effects caused by neural com-
relationships in the cranium, because the internal cerebral and pression and indirect effects caused by vascular compromise.
basal veins and many of their tributaries converge on the vein Symptoms may result from displacement, compression, and
of Galen within this area (Figs. 5.1, 5.5, and 5.6). The internal stretching of the brainstem and cranial nerves, hemorrhage
cerebral veins exit the velum interpositum and the basal veins and infarction caused by compression and tearing of arteries
exit the ambient cistern to reach the posterior incisural space, and veins, increasing edema and intracranial pressure caused
where they join to form the vein of Galen. The vein of Galen by venous obstruction, hydrocephalus caused by obstruction
passes below the splenium to enter the straight sinus at the of the aqueduct and subarachnoid space at the incisura, and
tentorial apex. The junction of the vein of Galen with the strangulation of the prolapsed tissue.
straight sinus varies from being nearly flat if the tentorial apex The type of the tentorial herniation in each case depends on
is located below the splenium to forming a sharp angle if the the position and rate of expansion of the lesion and the size
apex is located above the splenium, so that the vein of Galen and shape of the incisura. The signs appear early when struc-
must turn sharply upward to reach the straight sinus at the tures are deformed rapidly, whereas advanced distortion may
apex. The largest vein from the infratentorial part of the occur before the appearance of signs if the herniation devel-
posterior incisural space, the vein of the cerebellomesence- ops slowly. A wide space between the free edge and brain-

S144 Rhoton
stem facilitates cerebral herniation since more tissue can her- tral thalamic nuclei. Brainstem hemorrhage frequently accom-
niate into the space (20). A low position of the anterior portion panies tentorial herniation.
of the free edge also facilitates descending herniation (20). In the posterior type of tentorial herniation, the posterior
Descending herniations are divided into anterior, posterior, portion of the parahippocampal and lingual gyri and the
and complete types. In the anterior type, the uncus herniates isthmus of the cingular gyrus may shift through the incisura
into the interpeduncular and crural cisterns. This shift carries into the quadrigeminal cistern and compress and displace the
the brainstem to the opposite side, thus increasing the space dorsal half of the midbrain. Tectal compression may cause
between the free edge and the brainstem, and facilitating a vertical gaze disturbances. Compression and obstruction of
further shift of tissue through the aperture. Eventually, the the aqueduct causes hydrocephalus and raises the intracranial
parahippocampal gyrus, from the splenium to the uncus, may pressure. In the posterior type of herniation, the PCA or its
be forced through the opening and the incisura becomes calcarine branch is pressed against the free edge and may be
plugged with herniated temporal lobe, deformed hypothala- obstructed, causing infarction of the occipital cortex and
mus, and compressed midbrain. The amygdaloid nucleus is hemianopsia. The basal vein may be compressed between the
involved with the uncus in the herniated mass. Distortion and midbrain and herniated temporal lobe, and the vein of Galen
compression of the midbrain reticular activating pathways may be obstructed as it curves around the splenium, thus
causes a decreased level of consciousness. Compression of the aggravating the venous congestion, edema, and intracranial
ipsilateral cerebral peduncle causes contralateral pyramidal tension. The complete type of herniation yields a combination
signs and, if the lateral displacement of brainstem is severe, of signs and symptoms observed with anterior and posterior
the contralateral cerebral peduncle may be forced against the herniations.
free edge, thus producing a groove on the peduncle called a Hemorrhage into the brainstem as a result of tearing of
Kernohan’s notch, with ipsilateral pyramidal signs (30). In the arteries and veins without cerebral herniation may occur if the
terminal stage, deformation of the midbrain causes decere- incisura hugs the brainstem so tightly that it prevents cerebral
brate rigidity. Distortion and compression of the posterior herniation while allowing axial displacement of the brainstem.
In ascending herniation attributable to a posterior fossa
hypothalamus may cause cardiovascular, respiratory, and
mass lesion, the superior part of the cerebellar vermis and
thermoregulatory disturbances. The pituitary stalk may be
hemispheres herniate upward through the incisura into the
stretched and compressed against the dorsum sellae, causing
quadrigeminal cistern. Cerebellar infarction may result from
diabetes insipidus. The oculomotor nerve courses between the
compression of the branches of the SCA where they pass
medial border of the uncus and the posterior petroclinoidal
under the free edge. The hernia may compress the great
fold, and may be kinked or compressed here or between the
cerebral vein against the splenium, which is fixed above by
PCA and SCA, or it may be stretched as the hernia displaces
the falx, thus increasing the venous congestion, edema, and
the midbrain posteriorly. Initially, the pupilloconstrictor fi-
intracranial pressure.
bers, which are concentrated on the superior surface of the
nerve, are compressed. Later, somatic fibers to the extraocular
muscles are disturbed. In the early stages, irritation of the Pathology and operative approaches
pupilloconstrictor fibers may cause pupillary constriction, but Most aneurysms, many pineal, sellar, parasellar, and third
this usually gives way to a paralytic effect with pupillary ventricular tumors, and some anteriovenous malformations
dilation as the hernia enlarges. The optic tract is displaced are approached through the incisural spaces. The arteries in
medially and downward, but the resulting visual loss is often the incisura have been subject to bypass procedures, and
masked by deepening coma. Compression of the uncus, many operations for trigeminal neuralgia are directed
amygdaloid nucleus, parahippocampal gyrus, and hippocam- through this area. In addition, structures bordering the area
pal formation against the free edge may cause memory, be- have been ablated either at craniotomy or stereotactically for
havior, and personality changes. Residual scarring of the hip- the control of epilepsy. The selection of the best operative
pocampal formation may cause seizures. The trochlear nerve approach for a given lesion of the incisura depends on the
usually escapes involvement in such herniations, but caudal space involved.
displacement of the brainstem may result in a palsy of the
abducens nerve by stretching it in the subarachnoid space or Anterior incisural space
by strangling it in its course around the AICA. Nearly 95% of saccular arterial aneurysms arise within the
Stretching or compression of the anterior choroidal and anterior incisural space. The basic anatomy of the common
PCA between the temporal lobe and the peduncle or obstruc- aneurysms has been reviewed elsewhere by Rhoton (23).
tion of the PCA as it crosses the free edge may cause visual The aneurysms arising from the part of the circle of Willis
field loss caused by ischemia of the optic tract, optic radiation, located anterior to Liliequist’s membrane, and from the inter-
or the lateral geniculate body; contralateral hemiplegia caused nal carotid and middle cerebral artery are most commonly
by involvement of the cerebral peduncle and midbrain; or approached through a frontotemporal (pterional) craniotomy
changes in personality and behavior caused by damage to the (35) (Fig. 5.9). Aneurysms located behind Liliequist’s mem-
amygdaloid nucleus or hippocampal formation; unconscious- brane at the basilar apex in the interpeduncular fossa may be
ness and decerebrate rigidity caused by midbrain ischemia; exposed through either a frontotemporal or subtemporal cra-
and contralateral sensory loss caused by ischemia of the ven- niotomy if they are located above the dorsum sellae (35, 36)

FIGURE 5.9. A–F. Exposure of the anterior incisural space through a frontotemporal craniotomy. A, the insert shows the site of the
craniotomy. The frontal and temporal lobes have been retracted to expose the optic and oculomotor nerves and the anterior and
middle cerebral and posterior communicating arteries. B, the opticocarotid triangle, located between the optic nerve and the
carotid and anterior cerebral arteries, has been opened with gentle retraction to expose the basilar apex and the ipsilateral oculo-
motor nerve passing forward between the PCA and SCA. C, the exposure has been directed medially above the optic chiasm to
expose the region of the anterior communicating artery. D, the frontal lobe has been elevated to expose the contralateral carotid
and anterior and middle cerebral arteries. E, the carotid artery has been elevated to expose the basilar artery apex through the
interval between the carotid artery and oculomotor nerve. The posterior clinoid process blocks access to the basilar artery. F, the
anterior clinoid process and the roof of the cavernous sinus have been removed to provide access to the posterior clinoid process.
The upper dural ring is located at the level of the upper margin of the anterior clinoid process. A., artery; A.C.A., anterior cerebral
artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; Clin., clinoid; CN, cranial nerve; Comm., communicating; Con-
tra., contralateral; Ipsi., ipsilateral; Lam., lamina; M.C.A., middle cerebral artery; P.C.A., posterior cerebral artery; Post., posterior;
S.C.A., superior cerebellar artery; Term., terminalis; V1., first ophthalmic branch, trigeminal nerve.

S146 Rhoton
FIGURE 5.9. G–J. Exposure of the anterior incisural space through a frontotemporal craniotomy. G, the posterior clinoid
process has been removed to increase access to the upper portion of the basilar artery. H, the anterior part of the tentorial
edge has been removed to expose the upper margin of the posterior trigeminal root in Meckel’s cave and to provide
increased access to the upper anterior part of the posterior fossa. The trochlear nerve was preserved in opening the anterior
part of the tentorial edge. I, another dissection in which the anterior clinoid process and roof of the cavernous sinus were
removed to expose the posterior clinoid process in the interval between the carotid anteriorly and the oculomotor posteri-
orly. J, the posterior clinoid was removed to provide increased access to the upper part of the basilar artery.
(Figs. 5.8 and 5.9). Those located below the dorsum or in the commonly stretched around lesions in this area. Hypoplastic
prepontine cistern may require a pretemporal, anterior, or arterial segments in the circle of Willis should not be sacri-
mid subtemporal craniotomy with incision or retraction of the ficed during the exposure because hypoplastic segments have
tentorium (Fig. 5.7). been found to have the same number and size of perforating
Incision and retraction of the tentorium are commonly re- branches as arteries of a normal diameter (23).
quired to gain access to lesions around the incisura. The Tumors arising in or extending into the anterior incisural
incision in the tentorium to expose the interpeduncular and space include pituitary adenomas, craniopharyngiomas, clival
prepontine cisterns is usually located just posterior to the chordomas, meningiomas arising from the tuberculum sellae,
point where the trochlear nerve enters the free edge. The free clivus, and medial part of the sphenoid ridge, gliomas of the
edge may be retracted by means of sutures placed near to it, optic nerve and hypothalamus, some dermoid cysts and ter-
but special care is required to avoid stretching and damaging atomas, and neuromas of the oculomotor nerve. Tumors in
the trochlear nerve in its course inferomedial to and entering the the anterior incisural space may be approached by the bifron-
free edge near the posterior margin of the oculomotor trigone. tal, subfrontal, frontal-interhemispheric, frontotemporal, sub-
The tentorial arteries and venous sinuses may be encountered in temporal, and transsphenoidal routes. Tumors located ante-
sectioning the tentorium (16). Sectioning of the tentorium has rior to Liliequist’s membrane between the optic chiasm and
been used to alleviate pressure on the brainstem caused by large the sellar floor are commonly operated on by the transsphe-
incisural lesions that cannot be removed (2). noidal or subfrontal route. The transsphenoidal approach is
Perforating arteries to the brainstem are at greatest risk in preferred if the tumor extends upward out of an enlarged
approaches to the anterior incisural space, because they are sella turcica and is located above a pneumatized sphenoid

sinus. The subfrontal intracranial approach is reserved for and the petrous apex, gliomas of the temporal lobe and thal-
those tumors in the chiasmatic cistern that are not accessible amus, anteriovenous malformations of the medial temporal
by the transsphenoidal route because they are located entirely lobe, and neuromas of the trochlear and trigeminal nerves.
above the diaphragma sellae, or extend upward out of a The infrequent aneurysms arising in the middle incisural
normal or small sella, or are located above a nonpneumatized space are usually located on the PCA at the origin of its first
(conchal) type of sphenoid sinus. The subfrontal approach major cortical branch or on the SCA at its bifurcation into
permits exposure of the tumor within the anterior incisural rostral and caudal trunks. Bypass operations using vein and
space by four routes: 1) the subchiasmatic approach between arterial grafts have been applied to the trunks and branches of
the optic nerves and below the optic chiasm; 2) the opticoca- the posterior cerebral and superior cerebellar branches in the
rotid route directed between the optic nerve and carotid ar- middle incisural space bordering the incisura. The middle
tery; 3) the lamina terminalis approach directed above the incisural space is exposed in performing amygdalohip-
optic chiasm through a thinned lamina terminalis; and 4) the pocampectomy and temporal lobectomy for epilepsy since
transfrontal-transsphenoidal approach obtained by entering both the amygdalae and hippocampus extend medial to the
the sphenoid sinus and sella through the transfrontal craniot- free edge. The trigeminal nerve is also frequently exposed in
omy (22, 25, 26). The subchiasmatic approach is used if the the middle incisural space in the course of operations for
subchiasmatic opening is enlarged by the tumor. The optico- trigeminal neuralgia.
carotid route is selected if parasellar extension of the tumor Approaches to the middle incisural space include the poste-
widens the space between the carotid artery and the optic rior frontotemporal, subtemporal, temporal-transventricular,
nerve and the tumor cannot be reached by the subchiasmatic and the lateral suboccipital routes (Figs. 5.7 and 5.8). The
approach. The lamina terminalis approach is selected if the subtemporal approach with elevation of the temporal lobe is
tumor has pushed the chiasm into a prefixed position and commonly used to expose lesions in the cisterns around the
extends into the third ventricle to stretch the lamina terminalis incisura. Hemorrhage, venous infarction, and edema follow-
so that the tumor is visible through it. The transfrontal- ing retraction of the temporal lobe during this approach are
transsphenoidal approach is selected if the tumor grows up- minimized by placing the lower margin of the craniotomy and
ward out of the sella, the sphenoid sinus is pneumatized and dural exposure at the cranial base so as to reduce the need for
the tumor does not stretch the lamina terminalis or widen the retraction, and by avoiding occlusion of the bridging veins,
opticocarotid space, and a prefixed chiasm blocks the subchi- especially the vein of Labbé. The tentorium is frequently
asmatic exposure. A bifrontal craniotomy may be used if the divided to increase the exposure or to decompress the brain-
tumor extends forward in both anterior cranial fossae and stem when mass lesions are impacted in the incisura (2).
cannot be reached by a unilateral subfrontal exposure. A Resection of part of the parahippocampal gyrus may facilitate
frontal interhemispheric approach directed along the anterior exposure of the upper part of the middle incisural space (1). A
part of the falx is used for lesions restricted to the part of the transventricular approach using a cortical incision in the non-
anterior interhemispheric space located just below the ros- dominant inferior or middle temporal gyrus may be used if
trum, especially if the tumor arises in the genu or rostrum of the lesion involves the temporal horn, choroidal fissure, hip-
and grows into the anterior incisural space. pocampal formation, or the upper part of the middle incisural
The frontotemporal approach is used for a tumor arising space (9). A cortical incision in the medial occipitotemporal
from the sphenoid ridge or anterior clinoid process, or if it gyrus on the inferior surface of the temporal lobe has been
arises above the diaphragma and extends along the sphenoid used to minimize visual and speech deficits in exposing the
ridge or into the middle cranial fossa, or if the lesion is temporal horn of the dominant hemisphere. After entering
accessible through the spaces between the optic nerve and the temporal horn, the choroidal fissure is opened to expose
carotid artery or between the carotid artery and the oculomo- the middle incisural space. The subtemporal craniectomy may
tor nerve (Fig. 5.9). Some lesions may require that the above be combined with a suboccipital craniectomy with section of
approach be combined with resection of the cranial base if the the tentorium and transverse sinus to remove lesions in the
lesion involves the paranasal sinuses, nasal cavity, pharynx, prepontine or cerebellopontine cisterns. The trochlear nerve is
orbit, or cavernous sinus, and for those extending from the the cranial nerve most frequently injured in the middle inci-
anterior incisural space into the area behind the dorsum sella sural space. It can be injured in dividing the free edge and is
or petrous apex, and those in which the lower opening pro- so thin and friable that it may rupture from gentle retraction
vided by cranial base resection will yield a better angle of exposure on the leaves formed by dividing the tentorium. The above
or reduce the need for brain retraction. These approaches include approaches may be combined with cranial base approaches
the transcranial-transbasal, extended frontal, fronto-orbital, or- involving resection or mobilization of the orbital rim, zygo-
bitozygomatic, transcavernous, preauricular-infratemporal, and matic arch, floor of the middle fossa, or a portion of the
subtemporal anterior petrousectomy, some of which are dis- temporal bone as are accomplished in the orbitozygomatic
cussed more fully in the chapters on the foramen magnum and craniotomy, and the preauricular infratemporal or anterior
temporal bone. petrousectomy approaches.
The posterior trigeminal root is frequently exposed through
Middle incisural space a lateral suboccipital craniectomy in the infratentorial part of
Lesions in the middle incisural space include meningiomas the middle incisural space for rhizotomy or microvascular
arising from Meckel’s cave, the anterior part of the free edge decompression operations. The exposure is directed along the

S148 Rhoton
FIGURE 5.10. A–F. Comparison of the midline and paramedian infratentorial supracerebellar and the occipital transtentorial
approaches to the quadrigeminal cistern and the posterior third ventricle. A–D, views of the third ventricle and quadrigemi-
nal cistern. A, third ventricle from above. The body of the fornix separates the body of the lateral ventricle from the roof of
the third ventricle. The body of the fornix blends posteriorly into the crus of the fornix, which is situated above the posterior
part of the third ventricle. The choroidal fissure, the site of attachment of the choroid plexus, is situated between the fornix
and thalamus. B, the fornix was divided at the level of the columns, just behind the foramen of Monro, and reflected

angle formed by the insertion of the tentorium to the petrous better angle of access for some lesions involving the ipsilateral
ridge. The posterior root proximal to Meckel’s cave has also half of the cerebellomesencephalic fissure and posterior part
been exposed through a subtemporal craniectomy combined of the ambient cistern, although they may be located below
with incision of the tentorium (11). The posterior root may the level of the vein of Galen (21, 34) The posterior transcal-
also be exposed for rhizotomy within Meckel’s cave through losal approach, in which the splenium is divided, would be
a subtemporal extradural approach. used only if the lesion appears to arise in the splenium above
the vein of Galen and extends into the posterior incisural
Posterior incisural space space. The posterior transventricular approach provides ade-
Lesions in the posterior incisural space include pineal tu- quate exposure of the atrium and posterior portion of the
mors; meningiomas arising at the falcotentorial junction and body of the lateral ventricle and would be the preferred
from the tela choroidea of the velum interpositum and atrium; approach to a tumor involving the posterior incisural space if
gliomas of the splenium, pulvinar, quadrigeminal plate, and the tumor extends into the pulvinar or involves the atrium
cerebellum; aneurysms of the vein of Galen; and anterio- or the glomus of the choroid plexus. The preferable approach
venous malformations involving the medial occipital lobe and to the ventricle is through the superior parietal lobule, al-
upper cerebellum. though on approach to the pineal region using a cortical
Lesions in the posterior incisural space may be approached incision in the superior temporal gyrus and directed through
from above the tentorium along the medial surface of the the atrium has been advocated (31).
occipital lobe using an occipital transtentorial approach,
through the posterior part of the lateral ventricle using a
posterior transventricular approach, and through the corpus Comparison of occipital transtentorial and
callosum using a posterior interhemispheric transcallosal ap- infratentorial supracerebellar approaches
proach, or from below the tentorium through the supracer- In examining the posterior incisural space, we compared
ebellar space using an infratentorial supracerebellar approach the midline and paramedian variants of the infratentorial
(Figs. 5.10 and 5.11). The infratentorial supracerebellar and supracerebellar approach and the occipital transtentorial ap-
occipital transtentorial approaches, which are most com- proach (Figs. 5.10 and 5.11). The midline infratentorial suprac-
monly selected for pineal region tumors, may be combined erebellar approach is directed steeply upward over the apex
with incision of the tentorium lateral to the straight sinus and of the vermis where the large complex of veins emptying into
less commonly with division of the tentorium and transverse the vein of Galen, and especially the vein of the cerebellomes-
sinus. A tentorial branch of the PCA or SCA may enter the encephalic fissure, blocks access to the pineal region. The venous
dura lateral to the straight sinus. Venous sinuses are more complex could be gently displaced to expose the lower part of
commonly encountered in the posterior than in the anterior the splenium, the pineal, and the superior colliculus, but the
parts of the tentorium. Part of the tentorium may be removed prominent vermian apex forming the posterior lip of the cerebel-
in resecting tumors that arise from or invade it. lomesencephalic fissure limits exposure below the level of the
The infratentorial supracerebellar approach may be selected superior colliculus. In the paramedian variant of the infratento-
for lesions in the pineal region located below the vein of Galen rial supracerebellar approach, the retraction was advanced
and its major tributaries (29). The approach is best suited to above the hemisphere lateral to the vermis. This approach was
tumors in the midline that grow into the lower half of the not as upwardly steep as the approach above the vermian apex
posterior incisural space, displacing the quadrigeminal plate and provided access to the pineal region, the lower part of the
and apex of the tentorial cerebellar surface. The occipital splenium, and gave greater access to the ipsilateral half of the
transtentorial approach is preferred for lesions centered at or cerebellomesencephalic fissure. In addition, the approach could
above the tentorial edge, especially if they are located above be advanced along the lateral part of the cerebellar surface to
the vein of Galen. The latter approach may also provide a expose the posterior part of the ambient cistern. In the occipital
Š
posteriorly to expose the posterior commissure, pineal, and adjacent part of the quadrigeminal cistern. C, the quadrigeminal
cistern is located behind the pineal and the colliculi and between the pulvinars. It extends into the cerebellomesencephalic
fissure. The trochlear nerves arise below the inferior colliculi. D, view similar to C, except that the vessels have been pre-
served. The internal cerebral and basal veins join the vein of Galen behind the pineal. The PCA and SCA exit the ambient cis-
tern to enter the lateral part of the quadrigeminal cistern. Both the infratentorial supracerebellar and occipital transtentorial
approaches are directed to this area. E and F, midline infratentorial supracerebellar approach. E, the venous complex empty-
ing into the vein of Galen blocks access to the pineal region. This complex includes the internal occipital, basal and internal
cerebral veins, and the vein of the cerebellomesencephalic fissure. A tentorial branch of the SCA crosses the exposure. F, the
vein of Galen has been retracted to expose the splenium. The vein of the cerebellomesencephalic fissure has been retracted
to expose the pineal. A., artery; Bridg., bridging; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Chor., choroidal; Cist.,
cistern; CN, cranial nerve; Coll., colliculus; Comm., communicating; Fiss., fissure; For., foramen; Inf., inferior; Int., internal;
Lat., lateral; Med., medial; Occip., occipital; P.C.A., posterior cerebral artery; Ped., peduncle; Plex., plexus; Post., posterior;
Quad., quadrigeminal; Sag., sagittal; S.C.A., superior cerebellar artery; Str., straight; Sup., superior; Temp., temporal; Tent.,
tentorial; Trans., transverse; V., vein; Ve., vermian; Vent., ventricle.

S150 Rhoton
FIGURE 5.10. G–L. G and H, midline infratentorial supracerebellar approach. G, the left basal and internal cerebral veins have
been elevated and the vein of the cerebellomesencephalic fissure, which is joined by a superior vermian vein, has been retracted to
the right to expose the superior colliculus, pineal, and splenium. H, the tela choroidea attached to the upper surface of the pineal
has been opened to expose the posterior part of the third ventricle. I–L, paramedian variant of the infratentorial supracerebellar
approach. In this variant, the retraction of the tentorial surface is shifted off the vermis and tentorial apex to the paramedian part
of the hemisphere. This paramedian variant of the approach accesses the lateral part of the quadrigeminal cistern and the posterior
part of the ambient cistern and, in addition, provides a better view into the central and ipsilateral half of the cerebellomesence-
phalic fissure than the approach directed in the midline above the vermian apex. I, the retraction for the paramedian approach has
been shifted to the left of the vermis. J, the left internal cerebral and internal occipital veins have been retracted to expose the pos-
terior part of the splenium, the pineal and the superior and inferior colliculi, and the branches of the PCA and SCA exiting the
ambient cistern. K, enlarged view. The exposure has been shifted to where the PCA exits the ambient cistern. L, the paramedian
approach provides easier access to the superior and inferior colliculi and requires less retraction than is needed to expose these
structures in the approach directed in the midline above the apex of the tentorial cerebellar surface.

FIGURE 5.10. M–R. Occipital transtentorial approach. M, the occipital transtentorial is directed along the medial surface of
the occipital lobe below the lambdoid suture. This occipital lobe below the lambdoid suture is commonly free of bridging
veins to the superior sagittal sinus, making it a reasonable route for the occipital transtentorial approach. N, there are no
large bridging veins between the posterior 6 cm of the occipital lobe and superior sagittal sinus. The first vein encountered is
the internal occipital vein that passes from the anterior part of the medial occipital lobe to the vein of Galen. O, the vein of
Galen has been retracted to expose the splenium and pineal from above. P, the tentorium has been opened lateral to the
straight sinus, and the vein of Galen has been displaced to the left side to expose the pineal and the superior and inferior col-
liculi. Q, elevating the branches of the vein of Galen provides a satisfactory view into the quadrigeminal cistern, with a better
view into the cerebellomesencephalic fissure than can be achieved with the infratentorial supracerebellar approach directed
over the apex of the tentorial cerebellar surface. R, the exposure has been directed laterally along the side of the brainstem
to the ambient cistern where the lateral margin of the cerebral peduncle is exposed.

S152 Rhoton
FIGURE 5.11. Comparison of infratentorial supracerebellar, the occipital transtentorial, and the combined supra- and infrat-
entorial approaches. A, infratentorial supracerebellar approach. The approach has been directed between the lower surface
of the tentorium and the tentorial cerebellar surface. The large venous complex draining into the vein of Galen is in the cen-
tral part of the exposure and the PCA and SCA are exposed laterally. A large vein of the cerebellomesencephalic fissure
blocks access to the pineal and limits access to the cerebellomesencephalic fissure. This approach is selected for lesions
located in the midline below the vein of Galen and not extending deeply into the cerebellopontine fissure. The SCA
branches looping around the lip of the cerebellomesencephalic fissure may extend upward and limit access to the pineal
region. B, the vein of the cerebellomesencephalic fissure has to be divided to expose the pineal. The medial posterior
choroidal arteries are intertwined with the veins in the region. C, the occipital transtentorial approach has been
directed along the medial side of the right occipital lobe. The tentorium behind the quadrigeminal cistern has been
divided. The approach provides access to the splenium and the upper part of the cerebellomesencephalic fissure and has
been extended forward to the lateral surface of the cerebral peduncles. Both the superior and inferior colliculi can be
exposed and the arteries can be followed forward into the ipsilateral ambient cistern. In addition, the veins joining the
vein of Galen can be elevated to expose the pineal. The trochlear nerve is exposed just distal to its brainstem exit below
the inferior colliculus. D, combined supra and infratentorial exposure with the division of the transverse sinus and ten-
torium. Division of the transverse sinus, if it is small and well collateralized, provides an exposure that combines both
the supra- and infratentorial approaches. A., artery; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Chor., choroidal;
CN, cranial nerve; Coll., colliculus; Fiss., fissure; Inf., inferior; Int., internal; Med., medial; Occip., occipital; P.C.A., pos-
terior cerebral artery; Ped., peduncle; Post., posterior; S.C.A., superior cerebellar artery; Sup., superior; Temp., tempo-
ral; V., vein.
transtentorial approach, the occipital lobe was retracted and the vided wider access to the midline and ipsilateral half of the
tentorium divided along the edge of the straight sinus. This cerebellomesencephalic fissure than did the midline infratento-
provided access to the splenium above the vein of Galen and, rial supracerebellar approach. In addition, it provided an excel-
with gentle retraction of the venous complex in the posterior lent route for reaching the posterior part of the ambient cistern
incisural space, the pineal and the upper part of the cerebel- and even the lateral surface of the cerebral peduncle in the crural
lomesencephalic fissure could be visualized. The approach pro- cistern. The exposure of the lateral part of the contralateral half

of the quadrigeminal cistern was more limited than could be 17. Ono M, Ono M, Rhoton AL Jr, Barry M: Microsurgical anatomy
achieved with the midline infratentorial supracerebellar ap- of the region of the tentorial incisura. J Neurosurg 60:365–399,
proach. The supra and infratentorial approaches can be con- 1984.
verted into a combined approach by dividing the transverse 18. Perlmutter D, Rhoton AL Jr: Microsurgical anatomy of the ante-
sinus in addition to the tentorium, if the sinus is small and is well rior cerebral-anterior communicating-recurrent artery complex.
collateralized through the opposite side (Fig. 5.11). J Neurosurg 45:259–272, 1976.
19. Perlmutter D, Rhoton AL Jr: Microsurgical anatomy of the distal
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro- anterior cerebral artery. J Neurosurg 49:204–228, 1978.
logical Surgery, University of Florida Brain Institute, P.O. Box 100265, 20. Plaut HA: Size of the tentorial incisura related to cerebral herni-
100 S. Newell Drive, Building 59, L2–100, Gainesville, FL 32610-0265. ation. Acta Radiol (Diagn) 1:916–928, 1963.
21. Poppen JL: The right occipital approach to a pinealoma. J Neuro-
REFERENCES surg 25:706–710, 1966.
22. Renn WH, Rhoton AL Jr: Microsurgical anatomy of the sellar
1. Drake CG: The treatment of aneurysms of the posterior circula- region. J Neurosurg 43:288–298, 1975.
tion. Clin Neurosurg 26:96–144, 1979. 23. Rhoton AL Jr: Anatomy of saccular aneurysms. Surg Neurol
2. Fox JL: Tentorial section for decompression of the brainstem and 14:59–66, 1980.
a large basilar aneurysm: Case report. J Neurosurg 28:74–77, 1968. 24. Rhoton AL Jr, Fujii K, Fradd B: Microsurgical anatomy of the
3. Fujii Y, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the anterior choroidal artery. Surg Neurol 12:171–187, 1979.
choroidal arteries: Lateral and third ventricles. J Neurosurg 52: 25. Rhoton AL Jr, Hardy DG, Chambers SM: Microsurgical anatomy
165–188, 1980. and dissection of the sphenoid bone, cavernous sinus and cellar
4. Gibo H, Carver CC, Rhoton AL Jr, Lenkey C, Mitchell RJ: Micro- region. Surg Neurol 12:63–104, 1979.
surgical anatomy of the middle cerebral artery. J Neurosurg 26. Rhoton AL Jr, Yamamoto I, Peace DA: Microsurgery of the third
54:151–169, 1981. ventricle: Part 2—Operative approaches. Neurosurgery 8:357–
5. Gibo H, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the
373, 1981.
supraclinoid portion of the internal carotid artery. J Neurosurg
27. Saeki N, Rhoton AL Jr: Microsurgical anatomy of the upper
55:560–574, 1981.
basilar artery and the posterior circle of Willis. J Neurosurg
6. Gudmundsson K, Rhoton AL Jr, Rushton JG: Detailed anatomy of
46:563–578, 1977.
the intracranial portion of the trigeminal nerve. J Neurosurg
35:592–600, 1971. 28. Schechter MM, Zingesser LH, Rosenbaum A: Tentorial meningi-
7. Hardy DG, Peace DA, Rhoton AL Jr: Microsurgical anatomy of omas. AJR Am J Roentgenol 104:123–131, 1968.
the superior cerebellar artery. Neurosurgery 6:10–28, 1980. 29. Stein BM: Supracerebellar-infratentorial approach to pineal tu-
8. Harris FS, Rhoton AL Jr: Anatomy of the cavernous sinus: A mors. Surg Neurol 11:331–337, 1979.
microsurgical study. J Neurosurg 45:169–180, 1976. 30. Sunderland S: The tentorial notch and complications produced by
9. Heros RC: Arteriovenous malformations of the medial temporal herniations of the brain through that aperture. Br J Surg 45:422–
lobe: Surgical approach and neuroradiological characterization. 438, 1958.
J Neurosurg 56:44–52, 1982. 31. Van Wagenen WP: A surgical approach for the removal of certain
10. Howell DA: Upper brain-stem compression and foraminal impac- pineal tumors: Report of a case. Surg Gynecol Obstet 53:216–220,
tion with intracranial space-occupying lesions and brain swelling. 1931.
Brain 82:525–550, 1959. 32. Weinstein M, Stein R, Pollock J, Stucker TB, Newton TH: Menin-
11. Jannetta PJ, Rand RW: Transtentorial retrogasserian rhizotomy in geal branch of the posterior cerebral artery. Neuroradiology
trigeminal neuralgia by microneurosurgical technique. Bull Los 7:129–131, 1974.
Angeles Neurol Soc 31:93–99, 1966. 33. Yamamoto I, Rhoton AL Jr, Peace DA: Microsurgery of the third
12. Klintworth GK: Paratentorial grooving of human brains with ventricle: Part 1—Microsurgical anatomy. Neurosurgery 8:334–
particular reference to transtentorial herniation and the pathogen- 356, 1981.
esis of secondary brain-stem hemorrhages. Am J Pathol 53:391–
34. Yasargil MG, Antic J, Laciga R, Jain KK, Boone SC: Arteriovenous
408, 1968.
malformations of vein of Galen: Microsurgical treatment. Surg
13. Klintworth GK: The comparative anatomy and phylogeny of the
Neurol 3:195–200, 1976.
tentorium cerebelli. Anat Rec 160:635–641, 1968.
35. Yasargil MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD:
14. Liliequist B: The subarachnoid cisterns: An anatomic and roent-
genologic study. Acta Radiol Suppl 185:1–108, 1959. Microsurgical pterional approach to aneurysms of the basilar
15. Mastri AR: Brain herniations: Section I—Pathology, in Newton bifurcation. Surg Neurol 6:83–91, 1976.
TH, Potts DG (eds): Radiology of the Skull and Brain. St Louis, CV 36. Yasargil MG, Kasdaglis K, Jain KK, Weber HP: Anatomical ob-
Mosby, 1974, vol 2, book 4, pp 2659–2670. servations of the subarachnoid cisterns of the brain during sur-
16. Matsushima T, Rhoton AL Jr, de Oliveira E, Peace D: Microsur- gery. J Neurosurg 44:298–302, 1976.
gical anatomy of the veins of the posterior fossa. J Neurosurg 37. Zeal AA, Rhoton AL Jr: Microsurgical anatomy of the posterior
59:63–105, 1983. cerebral artery. J Neurosurg 48:534–559, 1978.

Deep thoracic and abdominal dissection revealing skeletal and neural structures, from, Bartolommeo Eustachio, Tabulae
anatomicae. Rome, Sumptibus Laurentii & Thomae Pagliarini, 1728. Courtesy, Rare Book Room, Norris Medical Library,
Keck School of Medicine, Los Angeles, California. (Also see pages S2, S28, S130, S194, and S298.)
CHAPTER 6
The Foramen Magnum

Key words: Cranial nerves, Craniovertebral junction, Foramen magnum, Microsurgery, Vertebral artery
T
he foramen magnum is located in the occipital bone, temporal bones at the occipitomastoid sutures. The convex
which has three parts: a squamosal part located behind external surface has several prominences on which the mus-
the foramen magnum; a basal (clival) portion located cles of the neck attach. The largest prominence, the external
anterior to the foramen magnum; and a condylar part that occipital protuberance or inion, is situated at the central part
connects the squamosal and clival parts (Fig. 6.1). The suboc- of the external surface. The inion is located an average of 1 cm
cipital approaches are directed through the squamosal part below the apex of the internal occipital protuberance and the
and the anterior approaches through the clival part. The con- inferior margin of the confluence of the sagittal and transverse
dylar part, which includes the occipital condyle, posterior sinuses. Two parallel ridges radiate laterally from the protu-
margin of the jugular foramen, and hypoglossal canal, is berance: the highest nuchal line is the upper and thinner
exposed in the far-lateral approach and its transcondylar, ridge, and the superior nuchal line is the lower and more
retrocondylar, and supracondylar modifications described in prominent one. The area below the nuchal lines is rough and
the chapter on the far lateral approach. Structures involved in irregular and serves as the site of attachment of numerous
foramen magnum lesions include the lower cranial and upper muscles. A vertical ridge, the external occipital crest, descends
spinal nerves, the caudal brainstem and rostral spinal cord, from the external occipital protuberance to the midpoint of
the vertebral artery and its branches, the veins and dural the posterior margin of the foramen magnum. The inferior
sinuses at the craniovertebral junction, and the ligaments and nuchal lines run laterally from the midpoint of the crest.
muscles uniting the atlas, axis, and occipital bone (5, 26). The The internal surface of the squamous part is concave and
foramen magnum is most commonly approached from pos- has a prominence, the internal occipital protuberance, near its
teriorly through the suboccipital and upper cervical region or center. The internal surface is divided into four unequal fos-
from anteriorly through the nasal and oral cavities, the phar- sae by the sulcus of the superior sagittal sinus that extends
ynx, or maxilla. upward from the protuberance, the internal occipital crest, a
prominent ridge that descends from the protuberance, and the
paired sulci for the transverse sinuses that extend laterally
THE FORAMEN MAGNUM
from the protuberance. The sulcus for the right transverse
Osseous relationships sinus is usually larger than the one on the left. The upper two
fossae are adapted to the poles of the occipital lobes. The
The osseous structures that must be considered in planning inferior two fossae conform to the contours of the cerebellar
an approach to the region of the foramen magnum are the hemispheres. The internal occipital crest bifurcates above the
occipital bone, the atlas, and the axis. foramen magnum to form paired lower limbs, which extend
along each side of the posterior margin of the foramen. A
Occipital bone depression between the lower limbs, the vermian fossa, is
The occipital bone surrounds the foramen magnum (Fig. occupied by the inferior part of the vermis. The falx cerebelli
6.1). The foraminal opening is oval shaped and is wider is attached along the internal occipital crest.
posteriorly than anteriorly. The wider posterior part transmits The basilar part of the occipital bone, which is also referred
the medulla, and the narrower anterior part sits above the to as the clivus, is a thick quadrangular plate of bone that
odontoid process. The occipital bone is divided into a squa- extends forward and upward, at an angle of about 45° from
mosal part located above and behind the foramen magnum, a the foramen magnum. It joins the sphenoid bone at the sphe-
basal part situated in front of the foramen magnum, and noccipital synchondrosis just below the dorsum sellae (7). The
paired condylar parts located lateral to the foramen magnum. superior surface of the clivus is concave from side to side and
The squamous part is an internally concave plate located is separated on each side from the petrous part of the tempo-
above and behind the foramen magnum. Its upper margins ral bone by the petroclival fissure. This fissure has the inferior
articulate with the parietal bones at the lambdoid sutures and petrosal sinus on its upper surface and ends posteriorly at the
its lower margins articulate with the mastoid portion of the jugular foramen. On the inferior surface of the basilar part, in

S156 Rhoton
FIGURE 6.1. Occipital bone and foramen magnum. A, inferior view. B, posteroinferior view. C, anterior-inferior view. D,
superior view. E, posterosuperior view. F, oblique posterosuperior view. The occipital bone surrounds the oval-shaped fora-
men magnum, which is wider posteriorly than anteriorly. The narrower anterior part sits above the odontoid process and it
encroached on from laterally by the occipital condyles. The wider posterior part transmits the medulla. The occipital bone is
divided into a squamosal part located above and behind the foramen magnum; a basal (clival) part situated in front of the
foramen magnum; and paired condylar parts located lateral to the foramen magnum. The squamous part is internally con-
cave. Its upper margin articulates with the parietal bone at the lambdoid suture, and its lower margin articulates with the
mastoid portion of the temporal bone at the occipitomastoid suture. The convex external surface of the squamosal part has
several prominences. The largest prominence, the external occipital protuberance (inion), is situated at the central part of the

Foramen Magnum S157
front of the foramen magnum, a small elevation, the pharyn- ally and forward around an upwardly directed, hook-shaped
geal tubercle, gives attachment to the fibrous raphe of the process, on the superior surface of the jugular process, and
pharynx. ends at the jugular foramen. The posterior condylar canal
The paired lateral or condylar parts are situated at the sides opens into the posterior cranial fossa close to the medial end
of the foramen magnum. The occipital condyles, which artic- of the groove for the sigmoid sinus.
ulate with the atlas, protrude from the external surface of this The jugular foramen is situated lateral and slightly superior
part. These condyles are located lateral to the anterior half of to the anterior half of the condyles. It is bordered posteriorly
the foramen magnum. They are oval in shape, convex down- by the jugular process of the occipital bone, and anteriorly and
ward, face downward and laterally, and have their long axes superiorly by the jugular fossa of the petrous portion of the
directed forward and medially. A tubercle that gives attach- temporal bone (14). The foramen sits at the posterior end of
ment to the alar ligament of the odontoid process is situated the petroclival suture. The jugular foramen is divided into
on the medial side of each condyle. The hypoglossal canal, two parts by the intrajugular processes on the opposing edges
which transmits the hypoglossal nerve, is situated above the of the petrous and occipital bones, which either join directly
condyle, and is directed forward and laterally from the pos- or are connected by a fibrous band. The smaller anteromedial
terior cranial fossa. The canal may be partially or completely part, the petrous part, transmits the inferior petrosal sinus,
divided by a bony septum. Septated hypoglossal canals were and the larger posterolateral part, the sigmoid part, transmits
found on one or both sides in 6% of the dry skulls (15). the sigmoid sinus. The intrajugular part, situated along the
The condylar fossa, a depression located on the external intrajugular processes, transmits the glossopharyngeal, vagus,
surface behind the condyle, is often perforated to form the and accessory nerves. The enlarged part of the internal jugular
posterior condylar canal through which an emissary vein vein located within the foramen is referred to as the jugular bulb.
connects the vertebral venous plexus with the sigmoid sinus. The jugular process also serves as the site of attachment of the
One or both condylar foramina may be absent or incompletely rectus capitis lateralis muscle behind the jugular foramen.
perforated (9). The jugular process, a quadrilateral plate of
bone, extends laterally from the posterior half of the condyle
to form the posterior border of the jugular foramen. It serves The atlas
as a bridge between the condylar and squamosal portions of The atlas, the first cervical vertebra, differs from the other
the occipital bone. The jugular process articulates laterally cervical vertebrae by being ring shaped and by lacking a
with the jugular surface of the temporal bone. On the intra- vertebral body and a spinous process (Fig. 6.2). It consists of
cranial surface of the condylar part an oval prominence, the two thick lateral masses situated at the anterolateral parts of
jugular tubercle, sits just superior to the hypoglossal canal the ring. The lateral masses are connected in front by a short
and just medial to the lower extent of the petroclival fissure. anterior arch and behind by a longer curved posterior arch.
The caudal part of the tubercle often presents a shallow fur- The position of the usual vertebral body is occupied by the
row above which the glossopharyngeal, vagus, and accessory odontoid process of the axis. The anterior arch is convexed
nerves course. The groove of the sigmoid sinus curves medi- forward and has a median anterior tubercle. The posterior
Š
external surface. The superior nuchal line radiates laterally from the protuberance. A vertical ridge, the external occipital
crest, descends from the external occipital protuberance to the midpoint of the posterior margin of the foramen magnum.
The inferior nuchal lines run laterally on both sides from the midpoint of the crest. The internal surface of the squamous part
is concave and has a prominence, the internal occipital protuberance, near its center. The internal surface is divided into four
unequal fossae by the sulcus of the superior sagittal sinus, the internal occipital crest, and the sulci for the transverse sinuses.
The internal occipital crest bifurcates above the foramen magnum to form a V-shaped ridge between the limbs of which is
the vermian fossa. The basilar part of the occipital bone, which is also referred to as the clivus, is a thick quadrangular plate
of bone that extends forward and upward to join the sphenoid bone just below the dorsum sellae. The superior surface of the
clivus slopes upward from the foramen magnum and is concave from side to side. The clivus is separated on each side from
the petrous part of the temporal bone by the petroclival fissure that ends posteriorly at the jugular foramen. The occipitomas-
toid suture extends posterolateral from the jugular foramen. On the inferior surface of the basilar part, a small elevation, the
pharyngeal tubercle, gives attachment to the fibrous raphe of the pharynx. The condylar parts of the occipital bone, on which
the occipital condyles an located, are situated lateral to the foramen magnum on the external surface. The alar tubercle,
which gives attachment to the alar ligament, is situated on the medial side of each condyle. The hypoglossal canal is situated
above the condyle. The condylar fossa, which may be converted into a foramen for the passage of an emissary vein, is
located behind the condyle. The jugular process of the occipital bone extends laterally from the posterior half of the condyle
and articulates with the jugular surface of the temporal bone. The sulcus of the sigmoid sinus crosses the superior surface of
the jugular process. The jugular foramen is bordered posteriorly by the jugular process of the occipital bone and anteriorly
by the jugular fossa of the petrous temporal bone. The jugular tubercle lies on the internal surface above the hypoglossal
canal. A., artery; Ac., acoustic; Car., carotid; Cond., condyle; Digast., digastric; Ext., external; Fiss., fissure; For., foramen;
Hypogl., hypoglossal; Inf., inferior; Jug., jugular; Occipitomast., occipitomastoid; Occip., occipital; Petrocliv., petroclival;
Pharyng., pharyngeal; Proc., process; Protrub., protuberance; Sag., sagittal; Sig., sigmoid; Sup., superior; Trans., transverse.

S158 Rhoton
FIGURE 6.2. A–D. The atlas. A, superior view; B, inferior view; C, anterior view; D, posterior view. The atlas consists of two
thick lateral masses situated at the anteromedial part of the ring, which are connected in front by a short anterior arch and
posteriorly by a longer curved posterior arch. The anterior and posterior tubercles are at the anterior and posterior mid-
line. The superior articular facet is an oval, concave facet that faces upward and medially to articulate with the occipital con-
dyle. The inferior articular facet is a circular, flat, or slightly concave facet that faces downward, medially, and slightly back-
ward and articulates with the superior articular facet of the axis. The medial aspect of each lateral mass has a small tubercle
for the attachment of the transverse ligament of the atlas. The transverse process projects from the lateral masses. The trans-
verse foramina transmit the vertebral arteries. The upper surface of the posterior arch adjacent to the lateral masses has
paired grooves in which the vertebral arteries course. A., artery; Ant., anterior; Art., articular; For., foramen; Lat., lateral;
Mass., masses; Post., posterior; Proc., process; Trans., transverse; Vert., vertebral.
arch is convex backward and has a median posterior tubercle approximately 1-cm wide. On the front of the dens is an
and a groove on the lateral part of its upper-outer surface in articular facet that forms a joint with the facet on the back of
which the vertebral artery courses. The groove may be partly the anterior arch of the atlas. The dens has a pointed apex that
or fully converted into a foramen by a bridge of bone that is joined by the apical ligament, has a flattened side where the
arches backward from the posterior edge of the superior alar ligaments are attached, and is grooved at the base of its
articular facet of the atlas to its posterior arch. The first cer- posterior surface where the transverse ligament of the atlas
vical spinal nerve also lies in the groove, which is located passes. The dens and body are flanked by a pair of large oval
between the artery and the bone. The upper surface of each facets that extend laterally from the body onto the adjoining
lateral mass has an oval concave facet that faces upward and parts of the pedicles and articulate with the inferior facets of
medially and articulates with the occipital condyle that faces the atlas. The superior facets do not form an articular pillar
downward and laterally. The inferior surface of each lateral with the inferior facets, but are anterior to the latter. The
mass has a circular, flat, or slightly concave facet that faces anterior aspect of the body is hollowed out on each side of
downward, medially, and slightly backward, and it articu- the midline in the area where the longus colli muscles at-
lates with the superior articular facet of the axis. The medial tach. The lamina are thicker than on any other cervical verte-
aspect of each lateral mass has a small tubercle for the attach- brae, the pedicles are stout, and the spinous process is large.
ment of the transverse ligament of the atlas, which passes The transverse processes of the axis are small. Their blunt
behind the dens. Each transverse foramen, which transmits a tips present a single tubercle, the anterior tubercle, situated at
vertebral artery, and upon which the nerve root sits, is situ- or near the junction of the anterior root of the transverse
ated between the lateral mass and the transverse process. process and the body. Each transverse foramen faces supero-
laterally, thus permitting the lateral deviation of the vertebral
The axis artery as it passes up to the more widely separated transverse
The axis, the second cervical vertebra, more closely resem- foramina in the atlas. The inferior articular facets are situated
bles the typical vertebrae than the atlas, but is distinguished at the junction of the pedicles and laminae, and face down-
by the odontoid process (dens), which projects upward from ward and forward. The spade-shaped vertebral foramen is
the body (Fig. 6.2). The dens is 1.0- to 1.5-cm long, and relatively large.

Foramen Magnum S159
FIGURE 6.2. E–H. The axis. E, anterior view; F, lateral view; G, superior view; H, inferior view. The axis is distinguished by the
odontoid process (dens). On the front of the dens is an articular facet that forms a joint with the facet on the back of the anterior
arch of the atlas. The dens is grooved at the base of its posterior surface where the transverse ligament of the atlas passes. The oval
superior articular facets articulate with the inferior facets of the atlas. The superior facets are anterior to the inferior facets. The
pedicles and laminae are thicker than on the other cervical vertebra and the lamina fuse behind to form a large spinous process.
The transverse foramina are directed superolaterally, thus permitting the lateral deviation of the vertebral arteries as they pass up
to the more widely separated transverse foramina in the atlas. The inferior articular facets face downward and forward.
The atlantoaxial joints transverse and vertical parts that form a cross behind the dens.
The transverse part, called the transverse ligament, is a thick
The articulation of the atlas and axis comprises four syno-
strong band that arches across the ring of the atlas behind the
vial joints: two median ones on the front and back of the dens,
dens and divides the vertebral canal into a larger posterior
and paired lateral ones between the opposing articular facets
on the lateral masses of the atlas and axis (Figs. 6.2-6.4). Each compartment containing the dura and the spinal cord and a
of the median joints, situated on the front and back of the dens, smaller anterior compartment containing the odontoid process.
has its own fibrous capsule and synovial cavity. The anterior one The transverse ligament is broader in the middle behind the
is situated between the anterior surface of the dens and the dens than at the ends where it is attached to a tubercle on the
posterior aspect of the anterior arch of the atlas. The posterior medial side of the lateral masses of the atlas. As it crosses
one has an even larger synovial cavity and lies between the the dens, small longitudinal bands are directed upward and
cartilage-covered anterior surface of the transverse ligament of downward from its posterior surface. The cranial extension is
the atlas and the posterior surface of the dens. attached to the upper surface of the clivus between the apical
The atlas and axis are united by the cruciform ligament, the ligament of the dens and the tectorial membrane. The lower
anterior and posterior longitudinal ligaments, and the articu- band is attached to the posterior surface of the body of the axis.
lar capsules surrounding the joints between the opposing The neck of the dens is constricted where it is embraced poste-
articular facets on the lateral masses. The cruciform ligament has riorly by the transverse ligament.

S160 Rhoton
FIGURE 6.3. A–D. Foramen

magnum. Posterior view. Stepwise
dissection. A, the cerebellar tonsils,
the foramen of Magendie, and lower
part of the fourth ventricle are
situated above the foramen magnum.
The vertebral artery penetrates the
dura below the foramen magnum and
ascends through the foramen in front
of the dentate ligament and accessory
nerves. The glossopharyngeal, vagus,
and accessory nerves pass through
the jugular foramen, which is located
lateral to the anterior half of the
foramen magnum. B, the cerebellum
has been removed. The vertebral
arteries pass through the foramen
magnum to reach the front of the
medulla. C, enlarged view of the left
half of the foramen magnum. The
vertebral artery passes behind and
below the atlanto-occipital joint,
penetrates the dura, and passes in
front of the dentate ligament and
accessory nerve. The rostral end of
the dentate ligament attaches to
the dura at the level of the foramen
magnum. The C1 nerve penetrates
the dura with the vertebral artery.
The hypoglossal nerve passes behind
the vertebral artery and enters the
hypoglossal canal. The hypoglossal
nerve is separated into several
bundles as it penetrates the dura. The
posterior spinal artery arises as the
vertebral artery enters the dura and
gives rise to ascending and
descending branches. D, a
longitudinal strip of the medulla and
floor of the fourth ventricle has been
removed to expose the
vertebrobasilar junction, the origin of
the anterior spinal artery, and
the median anterior medullary and
median anterior spinal veins. A.,
artery; A.I.C.A., anteroinferior
cerebellar artery; Ant., anterior; Asc.,
ascending; Atl., atlanto-; Bas., basilar;
Br., branch; Bridg., bridging; CN,
cranial nerve; Cruc., cruciform; Dent., dentate; Desc., descending; Flocc., flocculus; For., foramen; Horiz., horizontal; Lig.,
ligament; Med., median, medullary; Memb., membrane; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar
artery; Post., posterior; Sp., spinal; Trans., transverse; V., vein; Vent., ventricle; Vert., vertebral.
In front, the atlas and axis are connected by the anterior of the axis, and above to the transverse part of the cruciform
longitudinal ligament, which is a wide band fixed above to ligament and the clivus. Posterior to the spinal canal, the atlas
the lower border of the anterior arch of the atlas and below and axis are joined by a broad, thin membrane in series with
to the front of the body of the axis. The posterior longitudinal the ligamentum flavum that is attached above to the lower
ligament is attached below to the posterior surface of the body border of the posterior arch of the atlas, and below to the

Foramen Magnum S161
FIGURE 6.3. E–I. Foramen

magnum. Posterior view.
Stepwise dissection. E, the
right half of the medulla has
been removed. The anterior
spinal artery arises predomi-
nantly from the left vertebral
artery, but has a small contri-
bution from the right verte-
bral artery. Two bundles of
right hypoglossal rootlets
penetrate the dura. F, en-
larged view. The medulla has
been removed to expose the
vertebral and anterior spinal
arteries. The C1 nerve roots
penetrate the dura with the
vertebral artery. G, the intra-
dural segment of the verte-
bral arteries and the dura lining the anterior margin of the foramen magnum have been removed to expose the tectorial mem-
brane, a rostral extension of the posterior longitudinal ligament, and the vertebral venous plexus, which courses just outside the
dura. H, the tectorial membrane has been removed to expose the cruciform and alar ligaments. The horizontal portion of the cru-
ciform ligament, called the transverse ligament of the atlas, extends laterally to be attached to the medial edges of the lateral
masses of the atlas, and the vertical portion ascends to attach to the anterior margin of the foramen magnum deep to the tectorial
membrane. The alar ligaments pass upward and laterally and attach to the lateral edges of the foramen magnum. Anterior menin-
geal arteries pass along the dura and ligamentous structures in the anterior spinal canal. I, the vertical portion of the cruciform lig-
ament has been folded downward to expose the synovial joint between the anterior surface of the cruciform ligament and the pos-
terior surface of the dens. There is also another synovial joint between the anterior surface of the dens and the posterior surface of
the anterior atlantal arch. The apical ligament of the dens extends upward to be attached to the margin of the foramen magnum.
upper edges of the laminae of the axis. This membrane is anterior and posterior atlanto-occipital membranes (Figs. 6.2-
pierced laterally by the second cervical nerve. 6.4). The articular capsules of the atlanto-occipital joints are
sometimes deficient medially where the synovial cavities may
The atlanto-occipital joints communicate with the synovial bursa between the dens and
The atlas and the occipital bone are united by the articular the transverse ligament of the atlas. The anterior atlanto-
capsules surrounding the atlanto-occipital joints and by the occipital membrane is attached superiorly to the anterior edge

S162 Rhoton
FIGURE 6.4. Anterior view. Stepwise dissection of a cross section showing the relationship of the foramen magnum and cli-
vus to the nasal and oral cavities, pharynx, and infratemporal fossa. A, the soft palate, which has been preserved, is located
at the level of the foramen magnum. The infratemporal fossa, located below the greater sphenoid wing and middle cranial
fossa, contains the pterygoid muscles, maxillary artery, mandibular nerve branches, and the pterygoid venous plexus and
opens posteriorly into the area around the carotid sheath, as shown on the left side. B, enlarged view. The soft palate has
been divided in the midline and the leaves reflected laterally. The atlanto-occipital joints and the foramen magnum are
located at approximately the level of the hard palate. The anterior arch of C1 and the dens are located behind the orophar-
ynx, and the clivus is located behind the nasopharynx and sphenoid sinus. The prominence over the longus capitis and the

Foramen Magnum S163
of the foramen magnum, inferiorly to the superior edge of the the shoulder to attach to the scapula and the lateral third of
anterior arch of the atlas, and laterally to the capsule of the clavicle. The sternocleidomastoid passes obliquely down-
the atlanto-occipital joints. ward across the side of the neck from the lateral half of the
The posterior atlanto-occipital membrane is a thin sheet con- superior nuchal line and mastoid process to the upper part of
nected above to the posterior margin of the foramen magnum the sternum and the adjacent part of the clavicle. This muscle
and below to the upper border of the posterior arch of the atlas. divides the side of the neck into an anterior triangle and a
The lateral border of the membrane is free and arches behind the posterior triangle. The anterior triangle is bounded posteri-
vertebral artery and the first cervical nerve root. The lateral edge orly by the anterior border of the sternocleidomastoid, above
of this membrane may be ossified in the area where it arches by the mandible, and anteriorly by the median line of the
over the posterior aspect of the vertebral artery, thus creating a neck; the posterior triangle is bounded in front by the poste-
partial or complete osseous ring around the artery on the medial rior border of the sternocleidomastoid, below by the middle
side of the atlanto-occipital joint.
third of the clavicle, and behind by the anterior margin of the
Axis and occipital bone trapezius. The splenius capitis, situated deep to and partially
covered by the trapezius and sternocleidomastoid, extends
Four fibrous bands, the tectorial membrane, the paired alar
from the bone below the lateral third of the superior nuchal
ligaments, and the apical ligament, connect the axis and the
line to the spinous processes of the lower cervical and upper
occipital bone (Figs. 6.3 and 6.4). The tectorial membrane is a
thoracic vertebrae. Two muscles, both of which are situated
cephalic extension of the posterior longitudinal ligament that
deep to the splenius capitis and sternocleidomastoid and at-
covers the dens and cruciform ligament. It is attached below
to the posterior surface of the body of the axis, above to the tach below to the upper thoracic and lower cervical vertebrae,
upper surface of the occipital bone in front of the foramen are the semispinalis capitis, which attaches above in the area
magnum, and laterally to the medial sides of the atlanto- between the superior and inferior nuchal lines beginning
occipital joints. The alar ligaments are two strong bands that medially at the external occipital crest and extending laterally
arise on each side of the upper part of the dens and extend to the occipitomastoid junction, and the longissimus capitis
obliquely superolateral to attach to the medial surfaces of the muscle, which attaches above to the posterior margin of the
occipital condyles. The apical ligament of the odontoid pro- mastoid process.
cess extends from the tip of the dens to the anterior margin of The suboccipital muscles, located in the next layer, are a group
the foramen magnum and is situated between the anterior of muscles situated deep to the splenius, semispinalis, and lon-
atlanto-occipital membrane and the superior prolongation of gissimus capitis in the suboccipital area. This group includes the
the cruciform ligament. superior oblique, which extends from the area lateral to the
semispinalis capitis between the superior and inferior nuchal
Muscular relationships lines to the transverse process of the atlas; the inferior oblique,
The foramen magnum is surrounded by the muscles at- which extends from the spinous process and lamina of the axis
tached to the occipital bone and upper cervical vertebrae (Figs. to the transverse process of the atlas; the rectus capitis posterior
6.4 and 6.5). The trapezius covers the back of the head and major, which extends from and below the lateral part of the
neck. It extends from the medial half of the superior nuchal inferior nuchal line to the spine of the axis; and the rectus
line, the external occipital protuberance, and the spinous pro- capitis posterior minor, which is situated medial to and is
cesses of the cervical and thoracic vertebrae and converges on partially covered by the rectus capitis posterior major, extends
Š
anterior arch of C1 are seen through the pharyngeal mucosa. C, the mucosa lining the posterior pharyngeal wall has been
reflected to the right, exposing the longus capitis that attaches to the clivus and the part of the longus colli that attaches to
the anterior arch of C1. The eustachian tube has been divided. The rectus capitis anterior extends from the transverse process
of C1, posterolateral to the longus capitis, to attach to the occipital bone in front of the occipital condyle. D, the clivus and
anterior arch of C1 have been removed. The dura has been opened to expose the vertebral and basilar artery. The dens has
been preserved. The structures in the right infratemporal fossa and part of the right carotid artery and mandible have been
removed to expose the right vertebral artery ascending between the C2 and C1 transverse processes. E, enlarged view of the
step between C and D. The anterior arch of C1 has been removed to expose the odontoid process and the lower part of the
clivus. The left longus coli and longus capitis have been reflected out of the exposure. The atlanto-occipital joint is exposed at
the level of the odontoid apex. The transverse part of the cruciform ligament, also called the transverse ligament, extends
across the back of the dens and attaches to a tubercle on the medial side of each lateral mass of the axis. The tectorial mem-
brane, a cephalic extension of the posterior longitudinal ligament, lines the posterior clival surface. The alar ligaments attach
to the lateral edges of the foramen magnum. F, enlarged view of the exposure shown in D. G, exposure after opening of the
clivus. Both vertebral and anteroinferior cerebellar arteries (AICAs) and the anterior spinal artery are exposed. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Atl., atlanto-; Cap., capitis; Car., carotid; CN, cranial nerve; Eust.,
eustachian; For., foramen; Infratemp., infratemporal; Int., internal; Jug., jugular; Lat., lateral; Lig., ligament; Long., longus; M.,
muscle; Mandib., mandibular; Max., maxillary; Med., medial; Memb., membrane; Occip., occipital; Pteryg., pterygoid; Rec.,
rectus; Sp., spinal; Sphen., sphenoid; Trans., transverse; Vert., vertebral.

S164 Rhoton
FIGURE 6.5. Suboccipital muscles. Stepwise dissection. A, the right trapezius and sternocleidomastoid have been preserved.
The left trapezius and sternocleidomastoid have been reflected along with the galea aponeurotica to expose the underlying
semispinalis capitis, splenius capitis, and levator scapulae. B, the right sternocleidomastoid and trapezius have been reflected
to expose the splenius capitis. The left splenius capitis has been removed to expose the underlying semispinalis and longissi-
mus capitis. C, the right splenius capitis has been removed to expose the semispinalis and longissimus capitis. The left semi-
spinalis and longissimus capitis have been removed to expose the suboccipital triangle formed by the superior oblique, which
passes from the C1 transverse process to the occipital bone, the inferior oblique, which extends from the transverse process
of C1 to the spinous process of C2, and the rectus capitis posterior major, which extends from the occipital bone below the
inferior nuchal line to the spinous process of C2. The vertebral artery courses in the depths of the suboccipital triangle as it
passes behind the superior facet of C1 and across the upper edge of the posterior atlantal arch. D, both semispinalis capitis
muscles have been reflected laterally to expose the suboccipital triangles bilaterally. E, the muscles forming the left suboccipi-
tal triangle have been removed. The vertebral artery ascends slightly lateral from the transverse process of C2 to reach the

Foramen Magnum S165
from the medial part and below the inferior nuchal line to the posterior triangle of the neck. Superiorly it is attached to the
tubercle on the posterior arch of the atlas. base of the skull, and inferiorly it continues downward be-
The suboccipital triangle is a region bounded above and hind the pharynx and in front of the longus colli into the
medially by the rectus capitis posterior major, above and superior mediastinum. The deep fascia is fused above to
laterally by the superior oblique, and below and laterally by the superior nuchal line, mastoid process, zygomatic arch,
the inferior oblique (Fig. 6.5). It is covered by the semispinalis styloid process, and mandible, and below to the scapula,
capitis medially and by the splenius capitis laterally. The floor clavicle, and sternum.
of the triangle is formed by the posterior atlanto-occipital
membrane and the posterior arch of the atlas. The structures
in the triangle are the terminal extradural segment of the Neural relationships
vertebral artery and the first cervical nerve. The neural structures situated in the region of the foramen
The platysma is a broad sheet extending downward from magnum are the caudal part of the brainstem, cerebellum and
the lower part of the face and across the clavicle to the fascia fourth ventricle, the rostral part of the spinal cord, and the lower
covering the pectoralis major and deltoid. The anterior verte- cranial and upper cervical nerves (Figs. 6.3 and 6.6) (5, 19).
bral muscles insert on the clival part of the occipital bone
anterior to the foramen magnum. This group includes the
longus colli, which attach to the anterior surface of the verte- Spinal cord
bral column between the atlas and the third thoracic vertebra; The spinal cord blends indistinguishably into the medulla
the longus capitis, which extends from the clivus in front of at a level arbitrarily set to be at the upper limit of the dorsal
the foramen magnum to the transverse processes of the third and ventral rootlets forming the first cervical nerve (Figs. 6.3
through the sixth cervical vertebrae; the rectus capitis ante- and 6.6). It is easier to differentiate this level on the ventral
rior, which is situated behind the upper part of the longus than on the dorsal surface because the ventral rootlets of the
capitis and extends from the occipital bone in front of the first cervical nerve are always present, whereas the dorsal
occipital condyle to the anterior surface of the lateral mass rootlets are absent in many cases. The fact that the junction of
and transverse process of the atlas; and the rectus capitis the spinal cord and medulla is situated at the rostral margin of
lateralis, which extends from the jugular process of the occip- the first cervical root means that the medulla, and not the
ital bone to the transverse process of the atlas. spinal cord, occupies the foramen magnum.
The muscles described above are embedded in the cervical The spinal cord immediately below the level of the foramen
fascia. This fascia is divided into superficial and deep layers. magnum is round, and it is divided by one fissure and several
The superficial layer is a lamina of loose connective tissue sulci. The anteromedian fissure and the posteromedian sulcus
below the dermis, which invests the platysma. The deep layer divide the spinal cord into symmetrical halves. The antero-
lies internal to the platysma, invests the muscles, and con- median fissure reaches a depth of several millimeters. The pos-
denses into fibrous sheaths that bind the arteries and accom- teromedian sulcus is much shallower, and from it the postero-
panying veins together. The superficial lamina of the deep median septum penetrates the spinal cord, almost reaching the
fascia attaches in the posterior midline to the ligamentum central canal. The posterior lateral sulcus is situated along the
nuchae, thinly invests the trapezius, continues forward cov- line where the dorsal roots enter the spinal cord. The posterior
ering the posterior triangle of the neck, divides at the poste- funiculus is situated between the posteromedian and poste-
rior border of the sternocleidomastoid to enclose the muscle, rior lateral sulci. At the upper cervical level, the surface of
and at its anterior margin again forms a lamina that covers the each posterior funiculus is divided by another shallow longi-
anterior triangle of the neck and reaches the median plane, to tudinal furrow, the posterior intermediate sulcus, into the
be continuous with the corresponding lamina from the oppo- fasciculus gracilis medially and the fasciculus cuneatus later-
site side. The carotid sheath is a condensation of the cervical ally. The region of the spinal cord between the posterior
fascia, which invests the common and internal carotid arter- lateral sulcus and the anteromedian fissure is divided into
ies, the internal jugular vein, and the vagus nerve. The pre- anterior and lateral funiculi by the exiting ventral rootlets of
vertebral lamina of the cervical fascia covers the prevertebral the spinal nerves. The anterior funiculus includes the zone of
muscles, extends laterally to connect with the carotid sheath, emergence of the ventral roots. The lateral funiculus lies between
and covers the scalene muscles to form a fascial floor for the the ventral roots and the posterior lateral sulcus. In the upper
Š
transverse process of C1 and turns medially behind the superior facet of C1 to reach the upper surface of the posterior arch of C1.
The C2 ganglion is located between the posterior arch of C1 and the lamina of C2. The dorsal ramus of C2 produces a medial
branch that forms the majority of the greater occipital nerve. F, the muscles forming both suboccipital triangles have been
removed. The rectus capitis posterior minor, which extends from the posterior arch of C1 to the occipital bone below the inferior
nuchal line, has been preserved. The vertebral arteries cross the posterior arch of the atlas and penetrate the posterior atlanto-
occipital membrane to reach the dura. A., artery; Atl., atlanto-; Cap., capitis; Car., carotid; CN, cranial nerve; Inf., inferior; Int.,
internal; Jug., jugular; Lev., levator; Longiss., longissimus; M., muscle; Maj., major; Memb., membrane; Min., minor; Obl., oblique;
Occip., occipital; Post., posterior; Proc., process; Rec., rectus; Scap., scapulae; Semispin., semispinalis; Spin., spinalis; Splen., sple-
nius; Sternocleidomast., sternocleidomastoid; Sup., superior; Trans., transverse; V., vein; Vert., vertebral.

S166 Rhoton
FIGURE 6.6. Foramen magnum. A–D, posterior views; E and F, anterior views. A, a suboccipital craniectomy and upper cer-
vical laminectomy exposes the dura. The vertebral arteries pass medially across the upper surface of the atlas where they give
off the posterior meningeal arteries that ascend to supply the dura on the posterior aspect of the foramen magnum and poste-
rior fossa. Insert, upper right. The upper margin of the left half of the arch of the atlas forms an osseous ring around the ver-
tebral artery just proximal to where it enters the dura. B, enlarged view of another foramen magnum after opening the dura.
The right PICA arises outside the dura and penetrates the dura with the vertebral artery. The rostral end of the dentate liga-
ment passes between the vertebral artery and the PICA to insert into the dura along the lateral margin of the foramen mag-
num. The accessory nerve ascends posterior to both the PICA and the vertebral artery. The vertebral artery gives rise to a
posterior spinal artery that passes along the posterolateral aspect of the spinal cord and medulla. The hypoglossal rootlets are
stretched over the posterior aspect of the vertebral artery. C, the right tonsil has been retracted to expose the caudal end of
the fourth ventricle, which is located above the foramen magnum. The right PICA ascends through the foramen magnum and

Foramen Magnum S167
cervical region, the rootlets that unite to form the spinal part of part of the posterior surface is composed of the gracile fascic-
the accessory nerve emerge through the lateral funiculus. ulus and tubercle medially, and the cuneate fasciculus and
tubercle laterally.
Dentate ligament
The dentate ligament is considered with the spinal cord Cerebellum
because it is attached to it (Figs. 6.3 and 6.6). This ligament is The suboccipital cerebellar surface rests above the posterior
a white fibrous sheet that is attached to the spinal cord me- and lateral edge of the foramen magnum. Only the lower part
dially and to the dura mater laterally. The medial border of of the hemispheres formed by the tonsils and the biventral
the dentate ligament, which is attached to the pia mater lobules, and the lower part of the vermis formed by the
between the dorsal and ventral rootlets along the length of nodule, uvula, and pyramid, are related to the foramen mag-
each side of the spinal cord, presents a series of triangular num. The biventral lobule sits above the lateral part of the
toothlike processes on each side that are attached at intervals foramen magnum, and the tonsils rest above the level of the
to the dura mater. At the craniocervical junction, the dentate posterior edge (Figs. 6.3 and 6.6). The cerebellar surface above
ligament is located between the vertebral artery and the ven- the posterior part of the foramen magnum has a deep vertical
tral roots of C1 anteriorly and the branches of the posterior depression, the posterior cerebellar incisura, which contains
spinal artery and the spinal accessory nerve posteriorly; in the falx cerebelli and extends inferiorly toward the foramen
addition, it is often incorporated into the dural cuff around magnum. The tonsils, which sit above the posterior edge of
the vertebral artery at the site of dural penetration. The most the foramen magnum, are commonly involved in herniations
rostral attachment of the dentate ligament is located at the through the foramen magnum. Each tonsil is an ovoid struc-
level of the foramen magnum, above where the vertebral ture that is attached along its superolateral border to the
artery pierces the dura. The ligament courses behind the remainder of the cerebellum. The cerebellomedullary fissure
accessory nerve at that level, although the dentate ligament is extends superiorly between the cerebellum and the medulla
located anterior to the accessory nerve at lower levels. The and is situated rostral to the posterior margin of the foramen
second triangular process is attached to the dura below the magnum.
site at which the vertebral artery and the roots of C1 pierce the
dura. Sectioning the upper two triangular processes will in- Cranial nerves
crease access anterior to the spinal cord. The first cervical The accessory nerve is the only cranial nerve that passes
nerve courses along the posteroinferior surface of the verte- through the foramen magnum (Figs. 6.3 and 6.6). It has a
bral artery as it pierces the dura. The ventral root is located cranial part composed of the rootlets that arise from the
anterior to the dentate ligament, and the dorsal root, which is medulla and join the vagus nerve, and a spinal portion
infrequently present, passes posterior to the dentate ligament. formed by the union of a series of rootlets that arise from the
There are frequently communications between the C1 nerve lower medulla and upper spinal cord. In the posterior fossa,
root and the spinal accessory nerve. the accessory nerve is composed of one main trunk from the
spinal cord and three to six small rootlets that emerge from
Brainstem the medulla. The most rostral medullary rootlets are function-
The lower medulla blends indistinguishably into the upper ally inferior vagal rootlets, since they arise from the vagal
spinal cord at the level of the C1 nerve roots (Figs. 6.3, 6.4, and nuclei (25). The lower medullary rootlets join the spinal por-
6.6). The anterior surface of the medulla is formed by the tion of the nerve. The upper medullary rootlets enter the
medullary pyramids, which face the clivus, the anterior edge jugular foramen without joining the spinal portion, but once
of the foramen magnum, and the rostral part of the odontoid inside the jugular foramen, they join either the vagus or
process. The lateral surface is formed predominantly by the accessory nerve. The spinal contribution arises from the cer-
inferior olives. The posterior surface of the medulla is divided vical portion of the spinal cord as a series of rootlets situated
into superior and inferior parts. The superior part is com- midway between the ventral and dorsal rootlets. The lowest
posed in the midline of the inferior half of the fourth ventricle, level of origin of the rootlets contributing to the accessory
and laterally by the inferior cerebellar peduncles. The inferior nerves was at the C7 root level in 2 of the 50 nerves examined,
Š
along the posterior margin of the medulla to reach the cerebellomedullary fissure. D, another specimen. The rostral end of
the dentate ligament passes between the posterior spinal artery and vertebral artery and attaches to the dura at the level of
the foramen magnum. The accessory nerve ascends behind the posterior spinal artery. The C1 nerve root receives a contribu-
tion from the accessory nerve and passes through the dura with the vertebral artery and courses along the lower margin of
the artery. The posterior spinal artery arises inside the dura and passes between the dentate ligament and accessory nerve
and gives rise to ascending branches to the medulla and descending branches to the spinal cord. E, the anterior skull base has
been removed. The vertebral arteries ascend in front of the brainstem and give rise to the anterior spinal artery. F, enlarged
view. The C1 ventral roots penetrate the dura with the vertebral artery. The hypoglossal rootlets pass behind the vertebral
arteries. A., artery; Bas., basilar; Cer.Med., cerebellomedullary; CN, cranial nerve; Cond., condyle; Dent., dentate; Fiss., fis-
sure; Hypogl., hypoglossal; Lig., ligament; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Post.,
posterior; Sp., spinal; Vert., vertebral.

S168 Rhoton
C6 in 10, C5 in 13, C4 in 11, C3 in 7, C2 in 5, and Cl in 2 (5). ramus divides into a large medial and a small lateral branch.
These rootlets unite to form a trunk with a diameter of ap- It is the medial branch that is most intimately related to this
proximately 1.0 mm, which ascends through the foramen suboccipital operative field and that forms the greater occip-
magnum between the dentate ligament and the dorsal spinal ital nerve. It ascends obliquely between the inferior oblique
roots to enter the posterior cranial fossa behind the vertebral and the semisplenius capitis, pierces the latter and the trape-
artery. zius muscle near their attachments to the occipital bone, and
Of the 50 accessory nerves examined in our previous study, is joined by a filament from the medial branch of C3. It
all had connections with the dorsal roots of the upper cervical supplies the semispinalis capitis muscle, ascends with the
nerves. The most common and largest anastomosis was with occipital artery, and supplies the scalp as far forward as the
the dorsal root of the first cervical nerve (5, 22). Twenty-eight vertex, and occasionally the back of the ear. The lateral branch
of the C1 dorsal roots arose solely from the accessory nerve sends filaments that innervate the splenius, longissimus, and
without there being a contribution from the C1 level of the semisplenius capitis, and is often joined by the corresponding
spinal cord. All of the 15 Cl dorsal roots that received rootlets branch from the C3 nerve. The C2 ventral ramus courses
arising from the spinal cord at the C1 level also had anasto- between the vertebral arches and transverse processes of the
motic fibers from the accessory nerve. Four of the 50 accessory atlas and axis and behind the vertebral artery to leave this
nerves had an anastomotic connection with the C2 nerve root, operative field. Two branches of the C2 and C3 ventral rami,
10 with the C3, 8 with the C4, and 2 with the C5. the lesser occipital and greater auricular nerves, curve around
The lower four cranial nerves are sufficiently close to the the posterior border and ascend on the sternocleidomastoid
foramen magnum that they may be involved by lesions aris- muscle to supply the skin behind the ear.
ing there (Figs. 6.3 and 6.6). Their intradural anatomy is de- The first cervical nerve, located just below the foramen
scribed in the chapter of this issue on the cerebellopontine magnum, deserves special attention (Figs. 6.3 and 6.6). It
angle and posterior fossa cranial nerves. differs from the other cervical nerves in the consistency and
origin of the dorsal rootlets forming the nerve. The C1 ventral
root is composed of four to eight rootlets that joined and
Cervical nerve roots coursed laterally. Before entering the dural foramina, the C1
Each dorsal and ventral root is composed of a series of six ventral root, and the corresponding dorsal root if present,
to eight rootlets that fan out to enter the posterolateral and attaches to the posteroinferior surface of the initial intradural
anterolateral surfaces of the spinal cord, respectively (Figs. 6.3 part of the vertebral artery, and both exit the dural sac
and 6.6). The dorsal and ventral roots cross the subarachnoid through the funnel-shaped dural foramen around the verte-
space and transverse the dura mater separately, then unite bral artery. The ventral root joins the dorsal root in or external
close to the intervertebral foramen to form the spinal nerves. to the dural foramen.
The rootlets in the region of the foramen magnum pass almost The dorsal root of the first cervical nerve is more compli-
directly lateral to reach their dural foramina. The neurons of cated than the ventral root because of the variations in its
the dorsal roots collect to form ganglia located just proximal composition and its connections with the accessory nerve. In
to the union of the dorsal and ventral root in the intervertebral the 25 cervical spinal cords examined, in which one would
foramina, however the first cervical dorsal root and associated expect to find 50 C1 dorsal roots arising from the posterior
ganglion may be absent. The C1, C2, and C3 nerves, distal to lateral sulcus, only 15 were found (5). The accessory nerve
the ganglion, divide into dorsal and ventral rami. The dorsal contributed a root to the C1 nerve in 28 of the 35 roots lacking
rami divide into medial and lateral branches that supply the a dorsal root arising from the spinal cord. In the remaining 7
skin and muscles of the posterior region of the neck. The C1 cases, the C1 dorsal root was absent. Each of the 15 dorsal
nerve, termed the suboccipital nerve, leaves the vertebral roots that arose from the spinal cord also had a contribution
canal between the occipital bone and atlas and has a dorsal from the accessory nerve.
ramus that is larger than the ventral ramus. The dorsal ramus
courses between the posterior arch of the atlas and the verte-
bral artery to reach the suboccipital triangle, where it sends Arterial relationships
branches to the rectus capitis posterior major and minor, The major arteries related to the foramen magnum are the
superior and inferior oblique, and the semispinalis capitis, vertebral and posteroinferior cerebellar arteries (PICA), and
and occasionally has a cutaneous branch that accompanies the the meningeal branches of the vertebral, and external and
occipital artery to the scalp. The C1 ventral ramus courses internal carotid arteries (Figs. 6.3, 6.4, and 6.6) (16, 20, 21).
between the posterior arch of the atlas and the vertebral artery
and passes forward, lateral to the lateral mass of the atlas and
medial to the vertebral artery, and supplies the rectus capitis Vertebral artery
lateralis. The C2 nerve emerges between the posterior arch of The paired vertebral arteries arise from the subclavian ar-
the atlas and the lamina of the axis where the spinal ganglion teries, ascend through the transverse processes of the upper
is located extradurally, medial to the inferior facet of C1 and six cervical vertebrae, pass behind the lateral masses of the
the vertebral artery. Distal to the ganglion, the nerve divides axis, enter the dura mater behind the occipital condyles, as-
into a larger dorsal and a smaller ventral ramus. After passing cend through the foramen magnum to the front of the me-
below and supplying the inferior oblique muscle, the dorsal dulla, and join to form the basilar artery at the pontomedul-

Foramen Magnum S169
lary junction. Each artery is divided into intradural and preolivary sulcus, courses in front of, or between, the hypo-
extradural parts (Figs. 6.3-6.6). glossal rootlets, and crosses the pyramid to join with the other
The extradural part is divided into three segments. The first vertebral artery at or near the pontomedullary sulcus to form
segment extends from the origin at the subclavian artery to the basilar artery. In its ascending course, the anterior and
the entrance into the lowest transverse foramen, usually at the lateral surfaces of the lateral medullary segments face the
C6 level. The second segment ascends through the transverse occipital condyles, the hypoglossal canals, and the jugular
foramina of the upper six cervical vertebrae in front of the tubercles. The anterior medullary segment rests on the clivus.
cervical nerve roots. This segment deviates laterally just above The branches arising from the vertebral artery in the region of
the axis to reach the laterally placed transverse foramen of the the foramen magnum are the posterior spinal, anterior spinal,
atlas. The third segment, the one most intimately related to PICA, and anterior and posterior meningeal arteries.
the foramen magnum, extends from the foramen in the trans-
verse process of the atlas to the site of passage through the Posterior spinal artery
dura mater. The artery, after passing through the transverse The paired posterior spinal arteries usually arise from the
process of the atlas, is located on the medial side of the rectus posteromedial surface of the vertebral arteries, just outside
capitis lateralis. The third segment passes medially behind the the dura mater, but they may also arise from the initial intra-
lateral mass of the atlas and atlanto-occipital joint and is dural part of the vertebral arteries, or from the PICA (Figs. 6.3
pressed into the groove on the upper surface of the lateral part and 6.6) (5, 16, 21). Care should be taken to preserve the
of the posterior arch of the atlas, where it courses along the posterior spinal artery during dural opening because it may
floor of the suboccipital triangle. It enters the vertebral canal be incorporated into the dural cuff around the vertebral artery.
by passing anterior to the lateral border of the atlanto- As each posterior spinal artery passes through the dura mater, it
occipital membrane. It is partially covered by the posterior is surrounded by the same fibrous tunnel as the vertebral artery
atlanto-occipital membrane and semispinalis capitis, the rec- and the first cervical nerve root. In the subarachnoid space, it
tus capitis posterior major, and the superior and inferior courses medially behind the rostral-most attachments of the
oblique muscles. It is surrounded by a venous plexus com- dentate ligament, and on reaching the lower medulla, it divides
posed of anastomoses between the deep cervical and epidural into ascending and descending branches. The ascending branch
veins. The C1 nerve root passes through the dura mater on the courses through the foramen magnum and supplies the resti-
lower surface of the vertebral artery between the artery and form body, the gracile and cuneate tubercles, the rootlets of the
the groove on the posterior arch of the atlas with the vertebral accessory nerve, and the choroid plexus near The foramen of
artery. This bony groove is frequently transformed into a Magendie, and may give rise to branches that anastomose with
bony canal that completely surrounds a short segment of the branches of the PICA. The descending branch passes downward
artery. Of the 50 arteries we examined, 24 (48%) were in a between the dorsal rootlets and the dentate ligament on the
shallow groove, 12 (24%) were partially, but incompletely, posterolateral surface of the spinal cord, and supplies the super-
surrounded by bone, and 14 (28%) coursed through a bony ficial part of the dorsal half of the cervical spinal cord. It anas-
ring that completely surrounded the artery (Fig. 6.6) (5). The tomoses with the posterior branches of the radicular arteries that
terminal extradural segment of the vertebral artery gives rise enter the vertebral foramen at lower levels. The descending
to the posterior meningeal and posterior spinal arteries, branch gives rise to collateral branches, each lower one being
branches to the deep cervical musculature, and infrequently smaller and less constant than the last one, which course medi-
the PICA. ally across the posterior surface of the spinal cord, and join to
The intradural segment begins at the dural foramina just form an artery that courses in the midline, parallel to the poste-
inferior to the lateral edge of the foramen magnum. The dura rior spinal arteries.
in this region is much thicker than in other areas, and it forms
a funnel-shaped foramen around a 4- to 6-mm length of the Posteroinferior cerebellar artery
artery. The first cervical nerve exits the spinal canal, and the The PICA is the largest branch of the vertebral artery (Figs.
posterior spinal artery enters the spinal canal through this 6.3 and 6.6). It usually originates with the dura mater, but it
dural foramen with the vertebral artery. These three struc- may infrequently originate from the terminal extradural part
tures are bound together at the foramen by fibrous dural of the vertebral artery. It may arise at, above, or below the
bands. The initial intradural segment of the vertebral artery level of the foramen magnum; of the 42 arteries found in 50
passes just superior to the dorsal and ventral roots of the first cerebellae examined, 35 arose above and 7 arose below the
cervical nerve, and just anterior to the posterior spinal artery, foramen (16). The tonsillomedullary PICA segment, which
the dentate ligament, and the spinal portion of the accessory forms the caudal loop related to the lower part of the tonsil, is
nerve. most intimately related to the foramen magnum. The lower
Once inside the dura mater, the artery ascends from the end of the caudal loop was found to be above the edge of the
lower lateral to the upper anterior surface of the medulla. The foramen magnum in 37 of the 42 arteries examined, below the
intradural part of the artery is divided into lateral and anterior edge in 4, and at the level of the edge of the foramen in 1.
medullary segments (5, 16). The lateral medullary segment
begins at the dural foramen and passes anterior and superior Anterior spinal artery
along the lateral medullary surface to terminate at the preo- The anterior spinal artery is formed by the union of the
livary sulcus. The anterior medullary segment begins at the paired anterior ventral spinal arteries, which originate from

S170 Rhoton
the anterior medullary segment of the vertebral arteries near penetrates the dura before reaching the posterior edge of the
the origin of the basilar artery (Figs. 6.3, 6.4, and 6.6). The foramen magnum. After passing through the foramen mag-
junction of the anteroventral spinal arteries was located above num, it ascends near the falx cerebelli and divides near the
the level of the foramen magnum near the lower end of the torcula into several branches that terminate in the posterior
olives in 84% of our specimens (5). In some cases, one of part of the tentorium and cerebral falx. It supplies the dura
the anterior ventral spinal arteries continued inferiorly as the mater lining the posterolateral and posterior part of the pos-
anterior spinal artery, and the other terminated on the ante- terior cranial fossa, and anastomoses with the meningeal
rior surface of the medulla or in a rudimentary channel con- branches of the ascending pharyngeal and occipital arteries.
nected the smaller anterior ventral spinal artery with a dom- The ascending pharyngeal branch of the external carotid
inant one. artery usually sends two branches to the dura above the
The anterior spinal artery descends through the foramen foramen magnum. One branch passes through the hypoglos-
magnum on the anterior surface of the medulla and the spinal sal canal and the other enters through the jugular foramen
cord in or near the anteromedian fissure. On the medulla, it (14). The branch passing through the hypoglossal canal di-
supplies the pyramids and their decussation, the medial lem- vides into an ascending branch that passes upward in the
niscus, the interolivary bundles, the hypoglossal nuclei and dura covering the clivus and anastomoses with the branches
nerves, and the posterior longitudinal fasciculus (17). It anas- of the dorsal meningeal artery, and a descending branch that
tomoses with the anterior branches of the radicular arteries courses inferomedially toward the anterior edge of the fora-
entering the cervical foramina. There are few anastomoses men magnum and anastomoses with branches of the arcade
with the anterior radicular branches if the descending channel above the odontoid process formed by the anterior meningeal
is large, but it has frequent connections with the anterior arteries. This anastomotic rete in the dura anterior to the
radicular arteries if it is small. foramen magnum and on the clivus gives osseous branches to
the clivus. The branches that enter through the jugular fora-
men divide into branches that course posteriorly and postero-
Meningeal arteries
superiorly to anastomose with the meningeal branches of the
The dura mater around the foramen magnum is supplied occipital and posterior meningeal arteries, and supply the dura
by the anterior and posterior meningeal branches of the ver- mater in the posterior and posterolateral parts of the posterior
tebral artery, and the meningeal branches of the ascending cranial fossa.
pharyngeal and occipital arteries (Figs. 6.3 and 6.6) (5, 20). The meningeal branch of the occipital artery is inconstant
These arteries, plus the dorsal meningeal branch of meningo- and, if present, it penetrates the cranium through the mastoid
hypophyseal trunk that arises from the intracavernous seg- emissary foramen. It divides into one branch that courses
ment of the internal carotid artery, supply all of the dura posterosuperiorly to join the branches of the posterior men-
lining the posterior cranial fossa. Infrequently, the PICA, the ingeal artery that supplies the dura mater in the posterior part
posterior spinal artery, and the intradural part of the vertebral of the posterior fossa, and another branch that courses antero-
artery give rise to meningeal branches. laterally and joins the meningeal branches of the ascending
The anterior meningeal branch of the vertebral artery arises pharyngeal artery.
from the medial surfaces of the extradural part of the verte-
bral artery immediately above the transverse foramen of the
third cervical vertebra (Fig. 6.3). The artery enters the spinal Venous relationships
canal through the intervertebral foramen between the second
and third cervical vertebrae, and ascends between the poste- The venous structures in the region of the foramen magnum
rior longitudinal ligament and the dura mater. At the level of are divided into three groups: one composed of the extradural
the apex of the dens, each artery courses medially to join its veins, another formed by the intradural (neural) veins, and a
mate from the opposite side and forms an arch over the apex third constituted by the dural venous sinuses (13, 18). The three
of the dens. Its branches supply the dura mater in the region groups anastomose through bridging and emissary veins.
of the clivus and the anterior part of the foramen magnum
and upper spinal canal, and they anastomose with the
branches of the ascending pharyngeal and dorsal meningeal
Extradural groups
arteries that supply the dura mater covering the anterior and Venous flow in this area empties into two systems: one
anterolateral part of the posterior fossa. The anterior menin- drained by the internal jugular vein and another draining into
geal artery also gives rise to muscular and osseous branches the vertebral venous plexus. The internal jugular vein and its
that supply the body and odontoid process of the axis and the tributaries form the most important drainage system in the
articulate plate of the atlanto-occipital and atlantoaxial joints. craniocervical area. The internal jugular vein originates at the
The posterior meningeal artery arises from the posterosu- jugular foramen by the confluence of the sigmoid and inferior
perior surface of the vertebral artery as it courses around the petrosal sinuses (14, 18, 25). The venous plexus surrounding
lateral mass of the atlas, above the posterior arch or just before the vertebral artery in the suboccipital triangle is formed by
penetrating the dura; however, it may have an intradural numerous small channels that empty into the internal verte-
origin, in which case, it penetrates the arachnoid to reach the bral plexuses (between the dura and the vertebrae), which
dura (Fig. 6.6) (5). It pursues a tortuous ascending course and issue from the vertebral canal above the posterior arch of the

Foramen Magnum S171
atlas. This vertebral venous plexus and multiple small veins anterolateral medullary (preolivary) sulcus along the line of
from the deep muscles communicate with the dense venous origin of the hypoglossal rootlets. The lateral posterior spinal
plexus, which accompanies the vertebral artery into the fora- vein, which courses along the line of origin of the dorsal roots
men in the transverse process of the atlas and descends in the posterior lateral spinal sulcus, is continuous above with
through the transverse foramina of successive cervical verte- the lateral medullary vein that courses along the retro-olivary
brae into the brachiocephalic vein. The posterior condylar sulcus, dorsal to the olive. The median posterior spinal vein,
emissary vein, which passes through the posterior condylar canal, which courses along the posteromedian spinal sulcus, is con-
forms a communication between the vertebral venous plexus and tinuous above with the main vein on the posterior surface of
the sigmoid sinus. The venous plexus of the hypoglossal canal the medulla, the median posterior medullary vein that
passes along the hypoglossal canal to connect the basilar venous courses along the posteromedian medullary sulcus. The trans-
plexus with the marginal sinus, which encircles the foramen verse medullary and transverse spinal veins cross the medulla
magnum. Obliteration of a portion of the venous plexus exposes and spinal cord at various levels, interconnecting the major
the upper extradural segment of the vertebral artery. longitudinal channels. Bridging veins may connect the neural
veins with the dural sinus in the region of the foramen
Dural venous sinuses magnum.
The venous channels in the dura mater surrounding the
foramen magnum are the marginal, occipital, sigmoid, infe-
DISCUSSION
rior petrosal, and basilar venous plexus. The marginal sinus is
located between the layers of the dura in the rim of the Herniations
foramen magnum. It communicates anteriorly, through a se-
ries of small sinuses, with the basilar sinus on the clivus, and Herniation of cerebellar tissue into the foramen magnum
posteriorly with the occipital sinus. It is usually connected to may cause neural compression and even death. These hernia-
the sigmoid sinus or jugular bulb, by a sinus that passes tions are commonly referred to as tonsillar herniations (8, 27),
across the intracranial surface of, and communicates with, the but the herniation usually involves the tonsils and biventral
veins in the hypoglossal canal. These anastomoses provide an lobules, both of which are deeply grooved by the edge of the
alternative route for venous drainage in the case of obstruc- foramen magnum. The herniation may compress the medulla
tion of the internal jugular vein. The occipital sinus courses in and be so severe that the herniated tissue undergoes necrosis.
the cerebellar falx. Its lower end divides into paired limbs Patients with herniation at the foramen magnum may be asymp-
each of which courses anteriorly around the foramen mag- tomatic; or may present with pain, signs of neural compression,
num to join the sigmoid sinus or the jugular bulb and its increased intracranial pressure, and sudden unexpected death.
upper end joins the torcula. Symptoms caused by dysfunction of the cerebellum, brainstem,
The basilar venous plexus is located between the layers of and lower cranial and upper spinal nerves include pain in the
the dura mater on the upper clivus. It is formed by intercon- neck and upper arms, dizziness, ataxia, disturbances of gait,
necting venous channels that anastomose with the inferior diplopia, dysphagia, tinnitus, decreased hearing, nystagmus,
petrosal sinuses laterally, the cavernous sinuses superiorly, weakness up to the degree of quadriparesis, and sensory deficit in
and the marginal sinus and epidural venous plexus inferi- the extremities. Coughing or sneezing may aggravate the symp-
orly. The inferior petrosal sinuses extend along the petroclival toms and cause syncope. Some patients without previous
fissure and communicate above with the basilar sinus and symptoms who die suddenly are found to have herniations
below with the jugular bulb. The sigmoid sinus descends through the foramen magnum at autopsy. The occurrence of
along the sigmoid groove and exits the cranium through the sudden death in these patients means that herniation at the
sigmoid part of the jugular foramen, and descends anterolat- foramen magnum is a precarious situation that can be aggra-
eral to the occipital condyle, and anterior to the transverse vated by minor stresses (8). The common denominator in
process of the atlas. these cases with sudden death is herniation of the tonsils and
adjacent part of the biventral lobule into the foramen mag-
num. The herniation may be bilateral and symmetrical, al-
Intradural (neural) veins
though more commonly it is not strictly symmetrical and may
The intradural veins in the region of the foramen magnum be unilateral. The herniated tonsils are tightly pressed against
drain the lower part of the cerebellum and brainstem, the the medulla. Acute or chronic herniations may be seen with
upper part of the spinal cord, and the cerebellomedullary space-occupying lesions, such as cerebellar astrocytomas or
fissure. The veins of the medulla and spinal cord form longi- cystic tumors. Chronic herniation is seen with the Arnold-
tudinal plexiform channels that anastomose at the foramen Chiari malformation.
magnum. The median anterior spinal vein that courses in the
anteromedian spinal fissure deep to the anterior spinal artery
is continuous with the median anterior medullary vein that Tumors
courses on the anteromedian sulcus of the medulla. The lat- Tumors arising in the region of the foramen magnum are
eral anterior spinal vein courses longitudinally along the or- divided by Cushing and Eisenhardt (4) into a craniospinal
igin of the ventral roots and superiorly joins the lateral ante- group that arises above and grows downward toward the
rior medullary vein that courses longitudinally in the foramen magnum, and a spinocranial group that arises below

S172 Rhoton
FIGURE 6.7. Surgical approaches to the foramen magnum. The posterior operative approach is commonly selected for intra-
dural lesions. An anterior approach is frequently selected for extradural lesions situated anterior to the foramen magnum. A
lateral approach may be selected for intradural lesions located lateral to and/or in front of the brainstem, especially if they
involve or are contiguous with the temporal bone. The lateral approaches directed through the temporal bone are considered
in a later section of this issue.
and grows upward toward the foramen magnum. The intra- cervical, spondylosis, multiple sclerosis, or degenerative dis-
dural extramedullary tumors in this region are usually be- eases (1, 23, 30). Symptoms or signs, common in other disor-
nign, with meningiomas and schwannomas being the most ders that should also suggest the presence of a tumor in the
frequent. The intramedullary tumors are represented mainly region of the foramen magnum include neck stiffness and
by astrocytomas and ependymomas. Cerebellar tumors, espe- pain, involvement of the lower cranial nerves, especially the
cially those originating in the fourth ventricle and those aris- spinal accessory nerve, unilateral upper extremity weakness
ing in the lower part of the cerebellar hemisphere or vermis, and atrophy, incoordination of the hands, gait disturbances,
may extend into or through the foramen magnum into the vague sensory disturbances or paresthesia in the extremities,
upper spinal canal. Chordomas and metastases are the most objective sensory loss in a nonanatomic pattern, incoordina-
common extradural tumors. The chordomas usually arise at tion in the upper extremities, and pyramidal tract findings
the level of the clivus and may extend caudally into the with spastic gait. Those tumors arising in the caudal part of
foramen magnum. the fourth ventricle or cerebellum may cause increased intra-
Foramen magnum tumors have frequently eluded early cranial pressure by obstructing cerebrospinal fluid drainage
diagnosis because they cause bizarre symptoms that simulate at the level of the fourth ventricle.

Foramen Magnum S173
FIGURE 6.8. Suboccipital

approaches. Either a vertical
midline or hockey-stick
incision is used, depending
on the site of the lesion. A,
the patient is most
commonly placed in the
three-quarter prone position.
B, the vertical midline
incision is selected for
lesions situated in the upper
spinal canal and for those
located posteriorly or
posterolaterally in the area
above the foramen magnum.
The subcutaneous tissues are
separated from the
underlying fascia near the
inion to gain room for a Y-
shaped incision in the
muscles. The upper limbs of
the “Y” begin at the level
of the superior nuchal line
and join below the inion. C,
the incision is of sufficient
length to complete a
suboccipital craniectomy and
a laminectomy of the axis
and atlas (oblique lines). D,
the dural incision is outlined
(interrupted lines). E,
intradural exposure. The
major extracranial hazard is
injury to the vertebral artery
as it courses below the
atlantoaxial joint and across
the posterior arch of the
atlas. The vertebral arteries
and PICAs are in the lower
part of the exposure. The
accessory nerve ascends
posterior to the dentate
ligament. The
accessory nerves pass toward the jugular foramen. F, upper left. Hockey-stick retrosigmoid exposure. Skin incision (solid line)
and bone removal (oblique lines). Lower right. Intradural exposure. The hockey-stick incision extends superomedial from the
mastoid process along the superior nuchal line to the inion and downward in the midline. This incision is selected if the
lesion extends anterolateral or anterior to the brainstem toward the jugular foramen or cerebellopontine angle. This exposure
permits the removal of the full posterior rim of the foramen magnum, the posterior elements of the atlas and axis, and, in
addition, the ability to complete a unilateral suboccipital craniectomy of sufficient size to expose the anterolateral surface of
the brainstem and the nerves in the cerebellopontine angle. Tumors in this area may extend upward through the
cerebellomedullary fissure to be attached to the roof or floor of the fourth ventricle. Laterally situated tumors may be
attached to the initial intradural segment of the vertebral artery and the thick dural cuff around the artery, which also
incorporates the posterior spinal arteries and the C1 nerve root in fibrous tissue. As one moves superiorly along the lateral
surface of the medulla, the origin of the PICA and the glossopharyngeal, vagus, accessory, facial, vestibulocochlear, and
trigeminal nerves are encountered. The dura is closed with a dural substitute if closure of the patient’s dura constricts the
cerebellar tonsils or the cervicomedullary junction. A., artery; A.I.C.A., anteroinferior cerebellar artery; Lig., ligament;
P.I.C.A., posteroinferior cerebellar artery; Vert., vertebral.

S174 Rhoton
FIGURE 6.9. Transnasal route to the upper clivus. A, the section of the facial structures extends across the nasal cavity,
superior and middle turbinates, maxillary sinuses, the orbits near the apex, and the ethmoid sinuses in front of the sphenoid
sinus. The zygomatic and infraorbital nerves arise from the mandibular nerve in the pterygopalatine fossa, which is located
behind the posterior wall of the maxillary sinus. B, the turbinates and posterior ethmoid air cells have been removed to
expose the vomer and the anterior face of the sphenoid sinus. The nasolacrimal duct descends along the lateral wall of the
nasal cavity and opens below the inferior turbinate into the inferior meatus. C, the anterior face of the sphenoid sinus has
been removed to expose the multiseptated sphenoid sinus and the anterior wall of the sella. The bony prominences over the
optic canals are situated in the superolateral margins of the sphenoid sinus. D, the anterior wall of the sella and the lateral
walls of the sphenoid sinus have been removed to expose the petrous and cavernous carotid and the pituitary gland. The pos-
terior wall of the sphenoid sinus, which forms the anterior surface of the upper clivus, has been preserved. A., artery; Car.,
carotid; Cav., cavernous; CN, cranial nerve; Gang., ganglion; Gl., gland; Inf., inferior; Infraorb., infraorbital; M., muscle;
Max., maxillary; M.C.A., middle cerebral artery; Med., medial; Mid., middle; N., nerve; Nasolac., nasolacrimal; Pet., petrous;
Rec., rectus; Sphen., sphenoid; Sup., superior; Turb., turbinates.
Surgical approaches Posterior approaches

The foramen magnum is most commonly approached from The vertical midline incision is used for lesions situated in
posteriorly or anteriorly, and less frequently from laterally the upper spinal canal and posterior or posterolateral at the
(Fig. 6.7). The posterior operative approach is commonly se- level of or above the foramen magnum (Figs. 6.3, 6.6, and 6.8).
lected for intradural lesions, and an anterior approach is The vertical midline skin incision is of sufficient length to
frequently selected for extradural lesions situated anterior to complete a craniectomy above the foramen magnum and a
the foramen magnum. A lateral approach may be selected for laminectomy of the axis and atlas. The subcutaneous tissues
lesions located lateral to or in front of the brainstem, espe- are separated from the underlying fascia near the inion to gain
cially if they involve, or are located contiguous to the tempo- room for a Y-shape muscle incision. The upper limbs of the
ral bone and clivus. The lateral approaches directed through “Y” begin at the level of the superior nuchal line, lateral to the
the temporal bone are reviewed in the chapter on the tempo- external occipital protuberance, and join several centimeters
ral bone. below the inion, leaving a musculofascial flap along the su-

Foramen Magnum S175
FIGURE 6.10. Nasal pathway to the clivus. Stepwise dissection showing the structures that form the lateral limit of the trans-
nasal route to the clivus. A, the entire clivus is located above the level of the hard palate and, in most cases, can be accessed
through the nasal cavity and nasopharynx. The nasal turbinates and meati and the eustachian tubes are in the lateral margin
of the exposure. B, a portion of the superior, middle, and inferior turbinates has been removed and the area between the sphenoid
pterygoid process and the posterior wall of the maxilla has been opened to expose the pterygopalatine fossa in the lateral wall of
the nasal cavity. The ostia of the maxillary and frontal sinuses opens into the middle meatus located below the middle turbinate.
The nasolacrimal duct opens below the lower turbinate into the inferior meatus. The eustachian tube, located in front the foramen
magnum and lower edge of the clivus, opens into the nasopharynx at the posterior edge of the pterygoid process. Accessing the
clivus plus the atlas and axis requires an approach that can be directed above and below the level of the palate. Rosenmuller’s
fossa is located behind the eustachian tube. C, the medial wall of the maxillary sinus has been opened to expose the infraorbital
nerve, which arises in the pterygopalatine fossa and passes forward in the sinus roof. The maxillary nerve passes through the fora-
men rotundum to enter the pterygopalatine. The upper cervical carotid and eustachian tube form the lateral limit of the exposure
of the lower clivus and the junction of the petrous and cavernous carotid limits the lateral exposure of the upper clivus. D,
enlarged view. The bone and dura covering the optic canal in the superolateral part of the sphenoid sinus has been opened to
expose the optic nerve and ophthalmic artery in the optic canal. The junction of the petrous and cavernous carotid limits the expo-
sure below the level of the sella. The maxillary nerve exits the foramen rotundum and enters through the pterygopalatine fossa
where it gives rise to the infraorbital, zygomatic, and greater palatine nerves, plus communicating rami to the pterygopalatine gan-
glion. Terminal branches of the maxillary artery intermingle with the neural structures in the pterygopalatine fossa. A., artery; Ant.,
anterior; Car., carotid; Cav., cavernous; Eust., eustachian; For., foramen; Gang., ganglion; Gr., greater; Inf., inferior; Infraorb.,
infraorbital; Max., maxillary; Mid., middle; N., nerve; Ophth., ophthalmic; Palat., palatine; Pet., petrosal; Proc., process; Pteryg.,
pterygoid; Pterygopal., pterygopalatine; Sup., superior.
perior nuchal line for closure. The inferior limb of the “Y” muscles are stripped from the lateral part of the posterior arch
incision extends downward in the midline. The major ex- of the atlas. The emissary veins and vertebral venous plexus
tracranial hazard is injury to the vertebral artery as it courses should be obliterated quickly if they are opened.
along the lateral part of the posterior arch of the atlas. This The hockey-stick incision is selected if the lesion extends
artery is not encountered if the incision is strictly midline, but anterior or anterolateral to the brainstem toward the jugular
it is frequently encountered in the floor of the suboccipital foramen or the cerebellopontine angle. The skin incision ex-
triangle if the muscle incision deviates laterally, or when the tends from the mastoid process along the superior nuchal line to

S176 Rhoton
FIGURE 6.11. Nasal route to the clivus. A, this cross section extends through the nasal cavity, orbits, and maxillary and eth-
moid sinuses. The ethmoid sinuses are situated in front of the sphenoid sinus. The middle and inferior turbinates have been
preserved. B, the anterior wall of the sphenoid sinus has been opened to expose a multiseptated sinus and the anterior sellar
wall. The left turbinates have been removed. Part of the posterior wall of the left maxillary sinus has been removed to expose
the greater palatine artery which arises from the maxillary artery in the pterygopalatine fossa. The internal carotid arteries

Foramen Magnum S177
the inion, and downward in the midline. A muscular cuff is left vertebral artery. Before sacrificing any rootlets of these
attached along the superior nuchal line to facilitate the closure. nerves, an attempt should be made to gently separate the
This incision permits removal of the full posterior rim of the rootlets and to operate through the interval between the root-
foramen magnum, the posterior elements of the atlas and axis, lets. Often, tumors expand and widen the interval between
and, in addition, to complete a unilateral suboccipital craniec- the rootlets, thus providing some access to medially placed
tomy of sufficient size to expose the anterolateral surface of the lesions. Another route through which it may be easier to reach
brainstem and the nerves in the cerebellopontine angle. a lesion anterior to the medulla and pons is the interval
In opening the dura mater, using either the midline or between the lower margin of the vestibulocochlear and facial
hockey-stick approach, the marginal and occipital sinuses, nerves and the upper margin of the glossopharyngeal nerve.
along with the bridging veins passing from the neural sur- It is uncommon to be able to work between the vagal rootlets;
faces to these and the sigmoid sinus, are encountered. Poste- however, the lower cervical rootlets of the accessory nerve are
rior intradural lesions may separate easily from the surface of very fine and are often separated by a wide interval. Consid-
the brain and spinal cord. On the other hand, they may be eration might be given to sacrificing a few of the lower acces-
attached to the nerve roots and spinal cord, or they may sory rootlets if it will make an otherwise incurable lesion
extend upward through the cerebellomedullary fissure to be curable. The intracapsular contents of the tumor are removed,
attached to the inferior medullary velum, choroid plexus, or and the remaining tumor capsule is separated from the sur-
the floor of the fourth ventricle. Opening the tela choroidea face of the brainstem and nerves rather than attempting to
and inferior medullary velum may facilitate the exposure of deliver the whole intact tumor through the limited exposure.
tumors in this area. Care is required to avoid injury to the Extreme care should be used when cutting into tumors situ-
PICA as it courses around the tonsil and through the cleft ated anterolateral to the brainstem, since these tumors, espe-
between the superior pole of the tonsil and inferior medullary cially meningiomas, may encase a segment of the vertebral
velum and tela choroidea. artery or the PICA. The dura mater is closed with a dural
Laterally situated tumors may be attached to the initial substitute if closure of the patient’s dura mater constricts the
intradural segment of the vertebral artery and the thick dural cerebellar tonsils or the cervicomedullary junction. A pseudo-
cuff around the artery, which also incorporates the posterior meningocele may form at the operative site if there is any
meningeal and posterior spinal arteries, Cl nerve root, acces- tendency toward the development of hydrocephalus. Spinal drain-
sory nerve, and the dentate ligament. Dealing with these age, repeated spinal punctures, or a shunting procedure may be
lesions may be facilitated by using a far-lateral approach, required to decompress a postoperative pseudomeningocele.
which is extended to include exposure of the atlanto-occipital
joint, extradural vertebral artery, and transverse process of
C1, combined with drilling of the occipital condyle, as de- Anterior operative approaches
scribed in detail in the chapter on the far lateral approach (29, The anterior approach was first used to reach lesions ante-
33). Dividing the attachments of the upper triangular pro- rior to the spinal cord, and was subsequently used to expose
cesses of the dentate ligaments may facilitate the exposure of lesions anterior to the brainstem (Figs. 6.4, 6.5, and 6.9-6.11).
anteriorly situated lesions. Structures encountered in expos- The greatest advantage of the anterior approach is the direct
ing superiorly along the lateral surface of the medulla include route to the lesion, and the major disadvantages are the con-
the PICA and the glossopharyngeal, vagus, accessory, and taminated field and the frequency of cerebrospinal fluid fis-
hypoglossal nerves. The vertebral artery may be followed tula, pseudomeningocele, and meningitis after the exposure
upward to its junction with the basilar artery through the of intradural lesions by this approach. The depth of the op-
hockey-stick exposure. The most difficult lesions to remove erative field was once considered a disadvantage, but the use
are those situated anterior to the glossopharyngeal, vagus, of the operating microscope has reduced the importance of
and accessory nerves and the lateral medullary segment of the that factor.
Š
form serpiginous prominences in the lateral wall of the sphenoid sinus. C, the mucosa and bony wall of the sphenoid sinus
have been removed to expose both the internal carotid arteries, which form the lateral limit of the transnasal exposure of the
upper clivus. The pituitary gland has been exposed. Additional posterior wall of the left maxillary sinus has been removed to
expose the infratemporal fossa, which contains the branches of the maxillary artery, the pterygoid muscles, pterygoid venous
plexus, and branches of the mandibular nerve. The nasopharyngeal mucosa covering the longus capitis and the lower clivus is
exposed in the interval between the palate and the vomer. D, enlarged view of the sphenoid sinus and sellar region. The
anterior surface of the upper clivus is exposed below the pituitary gland. The lateral clival exposure is limited at this level by
the internal carotid arteries. E, oblique view. The medial wall of the left cavernous sinus has been opened to expose the
abducens and oculomotor nerves. The pterygopalatine fossa is located below the orbital apex. The maxillary nerve passes
through the foramen rotundum and gives rise to the communicating rami to the pterygopalatine ganglion and the infraorbital
nerve that courses along the floor of the orbit. F, enlarged view of the structures in the medial cavernous sinus. The ophthal-
mic artery courses below the optic nerve in the optic canal. A., artery; Car., carotid; Cav., cavernous; CN, cranial nerve; Gl.,
gland; Gr., greater; Inf., inferior; Infratemp., infratemporal; Max., maxillary; Mid., middle; Ophth., ophthalmic; Palat., pala-
tine; Pterygopal., pterygopalatine; Sphen., sphenoid; Turb., turbinates.

S178 Rhoton
FIGURE 6.12. A–F. Transoral,

transpalatal, and transmaxillary
approaches to the clivus and foramen
magnum. A, forced opening of the mouth
permits the clivus to be exposed below
the palate. B, anterior view through the
open mouth. The soft palate, which
extends backward from the hard palate,
will block the view of the upper clivus. C,
an incision has been outlined in the
midline of the soft palate. D, the soft
palate has been divided to expose the
mucosa lining the lower clivus. E, the
pharyngeal mucosa has been opened in
the midline and the longus capitis and
longus coli have been exposed and
the longus capitis reflected laterally.
F, the left longus capitis and longus coli
have been reflected laterally. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Cap., capitis; CN, cranial nerve; For., foramen; Gr.,
greater; Infratemp., infratemporal; Jug., jugular; Long., longus; M., muscle; Max., maxillary; N., nerve; P.I.C.A., posteroinferior
cerebellar artery; Sp., spinal; Sphen., sphenoid; Temp., temporal; Vert., vertebral; Vert., vertebral; Zygom., zygomatic.
Anterior approaches have been used to reach tumors of the such as basilar invagination, which compress the medulla or
atlas, axis, and clivus; for the resection and fixation of the odon- spinal cord from anteriorly; and for approaching aneurysms of
toid process after ligamentous and osseous injury; for decom- the lower third of the basilar artery, the vertebrobasilar junction,
pressing bony malformations of the craniovertebral junction, and the upper part of the vertebral arteries.

Foramen Magnum S179
FIGURE 6.12. G–J. Transoral, transpalatal, and transmaxillary approaches to the clivus and foramen magnum. G, the lower clivus
has been opened to expose both vertebral arteries, lower part of the basilar artery, right PICA, left AICA, and the abducens and
hypoglossal nerves. H, the anterior arch of C1 has been removed to expose the odontoid process. I, a degloving subperiosteal dis-
section exposes the anterior face of the maxilla and the lower part of the anterior piriform aperture. J, the transverse maxillary
(LeFort I) osteotomy extends through the maxillary sinus above the apex of the teeth and below the infraorbital canals.
The transoral route through the mouth and the posterior pharyngeal wall is incised longitudinally in the midline (Figs.
pharyngeal wall, referred to as the buccopharyngeal ap- 6.4, 6.12, and 6.13). The mucosa and prevertebral muscles are
proach, is the anterior approach most commonly selected. The elevated as a single mucoperiosteal layer using subperiosteal
basic transoral approach may be modified to include a trans- dissection, and are retracted laterally. To expose the clivus, it
palatine approach in which the soft palate, or both the soft is often necessary to split the soft palate in the midline. If
and hard palates, are opened, and a labiomandibular or la- added craniad exposure is needed, laterally based mucoperi-
bioglossomandibular approach in which the lip, mandible, osteal flaps may be elevated from the lower surface of the
and possibly the tongue and floor of the mouth are split to hard palate, and the posterior part of the hard palate may be
increase the exposure. Other types of anterior approaches are: removed. The mucosa covering the upper surface of the hard
the transcervical approach directed through the submandib- palate should be retracted and not opened. This permits the
ular area along the anterior border of the sternocleidomastoid pharyngeal incision to be extended upward through the vault
muscle (31); the transcranial-transbasal approach in which the of the nasopharynx to the posterior border of the vomer.
clivus is reached through a bifrontal craniotomy after resection When elevating the mucoperiosteal layer from the clivus, the
of the sphenoid and ethmoid sinuses (6); the extended frontal lateral margins slope dorsally into “gutter-like” depressions
approach in which the bifrontal craniotomy is combined with an in which the tissue becomes thicker and more adherent. De-
osteotomy of the orbital rims; and the transsphenoidal approach pending on the lesion, the clivus, the anterior arch of the atlas,
directed under the lip, along the nasal septum, and through the the dens, and bodies of C2 and C3 may be removed with a
sphenoid sinus to the upper part of the clivus. drill and rongeurs. The clival exposure between the occipital
condyles is 2- to 2.5-cm wide and 2.5- to 3.0-cm long. Care
Transoral approaches must be taken to avoid the sixth through the twelve cranial
For the transoral approach, the soft palate is retracted to nerves, the internal carotid arteries, the internal jugular veins,
reach the anterior part of the atlas and axis, and the posterior and the inferior petrosal sinuses that are on the periphery of

S180 Rhoton
FIGURE 6.12. K–N. Transoral, transpalatal, and transmaxillary approaches to the clivus and foramen magnum. K, the lower
maxilla has been displaced downward. The clival window and vertebral arteries can be seen through the exposure. L,
enlarged view of the clival opening. M, the maxilla has been split vertically in the midline and the halves reflected laterally,
allowing the clival opening to be extended upward. N, enlarged view of the clival exposure. The right AICA passes behind the
right abducens nerve and the left AICA passes in front of the left abducens nerve.
the exposure. The most common lesions approached by this mandibular osteotomy accomplished in the midline after re-
route are in an extradural location. Opening the dura mater moval of a central incisor tooth. Spreading the mandibular
will expose both vertebral arteries and the lower part of the edges laterally, without splitting the tongue, permits the
basilar artery. tongue to be depressed downward between the mandibular
To increase the exposure and reduce the operative depth, halves. If the exposure is still inadequate, the tongue and floor
the lip and chin may be incised vertically and a step-like of the mouth may be split in the midline. Spreading the

Foramen Magnum S181
FIGURE 6.13. The transoral approach is the anterior approach most commonly selected. Variants of the transoral approach include the
transpalatal variant in which the soft palate or both the soft and hard palates are opened, and the labiomandibular or labioglossoman-
dibular variants in which the lip, chin, mandible, and possibly the tongue and floor of the mouth are split in the midline to increase the
exposure. The transoral approach and its variants permit removal of the clivus, the anterior arch of the atlas, the odontoid process, and
the bodies of C2 and C3. A, transoral approach. The patient is positioned with the head fixed so that lateral x-ray or image intensification
is available to verify the location. A tracheostomy is commonly performed. Catheters inserted through the nasal passages and brought
behind the soft palate and out the mouth or a silk suture brought through the base of the uvula and attached to a nasal catheter may be
used to retract the soft palate. The posterior pharyngeal wall is incised longitudinally in the midline (interrupted line). B, the mucosa and
muscles are retracted laterally as a single layer, using subperiosteal dissection to reach the atlas, axis, and lower clivus. The anterior arch
of the atlas, the odontoid process, and the body of the atlas may be removed (interrupted line) to expose the dura. C, it may be necessary
to split the soft palate in the midline to expose the clivus (palatal incision, continuous line; pharyngeal incision, interrupted line). D, the
anterior surface of the clivus has been exposed through the transpalatal approach. The anterior arch of the atlas and the odontoid process
may be removed and an opening made in the clivus (interrupted line). E, if further craniad exposure is needed, laterally based mucoperi-
osteal flaps may be elevated from the lower surface of the hard palate (interrupted line), and the soft palate split in the midline (continu-
ous line). The posterior part of the hard palate may be removed (oblique lines). F, care is taken to retract rather than open the mucosa
lining the upper surface of the hard palate. The pharyngeal incision is extended upward through the vault of the nasopharynx to the pos-
terior border of the vomer. When elevating the mucoperiosteal layer from the clivus, the lateral margins slope dorsally into gutter-like
depressions where the tissue becomes more adherent. The clivus, anterior arch of the atlas, dens, and bodies of C2 and C3 may be
removed. The clival defect is packed with muscle or fat and may be reinforced with a bone graft. The prevertebral muscle and mucosal
layers and the palatal openings are closed with absorbable sutures. G, the lower lip and mandible may be split (interrupted line) to
increase the exposure and reduce the operative depth. H, a step-like mandibular osteotomy (interrupted line) is accomplished in the mid-
line after removal of a central incisor tooth. I, spreading the mandibular halves laterally without splitting the tongue permits the tongue to
be depressed downward between the mandibular halves. J, if the exposure is still inadequate, the tongue and floor of the mouth may be
split in the midline. Spreading the mandibular-lingual halves exposes the pharynx down to the C3 level. The mucosa and musculature of
the tongue and floor of the mouth are reapproximated; the mandibular osteotomy is closed with plates; and the lip, chin, and submandib-
ular region are carefully closed after dealing with the lesion. (From, Rhoton AL Jr, de Oliveira E: Anatomical basis of surgical approaches
to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New
York, Thieme, 1998, pp 13–57 [26].)

S182 Rhoton
FIGURE 6.14. A–D. Lower maxillotomy route to the clivus and foramen magnum. A, the approach can be made through a
degloving incision inside the mouth; however, in this case, to more fully show the anatomy, a Weber-Fergusson paranasal
incision with an infraorbital extension is used to expose the anterior face of the maxilla. The infraorbital nerve has been
divided, although it can usually be preserved with the degloving incision. The masseter is attached along the lower margin of
the zygoma. B, the mucosal lining the maxillary sinus is exposed below the zygomatic arch. The coronoid process of the man-
dible is removed or reflected with the temporalis muscle to expose the medial and lateral pterygoid muscles and the maxil-
lary artery in the infratemporal fossa. C, the lateral pterygoid muscles and a segment of the maxillary artery have been
removed. Removal of the lateral pterygoid exposes the mandibular nerve and its branches in the medial part of the infratem-
poral fossa. D, a lower maxillectomy has been completed. In this approach, the maxilla can be folded on a vascularized pedicle of
soft palate into the floor of the mouth. The pterygoid process, which forms the posterior wall of the pterygopalatine fossa, has been
preserved. The nasal mucosa remains intact. The maxillary artery exits the infratemporal fossa to enter the pterygopalatine fossa.
A., artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., anterior; Bas., basilar; Cap., capitis; Car., carotid; Cav., cav-
ernous; CN, cranial nerve; Eust., eustachian; Gl., gland; Inf., inferior; Infraorb., infraorbital; Int., internal; Intercav., intercavernous;
Lat., lateral; Long., longus; M., muscle; Max., maxillary; Med., medial; N., nerve; Pal., palatini; Pet., petrous; Pteryg., pterygoid;
Pterygopal., pterygopalatine; Tens., tensor; TM., temporomandibular; Vert., vertebral.
mandibular-lingual halves exposes the pharyngeal wall down which is difficult to reach by the transoral approach (Figs. 6.12
to the level of the arytenoid cartilages. After dealing with the and 6.14-6.16). Four different types of transmaxillary ap-
lesion, the mucosa and musculature of the tongue and floor of proaches have been used (2, 3). In one approach, a LeFort I
the mouth are reapproximated, the mandibular osteotomy is osteotomy is completed, and the maxilla and hard palate are
repositioned with wire, and the lip, chin, and submandibular down-fractured into the oral cavity. In the second approach,
region are carefully closed. called the extended maxillectomy, the LeFort osteotomy is
combined with a midline incision of the hard and soft palate
Transmaxillary approach and the halves of the maxilla are swung laterally. In the third
Transmaxillary approaches have been advocated for pa- approach, the unilateral lower subtotal maxillotomy, half of
thology extending to the upper and middle third of the clivus, the maxilla, and the hard palate are hinged on the soft palate

Foramen Magnum S183
FIGURE 6.14. E–H. Lower maxillotomy route to the clivus and foramen magnum. E, the nasal mucosa has been opened and
the posterior pharyngeal wall reflected to the opposite side. The longus capitis attachments have been separated from the cli-
vus. F, the longus capitis and longus coli have been reflected laterally to expose the anterior arch of the atlas and the dens
and body of the axis. G, the clivus and the dura have been opened to expose the medulla and vertebral arteries. H, the expo-
sure has been extended upward by removing the anterior wall of the sphenoid sinus and sella. The terminal part of the
petrous carotids limits the lateral exposure at the level of the clivus, and the cavernous carotids limit the lateral exposure at
the level of the sphenoid sinus. The intercavernous sinuses interconnect the paired cavernous sinuses.
and folded downward into the floor of the mouth (6). The roots, and extending into the nasal cavity leaving the
medial maxillotomy is a fourth and less extensive approach branches of the internal maxillary artery and the nerves to
permitting exposure of the clivus. It involves removing the the maxilla and palate intact. The mucosa on the nasal
medial part of the anterior maxillary wall and the part of the surface of the maxilla is dissected off, and the nasal septum
maxilla bordering the anterior piriform aperture (Fig. 6.15). is divided just above its attachment to the palate. The freed
This provides an opening through the sinus and adjacent part bone block includes, in one piece, the part of both maxilla and
of the nasal cavity that exposes the clivus above the level of the maxillary teeth situated below the infraorbital foramen
the upper side of the hard palate. The sinus wall and the with their intact blood and nerve supply, which enters in the
anterior piriform aperture can be reconstructed at the end of region of the infratemporal fossa and pterygoid plates. The
the procedure. It can commonly be performed through a fact that the soft palate is left intact reduces the incidence of
degloving incision, although a lateral rhinotomy incision speech and swallowing disorders. The intact maxillary block,
would be used if there is a need to extend the approach to the however, blocks access to the craniovertebral junction, al-
medial orbit (11, 12). though it provides reasonable access to the upper and middle
In the first approach, with a LeFort osteotomy, the upper third of the clivus. In an effort to increase access to the
lip is elevated and a mucosal incision is made along the craniovertebral junction, the LeFort osteotomy has been com-
upper alveolar margin, extending around the molars on bined with a midline incision of the hard and soft palate, thus
both sides (Fig. 6.16). The mucosa is stripped off the ante- allowing the maxillary halves, with their attachment, to be
rior face of the maxilla below the infraorbital foramen. The reflected laterally (3). The disadvantage of the procedure is
saw cuts extend into the maxillary sinuses below the in- the difficulty obtaining good dental occlusion and proper
fraorbital foramen and high enough to avoid the dental functioning of the hard and soft palate.

S184 Rhoton
FIGURE 6.15. Medial

maxillotomy approach to the
clivus and foramen magnum. A, a
lateral rhinotomy incision has
been extended along the medial
orbital rim. The medial canthal
ligament has been exposed. B, the
medial canthal ligament has been
divided to expose the medial
aspect of the orbit. The ligament
can be preserved and the medial
orbital wall left intact if orbital
exposure is not needed. The
anterior pyriform aperture is
exposed. C, the osteotomies are
as outlined to open the nasal
cavity and medial maxilla. The
medial one opens the nasal cavity
and the lateral bone removal
exposes the maxillary sinus. The
medial maxillotomy aids in expos-
ing the clivus. D, the exposure has been directed to the posterior nasopharyngeal wall behind which the clivus sits. The anterior
wall of the sphenoid sinus has been removed, exposing the sphenoid septum. The posterior part of the nasal septum has been re-
moved to expose the clivus below the sphenoid sinus. Removal of the medial part of the posterior wall of the maxillary sinus ex-
poses the maxillary artery in the pterygopalatine fossa. E, enlarged view of the pterygopalatine fossa exposed by removing the me-
dial part of the posterior wall of the maxillary sinus. The maxillary nerve and artery enter the pterygopalatine fossa. The maxillary
artery is the major source of bleeding during surgery in this area. The maxillary artery enters the pterygopalatine fossa by passing
through the pterygomaxillary fissure. The maxillary nerve enters the fossa by passing through the foramen rotundum and gives off
communicating rami to the pterygopalatine ganglion. F, the pharyngeal mucosa has been opened, the longus capitis reflected later-
ally, and the clivus and dura opened to expose the basilar artery ascending in front of the pons. The pituitary gland is at the upper
margin of the exposure. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Cap., capitis; CN, cranial
nerve; Eust., eustachian; Gang., ganglion; Gl., gland; Gr., greater; Lig., ligament; Long., longus; M., muscle; Max., maxillary; Med.,
medial; N., nerve; Nasolac., nasolacrimal; Post., posterior; Pterygopal., pterygopalatine; Sphen., sphenoid; Vert., vertebral.

Foramen Magnum S185
FIGURE 6.16. Transmaxillary approaches. Three variants of the transmaxillary approaches are shown. All three can be com-
pleted through an intraoral incision with degloving. Another type of incision extending onto the face, such as a Weber-
Fergusson incision, might be considered. A, the upper lip is elevated and the mucosa is incised along the upper alveolar mar-
gin around the molars. The mucosa is elevated from the anterior face of the maxilla below the infraorbital foramen, but high
enough to avoid the dental roots. The mucosa is elevated from the nasal surface of the maxilla, and the nasal septum is
divided above its attachment to the palate. B, the saw cuts (solid line) extend into the maxillary sinus on both sides. The free
block of maxilla is moved downward (arrow) to give access to the clivus. C, the intraoral retractor has been placed. Displac-
ing the maxilla downward gives wide access to the clivus. D, a modified technique, called the extended maxillectomy,
includes the LeForte I osteotomy with a midline incision of the hard and soft palate (solid lines). E, this allows the halves of
the maxilla, which are attached to the muscles and vessels in the infratemporal fossa, to be reflected laterally, providing
wider exposure to the clivus and upper cervical spine. F, retractors have been placed to expose the clivus and upper cervical
area. The approach can be extended upward into the sphenoid and ethmoid sinuses and downward to C2 or C3. G–I. Unilat-
eral maxillotomy. G, in this approach, half of the maxilla is mobilized by a bone cut, which extends back to the infratemporal
fossa in the area just below the infraorbital foramen, and the maxilla is divided in the midline. A mucosal incision is made
along the low surface of the hard palate parallel to the midline on the side opposite the saw cut through the hard palate, and
the anterior face of the maxilla is degloved on one side. The soft palate is left intact. H, the unilateral block of maxilla, which
is still attached to the structures in the infratemporal fossa along the pterygoid plates and to the soft palate, which is not
interrupted, is folded downward into the floor of the mouth. I, the anterior part of the nasal septum is left undisturbed, but
the posterior part is removed along with some of the turbinates and wall of the sinuses to provide a wide exposure of the cli-
vus. This exposure can be enlarged to include the walls of the sphenoid and ethmoid sinuses. (From, Rhoton AL Jr: Anatomi-
cal basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Sur-
gery of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)
In the lower subtotal maxillotomy approach, the part of half palate. This opens a route through the nasal and oral cavities to the
of the maxilla, located below the orbital floor and infraorbital clivus, foramen magnum, and upper cervical area.
canal, is folded into the floor of the mouth on a hinge of In each of the approaches, the posterior part of the nasal
vascularized tissue, including the internal maxillary artery septum and turbinates may be removed to expose the poste-
and leaving the soft palate intact (Fig. 6.14) (2, 11). The hard rior pharyngeal wall and provide access to the clivus and
palate is divided in the midline, care being taken to preserve the soft upper cervical vertebrae. These approaches also provide ac-

S186 Rhoton
divided than when it is left intact. In each approach, plates and

screws are positioned before making the bone cuts to achieve
satisfactory dental occlusion after the procedure. The unilateral
lower maxillotomy provides a more rapid recovery of oropalatal
function because only half of the maxilla is disturbed, and the
soft palate remains intact. That approach to the clivus is slightly
oblique, but can provide as wide an exposure as is achieved with
the approaches involving a bilateral maxillotomy.
Transsphenoidal approach
The transsphenoidal approach along the nasal septum may
be used to expose the upper third of the clivus (Figs. 6.9-6.11
and 6.17) (10). The vomer is resected to enter the sphenoid
sinus and expose the floor of the sella turcica and the ventral
surface of the clivus. The anterior nasal spine and the anterior
part of the septal cartilage are preserved. In approaching the
clivus, the floor of the sella turcica may be removed and the
bony opening extended downward on the clivus to the infe-
rior margin of the sphenoid sinus. Lesions extending to the
upper third of the clivus may be biopsied or partially re-
moved through this approach. The sellar and clival openings
are closed with fat or muscle and nasal septal cartilage. The
advantage of this approach is the low complication rate, and
the disadvantage is the small operative field limited to the
superior third of the clivus.
Transcervical approach
FIGURE 6.17. Transsphenoidal approach. A, Upper left, this
approach, directed beneath the upper lip, along the nasal The transcervical approach, as performed by Stevenson et
septum, and through the sphenoid sinus, may be used to al., is directed through the fascial planes of the neck to the
expose the upper third of the clivus. The resectable area region of the foramen magnum (Fig. 6.18) (31). It avoids
(oblique lines) includes the floor and anterior wall of the sella, opening the oropharyngeal mucosa, but is selected infre-
the vomer, and the upper third of the clivus. This approach is quently because of the depth of the exposure and because it is
suitable for biopsying some tumors that extend upward from not a direct midline exposure. A tracheostomy, which allows
the foramen magnum. Lower right, a cup forceps biopsies a the jaws to be closed tightly, facilitates the exposure. The
clival tumor. B, view through nasal speculum. The anterior T-shaped skin incision includes a submandibular incision
nasal spine is preserved and the anterior part of the septal carti- from the mastoid tip to the symphysis menti and an inferior
lage remains attached to the septal mucosa on one side. The extension carried from the midpoint of the submandibular
nasal speculum is inserted between the left side of the nasal incision across the sternocleidomastoid muscle. The fascial
septum and its mucosa. The nasal septum and the mucosa on plane between the pharynx and the prevertebral muscles is
the right side of the septum are pushed to the right by the reached through an exposure directed along the anterior bor-
speculum, and the mucosa on the left side of the septum is der of the sternocleidomastoid muscle and between the ca-
pushed to the left. The keel on the vomer is exposed. C, magni- rotid sheath laterally and the esophagus and trachea medially.
fied view. The vomer has been removed to open the sphenoid The prevertebral fascia and muscles are retracted laterally to
sinus. The sellar floor is above the midline septum. In approach- expose the ventral aspect of the clivus, atlas, and axis. Struc-
ing the clivus, the floor of the sella is removed, and the opening tures that may be divided from below to above to increase the
in the bone is extended downward on the clivus (interrupted exposure include the ascending pharyngeal and superior thy-
lines) to the inferior margin of the sphenoid sinus. roid arteries, external laryngeal nerve, ansa hypoglossi, internal
laryngeal nerve, lingual artery, hypoglossal nerve, stylohyoid
cess to the sphenoid and ethmoid sinuses and the sella, and muscle, anterior belly of the digastric muscle, stylohyoid liga-
the medial part of the floor of the anterior fossa. The posterior ment, glossopharyngeal nerve, and the stylopharyngeus and
part of the mucosa on both sides of the nasal septum may be styloglossus muscles. The anterior arch of the atlas and the
prepared to provide flaps that can be folded into the clival odontoid process, and a 2 cm width of clivus extending from the
defect for closure. In addition, planning will allow for a tempo- foramen magnum to the sphenooccipital synchondrosis may be
ralis muscle graft to be folded into the clival defect for closure. removed. Deviation laterally may damage the internal jugular
The incidence of swallowing and speech difficulties is signifi- vein, internal carotid artery, eustachian tube, and the ninth
cantly greater with those approaches in which the soft palate is through the twelfth cranial nerves.

Foramen Magnum S187
FIGURE 6.18. A, transcervical approach. A tracheostomy allows the jaws to be closed tightly. The T-shaped skin
incision (interrupted lines) includes a submandibular incision extending from the mastoid tip to the symphysis
menti and an inferior extension carried downward across the sternocleidomastoid muscle. B, the resectable area
(oblique lines) includes the clivus, anterior arch of the axis, and the body of the odontoid process of the axis. C,
the exposure is directed along the anterior border of the sternocleidomastoid and between the external and
internal carotid arteries and internal jugular vein laterally, and the esophagus, hypopharynx, and trachea medially.
Structures that may be divided to increase the exposure include the ascending pharyngeal and superior thyroid
arteries, the external laryngeal nerve, ansa hypoglossi, internal laryngeal nerve, lingual artery, hypoglossal nerve,
stylohyoid muscle, anterior belly of the digastric, stylohyoid ligament, glossopharyngeal nerve, and the stylopharyn-
geus and styloglossus. The accessory nerve passes behind the sternocleidomastoid. D, the prevertebral fascia and lon-
gus capitis and longus colli are separated in the midline from the clivus to C3 and are retracted laterally using sub-
periosteal dissection to expose the ventral aspect of the clivus, atlas, and axis. E and F, the anterior arch of the atlas
and the odontoid process, and a 2.5-mm width of clivus extending from the foramen magnum to the spheno-occipital
synchondrosis may be removed. The basilar, vertebral, and anterior spinal arteries are exposed in the dural opening.
After dealing with the pathology, the dura is closed, muscle and fat are placed in the clival window, and the preverte-
bral and fascia are sutured in the midline. (From, Rhoton AL Jr: Anatomical basis of surgical approaches to the
region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junc-
tion. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].) A., artery; Ant., anterior; Bas., basilar; Car.,
carotid; Ext., external; Inf., inferior; Int., internal; Jug., jugular; M., muscle; Sp., spinal; Sup., superior; V., vein; Vert.,
vertebral.

S188 Rhoton
FIGURE 6.19. A–F. Relationships in the transbasal and extended frontal approaches. A, a bicoronal scalp flap has been reflected forward.
The pericranium is commonly reflected as a separate layer for later use in closing the floor of the anterior cranial fossa. B, bone flap and
osteotomy. The transcranial-transbasal approach uses only a bifrontal craniotomy bordering the floor of the anterior cranial fossae with-
out the osteotomy. A large bifrontal craniotomy and a fronto-orbitozygomatic osteotomy have been completed. The osteotomized seg-
ment may extend through the nasal bone and lateral orbital rim, but for most clival lesions a more limited bone flap and osteotomy (dot-
ted lines) will usually suffice and can be tailored as needed to deal with involvement of the nasal cavity, paranasal sinuses, or orbit. C, the
periorbita has been separated from the walls of the orbit in preparation for the osteotomies. Division of the medial canthal ligament is not
necessary for most lesions, but may be required for lesions extending into the lower nasal cavity or orbit. The ligaments should be
re-approximated at the end of the procedure. D, the right medial canthal ligament has been divided and the orbital contents retracted
laterally to expose the nasolacrimal duct and the anterior ethmoidal branch of the ophthalmic artery at the anterior ethmoidal foramen.
E, the osteotomies have been completed and the frontal dura elevated. The dura remains attached at the cribriform plate. The upper part
of both orbits are exposed. F, an osteotomy around the cribriform plate leaves it attached to the dura and olfactory bulbs, a maneuver

Foramen Magnum S189
FIGURE 6.19. G–L. Relationships in the transbasal and extended frontal approaches. G, the sphenoid sinus has been opened to expose
the septa within the sinus. The sphenopalatine arteries cross the anterior face of the sphenoid. H, the septa within the sphenoid sinus, the
sellar floor, and the lateral sinus wall have been removed to expose the cavernous carotid arteries, pituitary gland, and optic canals. I, the
clivus has been opened to expose the dura facing the brainstem. The basilar sinus, which interconnects the posterior parts of the cavern-
ous sinus, is situated between the layers of dura on the upper clivus. J, the clivus has been opened to expose the tortuous vertebral arter-
ies, which join to form the basilar artery at the left lateral margin of the clival opening. Both AICA origins are exposed. A vein splits the
right abducens nerve into two bundles adjacent to the brainstem. K, the frontal dura has been opened and the frontal lobes elevated to
expose the olfactory and optic nerves, the internal carotid, and the anterior and middle cerebral arteries. L, enlarged view. The subfrontal
and clival openings are separated by the sella and pituitary gland. The lateral limit of the clival exposure is defined by the internal carotid
arteries and optic nerves. The lamina terminalis is exposed above the optic chiasm.
Š
that has been attempted to preserve olfaction, but is infrequently successful. The anterior face of the sphenoid sinus and both sphenoid
ostia are exposed between the orbits. A., artery; A.C.A., anterior cerebellar artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior;
Bas., basilar; Car., carotid; CN, cranial nerve; Ethm., ethmoidal; Gl., gland; Lam., lamina; Lig., ligament; M.C.A., middle cerebral artery;
Med., medial; Nasolac., nasolacrimal; Pit., pituitary; Sphen., sphenoid; Sphenopal., sphenopalatine; Sup., superior; Term., terminalis; Turb.,
turbinates; Vert., vertebral.

S190 Rhoton
FIGURE 6.20. A, the transcranial-

transbasal approach may be used
to approach tumors of the
anterior edge of the foramen
magnum if the tumor also
involves and requires resection of
part of the ethmoid and sphenoid
bones (oblique lines). B, insert.
The souttar scalp incision is
situated behind the hairline, and
the bifrontal craniotomy
(interrupted lines) is placed
strictly supraorbital without
regard for the frontal sinuses
(oblique lines). Lower right. The
subfrontal dura is separated from
the orbital roofs and the
extradural dissection is carried to
the lesser wings of the sphenoid
bone, the tuberculum sellae, and
the base of the anterior clinoid
processes. The clivus is reached
after resecting the posterior part
of the floor of the anterior cranial
fossa, the upper part of the walls
of the ethmoid and sphenoid
sinuses, and the floor of the sella.
Proceeding downward, the clivus is removed to open the anterior margin of the foramen magnum. Separation of the pharyngeal
mucosa from the front of the spine exposes the anterior arch of the atlas, and even the front of the C2 and C3 vertebral bodies.
The nasal and pharyngeal mucosa should not be opened. Dural defects are closed with a leak-proof dural graft after dealing with
the lesion. C, the orbital roof and the remainder of the cranial base are reconstructed using bone grafts. If the clivus has been
removed, the graft above the ethmosphenoidal space is fitted into the edge of a vertical graft extending from the anterior margin of
the foramen magnum or the anterior arch of the atlas to the floor of the sella. (From, Rhoton AL Jr: Anatomical basis of surgical
approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral
Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)
Transcranial-transbasal approach anterior margin of the foramen magnum. Separation of the

pharyngeal mucosa from the front of the spine permits expo-
The subfrontal-transbasal approach may be used to ap-
sure of the anterior arch of the atlas, and even the C2 and C3
proach tumors of the anterior side of the foramen magnum if
vertebral bodies. The nasal and pharyngeal mucosa are not
the tumor also involves and requires resection of part of the
opened in the transcranial transbasal approach, but are com-
ethmoid and sphenoid bones, and the clivus (Figs. 6.19 and
6.20). The transbasal approach, as performed by Derome (6), is monly exposed in those procedures that include a supraor-
made through a bicoronal scalp incision placed behind the bital osteotomy in addition to a bifrontal flap. Dural defects
hairline and a bifrontal free bone flap situated strictly su- are closed with a leak-proof dural substitute, more than twice
praorbital without regard for the frontal sinuses. The subfron- the size of the defect, which is sutured to the dura mater at the
tal dura mater is separated from the orbital roofs, the olfactory most remote margins of the exposure. The orbital roofs and
nerves are divided at the cribriform plates, and the extradural the remainder of the cranial base are reconstructed using
dissection is carried posteriorly to the lesser wings of the autogenous bone grafts. If the clivus has been removed, the
sphenoid bone, the tuberculum sellae, and the base of the graft above the ethmosphenoidal space is fitted into the edge
anterior clinoid processes. Attempts have been made to leave of a vertical graft extending from the anterior margin of the
the olfactory bulbs attached to the cribriform plate, but this foramen magnum or the anterior arch of the atlas to the floor
has usually not prevented the loss of the sense of smell seen of the sella. The advantages of the transbasal approach are
commonly after these procedures. The clivus is reached after that a tighter closure of the dura mater is possible than can be
resecting the posterior part of the floor of the anterior cranial achieved through the transoral approaches, the subcranial
fossa, the upper part of the walls of the ethmoid and sphenoid mucosal planes can be preserved, and it can be combined with
sinuses, and the floor of the sella turcica. Proceeding down- another intradural approach without the high risk of infection
ward from the sellar floor, the clivus is removed to open the associated with the transoral approaches. The transbasal ap-

Foramen Magnum S191
FIGURE 6.21. Extended frontal

approach. A, the upper left insert
shows the scalp flap and the order
of the removal of the cranial
bones (1, 2, 3). The third step, the
orbitofrontoethmoidal osteotomy,
includes both supraorbital ridges,
the anterior part of the roof of the
orbits, the frontal sinus,
cribriform plate, and part of the
ethmoid air cells in one block. B,
sagittal view. The oblique lines
along the skull base show the
possible extent of the bone
removal. The foramen magnum is
reached after removing the
posterior part of the floor of the
anterior fossa, the ethmoid air
cells, walls of the sphenoid sinus,
and the clivus. C, the periorbita is
exposed along both orbital roofs.
The bone removal has been
extended into the ethmoid air
cells and the sphenoid sinus. The
exposure can be extended along
the clivus down to the foramen
magnum. D, use of pericranial
flap for reconstruction. A fat graft is placed in the ethmoid and sphenoid sinuses before reflecting the pericranial flap over
them. In addition, a fat graft may also be applied to the inner side of the pericranial flap. (From, Rhoton AL Jr: Anatomical
basis of surgical approaches to the region of the foramen magnum, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery
of the Craniovertebral Junction. New York, Thieme Medical Publishers, Inc., 1998, pp 13–57 [24].)
proach may be combined with a transbasal-transsphenoidal men magnum are reached after resecting the posterior part of the
route to gain access to the sella turcica. In the transbasal floor of the anterior cranial fossa, the upper walls of the ethmoid
approach the clivus and sphenoid bone can be resected more and sphenoid sinuses, and the floor of the sella. If needed, the
extensively than by the transsphenoidal approach, but the supraorbital osteotomy can even be tailored in size and site to
subsellar area is hidden by the bulging dura in the transbasal include the lateral orbital rims.
approach. Both approaches may be combined to permit re-
moval of all of the clivus below the level of the dorsum sellae. Selection of operative approach
Anosmia is the only certain side effect. The most frequent
complications are cerebrospinal fluid leaks, meningitis, and Anterior extradural lesions of the clivus or upper cervical
pseudomeningoceles. vertebrae are best reached by one of the anterior approaches.
The transoral approach is selected for most anterior extra-
dural lesions involving the foramen magnum because it pro-
Extended frontal approach vides a midline exposure and is the most direct route to the
The extended frontal approach is similar to the transcranial- pathology. For more extensive lesions, a transmaxillary ap-
transbasal approach, except that it includes an orbitofrontoeth- proach may be considered. Before selecting an anterior
moidal osteotomy (Figs. 6.19 and 6.21) (28). It may also be used approach that would require that the dura mater be opened
to approach tumors of the anterior side of the foramen magnum, through the oropharynx, one should consider choosing a pos-
especially if the tumor requires resection of part of the ethmoid terior approach since the incidence of cerebrospinal fluid
and sphenoid bones as well as the clivus. The approach uses a leak, meningitis, and pseudomeningocele is high if the
souttar scalp incision, bifrontal bone flaps, and an orbitofronto- dura mater is opened through the oropharynx. The transcer-
ethmoidal osteotomy in which the supraorbital ridges, and part vical approach has the advantage of reaching the foramen
of the orbital roofs and possibly the upper nasion, the roof of the magnum through the deep fascial planes of the neck rather
ethmoid sinuses, and the cribriform plate are removed in a single than through the oropharynx; however, the depth of the ex-
block. The resection of the lesion may involve an extradural or posure, the length of the time required to complete the dis-
combined intradural-extradural approach. The clivus and fora- section, and the fact that the foramen magnum is not ap-

S192 Rhoton
proached from the midline have prevented it from gaining 6. Derome P: The transbasal approach to tumors invading the base
common usage. The transcranial-transbasal and extended of the skull, in Schmidek HH, Sweet WH (eds): Current Techniques
frontal approaches offer another anterior route for reaching in Operative Neurosurgery. New York, Grune and Stratton, 1977,
the foramen magnum, however these approaches should not pp 223–245.
be considered for approaching a tumor strictly localized in the 7. DiChiro G, Anderson WB: The clivus. Clin Radiol 16:211–223, 1965.
8. Friede RL, Roessmann U: Chronic tonsillar herniation: An at-
region of the foramen magnum, but might be used for an
tempt at classifying chronic herniations at the foramen magnum.
extensive lesion involving the ethmoid and sphenoid sinuses
Acta Neuropathol (Berl) 34:219–235, 1976.
as well as the clivus and foramen magnum. The transsphe- 9. Haas LL: The posterior condylar fossa, foramen, and canal and
noidal approach provides an easy route for biopsying lesions the jugular foramen. Radiology 69:546–552, 1957.
in the region of the foramen magnum if they extend to the 10. Hardy J, Grisoli F, Leclercq TA, Marino R: Trans-sphenoidal
upper third of the clivus, but it does not provide adequate approach to tumors of the clivus [in French]. Neurochirurgie
exposure for removing larger lesions of the region. The trans- 23:287–297, 1977.
sphenoidal approach may be combined with another ap- 11. Hitotsumatsu T, Rhoton AL Jr: Unilateral upper and lower sub-
proach in removing lesions involving the clivus and foramen total maxillectomy approaches to the skull base: Microsurgical
magnum. anatomy. Neurosurgery 46:1416–1453, 2000.
The posterior approaches are preferred for most intradural 12. Hitotsumatsu T, Matsushima T, Rhoton AL Jr: Surgical anatomy
lesions. The vertical midline incision, and a bilateral suboccipital of the midface and the midline skull base, in Spetzler RF (ed):
Operative Techniques in Neurosurgery. W.B. Saunders Co., 1999, vol
craniectomy and upper cervical laminectomy is used for lesions
2, pp 160–180.
situated in the upper spinal canal and posterior or posterolateral
13. Huang YP, Wolf BS: Veins of the posterior fossa, in Newton TH,
in the area above the foramen magnum. The hockey-stick inci-
Potts DG (eds): Radiology of the Skull and Brain. St. Louis, C.V.
sion and a unilateral suboccipital craniectomy and upper cervi- Mosby, 1974, vol 2, book 3, pp 2155–2219.
cal laminectomy is selected if the lesion extends anterolateral or 14. Katsuta T, Rhoton AL Jr, Matsushima T: The jugular foramen:
anterior to the brainstem toward the jugular foramen or cerebel- Microsurgical anatomy and operative approaches. Neurosurgery
lopontine angle. The far-lateral modification of the lateral sub- 41:149–202, 1997.
occipital approach, described in the next chapter on the far 15. Kirdani MA: The normal hypoglossal canal. Am J Roentgenol
lateral approach, gives a more direct approach to lesions ventral Radium Ther Nucl Med 99:700–704, 1967.
to the brainstem and along the anterior rim of the foramen 16. Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical
magnum, while reducing the need for retraction of neural struc- anatomy of the posterior inferior cerebellar artery. Neurosurgery
tures (32, 33). The foramen magnum can also be reached through 10:170–199, 1982.
the approaches directed through the temporal bone, the subject 17. Margaretten I: Syndromes of the anterior spinal artery. J Nerv
Ment Dis 58:127–133, 1923.
of the chapter on the temporal bone; however, for reaching the
18. Matsushima T, Rhoton AL Jr, de Oliveira E, Peace DA: Microsur-
foramen magnum and clivus, these approaches may require
gical anatomy of the veins of the posterior fossa. J Neurosurg
repositioning of the carotid artery or facial nerve, and possibly 59:63–105, 1983.
resection of the auditory and vestibular labyrinth. 19. Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the
fourth ventricle: Part 1—Microsurgical anatomy. Neurosurgery
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro- 11:631–667, 1982.
logical Surgery, University of Florida Brain Institute, P.O. Box 100265, 20. Newton TH: The anterior and posterior meningeal branches of
100 South Newell Drive, Building 59, L2-100, Gainesville, FL the vertebral artery. Radiology 91:271–279, 1968.
32610-0265. 21. Newton TH, Mani RL: The vertebral artery, in Newton TH, Pons
DG (eds): Radiology of the Skull and Brain. St. Louis, C.V. Mosby,
1974, vol 2, book 2, pp 1659–1709.
22. Ouaknine G, Nathan H: Anastomotic connections between the
REFERENCES
eleventh nerve and the posterior root of the first cervical nerve in
1. Abbott KH: Foramen magnum and high cervical cord lesions humans. J Neurosurg 38:189–197, 1973.
stimulating degenerative disease of the nervous system. Ohio 23. Piehl MR, Reese HH, Steelman HF: The diagnostic problem of
State Med J 46:645–651, 1950. tumors at the foramen magnum. Dis Nerv Syst 11:67–76, 1950.
2. Cocke EW Jr, Robertson JH, Robertson JT, Crook JP Jr: The ex- 24. Rhoton AL Jr: Anatomical basis of surgical approaches to the
tended maxillotomy and subtotal maxillectomy for excision of region of the foramen magnum, in Dickman CA, Spetzler RF,
skull base tumors. Arch Otolaryngol Head Neck Surg 116:92– Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New
104, 1990. York, Thieme Medical Publishers, Inc., 1998, pp 13–57.
3. Crockard HA: The transmaxillary approach to the clivus, in 25. Rhoton AL Jr, Buza R: Microsurgical anatomy of the jugular
Sekhar LN, Janecka IP (eds): Surgery of Cranial Base Tumors. New foramen. J Neurosurg 42:541–550, 1975.
York, Raven Press, 1993, pp 169–180. 26. Rhoton AL Jr, de Oliveira E: Suboccipital and retrosigmoid ap-
4. Cushing H, Eisenhardt L: Meningiomas. Springfield, Charles C proaches to the craniovertebral junction, in Dickman CA, Spetzler
Thomas, 1938, pp 169–180. RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction.
5. de Oliveira E, Rhoton AL Jr, Peace DA: Microsurgical anatomy of New York, Thieme Medical Publishers, Inc., 1998, pp 659–681.
the region of the foramen magnum. Surg Neurol 24:293–352, 27. Russell DS, Rubinstein LJ: Pathology of Tumors of the Nervous
1985. System. Baltimore, Williams & Wilkins, 1977, ed 4, p 368.

Foramen Magnum S193
28. Sekhar LN, Nanda A, Sen CN, Snyderman CN, Janecka IP: The 31. Stevenson GC, Stoney RJ, Perkins RK, Adams JE: A transcervical
extended frontal approach to tumors of the anterior, middle and transclival approach to the ventral surface of the brainstem for
posterior skull base. J Neurosurg 76:198–206, 1992. removal of a clivus chordoma. J Neurosurg 24:544–551, 1966.
29. Sen CN, Sekhar LN: An extreme lateral approach to intradural 32. Tedeschi H, Rhoton AL Jr: Lateral approaches to the petroclival
lesions of the cervical spine and foramen magnum. Neurosurgery region. Surg Neurol 41:180–216, 1994.
27:197–204, 1990. 33. Wen HT, Rhoton AL Jr, Katsuta T, de Oliveira E: Microsurgical
30. Stein BM, Leeds NE, Taveras JM, Pool JL: Meningiomas of the anatomy of the transcondylar, supracondylar, and paracondylar
foramen magnum. J Neurosurg 20:740–751, 1963. extensions of the far-lateral approach. J Neurosurg 87:555–585, 1997.
Drawings by Leonardo da Vinci of the human cranium and spinal canal. Measurement lines indicate an interest in the
study of anatomic proportions. Courtesy, Dr. Edwin Todd, Pasadena, California. (Also see pages S6 and S286.)

Anterior musculoskeletal anatomy, from, Bartolommeo Eustachio, Tabulae anatomicae. Rome, Sumptibus Laurentii & Thomae
Pagliarini, 1728. Courtesy, Rare Book Room, Norris Medical Library, Keck School of Medicine, Los Angeles, California. (Also see
pages S2, S28, S130, S154, and S298.)
CHAPTER 7
The Far-lateral Approach and Its Transcondylar,

Supracondylar, and Paracondylar Extensions

Key words: Cranial base, Cranial nerve, Craniocervical junction, Foramen magnum, Microsurgical anatomy, Occipital bone, Occipital condyle,
Skull base, Surgical approach, Temporal bone, Vertebral artery
T
he basic far-lateral exposure is carried up to but does suboccipital triangle, and examination of the relationship of
not include removal of the posterior part of the occipital the muscles to the occipital and vertebral arteries, the verte-
condyle. It includes 1) dissection of the muscles along bral venous plexus, the transverse process of the atlas, and the
the posterolateral aspect of the craniocervical junction to per- upper cervical nerves. The second stage, the extradural dis-
mit an adequate exposure of the C1 transverse process and the section, examines landmarks for the suboccipital craniectomy,
suboccipital triangle; 2) early identification of the vertebral the extent of occipital condyle removal, and the exposure and
artery either above the posterior arch of the atlas or in its identification of the hypoglossal canal, jugular process, jugu-
ascending course between the transverse processes of the atlas lar tubercle, and facial nerve. The final stage, the intradural
and axis; and 3) a suboccipital craniectomy or craniotomy exposure, reviews the relationships of the intradural segment
with removal of at least half of the posterior arch of the atlas of the vertebral artery and its branches, including the postero-
(5, 19, 20). It provides access for the following three ap- inferior cerebellar artery (PICA), the lower cranial and upper
proaches: the transcondylar approach directed through the cervical nerves, and the dentate ligament.
occipital condyle or the atlanto-occipital joint and adjoining
parts of the condyle; the supracondylar approach directed Muscular stage
through the area above the occipital condyle; and the para-
condylar exposure directed through the area lateral to the For our study of the region, the exposure was done using a
occipital condyle (Fig. 7.1). The transcondylar extension ac- horseshoe scalp flap because it provided a better display of
companied by drilling the condyles allows a more lateral the muscular layers and their relationships to the neural and
approach and provides access to the lower clivus and pre- vascular structures (Fig. 7.2A). The incision began in the mid-
medullary area. The supracondylar approach provides access line, approximately 5 cm below the external occipital protu-
to the region of and medial to the hypoglossal canal and berance, and was directed upward to just above the external
jugular tubercle. The paracondylar approach, which includes occipital protuberance, turned laterally just above the supe-
drilling of the jugular process of the occipital bone in the area rior nuchal line, reached the mastoid, and turned downward
lateral to the occipital condyle, accesses the posterior part of in front of the posterior border of the sternocleidomastoid
the jugular foramen, and the posterior aspect of the facial muscle onto the lateral aspect of the neck to approximately 5
nerve and mastoid on the lateral side of the jugular foramen. cm below the mastoid tip and below where the transverse
In the standard posterior and posterolateral approaches, an process of the atlas can be palpated through the skin. The skin
understanding of the individual suboccipital muscles is not flap was reflected downward and medially to expose the most
essential. However, these muscles provide important land- superficial layer of muscles formed by the sternocleidomas-
marks for the far-lateral approach and its modifications. Im- toid and splenius capitis muscles laterally and the trapezius
portant considerations include the relationship of the occipital and the semispinalis capitis muscles medially. In this descrip-
condyle to the foramen magnum, hypoglossal canal, jugular tion, the muscles are reflected separately but at an operation,
tubercle, the jugular process of the occipital bone, the mastoid, the scalp and muscles superficial to the suboccipital triangle
and the facial canal (1–3, 6, 7, 10, 12, 15–17). are reflected from the suboccipital area in a single layer,
leaving a musculofascial cuff attached along the superior
nuchal line for closure.
STAGES OF APPROACH
The approach is divided into three anatomic stages (Fig. Muscular dissection
7.2). The first stage, the muscular dissection, includes the skin The sternocleidomastoid and trapezius are in the first layer
incision, reflection of muscles, including those forming the encountered (Fig. 7.2, B--H). Dividing the sternocleidomastoid

S196 Rhoton
FIGURE 7.1. Osseous relationships. A, inferior view of the occipital condyles and foramen magnum. The occipital condyles are
ovoid structures located along the lateral margin of the anterior half of the foramen magnum. Their articular surfaces are convex,
face downward and laterally, and articulate with the superior facet of C1. A probe inserted through the hypoglossal canal passes
forward approximately 45 degrees from the midsagittal plane in an anterolateral direction. The hypoglossal canal is located above
the middle third of the occipital condyle and is directed from posterior to anterior and from medial to lateral. The intracranial end
of the hypoglossal canal (small oval ) is located approximately 5 mm above the junction of the posterior and middle third of the
occipital condyle and approximately 8 mm from the posterior edge of the condyle. The extracranial end of the canal is located
approximately 5 mm above the junction of the anterior and middle third of the condyle. The average length of the longest axis of
the condyle is 21 mm. The large arrow shows the direction of the transcondylar approach and the cross-hatched area shows the
portion of the occipital condyle that can be removed without exposing the hypoglossal nerve in the hypoglossal canal. The condy-
lar fossa is frequently the site of a canal, the condylar canal, which transmits the posterior condylar emissary vein that connects the
vertebral venous plexus with the sigmoid sinus just proximal to the jugular bulb. The condylar canal passes above and usually does
not communicate with the hypoglossal canal. The jugular process of the occipital bone extends laterally from the posterior half of
the occipital condyle to form the posterior margin of the jugular foramen. The portion of the jugular process located immediately
behind the jugular foramen serves as the site of attachment for the rectus capitis lateralis muscle. The stylomastoid foramen is situ-
ated lateral to the jugular foramen. The styloid process is located anterior and slightly medial to the stylomastoid foramen. B,
inferolateral view. A probe has been passed through the hypoglossal canal, which passes above occipital condyle. From its intracra-
nial to its extracranial end it is directed forward, lateral, and slightly upward. C, superior view. The occipital condyle projects
downward from the lateral margin of the anterior half of the foramen magnum. The intracranial entrance of the hypoglossal canal
is located above the condyle. The jugular tubercles are located above and anterior to the hypoglossal canals. The jugular process of
the occipital bone extends laterally from the condyles to form the posterior margin of the jugular foramen. The sigmoid sinus
crosses the occipitomastoid suture and turns in a hooklike groove on the upper surface of the jugular process to reach the jugular
foramen. Drilling the occipital condyle increases access to the anterolateral margin of the foramen magnum. Drilling in a supracon-
dylar location below the hypoglossal canal accesses the lateral edge of the clivus. Drilling in the supracondylar location above the
hypoglossal canal accesses the jugular tubercle, which projects upward and often blocks visualization of the junction of the middle
and lower clivus and the region of the pontomedullary junction during the far-lateral approach. Drilling the jugular process in a

Far-lateral Approach S197
just below and with preservation of its upper attachment for Vascular structures
closure and reflecting it laterally exposes the upper extension
Reflecting the muscles forming the suboccipital triangle, as
of the splenius capitis. Detaching the trapezius and splenius
described earlier, exposes the vertebral artery, which is sur-
capitis muscles, while preserving a cuff of their upper attach-
rounded by a rich venous plexus that must be obliterated and
ments for closure, and reflecting them medially exposes the
partially removed if the vertebral artery is to be exposed or
longissimus capitis muscle. Reflecting the longissimus capitis
transposed (Fig. 7.2, H and I).
downward exposes the semispinalis capitis and the superior
The vertebral artery, above the transverse foramen of the axis,
and inferior oblique muscles as well as the transverse process
veers laterally to reach the transverse foramen of the atlas, which
of the atlas, which has a prominent apex palpable through the
is situated further lateral than the transverse foramen of the
skin between the mastoid process and mandibular angle. The
axis. The artery, after ascending through the transverse pro-
semispinalis capitis is reflected medially to expose the suboc-
cipital triangle, which is limited by three muscles; above and cess of the atlas, is located on the medial side of the rectus
medially by the rectus capitis posterior major, above and capitis lateralis muscle. From here it turns medially behind
laterally by the superior oblique, and below and laterally by the lateral mass of the atlas and the atlanto-occipital joint and
the inferior oblique (Fig. 7.2G). is pressed into the groove on the upper surface of the poste-
The triangle deep to these muscles is covered by a layer of rior arch of the atlas, where it courses in the floor of the
dense fibrofatty tissue. The floor in the depth of the triangle is suboccipital triangle and is covered behind the triangle by
formed by the posterior atlanto-occipital membrane and the the semispinalis capitis muscle. The first cervical nerve
posterior arch of the atlas (Fig. 7.2H). The structures in the courses on the lower surface of the artery between the artery
triangle are the vertebral artery and the C1 nerve, both of which and the posterior arch of the atlas (Fig. 7.2, K–M). After
lie in a groove on the upper surface of the lateral part of the passing medially above the lateral part of the posterior arch of
posterior arch of the atlas. The suboccipital triangle is opened by the atlas, the artery enters the vertebral canal by passing
reflecting the rectus capitis posterior major inferiorly and medi- below the lower, arched border of the posterior atlanto-
ally, the superior oblique laterally, and the inferior oblique me- occipital membrane, which transforms the sulcus in which the
dially. Opening the triangle exposes the portion of the vertebral artery courses on the upper edge of the posterior arch of
venous plexus that surrounds the vertebral artery as it passes the atlas into an osseofibrous casing that may ossify, trans-
behind the atlanto-occipital joint and across the upper edge of forming it into a complete or incomplete bony canal sur-
the posterior arch of the atlas (Fig. 7.2I). Reflecting the superior rounding the artery (Fig. 7.2H) (5).
oblique muscle, as described earlier, exposes the rectus capitis The third segment of the vertebral artery, the segment
lateralis, a short, flat muscle that is an important landmark in located between the C1 transverse process and the dural
identifying the jugular foramen (Figs. 7.2, K and L, and 7.3). It entrance, gives rise to muscular branches and the posterior
arises from the upper surface of the transverse process of the meningeal arteries. The muscular branches arise as the artery
atlas and attaches above to the rough, lower surface of the exits the transverse foramen of C1 and courses around the
jugular process of the occipital bone behind the jugular foramen. lateral mass of the atlas to supply the deep muscles and
The jugular process is a plate of occipital bone extending later- anastomose with the occipital and ascending and deep cervi-
ally from the posterior half of the occipital condyle. It is indented cal arteries (Fig. 7.2I). Some of the muscular branches may
in front at the site of the jugular notch, which forms the posterior need to be divided to mobilize and transpose the vertebral
edge of the jugular foramen (Fig. 7.1). The rectus capitis lateralis, artery. The posterior meningeal artery arises from the poste-
because it is attached to the jugular process at the posterior edge rior surface of the vertebral artery as it passes behind the
of the jugular foramen, provides a landmark for estimating the lateral mass or above the posterior arch of the atlas or just
position of the jugular foramen and the facial nerve, which exits before penetrating the dura in the region of the foramen
the stylomastoid foramen just lateral to the jugular foramen. magnum, but it may also have an intradural origin from the
Š
paracondylar location accesses the posterior margin of the jugular bulb, which is situated in the sigmoid portion of the jugu-
lar foramen. D, medial aspect of the occipital condyle and supracondylar region. The inner surface of the mastoid portion of
the temporal bone is grooved by the sulcus of the sigmoid sinus. The asterion, the site of the junction of the lambdoid, pari-
etomastoid, and the occipitomastoid sutures, is an important landmark used to define the transition between the transverse
and sigmoid sinuses. The sigmoid sulcus crosses the occipitomastoid suture just behind the jugular foramen. The intracranial
end of the hypoglossal canal is located above the junction of the posterior and middle thirds of the occipital condyle. The
external occipital protuberance is located an average of 2 cm below the apex of the internal occipital protuberance and 1 cm
below the lower margin of the torcular herophili. The parietal notch, located at the junction of the squamosal and parieto-
mastoid sutures, defines the upper limit of the petrous portion of the temporal bone and the floor of the posterior portion of
the middle fossa. The midportion of the parietomastoid suture approximates the anterior edge of the junction of the trans-
verse and sigmoid sinuses. Ac., acoustic; Artic., articular; Car., carotid; Cond., condyle; Fiss., fissure; For., foramen; Hypogl.,
hypoglossal; Int., internal; Jug., jugular; Mast., mastoid; Med., medial; Occip., occipital; Parietomast., parietomastoid; Petro-
cliv., petroclival; Proc., process; Protub., protuberance; Sig., sigmoid; Squam., squamosal; Stylomast., stylomastoid; Tymp.,
tympanic.

S198 Rhoton
FIGURE 7.2. A–D. Far-lateral and transcondylar approach. A, a suboccipital scalp flap is commonly selected for the far-
lateral exposure. The medial limb extends downward in the midline so that a wide upper cervical laminectomy can be com-
pleted if needed. The lateral limb extends below the C1 transverse process, which can be palpated between the mastoid tip
and the angle of the jaw to access the vertebral artery as it ascends through the C1 transverse process. In this dissection, the
muscles are reflected separately to show their anatomy; however, at an operation, the muscles superficial to the suboccipital
triangle can be reflected from the suboccipital area in a single layer with the scalp flap, leaving a cuff of suboccipital muscle
and fascia attached along the superior nuchal line to aid in closure. B, the scalp flap has been reflected to expose the sterno-
cleidomastoid and trapezius, the edges of which form the margins of the posterior triangle of the neck. The splenius and
semispinalis capitis are in the floor of the triangle. C, the sternocleidomastoid has been detached from the lateral part of the
superior nuchal line and reflected laterally to expose the splenius capitis, which is attached just below the line. The asterion,
located at the junction of the lambdoid, occipitomastoid, and parietomastoid sutures, most commonly overlies the lower half
of the junction of the transverse and sigmoid sinuses. D, the splenius capitis has been reflected to expose the longissimus
capitis and deep cervical fascia. The occipital artery may pass superficial or deep to the longissimus capitis. A., artery; Atl.,
atlanto; Br., branch; Cap., capitis; CN, cranial nerve; Dent., dentate; Digast., digastric; Dors., dorsal; Gang., ganglion;
Hypogl., hypoglossal; Inf., inferior; Lat., lateralis; Lev., levator; Lig., ligament; Long., longissimus; M., muscle; Maj., major;
Mas., mastoid; Memb., membrane; Men., meningeal; Min., minor; Musc., muscular; Obl., oblique; Occip., occipital; P.I.C.A.,
posteroinferior cerebellar artery; Plex., plexus; Post., posterior; Proc., process; Rec., rectus; Scap., scapula; Semispin., semispi-
nalis; Splen., splenius; Suboccip., suboccipital; Sup., superior; Trans., transverse; Vent., ventral; Vert., vertebral.

FIGURE 7.2. E–J. Far-lateral and transcondylar approach. E, the fascia has been removed to expose the occipital artery
passing behind the superior oblique and semispinalis. F, the longissimus capitis has been reflected to expose the attach-
ment of the superior and inferior oblique muscles to the C1 transverse process. G, the suboccipital triangle, in the
depths of which the vertebral artery courses behind the atlanto-occipital joint and across the posterior arch of C1, is
situated in the depths of the area between the superior and inferior oblique and the rectus capitis posterior major. H,
the superior oblique muscle has been reflected laterally and the rectus capitis posterior major muscle inferomedially.
The floor of the suboccipital triangle is formed by the posterior atlanto-occipital membrane and the posterior arch of
the atlas. The vertebral artery and the C1 nerve root, which are surrounded by the vertebral venous plexus, course
along the upper surface of the posterior arch of the atlas. I, the muscles forming the margins of the suboccipital triangle
have been reflected to expose the vertebral artery ascending through the C1 transverse process and behind the atlanto-
occipital joint and the surrounding venous plexus. J, the venous plexus around the vertebral artery has been removed.
The vertebral artery gives off muscular branches, passes medially behind the atlanto-occipital joint and above the poste-
rior arch of C1, and turns upward and anterior to penetrate the dura.

S200 Rhoton
FIGURE 7.2. K–O. Far-lateral and transcondylar approach. K, a suboccipital craniectomy has been completed and the right
half of the posterior arch of C1 has been removed. The posterior root of the transverse foramen of the atlas has been
removed while preserving the portion of the tip of the transverse process of the atlas to which the rectus capitis lateralis,
levator scapulae, and the superior oblique attach. The atlanto-occipital joint and the posterior condylar emissary vein are
exposed. The ventral rami of the C1 and C2 nerve roots pass behind the vertebral artery. The dorsal ramus of C2 gives rise to
the greater occipital nerve, which passes through the semispinalis capitis to reach the posterior scalp. L, the area above the
occipital condyle has been drilled to the depth of the cortical bone surrounding the hypoglossal canal. The change from can-
cellous to cortical bone indicates that the hypoglossal canal has been reached. M, the hypoglossal canal has been opened to
expose the venous plexus, which surrounds the hypoglossal nerve in the canal and connects the basilar venous plexus with the
marginal sinus, which encircles the foramen magnum. The dorsal ramus of the C1 nerve root, also termed the suboccipital

vertebral artery, in which case it pierces the arachnoid over Neural structures
the cisterna magna to reach the dura (Fig. 7.2L) (20).
The neural structures encountered during the muscle dis-
The occipital artery is also exposed as the superficial and section arise predominantly from the C1 and C2, and to a
deep muscles in the region are reflected (Fig. 7.2, C--G). It lesser extent from the C3 spinal nerves that are formed by the
originates from the posterior wall of the external carotid ar- united dorsal and ventral roots and are described in the
tery at the level of the angle of the mandible, ascends parallel chapter on the foramen magnum (Fig. 7.2, J–M).
and medial to the external carotid artery and lateral to the
internal jugular vein to reach the area posteromedial to the
styloid process. At that point, it changes its course to posterior Extradural stage
and lateral, passing first between the rectus capitis lateralis The extradural stage begins with a suboccipital craniec-
and the posterior belly of the digastric and then between the tomy or craniotomy, identification of the occipital condyle,
superior oblique and the posterior belly of the digastric where and removal of at least half of the posterior arch of the atlas
it courses in the occipital groove medial to the mastoid notch, and possibly the posterior root of the transverse foramen, if
in which the posterior belly of the digastric muscle arises. mobilization of the vertebral artery is needed (Fig. 7.2K). Two
After exiting the area between the superior oblique muscle osseous landmarks important in planning the suboccipital
and the posterior belly of the digastric, it courses medially, craniotomy are the asterion located along the lower half of the
being related to the longissimus capitis and semispinalis ca- groove on the inner table of the cranium near the point where
pitis. If the occipital groove is present, the occipital artery will the transverse sinus empties into the sigmoid sinus, and the
course deep to the longissimus capitis muscle, but if the inion (external occipital protuberance) located an average of 1
groove is absent, the artery will course superficial to the cm below the apex of the internal occipital protuberance and
longissimus capitis muscle (Fig. 7.2E). It courses medially the inferior margin of the confluence of the sagittal and trans-
behind the semispinalis capitis just below the superior nuchal verse sinuses. In completing the removal of the posterior arch
line in the upper part of the posterior triangle to pass between of the atlas, the tip of the transverse process is preserved along
the upper attachment of trapezius and the semispinalis capi- with the attachment of the superior oblique, which is reflected
tis, where it pierces the attachment of the trapezius muscle to laterally while preserving the attachment of the rectus capitis
the superior nuchal line and ascends in the superficial fascia lateralis.
of the posterior scalp. At this stage, the segment of the vertebral artery extending
from the transverse foramen of C2 to its entrance to the dura
is exposed. Removal of the posterior root of the transverse
Osseous structures foramen will permit the artery to be displaced downward and
medially away from the atlanto-occipital joint to expose the
The transverse process of the atlas, an important landmark occipital condyle (Fig. 7.2, L--N). The occipital condyles
in these approaches, projects further lateral than the trans- project downward along the lateral edges of the anterior half
verse processes on the adjacent cervical vertebrae and has an of the foramen magnum (Figs. 7.1 and 7.3). The articular
apex that can be felt through the skin in the area between the surfaces, which are ovoid with the long axis in the AP direc-
mastoid process and angle of the mandible (Fig. 7.2A). Several tion, are located on the lower-lateral margin of the condyles.
muscles important in completing the exposure attach to the They face downward and laterally to articulate with the su-
transverse process of the atlas (Fig. 7.2G). The rectus capitis perior facets of the atlas, which face upward and medially.
lateralis arises from the anterior portion, and the superior The intracranial end of the hypoglossal canal is located
oblique arises from the posterior portion of the upper surface approximately 5 mm above the junction of the posterior and
of the transverse process. The inferior oblique muscle inserts middle third of the occipital condyle and appropriately 5 mm
on the lateral tip of the transverse process. The levator scap- below the jugular tubercle (Fig. 7.1). The canal is directed
ulae, splenius cervicis, and the scalenus medius attach to the forward and laterally at a 45-degree angle with the sagittal
inferior and lateral surface of the transverse process. The plane. The extracranial end of the hypoglossal canal is located
levator scapulae is also attached by tendinous slips to the immediately above the junction of the anterior and middle
posterior tubercles of the transverse processes of C2 to C4 (Fig. third of the occipital condyle and medial to the jugular fora-
7.2, F and G). men. The average length of the longest axis of the condyle is
Š
nerve, passes backward between the posterior arch of the atlas and the vertebral artery, supplies the muscles bordering the
suboccipital triangle, and sends fibers to the rectus capitis posterior minor and the semispinalis capitis muscles. N, an upper
cervical laminectomy has been completed and the dura opened. The dural incision completely encircles the vertebral artery,
leaving a narrow dural cuff on the artery so that the artery can be mobilized. The drilling in the supracondylar area exposes
the hypoglossal nerve in the hypoglossal canal, and can be extended extradurally to the level of the jugular tubercle to
increase access to the front of the brainstem. O, enlarged view of the site of dural penetration by the vertebral artery in
another specimen. The rostral end of the dentate ligament ascends behind the vertebral artery with the accessory nerve and
attaches to the dura along the lateral margin of the foramen magnum.

S202 Rhoton
FIGURE 7.3. Relationships in the transcondylar,

supracondylar, and paracondylar exposures. A, right
side. The segment of the vertebral artery coursing
behind the superior articular process of C1 has been
removed. The posterior condylar emissary vein
passes through the posterior condylar canal and joins
the sigmoid sinus. The rectus capitis lateralis
attaches below to the transverse process of C1 and
above to the jugular process of the occipital bone
that forms the posterior edge of the jugular foramen.
The internal jugular vein descends on the anterior
side of the rectus capitis lateralis and the C1
transverse process. B, the cancellous bone within the
occipital condyle has been drilled away while
preserving the cortical and articular surfaces to
expose the hypoglossal nerve in the hypoglossal
canal. The posterior condylar vein passes above the
occipital condyle and hypoglossal canal to empty
into the sigmoid sinus. The transition between the
sigmoid sinus and jugular bulb is located lateral to
the occipital condyle in front of the jugular process
of the occipital bone. The posterior third of the
occipital condyle can be removed without entering
the hypoglossal canal. The extracranial end of the hypoglossal canal is located medial to the jugular foramen. C, the portion
of the rectus capitis lateralis that attaches to the jugular process of the occipital bone has been removed to expose the
internal jugular vein, and the jugular process of the occipital bone has been removed to expose the jugular bulb. The facial
nerve is exposed laterally at the stylomastoid foramen. Several meningeal branches of the occipital artery ascend to pass
through the jugular foramen. An emissary vein passes from the jugular bulb to the vertebral venous plexus. A., artery; Atl.,
atlanto; Cap., capitis; CN, cranial nerve; Cond., condyle; Dent., dentate; Emiss., emissary; Int., internal; Jug., jugular; Lat.,
lateralis; Lig., ligament; M., muscle; Men., meningeal; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Post.,
posterior; Proc., process; Rec., rectus; Sig., sigmoid; V., vein; Vert., vertebral.
21 mm (range, 18–24 mm) and the average distance between hypoglossal canal, which communicates the basilar venous
the posterior edge of the occipital condyle and the posterior plexus with the marginal sinus that encircles the foramen
border of the intracranial end of the hypoglossal canal is 8.4 magnum (Figs. 7.2M, 7.3B, and 7.4, C and D). Posterior to the
mm (range, 6–10 mm) (20). The hypoglossal canal is sur- occipital condyle, a depression, the condylar fossa, may be
rounded by cortical bone. The contents of the hypoglossal pierced by the condylar canal, which transmits the posterior
canal are the hypoglossal nerve, a meningeal branch of the condylar emissary vein, a communication between the verte-
ascending pharyngeal artery, and the venous plexus of the bral venous plexus and the sigmoid sinus (Fig. 7.3). The canal

is directed slightly upward as it proceeds anteriorly to join the removing the jugular tubercle to avoid damaging the lower
sigmoid sinus at the hook-like turn immediately proximal to cranial nerves, either by direct trauma, by stretching the dura,
where the sinus empties into the jugular bulb. The condylar or by the heat generated by the drilling (Fig. 7.5, A–C). The
canal does not communicate with the hypoglossal canal. lateral margin of the jugular tubercle is situated just medial to
The jugular process of the occipital bone serves as a bridge and below the medial edge of the jugular bulb. If a more
between the condylar and squamosal parts of the occipital lateral exposure is needed, or the jugular foramen is to be
bone and forms the posterior margin of the jugular foramen opened from posteriorly, the jugular process of the occipital
(Fig. 7.1). It extends laterally from the posterior half of the bone, which extends laterally from the occipital condyle, can
condyle. The jugular process also serves as the site of attach- be removed after detaching the rectus capitis lateralis muscle
ment of the rectus capitis lateralis muscle behind the jugular from its lower surface (Figs. 7.3 and 7.4). Removing the jugular
foramen. The stylomastoid foramen, which transmits the fa- process, which forms the posterior margin of the jugular fo-
cial nerve, is situated lateral to the jugular foramen at the ramen, will expose the transition between the sigmoid sinus,
anterior end of the mastoid notch (Figs. 7.3C and 7.4C). The jugular bulb, and internal jugular vein. Care is required to
styloid process is located anterior to the stylomastoid foramen avoid damaging the vertebral artery, because it passes up-
and anterolateral to the jugular foramen. ward through the transverse process of the atlas and turns
After removing the superficial layer of cortical bone cover- medially in the area directly below the jugular process. For an
ing the occipital condyle, soft cancellous bone will be encoun- even more lateral exposure, the posterior belly of the digastric
tered. Further drilling of the cancellous bone in and above the muscle can be separated from the mastoid notch to expose the
posterior third of the condyle exposes the second layer of facial nerve just distal to the stylomastoid foramen (Figs. 7.3C,
hard, cortical bone that surrounds the hypoglossal canal (Figs. 7.4, B and C, and 7.6). A partial mastoidectomy can be per-
7.2N and 7.3–7.6). Subsequent drilling of this cortical bone formed to expose the mastoid segment of the facial nerve in
exposes the venous plexus of the hypoglossal canal. The lat- the facial canal at this stage.
eral aspect of the intracranial end of the hypoglossal canal is
reached with removal of approximately the posterior third of
the occipital condyle (8.4 mm of 21 mm) (Fig. 7.1) (20). Further Intradural stage
drilling of the occipital condyle can be done after reaching the The dural incision begins behind the sigmoid sinus and
lateral aspect of the intracranial end of the hypoglossal canal, extends behind the vertebral artery into the upper cervical
as the canal is directed anteriorly and laterally, permitting the area. The upper extent of the dural opening depends on how
lateral part of the posterior two-thirds of the condyle to be much of the cerebellopontine angle is to be exposed. Possible
removed without entering the hypoglossal canal. The distance sources of bleeding during the dural opening are the marginal
between the upper surface of the hypoglossal nerve and the sinus that encircles the foramen magnum and the posterior
roof of the hypoglossal canal averages 4.4 mm. Extensive meningeal artery, which usually originates from the vertebral
drilling around the canal may allow the nerve to be trans- artery extradurally, but may infrequently originate intra-
posed from its normal course (Fig. 7.6). durally, in which case it crosses the lateral medullary cistern
After exposing the hypoglossal canal above the occipital and pierces the arachnoid to reach the dura. Opening the dura
condyle, the bone of the jugular tubercle situated above the exposes the intradural segment of the vertebral artery. As the
hypoglossal canal can be removed extradurally to gain addi- artery pierces the dura, it is encased in a fibrous tunnel that
tional exposure (1–3, 9, 10, 13). The jugular tubercle is a binds the posterior spinal artery, dentate ligament, first cer-
rounded prominence located at the junction of the basilar and vical nerve, and the spinal accessory nerve to the vertebral
condylar parts of the occipital bone (Figs. 7.1, 7.4, C and D, artery (Figs. 7.2, N and O, 7.3) (14). Care should be taken to
and 7.5, A–C). It is situated above the hypoglossal canal and preserve the posterior spinal artery during the dural opening
medial to the lower half of the intracranial end of the jugular and mobilization of the vertebral artery because it may be
foramen. The average distance from the posterior edge of the incorporated into the dural cuff around the vertebral artery.
jugular tubercle (the site of the groove in which the lower At the craniocervical junction, the dentate ligament is lo-
cranial nerves course) to the upper border of the hypoglossal cated between the vertebral artery and ventral roots of C1
canal is 4.5 mm (20). The glossopharyngeal, vagus, and acces- anteriorly and the branches of the posterior spinal artery and
sory nerves cross the posterior portion of the jugular tubercle spinal accessory nerve posteriorly, and is often incorporated
in passing from the brainstem to the jugular foramen, some- into the dural cuff around the vertebral artery (Figs. 7.2O, 7.3,
times coursing in a shallow groove on the surface of the and 7.5). The most rostral attachment of the dentate ligament
tubercle (Figs. 7.4 and 7.5). is located at the level of the foramen magnum above where
The prominence of the jugular tubercle blocks access to the the vertebral artery pierces the dura and behind the accessory
basal cisterns and clivus anterior to the lower cranial nerves. nerve, although the dentate ligament is located anterior to the
As the jugular tubercle is removed extradurally the cranial accessory nerve at lower levels. Section of the upper two
nerves, which course along the back margin of the tubercle triangular processes will increase access anterior to the spinal
and are intradural, will not be visualized. As the drilling cord. The first cervical nerve courses along the posteroinferior
proceeds, bone will be removed from below the cisternal surface of the vertebral artery as it pierces the dura. The
segment of the accessory and the vagus nerves that course ventral root is located anterior to the dentate ligament, and
above the tubercle just inside the dura. Caution is required in the dorsal root, which is infrequently present, passes posterior

S204 Rhoton
FIGURE 7.4. Relationships in the transcondylar, supracondylar, and paracondylar exposures. A, a left suboccipital craniectomy has been
completed and the dura opened. The nerves entering the jugular foramen have been exposed. Bone has been removed above the occipi-
tal condyle to expose the hypoglossal nerve entering the hypoglossal canal. A bridging vein passes from the lateral aspect of the medulla
to the jugular bulb. B, the rectus capitis lateralis has been detached from the cranial base and the jugular process of the occipital bone,
which forms the posterior margin of the jugular foramen, has been removed to expose the jugular bulb. The posterior belly of the digas-
tric muscle has been reflected forward and a mastoidectomy completed to expose the mastoid segment of the facial nerve. C, the jugular
bulb and adjoining segment of the internal jugular vein have been removed to expose the glossopharyngeal, vagus, and accessory nerves
passing through the jugular foramen and descending behind the internal carotid artery. The cortical bone lining the hypoglossal canal has
been removed to expose the hypoglossal nerve and the venous plexus in the canal. The hypoglossal nerve joins the nerves exiting the jug-
ular foramen to descend in the carotid sheath. A mastoidectomy has been completed to expose the bony capsule of the semicircular
canals and the mastoid segment of the facial nerve. D, enlarged view of the nerves passing through the hypoglossal canal and jugular
foramen in the supracondylar and paracondylar areas. A., artery; Bridg., bridging; Car., carotid; CN, cranial nerve; Cond., condyle; For.,
foramen; Gl., gland; Hypogl., hypoglossal; Int., internal; Jug., jugular; Lat., lateral, lateralis; Occip., occipital; P.I.C.A., posteroinferior cere-
bellar artery; Post., posterior; Seg., segment; Sig., sigmoid; Stylomast., stylomastoid; Vert., vertebral.

FIGURE 7.5. Posterior view of the left cerebellopontine angle. A, the glossopharyngeal, vagus, accessory, and hypoglossal
nerves arise from the medulla. The hypoglossal canal has been exposed by drilling the cancellous bone above the occipital
condyle. The posterior root of the transverse process of C1 has been removed. The accessory nerve crosses the jugular tuber-
cle, the latter acting as a trochlea around which the accessory nerve courses to reach the jugular foramen. B, enlarged view.
The area above the occipital condyle has been drilled to further expose the cortical bone around the hypoglossal canal. The
atlanto-occipital joint has been preserved. C, the cortical bone lining the hypoglossal canal has been opened to expose the
hypoglossal nerve and the hypoglossal venous plexus in the canal. D, anterior view. The anterior surface of the posterior
fossa and the anterior wall of the hypoglossal canal have been removed to expose the hypoglossal nerve in its canal. The
rootlets of the hypoglossal nerve originate ventral to the inferior olive and join before exiting the hypoglossal canal. The glos-
sopharyngeal, vagus, and accessory nerves penetrate the dura on the medial side of the jugular bulb. The hypoglossal nerve
exits the hypoglossal canal on the medial side of the jugular foramen. A., artery; A.I.C.A., anteroinferior cerebellar artery;
Atl., atlanto; Bas., basilar; CN, cranial nerve; Cond., condyle; Dent., dentate; For., foramen; Hypogl., hypoglossal; Jug., jugu-
lar; Lig., ligament; Occip., occipital; P.I.C.A., posteroinferior cerebellar artery; Vert., vertebral.

S206 Rhoton
FIGURE 7.6. A, axial section extending through the occipital condyle and internal jugular vein below the right jugular fora-
men. The internal jugular vein descends just in front of the rectus capitis lateralis and behind the carotid artery. The occipital
condyle is located on the medial side of the jugular foramen, and the styloid process, facial nerve, and parotid gland are on the
lateral side. The nerves passing through the jugular foramen and hypoglossal canal collect together on the medial side of the inter-
nal jugular vein in an area just below the jugular foramen. B, the parotid gland has been removed. The facial nerve exits the stylo-
mastoid foramen on the lateral side of the internal jugular vein. The styloid process is located along the anterolateral margin of the
internal jugular vein. The central third of the occipital condyle has been removed to expose the hypoglossal nerve as it passes
through the hypoglossal canal and joins the nerves exiting the jugular foramen on the medial side of the internal jugular vein. The
rectus capitis lateralis and some of the jugular process of the occipital bone have been removed to expose the terminal part of the
sigmoid sinus. C–D. Transposition of the hypoglossal nerve. C, the vertebral artery has been displaced medially. The occipital con-
dyle, jugular tubercle, and the bone around and in front of the hypoglossal canal have been removed to expose the edge of the
lower clivus. The dura ostium of the hypoglossal nerve has been opened so that the nerve can be mobilized. D, enlarged view of
the mobilized hypoglossal nerve. A., artery; Atl., atlanto; Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; For., fora-
men; Gl., gland; Hypogl., hypoglossal; Int., internal; Jug., jugular; Lat., lateralis; M., muscle; Occip., occipital; P.I.C.A., posteroinfe-
rior cerebellar artery; Proc., process; Rec., rectus; Sig., sigmoid; Stylomast., stylomastoid; V., vein; Vert., vertebral.
to the dentate ligament. The rootlets forming the spinal por- medulla with its mate to form the basilar artery (Fig. 7.2,
tion of the accessory nerve, which arise from the cervical N and O). Before reaching the lower border of pons, the
portion of the spinal cord midway between the dorsal and vertebral artery gives off the PICA, which courses backward
ventral rootlets as far caudally as C5, unite to form a trunk around the lateral surface of the medulla and between the
that ascends through the foramen magnum between the den- rootlets of glossopharyngeal, vagus, and accessory nerves.
tate ligament and the dorsal roots and enters the posterior The anterior, lateral, and tonsillomedullary PICA segments
fossa behind the vertebral artery (5). and the intradural segment of the glossopharyngeal, vagus, and
The intradural segment of the vertebral artery, after emerg- accessory nerves, which may be exposed in this approach, are
ing from the fibrous dural tunnel, ascends in front of the described in greater detail in this issue in the chapters on the
rootlets of the hypoglossal nerve to reach the front of the me- cerebellar arteries and cerebellopontine angle (Figs. 7.2, N and
dulla oblongata where it unites near the junction of pons and O, and 7.3-7.5) (11).

DISCUSSION nerable to injury when one expects the artery to be passing

straight upward from the lower to the upper transverse fora-
The basic far-lateral approach without drilling of the occip-
men. The artery is also susceptible to damage as it passes
ital condyle may be all that is required to reach some lesions
behind the superior articular facet of the atlas. The artery
located along the anterolateral margin of the foramen mag-
normally hugs the posterior surface of the superior articular
num. However, it also provides a route through which the
facet of the atlas, extending upward only to the level of the
transcondylar, supracondylar, and paracondylar approaches
atlanto-occipital joint. However, if the artery elongates and
and several modifications of these approaches can be com-
becomes tortuous it can loop upward behind the occipital
pleted. The transcondylar exposures can be categorized into
condyle, even resting against the occipital bone behind the con-
several variants. An atlanto-occipital transarticular approach,
dyle. It also can loop backward and bulge posteriorly between
in which the adjacent posterior parts of the occipital condyle
the lips of the suboccipital triangle, which it can damage if one
and the superior articular facet of C1 are removed to facilitate
expects it to be found in the depth of the suboccipital triangle.
completion of a circular dural incision, permitting the verte-
In obliterating and coagulating the venous plexus around
bral artery with the surrounding cuff of dura to be mobilized.
the vertebral artery, there is the risk that some of the branches
A more extensive removal of the articular surfaces and con-
of the vertebral artery, which arise in an extradural location or
dyles can be done to gain access to extradural lesions situated even a hypoplastic vertebral artery, might be occluded or
along the anterior and lateral margins of the foramen mag- divided. The posterior spinal artery, and uncommonly the
num. Another variant, the occipital transcondylar variant, is PICA, may arise extradurally in the region of the portion of
directed above the atlanto-occipital joint through the occipital the vertebral venous plexus, which may need to be partially
condyle and below the hypoglossal canal to access the lower excised or obliterated to gain access to the vertebral artery.
clivus and the area in front of the medulla. The supracondylar The far-lateral approach, in which the exposure is carried
approach directed above the occipital condyle can also be up to, but does not include, the posterior margin of the
varied, depending on the pathology to be exposed. The su- occipital condyle, may be selected for lesions located along the
pracondylar exposure can be directed above the occipital lateral or anterolateral aspect of the foramen magnum. It is
condyle to the hypoglossal canal or both above and below the frequently necessary to remove a small portion of both the
hypoglossal canal to the lateral side of the clivus. In the transtu- occipital condyle and the superior articular facet of the atlas if
bercular variant of the supracondylar approach, the prominence there is a need to complete a circumferential dural incision
of the jugular tubercle that blocks access to the area in front of the around the site where the artery penetrates the dura, so that
glossopharyngeal, vagus, and accessory nerves is removed ex- the artery can be displaced for access to lesions located ventral
tradurally to increase visualization of the area in front of the to the artery and in front of the cervicomedullary junction. For
brainstem and to expose the origin of a PICA that arises from lesions requiring a greater anterior and superior exposure, the
the distal part of the vertebral artery near the midline. The posterior third of the occipital condyle can be removed with-
paracondylar approach also has several variants. In the trans- out entering the hypoglossal canal. It is possible to drill the
jugular variant, the exposure is directed lateral to the condyle cancellous bone of the occipital condyle to expose the lateral
through the jugular process of the occipital bone to the pos- clivus and hypoglossal canal while preserving some of the
terior surface of the jugular bulb. The approach can also be cortical bone of the condyle and the articular surface so that
extended lateral to the jugular foramen into the posterior the joint is not disrupted (Figs. 7.3 and 7.5). The cortical
aspect of the mastoid to access the mastoid segment of the surface around the hypoglossal canal can be preserved if there
facial nerve and the stylomastoid foramen. is no need to expose the nerve within the canal.
Many suboccipital operations are completed without re- Another key aspect of this approach is the condyle drilling,
quiring that each individual muscle be identified. However, which requires an understanding of the relationship of the
identification of selective muscles is an essential part of com- hypoglossal canal to the occipital condyle (Figs. 7.3–7.6). The
pleting the transcondylar, supracondylar, and paracondylar maximum extent of the upper portion of occipital condyle that
approaches. Muscles that are especially significant in identi- could be drilled without exposing the hypoglossal canal is the
fying the neural, vascular, and osseous structures involved in posterior third of its long axis. The occipital condyle some-
these exposures are the three muscles forming the suboccip- times can be covered by a hypertrophic superior articular
ital triangle and the levator scapulae, rectus capitis lateralis, facet of C1 that protrudes into the foramen magnum, making
and the posterior belly of the digastric. Identification of the it easy to overlook the upper medial portion of the occipital
individual muscles is also helpful in exposing and preserving condyle. In exposing lesions located along the anterior portion
the occipital artery if it is needed for a bypass procedure and of the cervical cord, the inferior portion of the occipital con-
in preserving the peripheral branches of the upper cervical dyle and the superior facet of C1 can be removed after re-
nerves. The levator scapulae muscle provides an excellent tracting the vertebral artery inferior and medially. In drilling
landmark for localizing the vertebral artery as it ascends the upper posterior portion of the condyle, the posterior con-
between the transverse foramina of the atlas and axis where dylar vein may be a source of bleeding, which could be
the artery is located medial to the upper attachments of the mistaken for bleeding from the venous plexus in the hypo-
muscle. The main risk in this area is related to a tortuous glossal canal. After exposing the hypoglossal canal, the jugu-
vertebral artery that loops posteriorly as it ascends between lar tubercle, which is located just above and anterior to the
the transverse processes of the axis and atlas, making it vul- canal, is identified. The drilling can be extended to a supra-

S208 Rhoton
condylar location above the hypoglossal canal for removal of inverted horseshoe incision, with the medial limb extended so
all or part of the jugular tubercle, so that the dura covering the that a wide C1 to C2 laminectomy can be completed, and a
tubercle can be pushed forward to gain access to the front of lateral limb extended below the C1 transverse process so that
the medulla and the pontomedullary junction. Removal of the the muscles attaching to the transverse processes are visual-
jugular tubercle may yield better visualization of the intra- ized (2, 5, 17, 18, 20). A musculofascial cuff is left attached
dural segment of vertebral artery and the origin of the PICA, along the superior nuchal line for closure. The flap on the
especially if the PICA originates from the upper part of the upper part of the occipital squama can be reflected as a single
vertebral artery. The supracondylar approach, in which the layer, however it is helpful to identify the muscles forming the
jugular tubercle is removed and the hypoglossal canal is suboccipital triangle as an aid to exposing the vertebral artery.
exposed or opened, provides a route for reaching extradural Anatomically, muscle dissection layer by layer offers the best
lesions located in the lower lateral part of the clivus in front of preservation of the muscular landmarks. However, reflection
the hypoglossal canal. The extradural removal of the jugular of the superficial muscles individually carries a greater risk of
tubercle should be performed with caution because of the risk flap dehiscence. Elevating the muscles attached to the upper
of injuring the glossopharyngeal, vagus, and the accessory part of the occipital squama with the scalp minimizes this
nerves that hug and often course in a shallow groove at the problem and allows identification of important deep muscu-
site where they cross the tubercle. lar landmarks, such as the suboccipital triangle and levator
The paracondylar exposure, which accesses the posterior scapulae for localizing the vertebral artery and the rectus
margin of the jugular foramen and the jugular bulb, can be capitis lateralis for localizing the posterior portion of the
completed without drilling the occipital condyle (8, 20). An jugular bulb.
excellent landmark for identifying the jugular process is the
rectus capitis lateralis, which extends upward from the trans- Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro-
verse process of the atlas to attach to the jugular process just logical Surgery, University of Florida Brain Institute, P.O. Box 100265,
behind the jugular bulb. The muscle is located medial to the 100 South Newell Drive, Building 59, L2-100, Gainesville, FL
site where the occipital artery enters the retromastoid area by 32610-0265.
passing between the rectus capitis lateralis and posterior belly
REFERENCES
of the digastric. The jugular foramen and jugular bulb is
accessed by drilling the jugular process at the posterior mar- 1. Arnold H, Sepehrnia A: Extreme lateral transcondylar approach.
gin of the foramen. Drilling lateral to the jugular bulb from J Neurosurg 82:313, 1995 (letter).
this posterior exposure risks damaging the facial nerve in the 2. Babu RP, Sekhar LN, Wright DC: Extreme lateral transcondylar
facial canal at and just above the stylomastoid foramen. The approach: Technical improvements and lessons learned. J Neuro-
posterior belly of the digastric muscle, which attaches along surg 81:49–59, 1994.
the digastric groove just posterior to the stylomastoid fora- 3. Baldwin HZ, Miller CG, van Loveren HR, Keller JT, Daspit CP,
Spetzler RF: The far lateral/combined supra- and infratentorial
men, provides a useful landmark for identifying the facial
approach: A human cadaveric prosection model for routes of
nerve. A limited or more extensive mastoidectomy may be access to the petroclival region and ventral brainstem. J Neuro-
completed, depending on the length of the mastoid segment surg 81:60–68, 1994.
of the facial nerve to be exposed and the extent to which the 4. Bertalanffy H, Seeger W: The dorsolateral, suboccipital, transcon-
bone on the lateral aspect of the jugular bulb must be re- dylar approach to the lower clivus and anterior portion of the
moved. A wider exposure of the jugular foramen is obtained craniocervical junction. Neurosurgery 29:815–821, 1991.
by a retrolabyrinthine transtemporal approach, in which a 5. de Oliveira E, Rhoton AL Jr, Peace D: Microsurgical anatomy of the
more extensive mastoidectomy is completed and the mastoid region of the foramen magnum. Surg Neurol 24:293–352, 1985.
and the tympanic segments of the facial nerve are exposed so 6. Hakuba A, Tsujimoto T: Transcondyle approach for foramen
that the facial nerve can be transposed forward to provide magnum meningiomas, in Sekhar LN, Janecka IP (eds): Surgery of
Cranial Base Tumors. New York, Raven Press, 1993, pp 671–678.
access to both the lateral and the posterior margin of the
7. Heros RC: Inferolateral suboccipital approach for vertebral and
jugular foramen. vertebrobasilar aneurysms, in Wilkins RH, Rengachary SS (eds):
Several controversies concern the positioning of the patient Neurosurgery Update: Vascular, Spinal, Pediatric, and Functional
and the type of skin incision (20). The modified park bench Neurosurgery. New York, McGraw-Hill, 1991, vol II, pp 106–109.
position that we use offers the main advantage of avoiding air 8. Katsuta T, Rhoton AL Jr, Matsushima T: The jugular foramen:
embolism (2, 3, 10, 14). The sitting position recommended by Microsurgical anatomy and operative approaches. Neurosurgery
others is associated with a less distended venous plexus, but 41:149–202, 1997.
the rich net of veins around the cervical muscles, vertebral 9. Kratimenos GP, Crockard HA: The far lateral approach for ven-
artery, and bone in the region offers the risk of air embolism trally placed foramen magnum and upper cervical spine tumors.
(4, 13). A straight scalp incision has been recommended as Br J Neurosurg 7:129–140, 1993.
10. Lang DA, Neil-Dwyer G, Iannotti F: The suboccipital transcondy-
being easier to open and close (10, 13). However, the thick
lar approach to the clivus and cranio-cervical junction for ven-
cervical muscular mass and need for extensive retraction cre- trally placed pathology at and above the foramen magnum. Acta
ate a deep surgical field and the lateral position of the incision Neurochir (Wien) 125:132–137, 1993.
makes it difficult to complete a wide removal of the posterior 11. Lister JR, Rhoton AL Jr, Matsushima T, Peace D: Microsurgical
C1 arch and C2 lamina, which is especially important if the anatomy of the posterior inferior cerebellar artery. Neurosurgery
lesion extends through the foramen magnum. We prefer an 10:170–199, 1982.

12. Matsushima T, Ikezaki K, Nagata S, Inoue T, Natori Y, Fukui M, 16. Sen CN, Sekhar LN: Surgical management of anteriorly placed
Rhoton AL Jr: Microsurgical anatomy for lateral approaches to the lesions at the cranio-cervical junction: An alternative approach.
foramen magnum: With special reference to the far lateral ap- Acta Neurochir (Wien) 108:70–77, 1991.
proach and the transcondylar approach, in Nakagawa H (ed): 17. Sen C, Sekhar LN: Extreme lateral transcondylar and transjugular
Surgical Anatomy for Microneurosurgery: Anatomy and Approaches to approaches, in Sekhar LN, Janecka IP (eds): Surgery of Cranial Base
the Craniocervical Junction and Spinal Column [in Japanese]. Tokyo, Tumors. New York, Raven Press, 1993, pp 389–411.
SciMed, 1994, vol VII, pp 81–89. 18. Spetzler RF, Grahm TW: The far-lateral approach to the inferior
13. Perneczky A: The posterolateral approach to the foramen mag- clivus and the upper cervical region: Technical note. BNI Q
num, in Samii M (ed): Surgery in and around the Brainstem and the 6:35–38, 1990.
Third Ventricle. Berlin, Springer-Verlag, 1986, pp 460–466. 19. Tedeschi H, Rhoton AL Jr: Lateral approaches to the petroclival
14. Rhoton AL Jr: Meningiomas of the cerebellopontine angle and region. Surg Neurol 41:180–216, 1994.
foramen magnum. Neurosurg Clin N Am 52:349–377, 1994. 20. Wen HT, Rhoton AL Jr, Katsuta T, de Oliveira E: Microsurgical
15. Sen CN, Sekhar LN: An extreme lateral approach to intradural anatomy of the transcondylar, supracondylar, and paracondylar
lesions of the cervical spine and foramen magnum. Neurosurgery extensions of the far-lateral approach. J Neurosurg 87:555–585,
27:197–204, 1990. 1997.
Cranium showing various anatomical structures. Vesalius was so confident that his work would be studied and
plagiarized that he obtained the sponsorship and copyright protection of the Emperor, the King of France, and the
Grand Council of Venice, the three great powers of his day. From, Andreas Vesalius, De Humani Corporis Fabrica.
Basel, Ex officina Ioannis Oporini, 1543. Courtesy, Rare Book Room, Norris Medical Library, Keck School of Medicine,
Los Angeles, California. (Also see pages S27, S68, and S285.)

The course of the nerve fibers transmitting the sensation of taste. Dean Lewis and Walter Dandy described the course of taste fi-
bers, which they believed to be from the tongue through the chorda tympani to the facial nerve, directly through the geniculate
ganglion and the nervous intermedius into the pons. Black ink on Ross scratchboard by Max Brödel. Courtesy, Journal of the
American Medical Association 21:249–288, 1930. (Also see pages S265 and S266.)
CHAPTER 8
The Temporal Bone and Transtemporal Approaches

Key words: Cranial base, Cranial nerves, Facial nerve, Internal carotid artery, Microsurgical anatomy, Skull base, Skull base neoplasm, Surgical
approach, Temporal bone
T
he temporal bone is divided into squamosal, petrous, the semicircular canals and vestibule; and 5) the transcochlear
mastoid, tympanic, and styloid parts (Figs. 8.1 and 8.2). modification, which includes removal of all the labyrinth,
The squamosal part helps enclose the brain. The mas- including the cochlear and possibly the petrous apex. These
toid part is trabeculated and pneumatized to a variable de- variants of the transmastoid approaches can all be combined,
gree and contains the mastoid antrum. The petrous part is as needed, with the supra- and infratentorial presigmoid ap-
compact and encloses the cochlea, the vestibule, and the semi- proaches to the middle and posterior fossa.
circular, facial, and carotid canals (Fig. 8.3). The tympanic part The final approach to be reviewed is the postauricular
forms part of the wall of the tympanic cavity and the external transtemporal approach, which allows lesions involving the
acoustic meatus. The styloid projects downward and serves as mastoid, tympanic cavity, petrous apex, and jugular foramen
the site of attachment of several muscles. This section exam- to be followed backward to the areas exposed by the retrosig-
ines these parts in greater detail and defines the anatomic moid and far-lateral approaches and forward to the infratem-
basis of the approaches directed through the temporal bone to poral, pterygopalatine and middle fossae, lateral maxilla, and
the posterior fossa and petroclival region. The approaches orbit. Selecting an approach directed through the temporal
examined are the middle fossa, translabyrinthine, transco- bone requires an understanding of its complex anatomy and
chlear, combined supra- and infratentorial presigmoid, sub- its relationship to the petroclival region, the infratemporal
temporal anterior transpetrosal, subtemporal preauricular in- fossa, and parapharyngeal space. Protecting and preserving
fratemporal, and the postauricular transtemporal approaches. the facial nerve, the petrous carotid artery, and the sensory
The approaches directed through the surface of the tempo- organs of the inner ear that are contained within the temporal
ral bone forming the middle fossa floor include 1) the very bone are important elements in operative approaches directed
limited middle fossa exposure of the internal acoustic meatus; through the lateral aspect of the cranial base.
2) the anterior petrosectomy approach directed medial to the
internal acoustic meatus through the petrous apex to access
the upper anterior part of the posterior fossa and clivus; 3) the THE TEMPORAL BONE AND
extended middle fossa approach, which may include not only TRANSTEMPORAL APPROACHES
resection of the roof of the internal acoustic meatus and pe-
trous apex, but is extended lateral to the internal acoustic Lateral surface
meatus to include resection, as needed, of the semicircular When the skull and temporal bone are viewed from a
canals, vestibule, roof of the mastoid antrum and tympanic lateral perspective, some landmarks useful in performing ap-
cavity, and the posterior face of the temporal bone; and 4) the proaches directed around and through the temporal bone can
subtemporal preauricular infratemporal fossa approach in be identified (Fig. 8.2). The posterior end of the superior
which the middle fossa exposure is combined with exposure temporal line continues inferiorly as the supramastoid crest
of the infratemporal fossa and, if needed, the petrous carotid, and blends into the upper edge of the zygomatic arch. The
petrous apex, pterygopalatine fossae, and orbit. supramastoid crest is located at the level of the floor of
The approaches directed through the mastoid in front of the the middle fossa. The junction of the supramastoid crest
sigmoid sinus vary in the amount of temporal bone resected. with the squamous suture is located at the lateral end of the
They include 1) the minimal mastoidectomy variant in which petrous ridge. The meeting point of the parietomastoid and
only enough presigmoid dura is exposed to open the dura in squamous sutures is located a few millimeters below the lateral
front of the sigmoid without exposing the labyrinth; 2) the end of the petrous ridge. The anterior edge of the junction of the
retrolabyrinthine approach, which exposes the bony capsule sigmoid and transverse sinuses is located at the junction of
of the labyrinth; 3) the partial labyrinthectomy, which in- the squamous and parietomastoid suture.
cludes removal of one or more of the semicircular canals; 4) The mastoid antrum, a pneumatized space opening into the
the translabyrinthine approach, which includes resection of tympanic cavity, is located about 1.5 cm deep to the su-

S212 Rhoton
FIGURE 8.1. Temporal bone. A

and B, inferior views. A, the
temporal bone has a squamosal
part, which forms some of the
floor and lateral wall of the
middle cranial fossa. It is also the
site of the mandibular fossa in
which the mandibular condyle
sits. The tympanic part forms the
anterior, lower, and part of the
posterior wall of the external
canal, part of the wall of the
tympanic cavity, the osseous
portion of the eustachian tube,
and the posterior wall of the
mandibular fossa. The mastoid
portion contains the mastoid air
cells and mastoid antrum. The
petrous part is the site of the
auditory and vestibular labyrinth,
the carotid canal, the internal
acoustic meatus, and the facial
canal. The petrous part also forms
the anterior wall and the dome
of the jugular fossa. The styloid
part projects downward and
serves as the site of attachment of
three muscles. B, inferior view of
the temporal and surrounding
bones. The squamosal and
petrous parts articulate anteriorly
with the greater wing of the
sphenoid. The petrous apex faces
the foramen lacerum and is
separated from the clival part of
the occipital bone by the
petroclival fissure. The occipital
bone joins with the petrous part
of the temporal bone to form the
jugular foramen. The mandibular
fossa is located between the
anterior and posterior roots of the
zygomatic process. C and D,
superior views. C, the medial part
of the upper surface is the site of
the trigeminal impression in which Meckel’s cave sits. Farther laterally is the prominence of the arcuate eminence overlying the
superior semicircular canal. Anterolateral to the arcuate eminences is the tegmen, a thin plate of bone overlying the mastoid
antrum and epitympanic area. The temporal bone articulates anteriorly with the sphenoid bone, above with the parietal bone, and
posteriorly with the occipital bone. The zygomatic process of the squamosal part has an anterior and a posterior root between
which, on the lower surface, is located the mandibular canal. D, temporal and surrounding bones. The squamosal part of the
temporal bone joins anteriorly with the sphenoid bone to form the floor of the middle cranial fossa. Posteriorly, it articulates with
the occipital bone to form a portion of the anterior wall of the posterior fossa. Medially, it articulates with the clival portion of the
occipital bone at the petroclival fissure. The sigmoid sulcus descends along the posterior surface of the mastoid portion and turns
forward to enter the jugular foramen. The foramen lacerum is located at the junction of the temporal, sphenoid, and occipital
bones. The porus of the internal acoustic meatus is located in the central part of the posterior surface. Ac., acoustic; Ant., anterior;
Arc., arcuate; Car., carotid; Cond., condyle; Digast., digastric; Emin., eminence; For., foramen; Gr., greater; Impress., impression;
Int., internal; Jug., jugular; Mandib., mandibular; N., nerve; Occip., occipital; Pet., petrosal; Post., posterior; Proc., process; Sig.,
sigmoid; Stylomast., stylomastoid; Trig., trigeminal; Tymp., tympanic.

Temporal Bone S213
FIGURE 8.2. Temporal bone. A, posterior view of a right temporal bone. The squamosal part forms part of the floor and lat-
eral wall of the middle fossa. The sigmoid sulcus descends along the posterior surface of the mastoid portion. The internal
acoustic meatus enters the central portion of the petrous part of the bone. The trigeminal impression and arcuate eminence
are located on the upper surface of the petrous part. The vestibular aqueduct connects the vestibule in the petrous part with
the endolymphatic sac, which sits on the posterior petrous surface inferolateral to the internal acoustic meatus. B, enlarged
view. The transverse crest separates the meatal fundus into a superior part where the facial canal and superior vestibular
areas are situated, and an inferior part where the cochlear and inferior vestibular areas are located. The vertical crest sepa-
rates the facial and superior vestibular areas. C, enlarged view of another internal acoustic meatus. The transverse crest
divides the meatal fundus into superior and inferior parts. The anterior part above the transverse crest is the site of the facial
canal and the posterior part is the site of the superior vestibular area. Below the transverse crest, the cochlear area is ante-
rior and the inferior vestibular area is posterior. D, another internal acoustic meatus. The view is directed to expose the sin-
gular foramen, for the singular branch of the inferior vestibular nerve that innervates the posterior ampullae. The inferior ves-
tibular nerve also has a saccular and, occasionally, a utricular branch. Ac., acoustic; Arc., arcuate; CN, cranial nerve; Coch.,
cochlear; Emin., eminence; Ext., external; For., foramen; Impress., impression; Inf., inferior; Int., internal; Mandib., mandibu-
lar; Occipitomast., occipitomastoid; Parietomast., parietomastoid; Proc., process; Sig., sigmoid; Sp., spine; Sup., superior;
Supramast., supramastoid; Trans., transverse; Trig., trigeminal; Vert., vertebral; Vest., vestibular.
prameatal triangle, a depression in the mastoid surface lo- verse and sigmoid sinuses at the posterior aspect of the mas-
cated between the posterosuperior edge of the external me- toid. The asterion located at the junction of the lambdoid,
atus, the supramastoid crest, and the vertical tangent along occipitomastoid, and parietomastoid sutures is usually lo-
the posterior edge of the meatus. The suprameatal spine of cated over the junction of the lower part of the transverse and
Henle is located at the outer end of the posterosuperior edge sigmoid sinuses. A burr-hole placed at this site will usually
of the external canal along the anterior edge of the su- expose the lower edge of this junction. A burr-hole located at
prameatal triangle and corresponds to the level of the lateral the junction of the supramastoid crest and the squamosal
semicircular canal and tympanic segment of the facial nerve at suture will be located at the posterior part of the middle fossa
a depth of approximately 1.5 cm. Several landmarks are also floor just above and anterior to the upper edge of the junction
helpful in identifying the location of the junction of the trans- of the transverse and sigmoid sinuses.

S214 Rhoton
FIGURE 8.2. E, lateral view of the temporal bone. The squamosal part forms part of the lateral wall of the middle fossa, the
posterior part of the zygomatic arch, and the upper part of the mandibular fossa. The tympanic part forms the posterior wall of the
mandibular fossa and almost all of the wall of the external canal. The styloid process is ensheathed at its base by the tympanic part
and projects downward, serving as the attachment of several muscles. The mastoid part is located posteriorly and contains the mas-
toid air cells that coalesce at the mastoid antrum. F, enlarged view of the external auditory canal. The spine of Henley, an excellent
landmark for locating the deep site of the lateral canal and tympanic segment of the facial nerve, is located along the posterosupe-
rior margin of the external canal. The mastoid antrum is located deep to the depressed area, called the suprameatal triangle,
located behind the spine of Henley. The view into the canal exposes the tympanic cavity, which has the promontory overlying the
basal turn of the cochlea and the oval and round windows in its medial wall. G, lateral surface of the temporal bone in the intact
skull. The tympanic part forms the anterior and lower and part of the posterior wall of the external canal. The mandibular fossa is
formed above and anteriorly by the squamosal part and behind by the tympanic part. The mastoid antrum is located posterosupe-
rior to the spine of Henley, between the spine of Henley and the anterior part of the supramastoid crest. The asterion, the junction
of the lambdoid, parietomastoid, and occipital mastoid sutures, is usually located over the lower half of the junction of the sigmoid
and transverse sinuses. The midpoint of the parietal mastoid suture is usually located at the anterior margin of the junction of the
transverse and sigmoid sinuses, and the lateral edge of the petrous ridge is located at the junction of the squamosal suture and the
supramastoid crest. H, the supra- and infratentorial areas have been exposed while preserving the bone at the site of the sutures.
The asterion, located at the junction of the lambdoid, occipitomastoid, and parietomastoid sutures, overlies the lower half of the
junction of the transverse and sigmoid sinuses. The junction of the supramastoid crest and the squamosal suture is located at the
posterior edge of the middle fossa and slightly anterior and above the junction of the transverse and sigmoid sinuses.
The tympanic part which closes the medial end of the external canal. The
The tympanic part of the temporal bone is a curved plate anterior surface, which is concave, forms the posterior wall
anterior to the mastoid process (Figs. 8.1, 8.2, and 8.4). Its of the mandibular fossa. Its lateral border forms most of the
concave posterior surface forms the anterior wall, floor, margin of the external acoustic meatus. Medially, it joins
and part of the posterior wall of the external acoustic the petrous part at the petrotympanic fissure through
meatus. The roof and upper posterior wall are formed by which the chorda tympani passes. The carotid canal and
the squamosal part. Its surface contains a portion of the the jugular foramen are located medial to the tympanic
tympanic sulcus for attachment of the tympanic membrane, part.

Temporal Bone S215
FIGURE 8.3. A–D. Posterior surface of the temporal bone. A, the internal meatus is located near the center and the jugular
foramen at the lower edge of the posterior surface. The sigmoid sinus descends along the posterior surface of the mastoid
and turns forward on the occipital bone to pass through the sigmoid part of the jugular foramen. The inferior petrosal sinus
descends along the petroclival fissure and passes through the petrosal part of the jugular foramen. The subarcuate fossa is
located superolateral and the ostium for the vestibular aqueduct lateral to the internal acoustic meatus. The trigeminal
impression is a shallow trough on the upper surface of the temporal bone behind the foramen ovale. The arcuate eminence
overlies the superior semicircular canals. B, temporal bone with the nerves preserved. The abducens nerve ascends to enter
Dorello’s canal. The trigeminal nerve passes above the petrous apex to enter the porus of Meckel’s cave. The facial and ves-
tibulocochlear nerves enter the internal acoustic meatus, and the glossopharyngeal, vagus, and accessory nerves enter the
jugular foramen. The posterior and superior semicircular canals have been exposed. C, enlarged view. The upper end of the
posterior canal and the posterior end of the superior canal share the common crus. The endolymphatic duct extends down-
ward from the vestibule and opens into the endolymphatic sac located beneath the dura inferolateral to the meatus. The
endolymphatic ridge, the bridge of bone forming the posterior lip of the vestibular aqueduct, has been preserved. The jugular
bulb can be seen through the thin bone below the internal meatus. D, enlarged view of the fundus of the meatus after
removal of the posterior wall. The upper edge of the porus has been preserved. The subarcuate artery enters the subarcuate
fossa. The inferior vestibular nerve gives rise to the singular branch to the posterior ampullae, plus utricular and saccular
branches. The superior vestibular nerve innervates the ampullae of the superior and lateral semicircular canals and commonly
gives rise to a utricular branch. A., artery; Ac., acoustic; Arc., arcuate; Car., carotid; CN, cranial nerve; Coch., cochlear;
Emin., eminence; Endolymph., endolymphatic; Fiss., fissure; For., foramen; Hypogl., hypoglossal; Impress., impression; Inf.,
inferior; Int., internal; Intermed., intermedius; Jug., jugular; Lat., lateral; N., nerve; Nerv., nervus; Pet., petrosal, petrous; Pet-
rocliv., petroclival; Post., posterior; Semicirc., semicircular; Sig., sigmoid; Subarc., subarcuate; Sup., superior; Trig., trigemi-
nal; Vest., vestibular.
The styloid process, a slender spicule ensheathed by the located immediately anterior to the emergence of the facial
inferior border of the tympanic bone, projects into the infra- nerve from the stylomastoid foramen and is covered laterally
temporal fossa and is the site of attachment for the styloglos- by the parotid gland. The stylomastoid foramen, the external
sus, stylopharyngeus, and stylohyoid muscles (Fig. 8.5). It is end of the facial canal, opens between the styloid and mastoid

S216 Rhoton
FIGURE 8.3. E–H. Posterior surface of the temporal bone. E, the petrous apex medial to the internal acoustic meatus has
been removed to expose the petrous carotid. The lateral genu of the petrous carotid, located at the junction of the vertical
and horizontal segments of the petrous carotid, is situated below and medial to the cochlea. The jugular bulb extends upward
toward the vestibule and semicircular canals adjacent to the posterior meatal wall. The inferior petrosal sinus courses along
the petroclival fissure and enters the petrosal part of the jugular foramen, and the sigmoid sinus descends in the sigmoid
groove and enters the sigmoid part of the foramen. The glossopharyngeal, vagus, and accessory nerves pass through the cen-
tral or intrajugular part of the foramen between the sigmoid and petrosal parts. F, bone has been removed along the anterior
margin of the meatal fundus to open the cochlea, and along the posterior margin to expose the vestibule. The jugular bulb
extends upward toward the semicircular canals and vestibule. G, enlarged view. The cochlear nerve penetrates the modiolus
of the cochlea where its fibers are distributed to the turns of the cochlear duct. The basal turn of the cochlea communicates
below the modiolus with the vestibule. H, enlarged view of the vestibule and cochlea. The stapes has been removed from the
oval window. The promontory in the medial wall of the tympanic cavity is located lateral to the basal turn of the cochlea. A
silver fiber has been introduced into the superior canal, a red fiber into the lateral canal, and a blue fiber into the posterior
canal. The ampullated ends are located at the bulbous ends of the three fibers. The common crus of the superior and poste-
rior canals is located at the site where the tips of the blue and silver fibers overlap. The superior vestibular nerve passes to
the ampullae of the superior and lateral canals. The singular branch of the inferior vestibular nerve innervates the
posterior ampullae. A small black fiber has been introduced into the opening of the endolymphatic duct into the vestibule.
processes. The facial nerve crosses the lateral surface of the The supramastoid crest extends backward across its posterior
styloid process, and the external carotid artery crosses the tip. part, giving attachment to the temporalis muscle and fascia.
Resecting the styloid process and reflecting the attached mus- The suprameatal triangle, a depressed area, located below the
cles downward exposes the internal jugular vein as it exits the anterior part of the crest and behind the posterosuperior
jugular foramen and the carotid artery as it enters the carotid margin of the external meatus, marks the deep location of the
canal medial to the tympanic bone. mastoid antrum. The cerebral surface of the squamosal part is
concave, accommodating the temporal lobe and joining the
The squamous part greater wing of the sphenoid anteriorly. The zygomatic pro-
The externally convex surface of the squamosal part gives cess of the squamosal part projects forward and with the
attachment to the temporalis muscle (Figs. 8.1, 8.2, and 8.5). zygomatic bone completes the zygomatic arch. The attach-

Temporal Bone S217
ment of the zygomatic process to the squama is wide giving it foramina through which an emissary vein to the sigmoid
anterior and posterior edges, referred to as the anterior and sinus and a dural branch from the occipital artery pass.
posterior roots. The temporalis fascia attaches to the supe- The medial aspect of the mastoid process is grooved by the
rior border of the arch and the masseter attaches to the lower sigmoid sinus (Figs. 8.1-8.4). The sinus represents the poste-
border. The posterior root of the zygomatic process blends rior limit of the mastoid cavity. The sinus meets the roof of the
posteriorly into the suprameatal crest. The anterior root is cavity at the level of the petrous ridge. The angle between
located at the anterior margin of the temporomandibular the superior petrosal and sigmoid sinuses and the middle
joint, with the joint forming a rounded fossa on the lower fossa dura delimits a dural space called the sinodural angle.
margin of the zygomatic process between the anterior and The sinodural angle is an important landmark when exposing
posterior roots. The upper margin of the zygomatic process the contents of the mastoid. Inferiorly, the sigmoid sinus
between the two roots gives attachment to the posterior part curves medially and forward, crossing the occipital bone to
of the temporalis muscle. The mandibular fossa, located on enter the jugular foramen. The superior aspect of the jugular
the lower margin of the process between the two roots, is foramen corresponds to the apex of the jugular bulb and
delimited in front by the articular tubercle and posteriorly by constitutes the inferior limit of the mastoid cavity.
the postglenoid tubercle adjacent to its junction with the The medial limit of the mastoid cavity is formed by the
tympanic bone. The squamotympanic fissure is located be- block of solid bone, the otic capsule, containing the bony
tween the medial part of the squamosal part of the mandib- labyrinth (Figs. 8.4 and 8.6). The area of posterior fossa dura
ular fossa and the medial part of the tympanic bone. The mater that can be exposed through the mastoid cavity be-
petrotympanic fissure is situated between the tympanic plate tween the sigmoid and superior petrosal sinuses, the otic
and the petrosal part and leads into the tympanic cavity; it capsule, and the jugular bulb is called Trautman’s triangle.
contains the anterior ligament of the malleus and the anterior The size of this dural triangle is important in surgical proce-
tympanic branch of the maxillary artery. The anterior canal- dures in which the dura delimited by the triangle must be
iculus for the chorda tympani exits the tympanic cavity in the opened medial to the sigmoid sinus. The distance from the
petrotympanic fissure. The rootlets of the temporal branch of anterior margin of the sigmoid sinus to the otic capsule at
the facial nerve cross the lateral aspect of the zygomatic arch the level of the posterior semicircular canal averages 8 mm
and course through the subcutaneous tissues on the superfi- (range, 6–9 mm) on the right side, and 7 mm (range, 4–9 mm)
cial layer of the temporal fascia. During resection of the zy- on the left (44).
gomatic arch, the superficial temporalis fascia should be care- The distance between the apex of the jugular bulb and the
fully dissected from the underlying deep fascia, starting as superior petrosal sinus is also an important determinate of the
close as possible to the tragal cartilage, and carried forward, size of exposure that can be achieved by opening Trautman’s
reflecting the superficial fascia anteriorly to avoid damage to triangle. This distance is reduced if there is a high jugular
the filaments of the temporal branch to the frontalis muscle. bulb. The jugular bulb usually lies inferior to the ampulla of
the posterior semicircular canal, but it can project superiorly
as far as the level of the lateral semicircular canal (27). The
The mastoid part average distance from the jugular bulb to the superior petro-
The mastoid is the posterior part of the temporal bone (Figs. sal sinus is 14 mm (range, 10–19 mm) on the right side, and 16
8.1, 8.2, and 8.4). It projects downward to form the process mm (range, 11–21 mm) on the left (44).
that is the site of attachment, from superficial to deep, of the The mastoid interior is composed of trabeculated bone,
sternocleidomastoid, splenius capitis and longissimus capitis which coalesces to form a cavity, the mastoid antrum, that
muscles, and the posterior belly of the digastric muscle (Fig. communicates through an opening, the aditus, that leads
8.5). The lower surface medial to the mastoid process is forward to the epitympanic part of in the tympanic cavity
grooved by the mastoid notch to which the posterior belly of (Figs. 8.4 and 8.6). The lateral semicircular canal is medial to
the digastric attaches. Medial to the notch, the occipital the epitympanic recess. The medial wall of the antrum faces
groove gives passage to the occipital artery. The fascia cover- the posterior semicircular canal. The roof is formed by the
ing the anterior margin of the posterior belly of the digastric tegmen in the floor of the middle cranial fossa. The mastoid
is continuous anteriorly with the connective tissue surround- segment of the facial canal courses adjacent to the anteroin-
ing the emergence of the mastoid segment of the facial nerve ferior margin of the antrum. The lateral wall of the mastoid
from the stylomastoid foramen and can be used as a landmark antrum, through which it is usually approached surgically, is
for identifying the initial extracranial segment of the nerve. formed by the postmeatal part of the squamous temporal
After exiting the stylomastoid foramen, the nerve divides in bone. The lateral wall of the antrum is located deep to the
the substance of the parotid gland into temporal, zygomatic, suprameatal triangle, which is demarcated superiorly by
buccal, marginal mandibular, and cervical branches (Fig. 8.5). the suprameatal crest, located at the level of the floor of the
The temporal and zygomatic branches cross the zygomatic middle fossa; anteroinferior by the posterosuperior margin of
arch and the superficial fascia of the temporalis muscle. Keep- the acoustic meatus, which indicates approximately the posi-
ing the connective tissue surrounding the nerve at the stylo- tion of the descending or mastoid part of the facial canal; and
mastoid foramen intact during mobilization of the facial nerve posteriorly by a posterior vertical tangent to the posterior
will reduce the risk of facial nerve damage. The posterior margin of the external meatus. The air cells in the mastoid
border of the mastoid process is perforated by one or more may extend behind the sigmoid sinus and into the squamosal

S218 Rhoton
FIGURE 8.4. Tympanic cavity and mastoid antrum. A, the tympanic bone forms the anterior, lower, and part of the posterior
wall of the external canal. The facial nerve exits the skull through the stylomastoid foramen, which is located medial to the
tympanomastoid suture. The spine of Henley approximates the deep site of the tympanic facial segment and the lateral canal.
The mastoid antrum is located between the posterosuperior wall of the external canal and middle fossa floor deep to the
depression behind the spine of Henle. B, a mastoidectomy has been completed to expose the capsule of the posterior and lat-
eral canals and the tympanic and mastoid facial segments. C, the posterior and superior wall of the external canal and the
tympanic membrane have been removed while preserving the malleus and chorda tympani. The mastoid segment of the facial
nerve descends through the facial canal and gives rise to the chorda tympani, which passes upward and forward across the
tympanic membrane and malleus neck. D, enlarged view. The head of the incus articulates with the head of the malleus, the
short process of the incus points backward toward the facial nerve, and the long process attaches to the stapes, which sits in
the oval window. The stapedial muscle passes forward below the tympanic segment of the facial nerve and attaches to the
neck of the stapes. E, the incus has been removed to expose the stapes sitting in the oval window. The chorda tympani

Temporal Bone S219
part of the temporal bone, the posterior root of the zygomatic stapes. The round window is posteroinferior to the oval win-
process, the osseous roof of the external acoustic meatus, the dow and opens under the overhanging edge of the promon-
floor of the tympanic cavity near the jugular bulb, and the tory. The prominence of the facial canal is located above the
petrous apex surrounding the carotid canal, eustachian tube, oval window. The posterior wall of the tympanic cavity is
and labyrinth. mainly the site of the aditus, the opening of the tympanic
The tympanic cavity is a narrow air-filled space between cavity, into the mastoid antrum. The medial wall of the aditus
the tympanic membrane laterally and the promontory con- has a round prominence overlying the lateral semicircular
taining the auditory and vestibular labyrinth medially (Figs. canal. The pyramidal eminence, which houses the stapedial
8.4, 8.6, and 8.7). It communicates posteriorly with the mas- muscle, is located just behind the oval window and anterior to
toid antrum and anteriorly through the eustachian tube with the mastoid part of the facial canal. The stapedius extends
the nasopharynx. It contains the malleus, incus, and stapes. forward from the eminence to attach to the neck of the stapes.
The tympanic cavity opens upward into the epitympanic The fossa incudis is a small depression low and posterior in
recess, which contains the heads of the malleus and the incus. the epitympanic recess; it contains the short process of the
The roof of the tympanic cavity is formed by a thin plate, the incus, which is fixed to the fossa by ligamentous fibers.
tegmen tympani, which separates the middle fossa and tym- The anterior wall of the tympanic cavity narrows and leads
panic cavities, and also roofs the mastoid antrum and the into the eustachian tube, which communicates the nasophar-
tensor tympani. The thin floor of the tympanic cavity sepa- ynx with the tympanic cavity (Figs. 8.4, 8.7, and 8.8). It has
rates the cavity from the jugular bulb. The medial part of the
bony and cartilaginous parts. The bony part begins in the
floor is perforated by an opening for the tympanic branch
anterior part of the tympanic cavity and is directed anteriorly
of the glossopharyngeal nerve. The lateral wall is formed
and medially. It joins the cartilaginous part at the junction of
by the tympanic membrane and the osseous ring to which
the squamous and petrous parts of the temporal bone. The
the membrane attaches. The ring is deficient above near the
cartilaginous part of the tube is attached to the lower margin
openings of the anterior and posterior canaliculi for the
of the sphenopetrosal groove, which is situated between the
chorda tympani (Figs. 8.4 and 8.6). The posterior canalicu-
petrous bone and the greater wing of the sphenoid bone, and
lus for the chorda tympani arises from the facial canal a few
its base lies directly under the mucous membrane of the
millimeters above the mastoid foramen and ascends in
front of the facial canal to open into the tympanic cavity at lateral wall of the nasaopharynx. Both the petrous carotid and
the level of the upper part of the handle of the malleus. The eustachian tube are directed anteromedially, with the eusta-
chorda tympani passes in close relation to the tympanic chian tube being located along the anterior margin of the
membrane and the medial aspect of the neck of the malleus carotid canal (Figs. 8.7 and 8.8). The tensor tympani muscle
and forward to enter its anterior canaliculus at the medial and its bony semicanal are located above the eustachian tube,
aspect of the petrotympanic fissure, and descends vertically parallel to the horizontal segment of the petrous carotid. The
medial to the sphenoid spine and lateral pterygoid muscle canals for the tensor tympani superiorly and the osseous part
to join the lingual nerve. of the eustachian tube inferiorly open into the upper part of
The medial wall of the tympanic cavity, which forms the the anterior wall of the tympanic cavity. These canals are
lateral boundary of the inner ear and the petrosal part of the inclined downward, anteriorly, and medially; they open into
temporal bone, is the site of the promontory, the oval and the angle between the squamous and petrous parts of the
round windows, and the prominence over the facial nerve temporal bone and are separated by a thin, bony septum. The
(Figs. 8.2 and 8.4). The tympanic nerve plexus grooves the canal for the tensor tympani extends posterolaterally on the
promontory overlying the lateral bulge of the basal turn of medial wall of the tympanic cavity, to end above the oval
the cochlea. The apex of the cochlea lies near the medial wall window where the posterior end of the canal curves laterally
of the cavity anterior to the promontory. The oval window is to form a pulley, the trochleariform process, around which the
posterosuperior to the promontory and connects the tympanic tensor tympani tendon turns laterally to attach to the handle
cavity to the vestibule, and is occupied by the footplate of the of the malleus.
Š
crosses the neck of the malleus. The promontory is located superficial to the basal turn of the cochlea. The labyrinth and fun-
dus of the internal meatus are located medial to the tympanic cavity. A line directed medially through the skull along the
long axis of the external meatus will also approximate the site of the long axis of the internal meatus on the medial side of
the promontory and acousticovestibular labyrinth. F, the stapes has been removed from the oval window. The handle of the
malleus attaches to the tympanic membrane, the neck is crossed by the chorda tympani, and the head articulates with the
incus, which has been removed. The tendon of the tensor tympani attaches to the upper part of the handle of the malleus.
The stapedial muscle is housed within the pyramidal eminence and its tendon inserts on the stapedial neck. Chor., chorda;
CN, cranial nerve; Emin., eminence; Endolymph., endolymphatic; Epitymp., epitympanic; Eust., eustachian; Jug., jugular; Lat.,
lateral; Long., longus; M., muscle; Mast., mastoid; Memb., membrane; N., nerve; Post., posterior; Proc., process; Seg., seg-
ment; Sig., sigmoid; Sp., spine; Squamomast., squamomastoid; Temp., temporal; Tymp., tympani, tympanic; Tympanomast.,
tympanomastoid.

S220 Rhoton
FIGURE 8.5. A–F. Muscular and osseous relationships. A, the skin and subcutaneous tissues have been removed to expose the
parotid gland and the facial nerve branches that course deep to the parotid gland on their way to the facial muscles. The
masseter muscle has two heads: a more superficial anterior head, which passes downward to the lateral surface of the angle
of the jaw, and a deeper posterior head, which arises from the medial surface of the zygomatic arch and passes to the man-
dibular body. The sternocleidomastoid attaches to the lateral part of the superior nuchal line and mastoid process, descends
in an anterior direction, and is crossed by the greater auricular nerve. The temporalis fascia attaches to the upper surface of
the zygomatic arch. The trapezius muscle attaches to the medial part of the superior nuchal line. The posterior triangle of the
neck, located between the sternocleidomastoid and trapezius, has the semispinalis capitis, splenius capitis, and levator scapu-
lae in its floor. The terminal branches of the occipital artery and the greater occipital nerve reach the subcutaneous tissues
by passing between the attachment of the trapezius and sternocleidomastoid muscles to the superior nuchal line. B, enlarged
view. The facial nerve branches are exposed along the anterior edge of the parotid gland. C, the parotid gland has been
removed to expose the facial nerve and its branches distal to the stylomastoid foramen. The nerve passes lateral to the styloid

Temporal Bone S221
The petrous part 8.7 and 8.8). The greater petrosal nerve can be identified
medial to the arcuate eminence as it leaves the geniculate
The petrous part of the temporal bone is wedged between
ganglion by passing through the facial hiatus to reach the
the sphenoid and occipital bones (Figs. 8.1 and 8.3). It contains
the acoustic and vestibular labyrinth and is the site of the middle fossa floor. It runs beneath the dura of the middle
jugular fossa and the facial and carotid canals (Figs. 8.3, 8.4, fossa in the sphenopetrosal groove formed by the junction of
and 8.7). It has a base, apex, three surfaces and margins. The the petrous and sphenoid bones, immediately superior and
apex is located in the angle between the greater wing of the anterolateral to the horizontal segment of the petrous carotid.
sphenoid and the occipital bone and is the site of the carotid In a previous study, we found that bone of the middle cranial
canals medial opening. It forms the posterolateral limit of the fossa was absent over the geniculate ganglion in 16% of the
foramen lacerum. The anterior surface faces the floor of specimens, thus exposing the facial nerve and geniculate gan-
the middle cranial fossa and its surface is grooved by the glion to the danger of injury during elevation of the dura from
trigeminal impression for the trigeminal ganglion; anterolat- the floor of the middle fossa (31). Facial nerve injury can also
eral to this, it forms the roof of the carotid canal (Figs. 8.1 and result from damaging the branch of the middle meningeal
8.7). Lateral to the trigeminal impression is a shallow depres- artery, which passes through the facial hiatus to supply the
sion, which partially roofs the internal acoustic meatus and is nerve, or from traction applied to the ganglion when manip-
limited laterally by the arcuate eminence, which overlies the ulating the greater petrosal nerve (30).
superior semicircular canal. The posterior slope of the arcuate The lesser petrosal nerve from the tympanic plexus passes
eminence overlies the posterior and lateral semicircular ca- through the tympanic canaliculus, which is located anterior to
nals. Farther laterally, the roof covers the vestibule and part of the facial hiatus and courses in an anteromedial direction
the facial canal. The tegmen extends laterally from here and parallel to the greater petrosal nerve (Fig. 8.8). The cochlea lies
roofs the mastoid antrum and tympanic cavities and the canal below the floor of the middle fossa in the angle between the
for the tensor tympani. Opening the tegmen from above ex- labyrinthine segment of the facial nerve and the greater petro-
poses the heads of the malleus, incus, the tympanic segment sal nerve, just medial to the geniculate ganglion, anterior to
of the facial nerve, and the superior and lateral semicircular the fundus of the internal acoustic meatus, and posterosupe-
canals (Fig. 8.7). The tympanic segment of the facial nerve rior to the lateral genu of the petrous carotid artery. The
begins at the geniculate ganglion and ends at the level of the cochlea is separated from the petrous carotid by a 2.1 mm
stapes, where the nerve turns downward below the lateral (range, 0.6–10.0 mm) thickness of bone and can be injured
semicircular canal. The tegmen anteriorly is grooved by the during exposure of the petrous carotid. The middle meningeal
greater petrosal nerve extending anterior and medial from artery, an important landmark when approaching the struc-
the area in front of the arcuate imminence and crossing the tures of the middle fossa, enters the cranial cavity through the
floor of the middle fossa toward the foramen lacerum (Figs. foramen spinosum of the sphenoid bone. The foramen spino-
Š
process, the external carotid artery, and mandibular neck. The superficial and deep heads of the masseter muscle are
exposed. This lower end of the sternocleidomastoid muscle has been reflected posteriorly by dividing its attachment to the
clavicle and sternum. The superficial temporal artery ascends in front of the ear. D, the upper part of the mandibular ramus
and the lower part of the temporalis muscle and its attachment to the coronoid process have been removed while preserving
the inferior alveolar nerve. The infratemporal fossa is located medial to the mandible and on the deep side of the temporalis
muscle. The upper and lower heads of the lateral pterygoid, which insert along the temporomandibular joint, and the superfi-
cial head of the medial pterygoid, which extends from the lateral pterygoid plate to the angle of the jaw, have been exposed.
The structures in the infratemporal fossa include the pterygoid muscles, branches of the mandibular nerve, the maxillary
artery, and the pterygoid venous plexus. The sternocleidomastoid muscle has been reflected out of the exposure to expose
the splenius capitis muscle. E, posterolateral view. The splenius capitis has been reflected downward to expose the longissi-
mus capitis, superior oblique, and semispinalis capitis. The occipital artery passes along the occipital groove on the medial
side of the digastric groove. F, the longissimus capitis has been reflected downward to expose the rectus capitis posterior
minor and major, which descend from the occipital bone to attach to the spinous process of C1 and C2, respectively; the
superior oblique, which passes from the occipital bone to the transverse process of C1; and the inferior oblique, which
extends from the spinous process of C2 to the transverse process of C1. The vertebral artery, in its ascent from C2 to C1, is
exposed medial to the attachment of the levator scapulae to the C1 transverse process. The C1 transverse process is situated
immediately behind the internal jugular vein and a short distance below and behind the jugular foramen. A., artery; Alv.,
alveolar; Ant., anterior; Aur., auricular; Brs., branches; Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; Constr.,
constrictor; Eust., eustachian; Ext., external; Gl., gland; Gr., greater; Inf., inferior; Int., internal; Jug., jugular; Lat., lateral;
Lev., levator; Long., longus; Longiss., longissimus; M., muscle; Maj., major; Mandib., mandibular; Max., maxillary; Med., medi-
al; Memb., membrane; Min., minor; N., nerve; Obl., oblique; Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal;
Pet., petrosal; Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rectus; Scap., scapula;
Semispin., semispinalis; Splen., splenius; Sternocleidomast., sternocleidomastoid; Suboccip., suboccipital; Sup., superior;
Superf., superficial; Temp., temporal, temporalis; Tens., tensor; TM., temporomandibular; Trans., transverse; Tymp., tympanic;
V., vein; Veli./Vel., veli; Vert., vertebral.

S222 Rhoton
FIGURE 8.5. G–L. Muscular and osseous relationships. G, the mandibular condyle and ramus have been removed to expose the styloid
process and attached muscles. The pterygoid muscles and some branches of the mandibular nerve have been removed to expose the auri-
culotemporal nerve, which splits into two roots that surround the middle meningeal artery. The levator veli palatini, which attaches the
lower margin of the eustachian tube, is in the medial part of the exposure. The longus capitis is exposed medial to the internal carotid
artery in the retropharyngeal area. H, the muscles that attach to the styloid process have been divided at their origin. The facial nerve
crosses the lateral surface of the styloid process. The attachment of the tensor veli palatine to the skull base extends between the foramen
ovale and the eustachian tube. I, the external auditory canal has been removed, but the tympanic membrane and cavity have been pre-
served. The levator veli palatine and part of the tensor veli palatine have been removed and the membranous part of the eustachian tube
opened. The eustachian tube crosses anterior to and is separated from the petrous carotid by a thin shell of bone. The jugular bulb and
lateral bend of the petrous carotid are located below the osseous labyrinth. The pterygopalatine fossa is exposed anteriorly. J, the eusta-
chian tube has been resected and the mandibular nerve divided at the foramen ovale to expose the petrous carotid. This exposes the lon-
gus capitis and rectus capitis anterior, both of which are located behind the posterior pharyngeal wall. K, the petrous carotid has been
reflected forward out of the carotid canal to expose the petrous apex medial to the carotid canal. L, the petrous apex and upper clivus
have been drilled and the dura opened to expose the anterolateral aspect of the pons below the trigeminal nerve. The sigmoid sinus and
the jugular bulb have been removed to expose the nerves exiting the jugular foramen.

Temporal Bone S223
FIGURE 8.6. A–D. Translabyrinthine exposure. A, the insert shows the site of the exposure directed through the mastoid. The
spine of Henley at the posterosuperior margin of the external meatus is a superficial landmark that approximates the deep
site of the lateral semicircular canal and the tympanic segment of the facial nerve. The mastoidectomy has been completed.
The superior petrosal and sigmoid sinuses, the jugular bulb, and the facial nerve are usually skeletonized in the approach,
leaving a thin layer of bone over them. The semicircular canals, which are located in the cortical bone medial to the cancel-
lous mastoid and the mastoid antrum, have been exposed. The dura between the sigmoid and superior petrosal sinuses, the
jugular bulb, and the labyrinth, which faces the cerebellopontine angle, is referred to as Trautman’s triangle. B, the mastoid
antrum opens through the aditus into the epitympanic part of the tympanic cavity, which contains the upper part of the mal-
leus and incus. The tympanic segment of the facial nerve passes between the lateral canal and the stapes in the oval window
and then turns downward as the mastoid segment. The chorda tympani arises from the mastoid segment of the facial nerve
and passes upward and forward along the deep surface of the tympanic membrane crossing the neck of the malleus. The
incus, the head of which is located in the epitympanic area, has a long process that attaches to the stapes. C, the semicircular
canals and vestibule have been removed and the dura lining the internal acoustic meatus has been opened to expose the ves-
tibulocochlear nerve. D, the dura has been opened to expose the petrosal cerebellar surface and the structures in the cer-
ebellopontine angle. Anatomic variants that limit the exposure include an anterior position of the sigmoid sinus, a high jugu-
lar bulb, or a low middle fossa plate. The jugular bulb may extend upward into the posterior wall of the internal acoustic
meatus and be encountered as the posterior meatal wall is being removed by either the translabyrinthine or retrosigmoid
approaches. Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery; Chor., chorda; CN, cranial nerve; Coch., cochlear; Inf.,
inferior; Int., internal; Intermed., intermedius; Jug., jugular; Laby., labyrinthine; Lat., lateral; Mast., mastoid; N., nerve; Nerv.,
nervus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Seg., segment; Sig., sigmoid; Sup., superior;
Tymp., tympani, tympanic; V., vein; Vest., vestibular.
sum is an average of 4.5 mm (range, 3–6 mm) anterolateral to with the mastoid surface (Figs. 8.1-8.3). The opening for the
the carotid canal and 14.0 mm (range, 11.0–17.0 mm) antero- internal auditory meatus is situated midway between the base
lateral to the geniculate ganglion (44). and the apex on the posterior surface. The lateral end of the
The posterior surface of the petrosal part faces the posterior meatus is divided into superior and inferior halves by the
cranial fossa and cerebellopontine angle and is continuous transverse crest. The area above the transverse crest is further

S224 Rhoton
FIGURE 8.6. E–H.

Translabyrinthine exposure. E,
enlarged view of the exposure
in the cerebellopontine angle.
In this case, the
nerves can be seen, although,
in the translabyrinthine
exposure, the jugular bulb
often obstructs the view of the
nerves entering the jugular
foramen. F, the
vestibulocochlear nerve has
been elevated to expose the
facial nerve. G, the
labyrinthine, tympanic, and
mastoid segments of the facial
nerve have been exposed in
preparation for transposition of
the nerve for a transcochlear
approach. H, the facial nerve
has been transposed backward
and the bone anterior to the
meatal fundus has been
removed to expose the cochlea
for a transcochlear approach in
which the cochlea is removed
to gain access to the side of
the clivus and front of the
brainstem. The cochlear nerve
has been divided. The cochlear
fibers innervating the cochlear
duct pass through the
modiolus.
divided by the vertical crest, also called Bill’s bar, which sac located between the dural layers. The opening of the
separates the anteriorly located facial canal from the posteri- cochlear aqueduct, also called the cochlear canaliculus and
orly located superior vestibular area (29). The cochlea and occupied by the perilymphatic duct, is situated inferior to the
inferior vestibular nerves penetrate the lateral end of the porus of the internal meatus at the anteromedial edge of the
meatus below the transverse crest, with the cochlear nerve jugular foramen, just superior and lateral to where the glos-
being located anteriorly. The posterior wall of the meatus, sopharyngeal nerve enters the intrajugular part of the jugular
lateral to the porus is the site of a small bony opening, the foramen.
subarcuate fossa, which gives passage to the subarcuate ar- The inferior surface is very irregular. The apex is connected
tery, a branch of the anteroinferior cerebellar artery (AICA), medially to the clivus by fibrocartilage and gives attachment
which usually ends blindly in the region of the superior to the levator veli palatini and the cartilaginous portion of the
semicircular canal. Inferolateral to the porus of the meatus is eustachian tube (Figs. 8.1 and 8.9). Behind this is the opening
the opening for the vestibular aqueduct, which transmits the of the carotid canal, behind which is the jugular fossa that
endolymphatic duct that opens below into the endolymphatic contains the jugular bulb. The small foramen for the tympanic

Temporal Bone S225
FIGURE 8.7. A–D. Middle fossa exposure of the temporal bone. A, superolateral view. The tentorium, except the edge, has
been removed. The dura has been removed from the middle fossa floor and cavernous sinus wall to expose the greater petro-
sal nerve, middle meningeal artery, and the nerves in the sinus wall. B, the middle fossa floor has been opened to expose the
cochlea, semicircular canals, petrous carotid artery, and the facial, cochlear, and superior vestibular nerves in the meatus.
The superior canal bulges upward into the middle fossa below the arcuate eminence. The cochlear nerve passes below the
facial nerve to enter the cochlea, which is located above the lateral genu of the petrous carotid in the angle between the pre-
geniculate facial and greater petrosal nerves. C, another temporal bone drilled to expose the internal acoustic meatus,
cochlea, vestibule, semicircular canals, tympanic cavity, and external meatus. The vestibule is located posterolateral and
the cochlea is anteromedial to the fundus of the internal meatus. The vestibule communicates below the meatal fundus
with the cochlea. The tensor tympani muscle and eustachian tube are layered along, but are separated from, the anterior sur-
face of the petrous carotid by a thin layer of bone. The tegmen has been opened to expose the head of the incus and malleus
in the epitympanic area. The internal acoustic meatus lies directly medial to, but is separated from, the external meatus by
the tympanic cavity and the labyrinth. D, the nerves in the meatus have been separated to expose the superior and inferior
vestibular, facial, and cochlear nerves. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery; Car., carotid; CN,
cranial nerve; Coch., cochlear; Eust., eustachian; Ext., external; Gang., ganglion; Genic., geniculate; Gr., greater; Inf., inferior;
Lat., lateral; M., muscle; Men., meningeal; Mid., middle; N., nerve; Pet., petrosal, petrous; Post., posterior; S.C.A., superior
cerebellar artery; Sup., superior; Tens., tensor; Tent., tentorial; Tymp., tympani, tympanic; Vert., vertebral; Vest., vestibular.
branch of the glossopharyngeal nerve is located on the ridge which resides the inferior petrosal sinus that connects the
between the carotid canal and jugular foramen (Fig. 9.2). On cavernous sinus and the medial wall of the jugular bulb.
the lateral wall of the jugular bulb is the mastoid canaliculus Behind this, the jugular fossa of the temporal bone joins with
for the auricular branch of the vagus nerve. The superior the jugular notch on the jugular process of the occipital bone
border, located along the petrous ridge, is grooved by the to form the margins of the jugular foramen.
superior petrosal sinus and serves as the attachment of The jugular foramen is located at the lower end of the
the tentorium cerebelli, except medially where it is crossed by petro-occipital fissure and is divided into a larger lateral
the posterior trigeminal root. The lower posterior border, opening, the sigmoid part, that receives the drainage of the
located along the petroclival fissure, is the site of a groove in sigmoid sinus, and a small medial part, the petrosal part, that

S226 Rhoton
FIGURE 8.7. E–H. Middle fossa exposure of the temporal bone. E, enlarged view. The vestibule, into which the semicircular
canals open, communicates below the meatal fundus with the cochlea. The vertical crest, often called Bill’s bar, separates the
superior vestibular and facial nerves at the meatal fundus. The tendon of the tensor tympani makes a right-angle turn around
the trochleariform process in the medial margin of the tympanic cavity to insert on the malleus. F, enlarged view. The supe-
rior canal projects upward in the floor of the middle fossa. The lateral canal is situated above the tympanic segment of the
facial nerve in the posteromedial part of the epitympanic area, and the posterior canal is located lateral to the posterior wall
of the internal acoustic meatus. G, bone has been removed below the greater petrosal nerve to expose the petrous carotid.
The tensor tympani muscle above and the eustachian tube below are layered along the anterior surface of the petrous
carotid. H, enlarged view. Suture has been placed in the three semicircular canals. The anterior end of the superior and lat-
eral canals and the lower end of the posterior canal are the site of the ampullae. The posterior end of the superior canal and
the upper end of the posterior canal join to form a common crus. The facial and superior vestibular nerves have been
removed to expose the cochlear and inferior vestibular nerves. The singular branch of the inferior vestibular nerve innervates
the posterior ampullae. The superior vestibular nerve innervates the superior and lateral ampullae.
transmits the inferior petrosal sinus (Fig. 9.1). The intrajugular The floor of the vestibule is separated from the apex of the
part, located between the sigmoid and petrosal parts, transjugular bulb by a thickness of bone that averages 6 mm
mits the glossopharyngeal, vagus, and accessory nerves. The (range, 4–8 mm) on the right side and 8 mm (range, 4–10 mm)
anterior border is joined laterally to the temporal squama at on the left side (44). This distance is particularly important
the petrosquamosal suture and medially articulates with the during translabyrinthine approaches since the height of the
sphenoid’s greater wing. jugular bulb is a major determinant of the size of the exposure
The bony labyrinth consists of three parts: the vestibule, the of the cerebellopontine angle that can be achieved with this
semicircular canals, and the cochlea. The vestibule, located in approach. A high-placed jugular bulb may be the source of
the central part of the bony labyrinth, is a small cavity at the troublesome bleeding and air emboli if it is opened during
confluence of the ampullate and nonampullated ends of the exposure of the labyrinth or internal acoustic meatus.
semicircular canals. It is situated lateral to the meatal fundus, The semicircular canals are situated posterosuperior to the
medial to the tympanic cavity, posterior to the cochlea, and vestibule (Figs. 8.3, 8.4, and 8.7). The anterior part of the lateral
superior to the apex of the jugular bulb (Figs. 8.3, 8.4, and 8.7). semicircular canal is situated above the tympanic segment of

Temporal Bone S227
FIGURE 8.8 A, superior view of the temporal bone and

infratemporal fossa and orbit. The floor of the middle fossa has
been removed to expose the temporalis muscle in the temporal
fossa and the pterygoid muscles and branches of the third
trigeminal division in the infratemporal fossa. The posterior part
of the middle fossa forming the upper surface of the
temporomandibular joint has been removed to expose the
mandibular condyle. The internal acoustic meatus extends
laterally from the posterior surface of the temporal bone. The
mastoid is located behind the external canal and lateral to the
semicircular canals and vestibule. B, enlarged view. The
trigeminal nerve has been reflected forward and bone has been
removed over the eustachian tube, tensor tympani muscle,
petrous carotid, and internal acoustic meatus. Dura has been
removed from the lateral wall of the cavernous sinus to expose
the trochlear, trigeminal, and oculomotor nerves in the sinus
wall and the abducens nerve passing below the petrosphenoid
ligament and through Dorello’s canal. The greater petrosal
nerve is joined by the deep petrosal branches of the carotid
sympathetic plexus to form the vidian nerve, which passes
forward in the vidian canal, which has been unroofed. The
lesser petrosal nerve arises from the tympanic branch of the
glossopharyngeal nerve, which passes across the promontory in
the tympanic nerve plexus and regroups to cross the floor of the
middle fossa, exiting the skull to provide parasympathetic
innervation through the otic ganglion to the parotid gland. The
tensor tympani muscle and eustachian are layered along, but
are separated from, the anterior surface of the petrous carotid
by a thin layer of bone. A., artery; Car., carotid; Cav.,
cavernous; Chor., chorda; CN, cranial nerve; Cond., condyle;
Eust., eustachian; Gang., ganglion; Gen., geniculate; Gr.,
greater; Lat., lateral; Less., lesser; Lig., ligament; M., muscle;
Mandib., mandibular; Max., maxillary; N., nerve; Ophth., ophthalmic; Pet., petrosal, petrous; Pteryg., pterygoid; Semicirc.,
semicircular; Sphen., sphenoid; Temp., temporal; Tens., tensor; Tymp., tympani, tympanic.
the facial nerve and can be used as a guide to locating that posterior canal may be damaged in removing the posterior
segment of the nerve. The posterior semicircular canal lies wall to expose the meatal contents by the retrosigmoid ap-
parallel to and in close proximity with the posterior surface of proach (Fig. 8.3).
the petrous bone in the area just behind and lateral to the During surgical approaches to the cerebellopontine angle in
lateral end of the internal acoustic meatus. The superior semi- which the posterior meatal lip is removed, care should be
circular canal projects toward the floor of the middle fossa, taken to avoid opening the vestibular aqueduct, vestibule,
usually in close relation to the arcuate eminence. Each canal posterior semicircular canal, or the common crus (Figs. 8.2 and
has an ampullated and a nonampullated end that opens into 8.3). In our studies, we observed that there is a constant set of
the vestibule. The anterior end of the lateral and superior relationships among the structures around the posterior
canals and the inferior end of the posterior canal are the site of meatal lip. The common crus of the posterior and superior
the ampullae, which are innervated by the vestibular nerves.
semicircular canals is located lateral to the entrance of the
The posterior ends of the superior and posterior canals, the
subarcuate artery into the subarcuate fossa. The vestibular
ends opposite the ampullae, join to form a common crus that
aqueduct has an oblique orientation. It leaves the vesti-
opens into the vestibule. The superior vestibular nerve inner-
vates the ampullae of the superior and lateral canals, and the bule and runs in a posterior direction to open beneath the
singular branch of the inferior vestibular nerve innervates dura mater at a level corresponding to that of the posterior
the posterior ampulla. The vestibular nerves also have semicircular canal. The average distance between the poste-
branches to the utricle and saccule located within the vesti- rior semicircular canal, at the level with the junction of the
bule. The internal auditory meatus can be found medial to the common crus, and the lateral edge of the porus was 7 mm
arcuate eminence at an angle of about 60 degrees medial from (range, 5–9 mm) (44).
the long axis of the superior semicircular canal. The superior The carotid artery, at the point where it enters the carotid
canal is the most susceptible to damage in completing the canal, is surrounded by a strong layer of connective tissue that
middle fossa approach to the internal acoustic meatus. The makes it difficult to mobilize the artery at this point (Figs. 8.9

S228 Rhoton
FIGURE 8.9. Inferior views of an

axial section of the skull base. A, the
infratemporal fossa is surrounded by
the maxillary sinus anteriorly, the
mandible laterally, the sphenoid
pterygoid process anteromedially,
and the parapharyngeal space
posteromedially, and contains the
mandibular nerve and maxillary
artery and their branches, the
medial and lateral pterygoid
muscles, and the pterygoid venous
plexus. B, part of the lateral
pterygoid muscle has been removed
to expose the branches of the
trigeminal nerve coursing in the
infratemporal fossa below the
greater sphenoid wing. The
pterygopalatine fossa is located
between the posterior maxillary wall
anteriorly, the sphenoid pterygoid
process posteriorly, the nasal cavity
medially, and the infratemporal fossa
laterally. The pharyngeal recess
(fossa of Rosenmüller) projects
laterally from the posterolateral
corner of the nasopharynx with its
lateral apex facing the internal
carotid artery laterally and the
foramen lacerum above. The
posterior nasopharyngeal wall is
separated from the lower clivus and
the upper cervical vertebra by the
longus capitis, and the
nasopharyngeal roof rests against the
upper clivus and the posterior part
of the sphenoid sinus floor. C, the
sphenoid pterygoid process has been
removed to expose the maxillary
nerve passing through the foramen
rotundum to enter the
pterygopalatine fossa where it gives
rise to the infraorbital nerve, which
courses in the roof of the maxillary
sinus. The maxillary nerve within the
pterygopalatine fossa gives off com-
municating rami to the pterygopalatine ganglion. The vidian nerve, formed by the union of the deep petrosal nerve from the ca-
rotid sympathetic plexus and the greater petrosal nerve, courses forward through the vidian canal to join the pterygopalatine gan-
glion. The terminal part of the petrous carotid is exposed above the foramen lacerum. D, enlarged view with highlighting of the
pre- (red ) and poststyloid (yellow) compartments of the parapharyngeal space. The styloid diaphragm, formed by the anterior part
of the carotid sheath, separates the parapharyngeal space into pre- and poststyloid parts. The prestyloid compartment, a narrow
fat-containing space between the medial pterygoid and tensor veli palatini, separates the infratemporal fossa from the medially lo-
cated lateral nasopharyngeal region containing the tensor and levator veli palatini and the eustachian tube. The poststyloid compartment,
located behind the prestyloid part, contains the internal carotid artery, internal jugular vein, and the cranial nerves IX through XII. A.,
artery; Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; Eust., eustachian; For., foramen; Gl., gland; Gr., greater; Infraorb.,
infraorbital; Infratemp., infratemporal; Int., internal; Jug., jugular; Lat., lateral, lateralis; Lev., levator; Long., longus; M., muscle; Mandib.,
mandibular; Max., maxillary; N., nerve; Nasolac., nasolacrimal; Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal; Proc., pro-
cess; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rectus; Tens., tensor; V., vein; Vel., veli.

Temporal Bone S229
FIGURE 8.10. A–D. Preauricular

subtemporal-infratemporal fossa
approach. A, the scalp flap has
been reflected forward. The flap
is positioned so that a neck
dissection as well as a
frontotemporal craniotomy can
be completed. The scalp flap has
been reflected forward while
protecting the facial nerve and its
branches. The neck dissection has
been completed below the
parotid gland. The facial nerve
branches passing deep to the
parotid have been preserved. B,
the dissection has been carried
around the parotid gland to
expose the branches of the facial
nerve. The internal jugular vein
and internal carotid artery are
exposed below the gland. C, the
parotid gland has been removed
to expose the branches of the
facial nerve distal to the
stylomastoid foramen. D, a
segment of the mandibular ramus
has been removed, leaving
the mandibular condyle in the
mandibular fossa, to expose the
maxillary artery and pterygoid
muscles in the infratemporal
fossa. Branches of the third
trigeminal division pass between
the lateral and medial pterygoid
muscles. The inferior alveolar
nerve descends to enter the
inferior alveolar foramen and
canal.
and 8.10) (38, 39). The vertical segment of the artery passes ing bone lateral to the trigeminal ganglion averages 8.1 mm
upward in the canal toward the genu, where it curves (range, 4.0–11.0 mm) (44). The length that can be exposed can
anteromedially to form the horizontal segment. The eusta- be increased if the mandibular branch of the trigeminal nerve
chian tube and the tensor tympani muscle are located paris retracted or divided, after which the average length that can
allel to and along the anterior margin of the horizontal be exposed increases to 20.1 mm (range, 17.5–28.0 mm) (Figs.
segment, where they are separated from the artery by a thin 8.7 and 8.8) (10, 17). Gaining this added exposure can be
layer of bone. particularly helpful during surgical procedures that are di-
The trigeminal ganglion and the adjacent part of the poste- rected through the petrous apex to complete a vascular anas-
rior root and their surrounding dural and arachnoidal cavern, tomosis, to occlude the artery for control of bleeding, and to
called Meckel’s cave, sit in an impression on the upper surface allow for mobilization of the vertical and horizontal segments
of the petrous apex above the medial part of the petrous of the artery (40). A venous plexus of variable size, an exten-
carotid (Figs. 8.1, 8.7, and 8.8). The length of the horizontal sion of the cavernous sinus within the periosteal covering of
segment of the petrous carotid that can be exposed by remov- the distal part of the canal, surrounds the artery.

S230 Rhoton
FIGURE 8.10. E, a frontotemporal craniotomy has been completed and the dura of the lateral wall of the cavernous
sinus has been elevated. In addition, the lateral orbital wall has been removed to expose the globe, extraocular muscles,
and lacrimal gland. F, enlarged view of the region of the cavernous sinus. The PCA and SCA have been exposed coursing
above and below the oculomotor and trochlear nerves, respectively. The optic nerve is exposed above the internal
carotid artery. An opening has been made into the lateral wall of the sphenoid sinus between the first and second
divisions. The maxillary nerve passes forward to join the terminal branches of the maxillary artery in the pterygopalatine
fossa. The maxillary nerve continues forward along the floor of the orbit as the infraorbital nerve. The superior ophthalmic
vein descends across the origin of the lateral rectus muscle and enters the anterior portion of the cavernous sinus. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Bas., basilar; Brs., branches; Cap., capitis; Car., carotid; Cav., cavern-
ous; CN, cranial nerve; Ext., external; Front., frontal; Gl., gland; Inf., inferior; Infraorb., infraorbital; Int., internal; Jug., jugu-
lar; Lac., lacrimal; Lat., lateral; Long., longus; M., muscle; Max., maxillary; Med., medial; N., nerve; Ophth., ophthalmic;
P.C.A., posterior cerebral artery; Pet., petrosal, petrous; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rectus; S.C.A.,
superior cerebellar artery; Sphen., sphenoid; Submandib., submandibular; Sup., superior; Temp., temporal; Tens., tensor; TM.,
temporomandibular; Tymp., tympani; V., vein; Vert., vertebral.
The facial nerve in the temporal bone, which often blocks point, the intradural compartments of the petroclival region
access to lesions within and deep to the temporal bone, is are divided along this petroclival line into 1) an inferior space
divided into three segments (Figs. 8.4, 8.5, and 8.7). The first, related to the medulla and to the structures around the re-
or labyrinthine segment, which is located in the petrous part, gion of the foramen magnum; 2) a middle space related to the
extends from the meatal fundus to the geniculate ganglion pons and to the structures in the prepontine and cerebel-
and is situated between the cochlea anteromedially and the lopontine angle; and 3) a superior space related to the con-
semicircular canals posterolaterally. The labyrinthine segment tents of the interpeduncular cistern, and to the sellar and
ends at the site at which the greater superficial petrosal nerve parasellar regions.
arises from the facial nerve at the level of the geniculate
ganglion. From there, the nerve turns laterally and posteriorly The inferior petroclival space
along the medial surface of the tympanic cavity, thus giving The inferior petroclival space corresponds to the anterior sur-
the name tympanic segment to that part of the nerve. The face of the medulla and adjacent part of the clivus and anterior
tympanic segment runs between the lateral semicircular canal margin of the foramen magnum (4). The neurovascular struc-
above and the oval window below. As the nerve passes below tures in this region are those contained in the premedullary
the midpoint of the lateral semicircular canal, it turns verti- cistern. The superior limit is the junction of the pons and me-
cally downward and courses through the petrous part adja- dulla. The inferior limit is the rostral margin of the first cervical
cent to the mastoid part of the temporal bone; thus the third nerve root, the site of the junction of the spinal cord and the
segment, which ends at the stylomastoid foramen, is called medulla. The inferior petroclival space includes the lower four
the mastoid or vertical segment. cranial nerves, lower part of the cerebellum, the vertebral artery
and its branches, and the structures around the occipital condyle.
Petroclival region
These transtemporal operative approaches are often di- The middle petroclival space
rected to the petroclival region located where the posterior The middle petroclival space corresponds to the anterolat-
surface of the petrous temporal bone meets the clival part of eral surface of the pons and cerebellum. Its superior limit is at
the occipital bone along the petroclival fissure. The junction of the pontomesencephalic sulcus and the lower limit is at the
the two bones forms a line that extends from the jugular pontomedullary sulcus. The lateral limits are formed by the
foramen to the petrous apex (Fig. 8.1). From a surgical stand- posterior surface of the petrous bone and by the contents of

Temporal Bone S231
FIGURE 8.10. G–J.

Preauricular subtemporal-
infratemporal fossa approach.
G, the floor of the middle fossa
has been resected back to the
level of the tensor tympani
muscle and eustachian tube,
and the petrous carotid artery.
The nerves exiting the jugular
foramen and hypoglossal canal
pass laterally between the
internal carotid artery and
internal jugular vein to reach
their end organs. H, the
eustachian tube and tensor
tympani have been resected
and the bone lateral to the
foramen ovale removed. This
exposes the full length of the
petrous carotid. I, the petrous
carotid has been reflected
forward out of the carotid
canal to expose the petrous
apex medial to the jugular
foramen and lateral wall of the
clivus. J, the petrous apex and
adjacent part of the clivus
medial to the jugular foramen
and cochlea have been
removed and the dura opened
to expose the junction of the
vertebral and basilar arteries
and the origin of the AICA.
the cerebellopontine angle including the trigeminal, abdu- cerebral artery (PCA) and superior cerebellar artery (SCA), and
cens, facial, and vestibulocochlear nerves, the basilar artery, the cavernous carotid and its intracavernous branches to the
and the AICA and the superior petrosal veins. dura of the upper clivus. The medial edge of the tentorium
divides the superior petroclival space into infra- and supraten-
The superior petroclival space torial compartments.
The superior petroclival space is located anterior to the
midbrain and corresponds to the anterior part of the tentorial
incisura. It extends anteriorly and laterally to the sellar and Adjacent structures
parasellar regions. Its roof is formed by the diencephalic The structures important in accessing the temporal bone
structures forming the floor of the third ventricle. The poste- from posteriorly and laterally have already been reviewed. This
rior limit is formed by the cerebral peduncles and the posterior section reviews the structures located in front of the temporal
perforated substance. The inferior limit is situated above the bone that are important in reaching lesions that involve the bone
origin of the trigeminal nerve at the pontomesencephalic sulcus. or involve both the bone and areas anterior to it. They include
It includes the intradural segment of the oculomotor and troch- several muscles, like the temporalis and masseter, the infratem-
lear nerves, the basilar artery and its branching into the posterior poral fossa, and the parapharyngeal spaces.

S232 Rhoton
The temporalis muscle, along with the deep temporal ves- and arises with superficial and deep heads; the superficial head
sels, passes between the gap formed by the zygomatic arch arises from the lateral aspect of the palatine pyramidal process
and the floor of the temporal fossa (Fig. 8.5). The muscle and the maxillary tuberosity and passes superficial to the lower
attaches to the coronoid process of the mandible. The super- head of the lateral pterygoid; and the deep head originates from
ficial and the deep temporalis fasciae attach, respectively, to the medial surface of the lateral pterygoid plate and the ptery-
the lateral and medial aspects of the upper border of the goid fossa between the two pterygoid plates and passes deep to
zygomatic arch. Inferiorly, the parotid fascia invests the pa- the lower head of the lateral pterygoid. Both heads descend
rotid gland and the masseter muscle and attaches to the lower backward and laterally to attach to the medial surface of
border of the zygomatic arch. The masseter muscle has two the mandibular ramus below the mandibular foramen. The
superimposed layers. A superficial layer which attaches to the sphenomandibular ligament, located medial to the mandibular
zygomatic process of the maxilla and anterior part of the condylar process, descends from the sphenoid spine to attach to
lower border of the zygomatic arch and a deep layer which the lingula of the mandibular foramen. The structures located or
attaches to the medial aspect of the whole zygomatic arch. passing between the sphenomandibular ligament and the man-
Inferiorly it inserts onto the angle and ramus of the mandible. dible are the lateral pterygoid and the auriculotemporal nerve
The parotid gland, the parotid duct, and the branches of the superiorly, and the inferior alveolar nerve, the parotid gland, the
facial nerve are located superficial to the masseter muscle maxillary artery and its inferior alveolar branch inferiorly.
(Figs. 8.5, 8.9, and 8.10). In surgical procedures in which the The maxillary artery is divided into three segments: man-
mandibular condyle is resected or displaced inferiorly, the dibular, pterygoid, and pterygopalatine (Figs. 8.8-8.10). The
parotid gland, along with the branches of the facial nerve, can mandibular segment arises from the external carotid artery
be dissected from the underlying masseter to avoid excessive near the posterior border of the condylar process, passes
traction on the facial nerve and to reduce the risk of facial between the process and the sphenomandibular ligament,
palsy (33). along the inferior border of the lower head of the lateral
Muscles commonly encountered in operative approaches to pterygoid, and gives rise to the deep auricular, anterior tym-
the region of the temporal bone include the posterior belly of panic, middle and accessory meningeal, and the inferior alve-
the digastric muscle and the muscles attached to the styloid olar arteries. The middle meningeal ascends medial to the
process. The posterior digastric belly originates in the digas- lateral pterygoid to enter the foramen spinosum, the accessory
tric groove, lateral to the occipital groove in which the occip- meningeal arises from the maxillary or middle meningeal to
ital artery courses, and inserts onto the hyoid bone. The enter the foramen ovale, and the inferior alveolar descends
muscles attached to the styloid process, the stylohyoid, stylo- to enter the mandibular foramen. The pterygoid segment
glossus, and stylopharyngeus muscles, extend to the hyoid usually courses lateral to, but occasionally medial to, the
bone, tongue, and pharyngeal wall, respectively. lower head of the lateral pterygoid and gives rise to the deep
temporal, pterygoid, masseteric, and buccal arteries. The
pterygopalatine segment courses between the two heads of
Infratemporal fossa the lateral pterygoid and enters the pterygopalatine fossa by
The infratemporal fossa, a route through which some tem- passing through the pterygomaxillary fissure. Its branching
poral bone lesions can be reached, is a not uncommon site of will be described with the pterygopalatine fossa.
involvement by lesions that also involve the temporal bone The pterygoid venous plexus is located in the infratemporal
(11). The osseous boundaries of the infratemporal fossa are fossa and has two parts: a superficial part located between
the posterolateral maxillary surface anteriorly, the lateral the temporalis and lateral pterygoid; and a deep part situ-
pterygoid plate anteromedially, the mandibular ramus later- ated between the lateral and medial pterygoids anteriorly,
ally, and the tympanic part of the temporal bone and the and between the lateral pterygoid and the parapharyngeal
styloid process posteriorly. The fossa is domed anteriorly by space posteriorly. The deep part is more prominent and con-
the infratemporal surface of the greater sphenoid wing, the nects with the cavernous sinus by emissary veins passing
site of the foramina ovale and spinosum, and posteriorly by through the foramina ovale and spinosum, and occasionally
the squamous part of the temporal bone (Figs. 8.8-8.10). The through the sphenoidal emissary foramen (foramen of Vesalius).
inferior, posteromedial, and superolateral aspects are open The main drainage of the pterygoid plexus is through the maxillary
without bony walls. vein to the internal jugular vein.
The structures located in the infratemporal fossa are the The mandibular nerve enters the infratemporal fossa by
pterygoid muscles and venous plexus and the branches of the passing through the foramen ovale on the lateral side of the
maxillary artery and mandibular nerve. The lateral pterygoid parapharyngeal space, where it gives rise to several smaller
muscle crosses the upper part of the infratemporal fossa, branches, and then divides into a smaller anterior trunk and a
originating from the upper and lower heads; the upper head larger posterior trunk (Figs. 8.8-8.10). The anterior trunk gives
arises from the infratemporal surface of the greater sphenoid rise to the deep temporal and masseteric nerves, which supply
wing, and the lower head originates from the lateral ptery- the temporalis and the masseter, respectively, and the nerve
goid plate (Figs. 8.8-8.10). Both heads pass posterolaterally and to the lateral pterygoid. The buccal nerve, which conveys
insert on the neck of the mandibular condylar process and the sensory fibers, passes anterolaterally between the two heads
articular disc of the temporomandibular joint. The medial ptery- of the lateral pterygoid, and descends lateral to the lower
goid muscle crosses the lower part of the infratemporal fossa head to reach the buccinator and the buccal mucosa. The

Temporal Bone S233
posterior trunk gives off the lingual, inferior alveolar, and medial to the foramina ovale and spinosum to the sphenoid
auriculotemporal nerves, which descend medial to the lateral spine and the posterior margin of the glenoid fossa. The
pterygoid. The lingual and inferior alveolar nerves, the former sharply angled inferior boundary is situated at the junction of
coursing anterior to the latter, pass between the lateral and the posterior digastric belly and the greater hyoid cornu. The
medial pterygoids. The auriculotemporal nerve usually splits poststyloid part, which contains the internal carotid artery,
to encircle the middle meningeal artery and passes postero- internal jugular vein, and the initial extracranial segment of
laterally between the mandibular ramus and the sphenoman- cranial nerves IX through XII, is separated from the infratem-
dibular ligament. The chorda tympani nerve, which con- poral fossa by the posterolateral portion of the prestyloid part.
tains the taste fibers from the anterior two-thirds of the tongue The glossopharyngeal nerve exits the skull through the intra-
and the parasympathetic secretomotor fibers to the subman- jugular part of the jugular foramen, anterior to the vagus and
dibular and sublingual salivary glands, enters the infratem- accessory nerves, and passes forward, medial to the styloid
poral fossa through the petrotympanic fissure, descends me- process in close relationship to the lateral surface of the ca-
dial to the auriculotemporal and inferior alveolar nerves, and rotid artery as the artery enters the carotid canal (Fig. 8.9).
joins the lingual nerve. The otic ganglion is situated immedi- Care is required to avoid injury to the glossopharyngeal nerve
ately below the foramen ovale on the medial side of the if the artery is to be mobilized at the carotid canal. The vagus
mandibular nerve. The ganglion receives the lesser petrosal nerve leaves the skull through the anteromedial edge of the
nerve, which crosses the floor of the middle fossa anterolat- intrajugular part of the foramen and courses deep within
eral to the greater petrosal nerve to exit through the foramen the carotid sheath, between the internal carotid artery and the
ovale or the more posteriorly situated canaliculus innomina- jugular vein. The accessory nerve exits the intrajugular part
tus and conveys parasympathetic secretomotor fibers to the and runs backward, lateral to the jugular vein and medial to
parotid gland via the auriculotemporal nerve. The medial the styloid process and the posterior belly of the digastric
pterygoid nerve arises from the medial aspect of the mandib- muscle, to innervate the sternocleidomastoid muscle.
ular nerve close to the otic ganglion and descends to supply The hypoglossal nerve exits through the hypoglossal canal,
the medial pterygoid and tensor veli palatini. The nervus deep to the jugular vein and to the nerves emerging from the
spinosus, a meningeal branch, also arises near the otic gan- jugular foramen, and runs downward, between the carotid
glion and ascends through the foramen spinosum to innervate artery and the jugular vein (Figs. 8.9 and 8.10). It becomes
the middle fossa dura. superficial at the level of the angle of the jaw where it crosses
the internal and external carotid arteries, close to the level of
the common carotid bifurcation, to innervate the tongue.
Parapharyngeal space
The parapharyngeal space is located in the lateral pharyn-
geal wall and is shaped like an inverted pyramid, with its base Pterygopalatine fossa
on the skull base superiorly and its apex at the hyoid bone The pterygopalatine fossa, which opens laterally into the
inferiorly. The parapharyngeal space is subdivided into pre- medial part of the infratemporal fossa, is bounded posteriorly
styloid and poststyloid compartments by the styloid dia- by the sphenoid pterygoid process, medially by the palatine
phragm, a fibrous sheet that also constitutes the anterior part perpendicular plate, that bridges the interval between the
of the carotid sheath (Figs. 8.5 and 8.9). The prestyloid part, maxilla and pterygoid process, and opens superiorly through
situated anteriorly between the fascia covering the opposing the medial part of the inferior orbital fissure into the orbital
surfaces of the medial pterygoid and tensor veli palatini, is a apex (Figs. 8.5, 8.9, and 8.10) (11). The fossa contains the
thin fat-filled compartment separating the structures in the maxillary nerve, pterygopalatine ganglion, maxillary artery,
infratemporal fossa from the eustachian tube and the tensor and their branches, all embedded in fat tissue. Its lateral
and levator veli palatini muscles in the lateral nasopharyngeal boundary, the pterygomaxillary fissure, opens into the infra-
wall. The upper portion of the prestyloid part is situated temporal fossa and allows passage of the maxillary artery
between two fascial sheets, which are oriented in a sagittal from the infratemporal into the pterygopalatine fossa, where
plane. The lateral sheet arises from the medial surface of the the artery gives rise to its terminal branches. The lower part of
medial pterygoid, passes upward, backward, and medial to the fossa is funnel-shaped, with its inferior apex opening
the mandibular nerve and the middle meningeal artery, in- into the greater and lesser palatine canals, which transmit the
corporating the sphenomandibular ligament posteriorly, and greater and lesser palatine nerves and vessels, and communi-
reaching the retromandibular deep lobe of the parotid gland. cate with the oral cavity. The sphenopalatine foramen, located
The medial sheet is formed by the fascia overlying the lateral in the upper part of the fossa’s medial wall, conveys the
surface of the tensor veli palatini and is continuous inferiorly sphenopalatine nerve and vessels, and opens into the superior
with the fascia over the superior pharyngeal constrictor and nasal meatus just above the root of the middle nasal concha.
posteriorly with the thick styloid diaphragm, which enve- The foramen rotundum opens just below the superior orbital
lopes the stylopharyngeus, styloglossus, and stylohyoid and fissure through the superior part of the posterior wall of the
blends into the carotid sheath. The superior border is located fossa. The pterygoid canal opens through the sphenoid ptery-
where the two fascial sheets fuse together and insert in the goid process inferomedial to the foramen rotundum and con-
skull base along a line extending backward from the ptery- veys the vidian nerve carrying autonomic fibers to the ptery-
goid process lateral to the origin of the tensor veli palatini, gopalatine ganglion. The maxillary nerve, after entering the

S234 Rhoton
fossa, gives off ganglionic branches to the pterygopalatine cervicalis, and by the lingual and facial veins. Medial to the
ganglion. It then deviates laterally just beneath the inferior digastric, it is crossed by the stylohyoid muscle and the oc-
orbital fissure, giving rise to, in order, the zygomatic and cipital and posterior auricular arteries. Superior to the digas-
posterosuperior alveolar nerves outside of the periorbita. It tric, the internal carotid artery is separated from the external
then turns medially as the infraorbital nerve, passing through carotid artery by the styloid process and the muscles attached
the inferior orbital fissure to enter the infraorbital groove, to it. At the entrance into the carotid canal, the artery is
where the anterior and middle superior alveolar nerves arise. involved by a dense sheath of connective tissue and is sepa-
Finally, it exits the infraorbital foramen to terminate on the rated from the internal jugular vein by the hypoglossal nerve
cheek. The pterygopalatine ganglion, located in front of the and by the nerves exiting from the jugular foramen.
pterygoid canal and inferomedial to the maxillary nerve, re- The internal carotid artery passes, almost straightly up-
ceives communicating rami from the maxillary nerve and ward, posterior to the external carotid artery and anterome-
gives rise to the greater and lesser palatine nerves from the dial to the internal jugular vein to reach the carotid canal. At
lower surface of the ganglion, the sphenopalatine nerve and the level of the skull base, the internal jugular vein courses
pharyngeal branch from the medial surface, and the orbital just posterior to the internal carotid artery, being separated
branch from the superior surface. The vidian nerve is formed from it by the carotid ridge. Between them, the glossopharyn-
by the union of the greater petrosal nerve, which conveys geal nerve is located laterally and the vagus, accessory, and
parasympathetic fibers arising from the facial nerve at the hypoglossal nerves medially.
level of the geniculate ganglion, and the deep petrosal nerve, After the internal carotid artery enters the carotid canal
which conveys sympathetic fibers from the carotid plexus, to with the carotid sympathetic nerves and surrounding venous
reach the lacrimal gland and nasal mucosa. The parasympa- plexus, it ascends a short distance (the vertical segment),
thetic fibers synapse in the pterygopalatine ganglion, whereas reaching the area below and slightly behind the cochlea,
the sympathetic fibers do not. The sympathetic fibers synapse where it turns anteromedially at a right angle (the site of the
in the superior cervical sympathetic ganglion. lateral bend) and courses horizontally (the horizontal seg-
The third or pterygopalatine segment of the maxillary ar- ment) toward the petrous apex (Figs. 8.8-8.10). At the medial
tery enters the pterygopalatine fossa by passing through the edge of the foramen lacerum, it turns sharply upward at the
pterygomaxillary fissure. This segment courses in an anterior, site of the medial bend to enter the posterior part of the
medial, and superior direction and gives rise to the infraor- cavernous sinus.
bital artery, which passes through the inferior orbital fissure
and courses with the infraorbital nerve; the posterosuperior
alveolar artery, which descends to pierce the posterolateral External carotid artery
wall of the maxilla; the recurrent meningeal branches, which The external carotid artery ascends anterior to the internal
pass through the foramen rotundum; and the greater and carotid artery on the posteromedial margin of the parotid
lesser palatine arteries, which descend through the greater gland and medial to the digastric and stylohyoid muscles.
and lesser palatine canals; the vidian artery to the pterygoid Proximal to its terminal bifurcation into the maxillary and the
canal; the pharyngeal branch to the palatovaginal canal; and superficial temporal arteries, it gives rise to six branches that
finally the sphenopalatine artery, which passes through the can be divided into anterior and posterior groups according to
sphenopalatine foramen to reach the nasal cavity and is con- their directions. The latter group is related to the region of the
sidered to be the terminal branch of the maxillary artery temporal bone.
because of its large diameter. The arterial structures in the The ascending pharyngeal artery, the first branch of the
pterygopalatine fossa are located anterior to the neural posterior group, often provides the most prominent supply to
structures. the meninges around the jugular foramen (18). It arises either
at the bifurcation or from the lowest part of the external or
Arterial relationships internal carotid arteries. Rarely, it arises from the origin of the
occipital artery. It courses upward between the internal and
The arteries that may be involved in pathological abnor- the external carotid arteries, giving rise to numerous branches
malities involving the temporal bone include the upper cer- to neighboring muscles, nerves, and lymph nodes. Its menin-
vical and petrous portions of the internal carotid artery, the geal branches pass through the foramen lacerum to be dis-
posteriorly directed branches of the external carotid artery, tributed to the dura lining the middle fossa and through the
and the upper portion of the vertebral artery. jugular foramen or the hypoglossal canal to supply the sur-
rounding dura of the posterior cranial fossa. The ascending
Common carotid artery pharyngeal artery also gives rise to the inferior tympanic
The common carotid artery bifurcates into the internal and artery, which reaches the tympanic cavity by way of the
external carotid arteries at the level of the upper border of the tympanic canaliculus along with the tympanic branch of the
thyroid cartilage. The internal carotid artery initially ascends glossopharyngeal nerve.
relatively superficial in the carotid triangle of the neck, but The occipital artery, the second and largest branch of the
assumes a much deeper position after passing medial to the posterior group, arises from the posterior surface of the ex-
posterior belly of the digastric (Figs. 8.9 and 8.10). Below the ternal carotid artery and courses obliquely upward between
digastric, it is crossed by the hypoglossal nerve and the ansa the posterior belly of the digastric muscle and the internal

Temporal Bone S235
jugular vein, and then medial to the mastoid process and clival area. It consists of one or more channels that, at its lower
either superficial or deep to the longissimus capitis muscle end, course rostral or caudal to or between the nerves passing
(Fig. 8.5). It courses deep to the latter muscle if it courses in the through the jugular foramen. It enters the medial wall of the
occipital groove of the mastoid bone, which is located medial jugular bulb just anterior to where the cranial nerves descend
to the digastric groove. After passing the longissimus capitis in the anteromedial wall of the jugular bulb (18). It joins the
muscle, the occipital artery courses deep to the splenius capi- cavernous sinus at its upper margin. The transverse sinus
tis muscle, finally reaching a subcutaneous location by pierc- begins at the level of the internal occipital protuberance and
ing the fascia between the attachment of the sternocleidomas- passes laterally and forward to the posterolateral part of the
toid and the trapezius muscles to the superior nuchal line. The temporal bone where it joins the superior petrosal sinus and
occipital artery gives rise to several muscular and meningeal continues as the sigmoid sinus. It receives drainage from the
branches, anastomoses with other branches of the external tentorial surface of the cerebellum through the tentorial si-
carotid including the ascending pharyngeal and also with nuses and from the temporal lobe through the vein of Labbé.
branches of the vertebral artery. Its meningeal branches, The basilar venous plexus consists of multiple interconnecting
which enter the posterior fossa through the jugular foramen channels situated between the layers of dura mater on the
or the condylar canal, may make a significant contribution to clivus. It forms the largest communication between the paired
tumors of the jugular foramen. cavernous sinus and communicates through the inferior
The posterior auricular artery, the last branch in the poste- petrosal sinuses with the sinuses in the region of the foramen
rior group, arises above the posterior belly of the digastric magnum (10).
muscle and travels between the parotid gland and the styloid
process. At the anterior margin of the mastoid process, it SURGICAL APPROACHES
divides into auricular and occipital branches, which are dis-
tributed to the postauricular and the occipital regions, respec- The suboccipital retrosigmoid approach, the traditional
tively. The stylomastoid branch, which arises below the stylo- neurosurgical route to intradural pathologies arising in the
mastoid foramen, enters the stylomastoid foramen to supply region of the cerebellopontine angle, lower clivus, and fora-
the facial nerve. Its loss can lead to a facial palsy, even though men magnum, is reviewed in the chapter on the cerebellopon-
it anastomoses with the petrosal branch of the middle men- tine angle. The approaches reviewed here are those directed
ingeal artery. The posterior auricular branch may share a through the temporal bone.
common trunk with the occipital artery, or sometimes it is
absent, in which case, the occipital artery gives rise to the Middle fossa approach
stylomastoid artery. Members of the anterior group, whose This section focuses on the middle fossa approach to the
origins may be visualized in exposing lesions in the region, internal acoustic meatus rather than on the more extensive
include the superior thyroid, lingual, and facial arteries. approaches directed through the petrous apex to the petroclival
The superficial temporal artery arises from the external region or the more extended approaches directed through the
carotid artery in the substance of the parotid gland behind the temporal bone lateral to the internal acoustic meatus. The middle
neck of the mandible where it is crossed by the temporal and fossa approach to the internal acoustic meatus is usually selected
zygomatic branches of the facial nerve (Fig. 8.5). It ascends for small tumors that are located predominantly within the
over the posterior root of the zygoma and divides into ante- internal acoustic meatus in which there is an opportunity to
rior and posterior branches that run with the superficial tem- preserve hearing. With this approach, the meatus is approached
poral vein and the auriculotemporal nerve over the superficial from above, through a temporal craniotomy located above the
temporalis fascia. ear and zygoma (Figs. 8.7 and 8.11) (2). The dura under the
temporal lobe is elevated from the floor of the middle cranial
Vertebral artery fossa until the arcuate eminence and the greater petrosal nerve
are identified. The distance from the inner table of the skull to the
The vertebral artery and its meningeal, posterior spinal,
facial hiatus, through which the greater petrosal nerve passes,
and posteroinferior cerebellar branches, which may be ex-
ranges from 1.3 to 2.3 cm (average, 1.7 cm) (42). When separating
posed in approaches directed through the temporal bone, are
the dura from the floor of the middle fossa, one should remem-
detailed in the chapter on the foramen magnum (4, 20, 24).
ber that bone may be absent over all or part of the geniculate
ganglion. In our previous study of 100 temporal bones, all or part
Venous relationships of the geniculate ganglion and the genu of the facial nerve were
The venous drainage of the structures of the skull base is found to be exposed in the floor of the middle fossa in 15 bones
through the internal jugular veins, the sinuses in the dura (15%) (31). In 15 other specimens, the geniculate ganglion was
mater, and a series of emissary veins communicating the completely covered, but no bone extended over the greater
intra- and extracranial compartments (25). The superior petro- petrosal nerve. The greatest length of greater petrosal nerve
sal sinus sits on the petrous ridge and connects the cavernous covered by bone was 6.0 mm. More than 50% of the specimens
and transverse sinuses. It receives tributaries from the inferior had less than 2.5 mm of greater petrosal nerve covered. It also is
surface of the temporal lobe and from the petrosal veins that important to remember that the petrous segment of the carotid
drain the cerebellum and brainstem. The inferior petrosal artery may be exposed without a covering of bone in the floor of
sinus courses along the petro-occipital fissure and drains the the middle fossa deep to the greater petrosal nerve (17) In a

S236 Rhoton
FIGURE 8.11. Middle fossa approach to the internal acoustic meatus. A, the vertical line shows the site of the scalp incision and
the stippled area outlines the bone flap bordering the middle fossa floor. B, the dura has been elevated to expose the middle men-
ingeal artery, the greater petrosal nerve, and the arcuate eminence. C, bone has been removed to expose the junction of the
greater petrosal nerve and the geniculate ganglion. A portion of the upper wall of the internal meatus has been removed. The
upper surface of the arcuate eminence has been drilled to expose the superior semicircular canal. In the middle fossa approach, for
an acoustic neuroma, the cochlea and semicircular canal are not opened, as seen in this dissection illustrating some of the impor-
tant structures that are to be avoided in opening the meatus. D, enlarged view. The cochlea, located below the middle fossa floor
in the angle between the facial and greater petrosal nerves, has been opened in the area anteromedial to the meatal fundus. The
roof of the meatus has been opened to expose the superior vestibular nerve, which innervates the ampullae of the superior and
lateral canals and the meatal segment of the facial nerve. E, the vestibule and semicircular canals are located posterolateral and the
cochlea is located anteromedial to the meatal fundus. The tensor tympani is layered along the anterior edge and the greater petro-
sal nerve above the petrous carotid. F, enlarged view. The vertical crest (Bill’s bar) separates the facial and superior vestibular
nerves at the meatal fundus. The superior and inferior vestibular nerves are located posteriorly and the facial and cochlear nerves
anteriorly in the meatus, with the cochlear nerve passing below the facial nerve to enter the modiolus. The labyrinthine segment of
the facial nerve courses superolateral to the cochlea. A., artery; Ac., acoustic; Arc., arcuate; Car., carotid; CN, cranial nerve; Coch.,
cochlear; Emin., eminence; Gang., ganglion; Genic., geniculate; Gr., greater; Inf., inferior; Int., internal; Laby., labyrinthine; M.,
muscle; Meat., meatal; Men., meningeal; Mid., middle; N., nerve; Pet., petrosal, petrous; Post., posterior; Seg., segment; Sup., supe-
rior; Tens., tensor; Tymp., tympani; Vert., vertebral; Vest., vestibular.

Temporal Bone S237
FIGURE 8.12. A–D. Anterior petrosectomy and extended

middle fossa approach. A, the site of the bone flap is the
same as shown in Figure 8.11A. The dura has been elevated
from the floor of the middle fossa. Bone has been removed
to expose the geniculate ganglion, the dura lining the
internal acoustic meatus, the tensor tympani, some of the
petrous carotid, and the superior semicircular canal. B, the
bone of the petrous apex between the trigeminal nerve and
the internal acoustic meatus has been removed to expose
the side of the clivus. C, the exposure under the trigeminal nerve extends to the edge of the inferior petrosal sinus. D, the
posterior fossa dura has been opened to expose the prepontine cistern, basilar artery, and abducens nerve. A., artery; Ac.,
acoustic; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Car., carotid; Cav., cavernous; Chor., chorda; CN, cranial
nerve; Ext., external; Gang., ganglion; Gen., geniculate; Genic., geniculate; Inf., inferior; Int., internal; Laby., labyrinthine;
Lat., lateral; M., muscle; Mast., mastoid; Men., meningeal; Mid., middle; N., nerve; P.C.A., posterior cerebral artery; Pet.,
petrosal, petrous; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg., segment;
Sup., superior; Tens., tensor; Tymp., tympani; Tent., tentorial; Trig., trigeminal; Tymp., tympani, tympanic.
previous study, we found that a 7-mm length of petrous carotid Two different methods are used for exposing the internal
artery may be exposed without a bony covering in the area acoustic meatus. One is to remove bone over the greater
below where the greater petrosal nerve passes below the lateral petrosal nerve and to follow it to the geniculate ganglion and
margin of the trigeminal ganglion to reach the vidian canal at the the genu of the facial nerve. From here, the labyrinthine
anterior margin of the anterior margin of the foramen lacerum portion of the facial nerve is followed to the lateral end of the
(30, 31). The foramen spinosum and middle meningeal artery internal auditory canal, after which the canal is unroofed. The
and the foramen ovale and third trigeminal division are situated other method is begun by drilling just in front of the petrous
at the anterior margin of the extradural exposure. The extradural ridge in the area medial to the arcuate eminence. The angle
exposure can usually be completed without obliterating the mid- between the long axis of the superior semicircular canal or the
dle meningeal artery at the foramen spinosum. greater petrosal nerve and the long axis of the internal acous-

S238 Rhoton
FIGURE 8.12. E–H. Anterior petrosectomy and extended middle fossa approach. E, additional bone has been removed
around the internal acoustic meatus and the dura opened to expose the facial and vestibulocochlear nerves. F, the exposure
has been extended lateral to the internal acoustic meatus. The tegmen has been opened to expose the head of the incus in
the epitympanic area. The osseous capsule of the labyrinth has been opened to expose the semicircular canals. The presig-
moid dura behind the labyrinth has been exposed and opened. G, a translabyrinthine approach directed through the middle
fossa has been completed by removing the semicircular canals and vestibule. The dura has been opened to give an exposure
through the middle fossa similar to that seen with the presigmoid approach. The labyrinthine, tympanic, and mastoid seg-
ments of the facial nerve have been exposed. H, this extended middle fossa exposure extends from the lateral wall of the cav-
ernous sinus, across the trigeminal nerve to the area lateral to the internal acoustic meatus, and provides wide access to the
anterior part of the posterior fossa.
tic meatus is helpful in selecting the site for drilling. The long approach if hearing is to be preserved. The vertical crest,
axis of the central part of the internal acoustic meatus is which is identified at the upper edge of the meatal fundus,
located an average of 61 degrees behind the long axis of the provides a valuable landmark for identifying the facial nerve.
greater petrosal nerve and an average of 37 degrees medial to In the final stage of bone removal, the upper wall of the
the long axis of the arcuate eminence and superior semicircu- internal auditory canal is removed to expose the dura lining
lar canal. The drilling is directed anterolateral to the meatal the entire superior surface of the internal auditory canal
fundus where the vertical crest is identified. from the vertical crest to the porus. The dura is opened to
The lateral part of the bone removal near the meatal fundus expose the pathology.
is limited posteriorly by the superior semicircular canal, The extended middle fossa approach used for the removal
which is located a few millimeters behind and oriented par- of larger acoustic neuromas includes wider opening of the
allel to the labyrinthine segment of the facial nerve (Figs. 8.7 posterior part of the petrous pyramid (21, 28, 42, 43). This
and 8.11). The anteromedial edge of the exposure is limited by approach combines different degrees of resection of the bony
the cochlea, which sits only a few millimeters anterior to the labyrinth with the subtemporal transtentorial routes (Fig.
site of bone removal, in the angle between the labyrinthine 8.12). Extending the resection of the petrous bone posteriorly
portion of the facial nerve and the greater petrosal nerve. The over the mastoid and the bony labyrinth exposes the whole
cochlea and the semicircular canals should be avoided in this intrapetrous course of the facial nerve, and provides access to

Temporal Bone S239
FIGURE 8.13. A–F. Subtemporal exposure of the right middle, infratemporal, and posterior fossae. A, the insert shows the side of the
scalp incision. A frontotemporal craniotomy has been completed and the dura has been elevated from the middle fossa floor and lateral
wall of the cavernous sinus. B, enlarged view. The bony roof over the geniculate ganglion and internal meatus has been removed and the
dura lining the meatus opened to expose the facial and superior vestibular nerves. C, additional middle fossa floor has been removed to
expose the petrous carotid, the cochlea in the angle between the greater petrosal nerve and pregeniculate part of the facial nerve, the
semicircular canals and tympanic cavity. The tensor tympani muscle and eustachian tube are exposed in front of the petrous carotid
artery. D, the bone between the superior and posterior canals has been removed to expose the vestibule with which both ends of the
semicircular canals communicate. The vestibule contains the utricle and saccule and communicates below the fundus of the meatus with
the cochlea. The meatal segment of the facial nerve courses in the internal acoustic meatus, the labyrinthine segment between the semi-
circular canals and the cochlea, the tympanic segment between the anterior margin of the lateral canal and the oval window on the
medial side of the tympanic cavity, and the mastoid segment descends to exit the stylomastoid foramen. E, the petrous apex, medial to
the cochlea and extending under the trigeminal nerve, has been removed to expose the lateral edge of the clivus and the posterior fossa
dura. F, the medial tentorial edge has been divided behind the petrous ridge to expose the oculomotor, trochlear, and trigeminal nerves
and the basilar artery. A., artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., anterior; Bas., basilar; Car., carotid; Chor.,
chorda, choroidal; CN, cranial nerve; Comm., communicating; Eust., eustachian; Gang., ganglion; Gen., geniculate; Genic., geniculate;
Gr., greater; Inf., inferior; Int., internal; Jug., jugular; Laby., labyrinthine; Lat., lateral; M., muscle; Mandib., mandibular; Mast., mastoid;
Max., maxillary; Meat., meatal; Men., meningeal; Mid., middle; N., nerve; P.C.A., posterior cerebral artery; Pet., petrosal, petrous; Post.,
posterior; S.C.A., superior cerebellar artery; Seg., segment; Sup., superior; Temp., temporal; Tens., tensor; Trig., trigeminal; Tymp., tym-
pani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.

S240 Rhoton
FIGURE 8.13. G–L. Subtemporal exposure of the right middle, infratemporal, and posterior fossae. G, the dural opening has been
extended downward to expose the lateral edge of the clivus and the inferior petrosal sinus coursing along the petroclival fissure.
The abducens nerve and the AICA are in the lower margin of the exposure. H, an osteotomy of the zygomatic arch and the floor
of the middle fossa surrounding the mandibular fossa has been completed to aid in exposing the infratemporal fossa. I, the mandib-
ular fossa and floor of the middle fossa, extending medially to the level of the foramen ovale, have been removed. Branches of the
mandibular nerve and maxillary artery are exposed in the infratemporal fossa. The greater petrosal nerve joins the deep petrosal
nerve from the carotid sympathetic plexus to form the vidian nerve, which passes forward in the vidian canal to reach the pterygo-
palatine fossa. J, the upper portion of the cervical carotid is exposed medial to the jugular foramen. The petrous carotid crosses
behind the eustachian tube and tensor tympani. K, the eustachian tube and tensor tympani have been resected, the petrous carotid
reflected forward out of the carotid canal, the petrous apex removed, and the posterior fossa dura opened to expose the vertebral
artery and the AICA. L, enlarged view. The right vertebral artery has been displaced forward to expose the left vertebral artery.
The AICA passes toward the nerves entering the internal acoustic meatus.

Temporal Bone S241
FIGURE 8.14. A–D. Presigmoid

approach. A, the insert shows the
temporo-occipital craniotomy and
the mastoid exposure. The
mastoidectomy has been
completed and the dense cortical
bone around the labyrinth has
been exposed. The tympanic
segment of the facial nerve and
the lateral canal are situated deep
to the spine of Henley.
Trautman’s triangle, the patch of
dura in front of the sigmoid sinus,
faces the cerebellopontine angle.
B, the presigmoid dura has been
opened and the superior petrosal
sinus and tentorium divided,
taking care to preserve the vein of
Labbé that joins the transverse
sinus, and the trochlear nerve that
enters the anterior edge of the
tentorium. The abducens and
facial nerves are exposed medial
to the vestibulocochlear nerve.
The posteroinferior cerebellar
artery courses in the lower margin
of the exposure with the
nerves. The SCA passes below the
oculomotor and trochlear nerves
and above the trigeminal nerve.
C, the semicircular canals have
been opened. The superior canal
is located under the middle fossa’s
arcuate eminence and the
posterior canal is located
immediately lateral to the
posterior wall of the internal
acoustic meatus. D, labyrinthine
exposure in another specimen.
The tympanic segment of the
facial nerve courses below the lateral canal and turns downward as the mastoid segment where it gives origin to the
chorda tympani, seen ascending along the inner surface of the tympanic membrane and neck of the malleus. The head
of the malleus and incus are located in the epitympanic area above the level of the tympanic membrane. The mastoid
antrum communicates through the aditus with the epitympanic area and tympanic cavity. A., artery; Ac., acoustic;
A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Br., branch; Chor., chorda; Cist., cisternal; CN, cranial nerve;
Coch., cochlear; Gang., ganglion; Genic., geniculate; Inf., inferior; Int., internal; Jug., jugular; Laby., labyrinthine; Lat.,
lateral; Marg., margin; Mast., mastoid; Meat., meatal; Memb., membrane; N., nerve; Pet., petrosal; P.I.C.A.,
posteroinferior cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg., segment; Sp., spine; Sup.,
superior; Tymp., tympani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.
the cerebellopontine angle by a combination of subtemporal, 8.13) (19). The dura is carefully elevated from the floor of the
translabyrinthine, and presigmoid routes, all directed through middle fossa to expose the middle meningeal artery, which
the posterior part of the floor of the middle fossa. may be obliterated and divided at the foramen spinosum.
Further elevation of the dura toward the petrous ridge will
Subtemporal anterior transpetrosal approach expose the arcuate eminence and greater petrosal nerve pos-
This approach is made through a temporal craniotomy that teriorly. The cochlea, which is to be preserved, and the ante-
extends down to the floor of the middle fossa (Figs. 8.12 and rior wall of the internal auditory canal constitute the lateral

S242 Rhoton
FIGURE 8.14. E–H. Presigmoid

approach. E, the
labyrinthectomy has been
completed to expose the internal
acoustic meatus. F, the dura
lining the meatus has been
opened and the facial nerve has
been transposed posteriorly. The
facial segments are the cisternal
segment located in the cistern
medial to the meatal porus, the
meatal segment that extends
laterally from the porus to the
meatal fundus, the labyrinthine
segment that is located between
the fundus and the geniculate
ganglion, the tympanic segment
that arises at the ganglion and
the sharp turn, the genu, and
passes between the lateral
semicircular canal and the oval
window, and the mastoid
segment that descends to exit
the stylomastoid foramen. The
labyrinthine segment courses
between the semicircular canals
and vestibule on its
posterolateral side and the
cochlea on its anteromedial
margin. The superior and
inferior vestibular nerves have
lost their end organs with the
drilling of the semicircular
canals and vestibule. The
cochlear nerve passes laterally
to enter the cochlea, which is
still preserved in the bone
anteromedial to the fundus of
the meatus. G, the cochlear
nerve has been divided and
reflected and bone removed to
expose the cochlea. H, the
transcochlear exposure,
completed by removing the
cochlea and surrounding petrous apex, provides access to the front of the brainstem and vertebrobasilar junction, but at
the cost of loss of hearing due to the labyrinthectomy and almost certain temporary or permanent facial weakness
associated with the posterior transposition of the facial nerve.
limit of the exposure through the petrous apex. The bone layer the inferior petrosal sinus at the lateral edge of the clivus. Care is
over the superior wall of the internal auditory canal, which required to prevent damage to the abducens nerve as it passes
averages 5 mm (range, 3–7 mm) in thickness, can be removed through Dorello’s canal located at the upper edge of the petro-
with a drill to improve the exposure (44). The petrous carotid clival fissure. The width of the bone resection from the trigemi-
forms the anterior limit of the exposure. The limit above the nal impression to the posterior wall of the internal auditory canal
medial part of the bone resection is the trigeminal nerve in averages 13 mm (range, 9–14 mm) (44). The depth of the expo-
Meckel’s cave. Drilling is directed behind the petrous carotid, sure, from the trigeminal ganglion to the petroclival fissure,
through the petrous apex medial to the cochlea and under the averages 13 mm (range, 9–17 mm). The cochlea lies below the
trigeminal nerve. The petrous apex is removed and the bone floor of the middle fossa near the apex of the angle formed by
removal is extended to the lateral side of the clivus, exposing the greater petrosal nerve anteriorly and the internal acoustic

Temporal Bone S243
FIGURE 8.15. A–D. Com-

parison of the retrosig-
moid approach and the mini-
mal mastoidectomy,
retrolabyrinthine, translabyrin-
thine, and transcochlear
approach modifications of the
presigmoid approach. A, ret-
rosigmoid approach. The left
cerebellum has been elevated to
expose the cranial nerves V
through XI in the cerebel-
lopontine angle. The illustra-
tions from each step are to be
compared with the views
from the other modifications
of the approach. B, the facial
and vestibulocochlear nerves
and the flocculus have been
retracted to expose the side
of the basilar artery. C, for
the minimal mastoidectomy,
only enough bone is removed
in front of the sigmoid sinus
to open the presigmoid dura
and divide the superior petro-
sal sinus and tentorium. D,
the presigmoid dura has been
opened and the sigmoid sinus
has been retracted posteri-
orly. The view is approxi-
mately the same as that seen
with the retrosigmoid expo-
sure. The retrosigmoid ap-
proach provides a better view
of the nerves entering the
jugular foramen. A., artery;
A.I.C.A., anteroinferior cere-
bellar artery; Bas., basilar;
Cist., cisternal; CN, cranial
nerve; Coch., cochlear;
Flocc., flocculus; Inf., infe-
rior; Laby., labyrinthine; Lat.,
lateral; Mast., mastoid; Meat., meatal; N., nerve; Pet., petrosal;
P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Presig.,
presigmoid; S.C.A., superior cerebellar artery; Seg., segment; Sig., sigmoid;
Suboccip., suboccipital; Sup., superior; Tymp., tympanic; V., vein; Vest.,
vestibular.
meatus posteriorly. The cochlea is to be avoided if hearing is to the lower margin of the opening through the petrous apex.
be preserved. The approach is then directed between the lower margin of
After the bone removal is completed, the superior petrosal the trigeminal nerve above, and the internal acoustic meatus
sinus is obliterated and divided in the area just lateral to the inferiorly and laterally (20).
trigeminal nerve, and the dural incision is extended across the The exposure is small, as described above, and may require
tentorium. The dural leaflets of the tentorium are retracted significant temporal lobe retraction, especially if the goal is to
with sutures and the dural incision is carried downward to reach the lower aspect of the brainstem. To reach the anterior

S244 Rhoton
FIGURE 8.15. E–H. Comparison of the

retrosigmoid approach and the minimal
mastoidectomy, retrolabyrinthine,
translabyrinthine, and transcochlear
approach modifications of the
presigmoid approach. E, the bony
capsule around the semicircular canals
and the facial nerve have been exposed
for the retrolabyrinthine variant of the
presigmoid approach. F, the exposure
with the retrolabyrinthine
version does not differ
significantly from that
achieved with the minimal
mastoidectomy. G, the
semicircular canals and
vestibule have been removed
and the dura lining the
internal acoustic meatus has
been opened to complete the
translabyrinthine exposure.
This yields an exposure of the
internal acoustic meatus but
provides only minimal
improvement in the exposure
of the structures medial to the
porus of the meatus. H, the
nerves have been separated
beginning laterally at the
fundus of the meatus and
extending the cleavage plane
medially toward the brainstem.
The superior vestibular nerve
is behind the facial nerve and
the inferior vestibular nerve is
behind the cochlear nerve.
aspect of the pons, the view must be directed from lateral to the internal auditory canal and by the transverse and vertical
medial above the internal auditory canal. The angles of view crests. The approach may also be combined with a retrosigmoid
through the area of the petrousectomy can be increased if the or a supra- and infratentorial presigmoid approach.
cranium is approached at a higher level through a frontotem- A retroauricular incision starts above the pinna and extends
poral craniotomy combined with zygomatic arch resection. inferiorly to the mastoid tip (3). A flap of periosteum and soft
tissues overlying the mastoid and retromastoid areas is ele-
Translabyrinthine approach vated. The cortical bone over the mastoid is drilled away and
In the translabyrinthine approach, the internal acoustic me- the mastoid air cells are removed, exposing the mastoid an-
atus and cerebellopontine angle are approached through a trum, the cortical bone around the labyrinth, and the digastric
mastoidectomy and labyrinthectomy (Fig. 8.6) (16, 29, 38) ridge leading anteriorly to the mastoid segment of the facial
There are two goals of bone removal in this approach. The nerve as it exits the stylomastoid foramen and the sinodural
first is to expose the dura of Trautman’s triangle on the angle. Drilling is continued to expose the semicircular canals
posterior surface of the temporal bone facing the cerebel- and to skeletonize the sigmoid sinus, middle fossa dura,
lopontine angle. The second is to remove enough bone to be able mastoid segment of the facial nerve, and the upper surface of
to identify the nerves lateral to the tumor as they course through the jugular bulb, leaving only a thin shell of bone over these

Temporal Bone S245
FIGURE 8.15. I and J. Compari-

son of the retrosigmoid
approach and the minimal mas-
toidectomy, retrolabyrinthine,
translabyrinthine, and transco-
chlear approach modifications of
the presigmoid approach. I, the
labyrinthine, tympanic, and mas-
toid segments of the facial nerve
have been exposed in prepara-
tion for the posterior transposi-
tion of the nerve needed to
complete the transcochlear
exposure. J, the facial nerve has
been transposed and the cochlea
and petrous apex removed to
complete the transcochlear
exposure of the anterior aspect
of the brainstem and the basilar
artery.
structures. The lateral semicircular canal is the most laterally and the ampullae of the posterior canal and around the su-
projecting canal and is the first one encountered by this ap- perolateral margin of the vestibule.
proach. It provides a valuable landmark in identifying the The internal auditory canal is located medial and anterior to
tympanic segment of the facial nerve and the other canals. The the tympanic segment of the facial nerve. The dura lining the
nerve is found below the lateral canal. The retrofacial air cells internal canal is exposed by drilling away the semicircular
are removed and the dome of the jugular bulb is identified canals and vestibule and the bone around the superior, pos-
inferiorly. In removing bone behind the internal acoustic me- terior, and inferior margins of the internal canal. Further bone
atus, it is important to remember that the jugular bulb may removal at the lateral end of the meatus exposes the trans-
bulge upward behind the posterior semicircular canal or in- verse and vertical crests (Fig. 8.2). The intrameatal portion of
ternal auditory meatus. The vestibular aqueduct and the en- the facial nerve is separated from the superior vestibular
dolymphatic sac may be opened and removed during the nerve at the lateral end of the canal by the vertical crest, also
bone removal between the meatus and the jugular bulb. The called Bill’s bar, that can be used to positively identify the
cochlear canaliculus will be seen deep to the vestibular aque- facial nerve (13, 16). The initial part of labyrinthine segment of
duct as bone is removed in the area between the meatus and the facial nerve, which lies just in front of the vertical crest, is
the jugular bulb. The lower end of the cochlear canaliculus is exposed at the meatal fundus. After identifying the facial
situated just above the area where the glossopharyngeal nerve nerve, the dura lining the meatus is opened. The dural inci-
enters the medial half of the jugular foramen. The labyrinthec- sion in Trautman’s triangle is V-shaped with the apex of the
tomy portion of the procedure involves removing the semi- “V” extending to the incision along the meatal dura. One limb
circular canals and the vestibule to expose the dura lining the of the “V” extends below the superior petrosal sinus and the
internal auditory canal. The lateral and posterior semicircular other limb extends above the jugular bulb. The dural flap is
canals are drilled away. As the bone removal proceeds medi- then reflected posteriorly to expose the structures in the me-
ally, the ampullae of the lateral and superior semicircular atus and the cerebellopontine angle. The subarcuate artery, or
canals are exposed. At this point some bleeding can occur as the AICA, may be encountered in the dura of Trautman’s
the subarcuate artery is encountered in the bone near the triangle. Usually, the subarcuate artery arises from the AICA
center of the superior semicircular canal. The vestibule is an and passes through the dura on the upper posterior wall of
oval-shaped cavity located immediately lateral to the internal the meatus as a fine stem. Occasionally, however, the subar-
acoustic meatus, which forms the communication between the cuate artery, along with its origin from the AICA, may be
semicircular canals and the cochlea. Bone is removed medial incorporated into the dura on the posterior face of the tem-
and posterior to the vestibule, completely exposing it anterior poral bone. The approach may include transection of the
and inferior to the facial nerve. Care is required to avoid external canal and obliteration of the middle ear with packing
injury to the facial nerve as it courses below the lateral canal of the eustachian tube at closure.

S246 Rhoton
FIGURE 8.16. A–F. Comparison of the retrosigmoid and the various modifications of the presigmoid exposure. The modifica-
tions of the presigmoid approach include the minimal mastoidectomy, retrolabyrinthine, partial labyrinthine, translabyrin-
thine, modified transcochlear, and the full transcochlear approach with facial nerve transposition. A, the scalp incision
(insert) is positioned for a supra- and infratentorial exposure through a temporo-occipital craniotomy. A temporo-occipital
craniotomy has been completed and the dura opened to expose the temporal lobe and the retrosigmoid area. The transverse
and sigmoid sinuses have been preserved. The cerebellum has been retracted to expose the nerves in the cerebellopontine
angle. B, enlarged view of the retrosigmoid exposure to compare with the exposure obtained with the various modification of
the presigmoid approach. C, in the retrosigmoid exposure the vestibulocochlear nerve has been elevated and the glossopha-
ryngeal nerve depressed to expose the basilar artery at the origin of the AICA. D, subtemporal exposure. The temporal lobe
has been elevated to expose the optic tract and oculomotor nerve and the PCA, internal carotid, and anterior choroidal arter-
ies. E, the tentorium has been opened while preserving the trochlear nerve. The SCA courses below and the PCA above the

Temporal Bone S247
Transcochlear approach canal. The facial canal is then left as a bridge over the opera-
tive field and the dura is exposed between the carotid artery
The transcochlear approach is primarily an anteromedial
and the jugular bulb.
extension of the translabyrinthine approach (Fig. 8.6) (3, 15,
16). It usually includes division and closure of the external
canal, resection of at least the posterior part of the osseous Combined supra- and infratentorial
external canal, and the tympanic membrane and ossicles, and presigmoid approach
obliteration of the eustachian tube. After exposing the dura The presigmoid approach combines the supra- and infrat-
lining the internal auditory canal, as described for the trans- entorial craniotomy centered on the mastoid and varying
labyrinthine approach, the incus is removed and the facial degrees of mastoid and labyrinthine resection (Fig. 8.14).
nerve is exposed from the geniculate ganglion to the stylo- The minimal degree of mastoid resection, which we refer to as
mastoid foramen. The greater superficial petrosal nerve is a minimal mastoidectomy, exposes only enough of the presig-
transected and the facial nerve is transposed posteriorly. In moid dura to open the dura in front of the sigmoid sinus for
the final stage, the bone removal is carried through the facial exposure of the cerebellopontine angle (Figs. 8.15 and 8.16).
canal, after nerve transposition, and the cochlea and adjacent The next more extensive degree of mastoid resection, the
part of the petrous apex are drilled away (Fig. 8.6). retrolabyrinthine modification, is a more complete mastoid-
Medially, the bone removal extends to the edge of the ectomy exposing the bony capsule of the semicircular canals
clivus, exposing the inferior petrosal sinus from the jugular and skeletonizing at least a portion of the facial nerve. In the
bulb below to the superior petrosal sinus above. The ascend- partial labyrinthectomy, one or two of the semicircular canals,
ing portion of the petrous carotid is exposed at the anterior commonly the superior and/or posterior canals, are resected
limit of the dissection. The bone removal, which now extends with preservation of the lateral canal. Removal of these canals
to the lateral edge of the clivus, could easily be carried medi- may, but not always, be associated with the loss of hearing
ally into the clivus. Extending the dural opening in this area (37). The posterior canal may be removed to increase access to
permits visualization of the abducent nerve medial to the the posterior fossa, and removing the superior canal alone
internal acoustic meatus, the lower margin of the trigeminal gives a more direct access to the petrous apex along the
nerve, the nerves entering the jugular foramen, a segment of middle fossa. The next more extensive modification is the
the basilar artery, and the origin and initial segment of the translabyrinthine approach, in which the semicircular canals
AICA. and vestibule are resected uniformly, resulting in the loss of
An alternative to transposing the facial nerve is to complete hearing. The translabyrinthine approach provides excellent
an extensive bone removal in the hypotympanic and retrofa- access to the internal auditory canal. The next more extensive
cial areas extending forward to the carotid canal, thus skele- modification is the transcochlear approach, in which the co-
tonizing the mastoid segment of the facial nerve and leaving chlea located anteromedial to the fundus of the meatus is
it suspended in a shell of bone, as described by Gantz and removed, thus providing access to the medial part of the
Fisch (7). In this approach, the external auditory canal is petrous apex and the side of the clivus. Another modification,
closed as a blind sac and the tympanic membrane, incus, and which we call the extended translabyrinthine approach, and is
body of the malleus are removed (7). A mastoidectomy is similar to the transcochlear approach, involves drilling bone
performed, including the removal of the retrofacial, retrolaby- both anterior and posterior to the facial nerve, leaving the
rinthine, and supralabyrinthine compartments. The facial facial nerve skeletonized in a column of bone and working
nerve is identified at its tympanic segment and at the stylo- both anterior and posterior to the facial nerve to remove the
mastoid foramen. The inferior part of the tympanic bone is cochlea and access the side of the clivus. Gaining access for
removed to expose the infralabyrinthine compartment, the drilling the cochlea anterior to the facial nerve commonly
jugular bulb, and the intrapetrous carotid artery. The retrofa- requires that at least part of the posterior part of the external
cial dissection is carried medially and superiorly, removing canal be removed, that the tympanic cavity be obliterated, and
the semicircular canals and vestibule. The dissection of the that the internal carotid artery be exposed below the
posterior fossa dura is carried inferiorly around the internal promontory.
auditory canal and under the facial canal. The cochlea is In evaluating these approaches in our laboratory, we have
drilled away by working inferior and anterior to the facial found that the minimal mastoidectomy gives approximately
Š
oculomotor and trochlear nerves. F, minimal mastoidectomy modification of the presigmoid approach. The minimal mastoid-
ectomy approach is completed by removing only enough bone in the front of the sigmoid sinus so that the presigmoid dura
can be opened to expose the posterior cranial fossa. The bony capsule of the labyrinth is not exposed in the minimal mastoid-
ectomy as it is in the retrolabyrinthine approach. The exposure shown with the minimal mastoidectomy in this figure is to be
compared with the retrosigmoid exposure shown in B. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery;
Ant., anterior; Bas., basilar; Car., carotid; Chor., choroidal; CN, cranial nerve; Comm., communicating; Inf., inferior; Int.,
internal; Lat., lateral; Mast., mastoid; P.C.A., posterior cerebral artery; Ped., peduncle; Pet., petrosal; P.I.C.A., posteroinferior
cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg., segment; Sig., sigmoid; Sup., superior; Temp., tem-
poral; Tent., tentorial; Tr., trunk; Trans., transverse; V., vein; Vert., vertebral.

S248 Rhoton

Temporal Bone S249
the same exposure as the retrolabyrinthine approach, but is Labbé with the transverse sinus. The posterior fossa dura is
done at reduced risk since the semicircular canals and facial opened anterior to the sigmoid sinus in Trautman’s triangle.
nerve are not skeletonized (Figs. 8.14 and 8.15). Removing the The dural incision is extended across the superior petrosal
posterior canal increases access to the posterior fossa, but sinus to join the dural incision in the temporal dura. After
access is only slightly increased over that achieved with the division of the superior petrosal sinus, the tentorium is in-
retrolabyrinthine approach. Removing the superior canal incised parallel to and just behind the petrous ridge and supe-
creases access to the middle fossa and petrous apex and rior petrosal sinus. This dural incision is extended from the
reduces the needed retraction of the temporal lobe. The trans- site of division of the superior petrosal sinus through the
labyrinthine approach does not significantly increase the ac- medial edge of the tentorium to the incisura behind where the
cess to the area medial to the porus of the internal acoustic trochlear nerve enters the tentorial edge. Care is taken to
meatus over that achieved with the minimal mastoidectomy avoid injury to the IVth cranial nerve in its course near the
or retrolabyrinthine approach, but does provide access to the tentorial margin. The posterior portion of the temporal lobe is
internal auditory canal. The transcochlear modification, in elevated and the sigmoid sinus is displaced posteriorly along
which bone is removed up to the edge of the clivus, does with the cerebellar hemisphere while preserving the junction
significantly increase access to the front of the brainstem and of the vein of Labbé with the sigmoid sinus. The sigmoid
clivus over that achieved with the lesser degrees of bony sinus limits the ability for superior retraction of the temporal
resection. The retrosigmoid, the presigmoid minimal mastoid- lobe and can be ligated to improve the exposure if bilateral
ectomy, and the retrolabyrinthine approaches were compared venous angiography show adequate communication through
and yielded nearly the same exposure of the cerebellopontine the torcular to the opposite side (24). The petroclival region
angle, but the retrosigmoid approach did not provide the can be exposed from the middle fossa and tentorial incisura to
additional exposure of the middle fossa and petrous apex that near the foramen magnum, although access to the lower
could be achieved in the combined supra- and infratentorial petroclival region may be limited by the jugular bulb. The
presigmoid approach. presigmoid exposure provides a shorter working distance to
The skin incision is started in the temporal region above the the petroclival area and provides multiple angles for dissec-
zygoma, and extends above the ear and downward in the tion. The major arteries in the posterior fossa are easily acces-
suboccipital area medial to the mastoid process (Figs. 8.14, sible. The exposure can also be combined with a far-lateral
8.15, and 8.17). The skin flap is reflected forward to the level approach (Fig. 8.17).
of the external auditory canal. The temporal muscle is ele-
vated and reflected anteriorly, and the muscles over the mas-
toid and suboccipital areas are swept inferiorly. A temporo- Subtemporal preauricular infratemporal fossa approach
occipital craniotomy is performed and the transverse sinus is The subtemporal preauricular infratemporal approach is
exposed. After the bone flap is elevated, a mastoidectomy is directed through the infratemporal and middle fossae to the
carried out without entering the labyrinth. The sigmoid sinus part of the anterior surface of the petrous bone located medial
is skeletonized from the sinodural angle to the jugular bulb. to the cochlea and to the petroclival region (Figs. 8.10, 8.13,
Bone is removed superiorly to expose the floor of the middle and 8.18). This description outlines the full extent of the
fossa and the superior petrosal sinus. Trautman’s triangle is anatomic exposure available through this approach, but it can
exposed in the area lateral to the otic capsule. often be tailored to a smaller, more limited, approach. A
The dura mater is then incised along the base of the tem- curvilinear incision starting in the frontal region turns down-
poral craniotomy, while preserving the junction of the vein of ward in front of the ear into the cervical region. The incision
Š
FIGURE 8.16. G–N. Comparison of the retrosigmoid and the various modifications of the presigmoid exposure. G, deep
exposure with the minimal mastoidectomy with retraction of the vestibulocochlear and glossopharyngeal nerves, to be com-
pared with the retrosigmoid approach shown in C. The exposure is similar to that obtained with the retrosigmoid approach.
H, retrolabyrinthine approach in which more extensive drilling of the mastoid has been completed to expose the osseous cap-
sule of the semicircular canals. I, the dura has been folded forward after completing the retrolabyrinthine exposure. The
exposure differs little from that obtained with the minimal mastoidectomy exposure shown in F and G. J, the exposure with
the posterior canal partial labyrinthectomy is similar to that achieved with the minimal mastoidectomy. K, the partial laby-
rinthectomy has been extended by removing the superior canal in addition to removal of the posterior canal. L, the infraten-
torial exposure does not differ significantly from that achieved with the minimal mastoidectomy, as shown in F and G.
Removal of the superior canal reduces the required temporal lobe retraction and aids in the exposure along the middle fossa
floor and petrous apex. M, translabyrinthine exposure in which the semicircular canals and the vestibule have been removed.
This adds the internal auditory canal to the exposure, but does not improve the exposure of the structures medial to the
meatus, as compared with the minimal mastoidectomy or even the retrosigmoid approach. N, the facial nerve has been trans-
posed posteriorly out of the field and the cochlea has been removed to complete the transcochlear approach. This approach
greatly improves access to the front of the brainstem, clivus, and basilar artery, but is done at the cost of a temporary or per-
manent facial paralysis and loss of hearing.

S250 Rhoton
may be extended downward only to the area just below the hypoglossal canal inferiorly. If the dura is opened, the struc-
tragus if only the petrous apex and upper part of the infra- tures along the lateral and anterior aspects of the upper me-
temporal fossa are to be exposed, but it can be extended onto dulla and lower two-thirds of the pons will be exposed (41).
the upper neck if a neck dissection is needed. The skin flap is The tentorium can be divided to give access to the upper clival
separated from the underlying tissues and reflected forward. region.
The facial nerve and its major branches are identified distal to Dividing the third trigeminal division above the foramen
the stylomastoid foramen and followed to the parotid gland. ovale will permit exposure of the junction of the petrous and
The parotid gland is separated from the masseteric fascia to cavernous carotid along with the structures in the inferolat-
avoid excessive stretching of the facial nerve at the stylomas- eral portion of the cavernous sinus (17, 39). The pterygopal-
toid foramen (33, 38, 39). The superficial temporalis fascia in atine fossa, parapharyngeal space, lateral maxilla, and orbit
which the upper facial branches course is separated from the can be exposed farther anteriorly. The lateral aspect of the
temporalis muscle and is reflected forward to prevent damage sphenoid bone and the sphenoid sinus can also be ap-
to the branch of the facial nerve to the frontalis muscle as the proached by removing bone medial to the maxillary nerve at
zygomatic arch is exposed. The zygomatic arch is divided at the root of the pterygoid process.
its anterior and posterior ends, and the temporalis muscle,
with the overlying segment of the zygomatic arch, is reflected
downward. The mandibular condyle and the capsule of the Postauricular transtemporal approach
temporomandibular joint are either dislocated downward or The postauricular transtemporal approach is most com-
excised. The temporomandibular joint can be removed in a monly selected for lesions that involve the mastoid and tym-
single piece for later replacement by dividing the mandibular panic cavities and track along the nerves and arteries to reach
neck below the condyle and osteotomizing the middle fossa the middle and infratemporal fossa (Figs. 8.19 and 8.20). It can,
floor around the mandibular fossa (Fig. 8.18). The internal however, be tailored at its posterior margin to include a
carotid artery, the internal jugular vein, and the vagus, acces- retrosigmoid, far-lateral, or presigmoid exposure of the pos-
sory, and hypoglossal nerves may be exposed in the neck if terior fossa or, at its anterior limits, to include exposure of the
needed. The posterior belly of the digastric muscle may be pterygopalatine fossa and lateral parts of the maxillary orbit
divided and the styloid process resected. or anterior cranial fossa.
A frontotemporal craniotomy is then performed. The dura A question mark incision is started behind the hairline in
is elevated from the floor of the middle fossa to expose and the temporal region, extending behind the ear over the mas-
obliterate the middle meningeal artery at the foramen spino- toid process and continuing inferiorly in front of the sterno-
sum and to expose the arcuate eminence, the third trigeminal cleidomastoid muscle onto the neck. The skin flap is then
division at the foramen ovale, and the greater petrosal nerve. reflected forward and the external auditory canal is divided at
The greater petrosal nerve is transected if necessary to avoid the bone-cartilage junction and closed as a blind sac. The
traction on the facial nerve. The floor of the middle fossa, includ- sternocleidomastoid muscle is detached from the mastoid
ing the lateral and inferior aspects of the superior orbital fissure, process and reflected inferiorly. The periosteum and posterior
and the lateral margin of the foramina ovale may be removed to portion of the temporalis muscle are reflected anteriorly, thus
expose the structures in the infratemporal fossa. exposing the temporal, mastoid, and retromastoid areas. The
If needed, bone can be removed medial to the mandibular posterior belly of the digastric muscle is divided and reflected
fossa to expose the eustachian tube and the tensor tympani inferiorly. At this point, the facial nerve is identified distal to
muscle, both of which may be resected (Figs. 8.10, 8.13, and the stylomastoid foramen and is followed, along with its
8.18). The bone removal is continued inferiorly, exposing the major branches, into the substance of the parotid gland (5).
ascending portion of the petrous carotid. In this segment, the The internal jugular vein, the carotid bifurcation, and the
carotid artery is surrounded by a periosteal sheath, which glossopharyngeal, vagus, accessory, and hypoglossal nerves
encloses a periarterial venous plexus that is an extension of are exposed and isolated in the neck. This allows for proximal
the cavernous sinus. At the entrance of the carotid canal, a control of the internal carotid artery and ligation of the main
dense fibrocartilaginous ring encircles the artery. If mobiliza- feeding vessels from the external carotid artery to a neoplasm
tion of the artery is required, care must be taken when divid- early in the procedure.
ing the ring not to damage the IXth cranial nerve that is in After this, temporal and/or retromastoid craniotomies may
close proximity to the carotid canal as it exits the jugular be performed with a simple mastoidectomy. The remaining
foramen. After mobilizing the carotid artery and displacing it skin of the external auditory canal, the tympanic membrane,
forward, the petrous apex and the clival region to the level of the malleus, incus, and stapes arch (leaving the footplate) are
the foramen magnum can be approached medial to and be- removed. The facial nerve is completely skeletonized from the
hind the artery. During drilling, the very hard cortical bone geniculate ganglion to the stylomastoid foramen.
along the petrous apex gives place to a crumbly cancellous If exposure of the jugular foramen and lower clival region
bone in the region of the clivus, as the dura of the anterior and is desired, a new facial canal is created by drilling a groove in
lateral aspects of the posterior fossa is being exposed. The area the bone of the anterior attic wall, between the geniculate
exposed is limited by Meckel’s cave superiorly, by the cochlea ganglion and the root of the zygoma. The facial nerve is
and internal auditory canal laterally, by the abducens nerve in carefully freed at the stylomastoid foramen, while leaving
its course through the Dorello’s canal medially, and by the some of the surrounding connective tissue attached to the

Temporal Bone S251
FIGURE 8.17. A–D. Combined

presigmoid and far-lateral
approach. A, the insert shows
the site of the scalp incision and
mastoid tip. The scalp flap has
been reflected forward. The
mastoidectomy exposes the
dense cortical bone housing the
semicircular canals. The bone
flap is outlined. The occipital
artery courses backward
between the digastric and
superior oblique. B, enlarged
view. The tympanic segment of
the facial nerve courses below
the lateral canal. The chorda
tympani arises from the mastoid
segment of the facial nerve. The
mastoid antrum, which has been
drilled away, opens through the
aditus into the epitympanic part
of the tympanic cavity. C, the
presigmoid and temporal dural
incisions have been outlined. D,
the temporal and presigmoid
dura has been opened. One goal
of the procedure is to preserve
the vein of Labbé, which
empties into the transverse
sinus. A., artery; A.I.C.A.,
anteroinferior cerebellar artery;
Atl-Occip., atlanto-occipital;
Cap., capitis; Car., carotid;
Chor., chorda; Cist., cisternal;
CN, cranial nerve; Epitymp.,
epitympanic; For., foramen;
Gang., ganglion; Genic.,
geniculate; Hypogl., hypoglossal;
Inf., inferior; Jug., jugular; Laby.,
labyrinthine; Lat., lateral; Lev.,
levator; M., muscle; Meat.,
meatal; Memb., membrane;
Men., meningeal; N., nerve;
Obl., oblique; Occip., occipital;
P.C.A., posterior cerebral artery;
P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; Post., posterior; Rec., rectus; S.C.A., superior cerebellar artery; Scap.,
scapula; Seg., segment; Semicirc., semicircular; Sig., sigmoid; Sp., spine; Suboccip., suboccipital; Sup., superior; Temp.,
temporal; Trans., transverse; Tymp., tympani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.
nerve, and the nerve is transposed anteriorly into the new nerves at the jugular foramen, as well as for their mobilization
bony groove of the epitympanum and imbedded for its pro- and posterior displacement if necessary. The posterior mobi-
tection into the parotid tissue (5). lization of the lower cranial nerves allows for a direct expo-
The dura of the middle fossa and the sigmoid sinus from sure of the structures along the lateral and anterior aspects of
the sinodural angle to the jugular bulb is skeletonized. Then the medulla and lower pons without the necessity for brain
the sigmoid sinus and the jugular vein are ligated in this retraction. Dissection in the area of the jugular foramen has
sequence, and the sigmoid sinus divided. Part of the wall of proven to be extremely difficult, as the lower cranial nerves
the sinus, bulb, and/or vein may be excised to increase the are particularly fragile and difficult to isolate from the sur-
exposure. This allows for dissection of the lower cranial rounding tissues.

S252 Rhoton
FIGURE 8.17. E–H. Combined

presigmoid and far-lateral
approach. E, the dural incision has
been extended through
Trautman’s triangle and across the
superior petrosal sinus and
tentorium, taking care to preserve
the vein of Labbé and the
trochlear nerve. The semicircular
canals have been opened. F,
enlarged view. The posterior canal
faces the posterior fossa lateral to
the internal acoustic meatus. The
superior canal projects upward,
below the arcuate eminence,
toward the floor of the middle
fossa. The lateral canal is a useful
landmark for identifying the
tympanic segment of the facial
nerve, which courses between the
canal and the stapes sitting in the
oval window. The epitympanic
area opens through the aditus into
the mastoid antrum. G, the
labyrinthectomy has been
completed and the dura lining the
meatus opened to expose the
cisternal, meatal, labyrinthine,
tympanic, and mastoid segments
of the facial nerve. The SCA
courses above the trigeminal
nerve. H, enlarged view along the
opened tentorial incisura. The
oculomotor and trochlear nerves
course between the PCA and SCA.
The SCA rests against the upper
surface of the trigeminal nerve.
Exposure of the middle clival structures requires removal of and medulla. This exposure extends from the inferior aspect
the bony labyrinth, as described for the translabyrinthine ap- of the trigeminal ganglion to the foramen magnum. The ex-
proach. The internal auditory canal is exposed, the facial nerve posure may be carried medially into the clivus and retropha-
identified, and the cochlear and vestibular nerves divided. The ryngeal space and anteriorly to expose the mucosa of the
greater superficial petrosal nerve is sectioned at its origin from sphenoid sinus.
the geniculate ganglion. The facial nerve is freed from all If the approach is to be extended to the parasellar and
its attachments in the temporal bone and reflected posteriorly. parasphenoidal areas, the zygomatic arch is divided and re-
The bony portion of the external auditory canal and the tym- flected inferiorly with the masseter muscle. The temporalis
panic bone are drilled away, exposing the ascending portion of muscle is separated from its attachment to the coronoid pro-
the intrapetrous carotid artery medial to the eustachian tube. cess of the mandible and reflected anteriorly and superiorly.
The dissection is continued by drilling away the cochlea, A temporal craniotomy is then performed, and extensive bone
starting at its basal turn, to expose part of the horizontal is removed along the whole lateral aspect of the middle
segment of the petrous carotid artery. Anterior displacement cranial fossa. The ascending ramus of the mandible is either
of the carotid artery and removal of the cochlea provides a displaced anteriorly or resected, and the petrous carotid is
wide exposure of the lateral and anterior portions of the pons exposed distally to the proximal portion of the intracavernous

Temporal Bone S253
FIGURE 8.17. I–L. Combined presigmoid and far-lateral approach. I, the insert shows the site of the additional skin incision
needed to add a retrosigmoid craniotomy and far-lateral approach. The scalp flap has been reflected to expose the suboccipi-
tal triangle located between the superior and inferior oblique and the rectus capitis posterior major and in the depths of
which the vertebral artery courses with a dense venous plexus. J, the venous plexus has been removed to expose the margins
of the suboccipital triangle. K, the rectus capitis posterior major and the inferior oblique have been reflected medially and
the superior oblique laterally to expose the vertebral artery and surrounding venous plexus behind the atlanto-occipital joint.
L, the venous plexus has been removed to expose the vertebral artery coursing with the C1 nerve behind the atlanto-occipital
joint and across the upper edge of the posterior atlantal arch.
segment after removing the cartilaginous portion of the eu- tend to achieve considerable size before producing clinical
stachian tube. The cavernous sinus can be approached and the manifestation (32). The distinction between the benign or
intracavernous carotid artery exposed by dividing the man- malignant tumors in this area is not rigid because many
dibular segment of the trigeminal nerve. The approach can benign tumors can have a very invasive characteristic. The
also be extended to the retrosigmoid area and down the selection of the best surgical approach depends on the loca-
vertebral artery to the C1 to C2 level, or to the suboccipital tion, extension, size, and nature of the pathology.
triangle for a far-lateral or transcondylar exposure. The lateral An advantage of these approaches directed through the
orbit and pterygopalatine fossa can be accessed at the anterior temporal bone to the petroclival area is that they reach the
limit of the exposure. area through tissue planes outside the oropharynx. They pro-
vide another route by which anterior intradural lesions situ-
DISCUSSION ated medial to the nerves entering the internal acoustic me-
Pathologies can arise anywhere within the petroclival re- atus and jugular foramen can be approached without entering
gion and frequently are not restricted to a single anatomic the nasopharynx. They also provide an avenue of exposure
compartment of the cranial base. Involvement of multiple for lesions that involve the temporal and sphenoid bones in
cranial nerves and arteries occurs because cranial base tumors addition to the clivus. One or a combination of the lateral

S254 Rhoton
FIGURE 8.17. M and N, combined

presigmoid and far-lateral approach.
M, a suboccipital craniotomy has
been completed, the posterior arch
and posterior ramus of the
transverse process of the atlas
removed, and the dural incision has
been outlined. The posterior
meningeal artery arises before the
vertebral artery penetrates the dura.
The C1 nerve root adheres to the
lower margin of the vertebral
artery. N, the dura has been opened
and the nerves passing toward the
jugular foramen exposed. Bone has
been removed above the atlanto-
occipital joint to expose the
hypoglossal nerve in the hypoglossal
canal. The accessory rootlets cross
the jugular tubercle on their way
to the jugular foramen.
approaches is frequently used to expose intra- or extradural to the nerve-related segments of the arteries of the posterior
clival lesions that also involve the temporal and sphenoid circulation. The vertebrobasilar junction can be exposed in
bones. They also provide access to the anterior aspect of the some cases, although the lower cranial nerves and the jugular
midbrain, pons, and medulla and to the cerebellopontine tubercle are frequent obstacles. Retraction of the pons and
angle and nerves in the posterior fossa. They may also pro- working between the cranial nerves is necessary to reach the
vide better access to the temporal bone, jugular foramen, and origin of the AICA from the basilar artery. The far lateral
petrous segment of the internal carotid artery than the other modification of the retrosigmoid approach, described in the
anterior or posterior approaches. The area may be approached chapter on the far lateral approach, was devised to provide a
from directly lateral through the mastoid, labyrinth, and co- better exposure of the lateral and anterior aspects of the
chlea, as in the translabyrinthine and transcochlear approach- cervicomedullary junction (45).
es; from above through a subtemporal middle fossa route; The presigmoid approach (1, 8, 32) combines a supra- and
from behind in the retrosigmoid suboccipital approach; or infratentorial exposure with various degrees of petrousec-
from multiple directions using such combined supra- and tomy, while preserving the junction of the vein of Labbé with
infratentorial approaches as the presigmoid approach, to the transverse sinus (Figs. 8.14-8.17). The amount of resection
which a translabyrinthine or transcochlear approach may
of the petrous bone can vary from a retrolabyrinthine minimal
be added. Alternative or extended approaches, most of
mastoidectomy exposure to a translabyrinthine or transco-
which include some route through the mastoid and petrous
chlear exposure with posterior displacement of the facial
parts, include the anterior transpetrosal, the subtemporal pre-
nerve. In selected cases, where angiography shows patency of
auricular infratemporal, and the far-lateral transcondylar
the communication between the two transverse sinuses across
approach.
the midline, the sigmoid sinus can be ligated to improve the
The retrosigmoid suboccipital approach, described in the
chapter on the cerebellopontine angle, offers a wide view of exposure (24). Preservation of the drainage of the vein of
the cerebellopontine angle and of the intradural structures Labbé and avoidance of excessive temporal lobe retraction are
behind the ipsilateral lower clivus, but the dural surface of the major goals of this approach to the upper clival region. Ap-
petrous apex, upper clivus, and tentorial incisura are not well proaching the structures in the inferior petroclival space may
seen from this exposure (26, 35, 36, 46) (Figs. 8.15 and 8.16). be restricted by the jugular bulb, which could be overcome by
Removal of posterior wall of the internal auditory canal division of the sigmoid sinus or by working posterior to it
through the retrosigmoid provides access to the contents of (36). The major advantages of this approach are the shorter
the meatus as far lateral as the vertical and transverse crests. working distance to clival lesions and the various angles for
The vestibule can be opened if needed to remove a tumor dissection that are provided. The approach provides access to
extending into the labyrinth. Care is required to avoid injury the ipsilateral cranial nerves III through XII and to the major
to the posterior semicircular canal and common crus if there is arteries in the posterior circulation. A major drawback to this
the possibility of preserving hearing (29). The retrosigmoid exposure is provided by the anatomic variants, described
approach provides easy access to the intradural part of cranial below, that limit the size of the exposure through Trautman’s
nerves V, VII, VIII, and IX through XII. It also provides access triangle and the labyrinth.

Temporal Bone S255
FIGURE 8.18. Preauricular

subtemporal-infratemporal fossa
approach. A, the scalp incision is posi-
tioned so that a frontotemporal crani-
otomy can be completed. The opera-
tion is often completed with an
incision that extends downward only
to the level of the tragus. However, it
can be extended if a neck dissection is
needed. The scalp flap has been
reflected forward, taking care to pro-
tect the branches of the facial nerve.
B, the temporalis muscle has been
refracted forward and the craniotomy
completed. The mandibular condyle
and fossa and a portion of the zygo-
matic arch were removed in a single
piece, as shown in the insert, and the
middle fossa floor removed. C, expo-
sure after removal of the middle fossa
floor lateral to the foramen ovale and
before resection of the tensor tympani
muscle. The lower orifice of the
carotid canal is located in front of the
jugular foramen. The eustachian tube,
which passes across the front of the
petrous carotid, has been opened. D,
the tensor tympani and eustachian
tube have been resected to expose the
horizontal segment of the petrous
carotid. E, the internal carotid artery
has been reflected forward and the
petrous apex drilled to expose the
posterior fossa dura and the inferior
petrosal sinus coursing along the pet-
roclival fissure. F, the dura facing the
petrous apex has been opened and the
vertebral arteries and AICA exposed.
This exposure is directed through the
petrous apex medial to the cochlea
and jugular foramen and does not risk
loss of facial nerve function or hear-
ing, as do the approaches directed
through the petrous apex that require
facial nerve transposition and resec-
tion of the labyrinth. A., artery;
artery; Brs., branches; Car., carotid;
CN, cranial nerve; Eust., eustachian;
Gang., ganglion; Gl., gland; Gr., great-
er; Inf., inferior; Int., internal; Jug.,
jugular; M., muscle; Max., maxillary;
Men., meningeal; Mid., middle; N.,
nerve; Pet., petrosal, petrous; Post.,
posterior; Temp., temporal; Tens., ten-
sor; TM., temporomandibular; Trig.,
trigeminal; Tymp., tympani; V., vein;
Vert., vertebral; Zygo., zygomatic.

S256 Rhoton
FIGURE 8.19. A–D. Anatomic basis of

the postauricular transtemporal
approach. A, the incision sweeps widely
around the posterior margin of the ear
so that a retrosigmoid, presigmoid, and
far-lateral exposure can be obtained
behind the ear, and a subtemporal,
infratemporal, pterygopalatine, and
orbital exposure can be obtained in
front of the ear. B, the scalp flap has
been reflected forward, the external
canal transected, and the parotid gland
and superficial branches of the facial
nerve exposed. C, the
sternocleidomastoid muscle has been
reflected. The neck dissection exposes
the internal jugular vein, C1 transverse
process, and the glossopharyngeal,
vagus, accessory, and hypoglossal
nerves. The accessory nerve is retracted
forward. D, the parotid gland has been
removed to expose the temporofacial
and cervicofacial trunks of the facial
nerve and the temporomandibular joint.
The splenius capitis muscle has been
reflected downward to expose the
superior and inferior oblique muscles,
which insert on the transverse process
of C1 and border the suboccipital
triangle in which the vertebral artery
courses. A., artery; Alv., alveolar; Aur.,
auricular; Br., branch; Brs., branches;
Cap., capitis; Car., carotid; Cerv.,
cervical; Chor., chorda, choroid; CN,
cranial nerve; Coch., cochlear; Cond.,
condyle; Endolymph., endolymphatic;
Eust., eustachian; Ext., external; Fac.,
facial; Gang., ganglion; Genic.,
geniculate; Gl., gland; Gr., greater;
Hypogl., hypoglossal; Inf., inferior;
Infraorb., infraorbital; Infratemp.,
infratemporal; Int., internal; Jug.,
jugular; Laby., labyrinthine; Lat., lateral; Lev., levator; M., muscle; Mandib., mandibular; Mast., mastoid; Max., maxillary;
Med., medial; N., nerve; Obl., oblique; Occip., occipital; Pal., palatini; P.C.A., posterior cerebral artery; Ped., peduncle; Pet.,
petrosal, petrous; P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; Post., posterior; Proc., process; Pteryg., pterygoid;
Pterygopal., pterygopalatine; Rec., rectus; S.C.A., superior cerebellar artery; Scap., scapula; Seg., segment; Semicirc.,
semicircular; Sig., sigmoid; Sphen., sphenoid; Splen., splenus; Sternocleidomast., sternocleidomastoid; Sup., superior; Superf.,
superficial; Symp., sympathetic; Temp., temporal; Tens., tensor; TM., temporomandibular; Trans., transverse; Tymp., tympani,
tympanic; V., vein; Vel., veli; Vert., vertebral; Vest., vestibular.
The translabyrinthine approach provides access to the facial tic meatus is usually poor. The extent of exposure achieved
nerve from its origin at the brainstem to the stylomastoid with the translabyrinthine approach is dependent on several
foramen, and exposure of the contents of the internal auditory anatomic factors. A high jugular bulb, an anteriorly placed or
meatus (Fig. 8.6) (12, 14). The lateral surface of the pons, the large sigmoid sinus, or a low middle fossa plate may severely
inferior aspect of the origin of the trigeminal nerve, and the restrict the exposure (22, 27).
facial and vestibulocochlear nerve complexes are well visual- The transcochlear approach shares similar limitations with
ized, but exposure of the region inferior to the jugular bulb, the translabyrinthine exposure, although the posterior trans-
above the trigeminal nerve, and anterior to the internal acous- position of the facial nerve in the transcochlear approach

Temporal Bone S257
FIGURE 8.19. E–H. Anatomic basis of

the postauricular transtemporal approach.
E, a segment of the mandibular ramus has
been removed to expose the upper and
lower head of the lateral pterygoid and
the maxillary artery in the infratemporal
fossa. The inferior alveolar canal and
nerve have been exposed. F, the
mandibular ramus, in front of the inferior
alveolar canal, has been removed to
provide a wider exposure of the
inferotemporal fossa. The upper head of
the lateral pterygoid muscle passes
backward from the inferotemporal
surface of the greater sphenoid wing and
the lower head passes upward from the
lateral pterygoid plate. Both heads insert
on the mandibular neck and the joint
capsule. The superficial head of the
medial pterygoid muscle passes from the
maxillary tuberosity and pterygoid plate
to the mandibular angle. The deep head
of the medial pterygoid arises from the
pterygoid fossa between the pterygoid
plates. G, enlarged view of the
infratemporal area after removal of the
mandibular condyle and lateral pterygoid
muscles. The branches of the mandibular
nerve are exposed below the foramen
ovale. The largest branches are the
lingual and superior alveolar nerves,
which are predominantly sensory. The
auriculotemporal nerve arises as two
roots, which often pass around the
middle meningeal artery before joining.
H, the pterygoid muscles, a segment of
the maxillary artery, and the mandibular
and facial nerve branches have been
reflected or removed to expose the
internal jugular vein exiting the jugular
foramen on the medial side of the
stylomastoid foramen, the internal carotid artery ascending to enter the carotid canal, the tensor and levator veli palatini
descending from their origin bordering the eustachian tube, and the terminal segment of the maxillary artery entering the
pterygopalatine fossa.
allows better visualization of the structures anterior to the cochlea to the petrous apex and petroclival junction, and from
internal auditory canal (15, 16). The area of exposure is very the petrous ridge posteriorly to the carotid canal anteriorly. A
narrow and restricted by the maintenance of the bony external significant degree of temporal lobe retraction may be re-
auditory canal, but can be increased by resecting the posterior quired. This may be reduced by using a frontotemporal cra-
part of the canal. Transposition of the facial nerve may be niotomy with zygomatic resection. Although only a small
followed by a transient or permanent facial palsy. window in the petrous bone is provided, exposure can be
The subtemporal anterior transpetrosal approach uses ex- expanded by dividing the adjacent part of the tentorium. The
tradural resection of the anterior petrous pyramid via a tem- lateral and anterior surfaces of the pons and the upper clivus
poral craniotomy (Figs. 8.12 and 8.13). It may be combined and adjacent part of the cavernous sinus can be approached
with zygomatic resection to increase access to the floor of the through this route (Fig. 8.13). The facial, vestibulocochlear,
middle fossa (20). The area of the petrous apex removal trigeminal, and abducens nerves can be identified. The pe-
extends from just medial to the internal auditory canal and trous carotid may limit the surgeon’s line of vision and restrict

S258 Rhoton
FIGURE 8.19. I–L. Anatomic basis of the

postauricular transtemporal approach. I, a
mastoidectomy has been completed to
expose the semicircular canals and the
mastoid segment of the facial canal. The
endolymphatic sac sits under the presigmoid
dura. J, the external canal has been resected
to expose the structures in the tympanic
cavity. The tympanic segment of the facial
nerve courses between the lateral
semicircular canal and the stapes sitting in
the oval window. The chorda tympani arises
from the mastoid segment of the facial
nerve, passes forward along the inner
surface of the tympanic membrane and the
neck of the malleus to enter its anterior
canaliculus, exits the skull along the
petrotympanic suture, and joins the lingual
nerve in the infratemporal fossa. The
promontory overlies the basal turn of the
cochlea. The tendon of the tensor tympani
muscle makes a right-angle turn around the
trochleiform process to insert on the
malleus. K, the incus and malleus have been
removed while preserving the stapes and
the tensor tympani muscle. The petrous
carotid has been exposed. The nerves
exiting the jugular foramen have been
retracted forward to expose the hypoglossal
nerve exiting the hypoglossal canal. L, a
frontotemporal craniotomy has been
completed and the floor of the middle
cranial fossa removed. The semicircular
canals have been exposed above the jugular
bulb and the stapes has been removed from
the oval window. The maxillary nerve has
been exposed in the pterygopalatine fossa.
The membranous wall of the eustachian
tube has been opened to expose the tube’s
opening into the nasopharynx.
access to the inferior part of the petroclival region, but this Removal of the posterior part of the petrous pyramid has
restriction may be overcome with anterior mobilization of the been used for acoustic neuroma removal as part of extended
artery (39, 41). The approach provides access to the anterior approaches directed through the middle fossa (21, 28, 42, 43)
aspect of the brainstem and basilar artery in the area between (Fig. 8.12). The extended approaches combine different de-
the trigeminal nerve above and the facial and vestibuloco- grees of resection of the bony labyrinth with the subtemporal
chlear nerves below. In approaching the basilar artery transtentorial routes. Extending the resection of the petrous
through this route, the size and location of the lesion in bone posteriorly over the mastoid and the bony labyrinth
relation to the petrous ridge is critical. The trigeminal nerve exposes the whole intrapetrous course of the facial nerve, and
can be mobilized to improve the exposure, although this may provides access to the cerebellopontine angle by a combina-
result in postoperative facial hypesthesia (19, 20). The anterior tion of subtemporal, translabyrinthine, and presigmoid routes
transpetrosal approach can be used alone for extradural pathol- (Figs. 8.12 and 8.13) (9).
ogies restricted to the petrous apex or as a surgical step to The subtemporal preauricular infratemporal approach
approaching intradural pathologies in the petroclival region. It reaches the skull base from an anterolateral direction (Figs.
provides a route for resecting extradural lesions that extend from 8.10, 8.13, and 8.18). Division of the zygomatic arch, resection
the level of the trigeminal nerve to the foramen magnum. or displacement of the mandibular condyle, and extensive

Temporal Bone S259
FIGURE 8.19. M–R. Anatomic basis of

the postauricular transtemporal approach.
M, a retrosigmoid craniotomy has been
completed and the nerves in the
cerebellopontine angle exposed. The
vestibulocochlear nerve has been
depressed to expose the facial nerve. N,
the facial nerve has been reflected
forward out of the facial canal. The
promontory has been drilled to expose
the cochlea and the vestibule. Both ends
of the semicircular canals open into the
vestibule, as does the basal turn of the
cochlea. The jugular bulb has been
removed to expose the jugular fossa in
which the bulb resides. The jugular bulb
is located below the vestibule. The nerves
exiting the jugular foramen have been
reflected backward to expose the
hypoglossal nerve exiting the hypoglossal
canal. The nerves passing through the
jugular foramen and hypoglossal canal
exit the skull on the medial side of the
internal jugular vein and descend
between the internal carotid artery and
internal jugular vein. O, the bone above
the occipital condyle has been drilled to
expose the hypoglossal nerve in the
hypoglossal canal. P, the posterior wall of
the internal acoustic meatus has been
removed to provide this presigmoid
inferolateral view of the nerves in the
internal meatus. The cochlear nerve
separates off the main bundle of the
vestibulocochlear nerve and penetrates
the modiolus. The inferior vestibular
nerve divides into the singular nerve
to the posterior ampullae and a branch to
the saccule. The superior vestibular nerve
innervates the superior and lateral
ampullae and sends a branch to the
utricle. Q, the medial wall of the jugular
fossa has been removed and the nerves
passing through the jugular foramen have
been exposed. The glossopharyngeal
nerve passes through the foramen
anterior to the vagus and accessory
nerves. A large superior petrosal vein
ascends to the superior petrosal sinus. R,
the glossopharyngeal, vagus, and
accessory rootlets arise behind and the
hypoglossal rootlets arise anterior to the
inferior olive.

S260 Rhoton
FIGURE 8.19. S–X. Anatomic basis of the postauricular transtemporal approach. S, enlarged view of the medial wall of the tympanic cav-
ity before mobilizing the facial nerve. The stapedial muscle passes forward from the pyramidal eminence below the facial nerve and
attaches on the neck of the stapes. The tensor tympani muscle passes backward and laterally, giving rise to a narrow tendon that makes a
sharp turn around the trochleariform process at the lateral end of its semicanal to insert on the handle of the malleus. The basal turn of
the cochlea is located deep to the promontory. The tympanic segment of the facial nerve courses above the stapes. T, enlarged view of
the labyrinth. The semicircular canals have been unroofed and the stapes has been removed from the oval window. The round window is
located below and behind the oval window. U, the facial nerve has been reflected forward out of the facial canal and the vestibule has
been opened. The ampullae of the superior and the lateral canal open into the vestibule anteriorly and are innervated by the superior
vestibular nerve. Only the upper edge of the superior canal was preserved in opening the vestibule. The ampullae of the posterior canal is
located at its lower end and is innervated by the singular branch of the inferior vestibular nerve. V, a probe is directed through the vesti-
bule to the inner surface of the membrane covering the round window, which is located behind and below the oval window. W,
enlarged view of the labyrinth after opening the promontory to expose the cochlea. The jugular bulb is located below the vestibule and
semicircular canals and the lateral genu of the internal carotid artery in position below the cochlea. The cochlea wraps around the modi-
olus through which the branches of the cochlear nerve are distributed to the cochlear duct. X, the temporal lobe has been elevated to
expose the internal carotid, PCA, and SCA in the basal cisterns. The dura has been elevated from the lateral wall of the cavernous sinus.

Temporal Bone S261
FIGURE 8.19. Y and Z, anatomic

basis of the postauricular
transtemporal approach. Y,
overview before opening the dura.
The postauricular approach offers
the potential for providing
retrosigmoid, presigmoid, and far-
lateral exposures and can be used
to access the infratemporal and
pterygopalatine fossae, the orbit,
and the subtemporal areas. In this
case, the exposure extends from the
retrosigmoid area forward to the
orbit. The maxillary sinus has been
opened below the orbital floor. Z,
overview of exposure after opening
the dura.
native lateral route to vascular lesions

of the midbasilar artery or at the ver-
tebrobasilar junction, when these le-
sions cannot be exposed through ei-
ther the retromastoid or subtemporal
transtentorial approaches.
The postauricular transtemporal ap-
proach, which combines a transco-
chlear exposure with an infratemporal
approach, may be used as an alterna-
tive to the preauricular infratemporal
approach when the pathology involves
the mastoid and the infratemporal
fossa and extends to the facial recess,
hypotympanic area, and jugular bulb
(5, 6, 34) (Figs. 8.19 and 8.20). The struc-
tures of the lower and middle clivus
can be exposed without the need for
brain retraction. The facial nerve is dis-
resection of the lateral part of the middle fossa floor exposes placed anterosuperiorly and the sigmoid sinus ligated and divided.
the infratemporal fossa, the nasopharynx, the para- and ret- Displacement of the facial nerve from its bony canal seriously
ropharyngeal areas, and the ethmoid, sphenoid, and maxil- interferes with its vascular supply and temporary or permanent
lary sinuses. The approach also provides access to the upper loss of function is to be expected (33). Resection of the jugular bulb
cervical and petrous carotid. The cavernous sinus also can be allows for exposure of the lower cranial nerves in the jugular fora-
approached through its lateral and basal aspects. Anterior men. Mobilization of the nerves in the medial part of the jugular
displacement of the petrous carotid allows direct access to the foramen is extremely difficult and nerve damage is likely to occur if
clivus and for extensive resection of the petrous bone medial it is attempted. The lateral and anterior surfaces of the lower pons,
to the cochlea. This exposes the extradural clival region from medulla, and cervicomedullary junction are well exposed. The ex-
the level of the trigeminal nerve to the foramen magnum (33, tent of exposure of the major arteries is dependent on the different
36, 38, 39). The approach can also provide access to the intra- anatomic variants and direction of displacement of the vessels.
dural space ventral to the brainstem (41). The exposure of the Exposure of the structures of the middle clivus requires posterior
cerebellopontine angle and foramen magnum is limited be- facial nerve displacement and drilling of the labyrinth with conse-
cause the approach is carried anterior and medial to cranial quent destruction of any residual hearing. The lateral and part of
nerves VII through XII and the cochlea is not resected (36). the anterior surfaces of the pons can be exposed up to the point of
Anterior transposition of the petrous carotid artery allows emergence of the trigeminal nerve. Exposure of the superior petro-
unhindered exposure of the origin of the AICA and the ver- clival space requires that the transtemporal exposure be combined
tebrobasilar junction. The approach could be used as an alter- with a subtemporal exposure. The transtemporal approach can

S262 Rhoton
FIGURE 8.20. A–F. Postauricular transtemporal approach. This exposure includes the transtemporal and infratemporal approaches in
combination with a craniotomy. A, the scalp flap has been reflected forward to expose the sternocleidomastoid, parotid gland, and the
greater auricular nerve. B, the external canal has been divided to reflect the flap forward for a parotid and neck dissection that exposes
the facial nerve and its trunks, the posterior digastric belly, and the internal jugular vein. C, the mastoidectomy has been completed to
expose the presigmoid dura, the sigmoid sinus, and the semicircular canals. The mandibular condyle has been resected to provide access
to the infratemporal fossa. D, a temporo-occipital craniotomy has been completed, the zygomatic arch opened, and the temporalis mus-
cle reflected to expose the maxillary artery and pterygoid muscles in the infratemporal fossa. E, enlarged view of the temporal and infra-
temporal exposures. The posterior wall of the external canal has been removed. The auriculotemporal branch of the mandibular nerve is
often split into two rootlets by the middle meningeal artery. F, enlarged view of the tympanic cavity. The anterior part of the lateral semi-
circular canal is located above the tympanic segment of the facial nerve. The promontory overlies the basal cochlear turn. A., artery; Ac.,
acoustic; Aur., auricular; Bas., basilar; Car., carotid; Chor., chorda; CN, cranial nerve; Cond., condyle; Ext., external; Gl., gland; Gr., great-
er; Inf., inferior; Int., internal; Jug., jugular; Lat., lateral; M., muscle; Mandib., mandibular; Mast., mastoid; Max., maxillary; Mid., middle;
Men., meningeal; N., nerve; Pet., petrosal, petrous; Proc., process; Seg., segment; Semicirc., semicircular; Sig., sigmoid; Sternocleidomast.,
sternocleidomastoid; Sup., superior; Temp., temporal; Trans., transverse; Tymp., tympani, tympanic; V., vein; Vert., vertebral.

Temporal Bone S263
FIGURE 8.20. G–L. Postauricular transtemporal approach. G, the external canal has been resected in preparation for
exposing the petrous carotid. H, the junction of the cervical and petrous carotid has been exposed in the area below the
promontory. The lateral margin of the stylomastoid and jugular foramina have been removed to expose the jugular bulb
below the semicircular canals. I, the mandibular nerve has been exposed below the foramen ovale. A more extensive
exposure of the petrous carotid has been completed so that the artery can be reflected forward out of the carotid canal
to provide access for drilling of the petrous apex. J, the petrous carotid has been reflected forward and the petrous apex
removed to expose the clivus and inferior petrosal sinus. K, the facial nerve has been moved out of the facial canal, and
a total labyrinth and petrous apicectomy have been completed. L, a segment of the sigmoid sinus and the jugular bulb
have been removed to expose the nerves passing through the jugular foramen. The dura has been opened and the facial
nerve displaced posteriorly. The temporal lobe has been elevated to expose the subtemporal area while preserving the
vein of Labbé.

S264 Rhoton
easily be extended to the infratemporal fossa, and the same expo- 13. House WF: Middle cranial fossa approach to the petrous pyra-
sure provided by the preauricular approach can be achieved. When mid. Arch Otolaryngol 78:460–469, 1963.
this approach is combined with an infratemporal fossa exposure 14. House WF: Evolution of transtemporal bone removal of acoustic
and anterior displacement of the intrapetrous carotid artery, the tumors. Arch Otolaryngol 80:731–742, 1964.
petrous part of the temporal bone can be completely removed, 15. House WF, Hitselberger WE: The transcochlear approach to the
skull base. Arch Otolaryngol 102:334–342, 1976.
providing the widest possible exposure of the petroclival region
16. House WF, De la Cruz A, Hitselberger WE: Surgery of the skull
(Figs. 8.19 and 8.20). The retrosigmoid, far-lateral, and transcondylar
base: Transcochlear approach to the petrous apex and clivus.
exposures can be obtained at the posterior margin of the exposure, Otolaryngology 86:770–779, 1978.
and the anterior limit can be extended to include the pterygopala- 17. Inoue T, Rhoton AL Jr, Theele D, Barry ME: Surgical approaches
tine fossa and lateral part of the maxilla, orbit, and anterior cranial to the cavernous sinus: A microsurgical study. Neurosurgery
fossa. 26:903–932, 1990.
Extensive removal of lesions involving the skull base fre- 18. Katsuta T, Rhoton AL Jr, Matsushima T: The jugular foramen:
quently require reconstruction of the resultant bony, neural, Microsurgical anatomy and operative approaches. Neurosurgery
and dural defects. The presence of cerebrospinal fluid leaks 41:149–202, 1997.
and the close proximity to contaminated spaces of the oro- or 19. Kawase T, Shiobara R, Toya S: Anterior transpetrosal-transtentorial
nasopharynx increases the risks of meningitis. Opened sinuses approach for sphenopetroclival meningiomas: Surgical method and
results in 10 patients. Neurosurgery 28:869–876, 1991.
should be obliterated, dural incisions and openings should be
20. Kawase T, Toya S, Shiobara R, Mine T: Transpetrosal approach for
sutured and sealed, nerves should be reanastomosed or grafted,
aneurysms of the lower basilar artery. J Neurosurg 63:857–861, 1985.
and devascularized grafts of bone or dura should be covered 21. King TT, Morrison AW: Translabyrinthine and transtentorial re-
with vascularized tissue whenever possible. moval of acoustic nerve tumors: Results in 150 cases. J Neurosurg
52:210–216, 1980.
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro- 22. King TT, Morrison AW: Translabyrinthine operation for the re-
logical Surgery, University of Florida Brain Institute, P.O. Box 100265, moval of acoustic nerve tumors, in Schmidek HH, Sweet WH
100 South Newell Drive, Building 59, L2-100, Gainesville, FL (eds): Operative Neurosurgical Techniques. New York, W.B.
32610-0265. Saunders Co., 1988, vol 1, pp 685–704.
23. Lister JR, Rhoton AL Jr, Matsushima T, Peace D: Microsurgical
anatomy of the posterior inferior cerebellar artery. Neurosurgery
10:170–199, 1982.
REFERENCES 24. Malis LI: Surgical resection of tumors of the skull base, in Wilkins
1. Al-Mefty O, Fox JL, Smith RR: Petrosal approach for petroclival RH, Rengachary SS (eds): Neurosurgery. New York, McGraw-Hill,
meningiomas. Neurosurgery 22:510–517, 1988. 1985, vol 1, pp 1011–1021.
2. Brackmann DE: The middle fossa approach, in Sekhar LN, 25. Matsushima T, Rhoton AL Jr, de Oliveira E, Peace D: Microsur-
Janecka IP (eds): Surgery of Cranial Base Tumors. New York, Raven gical anatomy of the veins of the posterior fossa. J Neurosurg
Press, 1993, pp 367–377. 59:63–105, 1983.
3. Brackmann DE: Translabyrinthine/transcochlear approaches, in 26. Mayberg MR, Symon L: Meningiomas of the clivus and apical
Sekhar LN, Janecka IP (eds): Surgery of Cranial Base Tumors. New petrous bone: Report of 35 cases. J Neurosurg 65:160–167, 1986.
York, Raven Press, 1993, pp 351–365. 27. McElveen JT: The translabyrinthine approach to the cerebel-
4. de Oliveira E, Rhoton AL Jr, Peace D: Microsurgical anatomy of lopontine angle tumors, in Wilkins RH, Rengachary SS (eds):
the region of the foramen magnum. Surg Neurol 24:293–352, Neurosurgery Update I: Diagnosis, Operative Technique, and Neuro-
1985. oncology. New York, McGraw-Hill, 1990, pp 415–423.
5. Fisch U, Pillsbury HC: Infratemporal fossa approach to lesions in 28. Morrison AW, King TT: Experiences with a translabyrinthine-
the temporal bone and base of the skull. Arch Otolaryngol 105: transtentorial approach to the cerebellopontine angle. J Neuro-
99–107, 1979. surg 38:382–390, 1973.
6. Fisch U, Fagan P, Valavanis A: The infratemporal fossa approach 29. Pait TG, Harris FS, Paullus WS, Rhoton AL Jr: Microsurgical
for the lateral skull base. Otolaryngol Clin North Am 7:513–552, anatomy and dissection of the temporal bone. Surg Neurol 8:363–
1984. 391, 1977.
7. Gantz BJ, Fisch U: Modified transotic approach to the cerebel- 30. Paullus WS, Pait TG, Rhoton AL Jr: Microsurgical exposure of the
lopontine angle. Arch Otolaryngol 109:252–256, 1983. petrous portion of the carotid artery. J Neurosurg 47:713–726, 1977.
8. Hakuba A, Nishimura S, Inoue Y: Transpetrosal-transtentorial 31. Rhoton AL Jr, Pulec JL, Hall GM, Boyd AS Jr: Absence of bone
approach and its application in the therapy of retrochiasmatic over the geniculate ganglion. J Neurosurg 28:48–53, 1968.
craniopharyngiomas. Surg Neurol 24:405–415, 1985. 32. Samii M, Ammirati M, Mahran A, Bini W, Sepehrnia A: Surgery
9. Hakuba A, Nishimura S, Jang BJ: A combined retroauricular and of petroclival meningiomas: Report of 24 cases. Neurosurgery
preauricular transpetrosal-transtentorial approach to clivus me- 24:12–17, 1989.
ningiomas. Surg Neurol 30:108–116, 1988. 33. Schramm VL Jr: Infratemporal fossa surgery, in Sekhar LN,
10. Harris FS, Rhoton AL Jr: Anatomy of the cavernous sinus: A Schramm VL Jr (eds): Tumors of the Cranial Base: Diagnosis and
microsurgical study. J Neurosurg 45:169–180, 1976. Treatment. Mount Kisco, Futura Pub. Co., 1987, pp 421–437.
11. Hitotsumatsu T, Rhoton AL Jr: Unilateral upper and lower sub- 34. Sekhar LN, Estonillo R: Transtemporal approach to the skull base:
total maxillectomy approaches to the skull base: Microsurgical An anatomical study. Neurosurgery 19:799–808, 1986.
anatomy. Neurosurgery 46:1416–1453, 2000. 35. Sekhar LN, Jannetta PJ: Cerebellopontine angle meningiomas:
12. Hitselberger WE, House WF: Surgical approaches to acoustic Microsurgical excision and follow up results. J Neurosurg 60:500–
tumors. Arch Otolaryngol 84:286–291, 1966. 505, 1984.

Temporal Bone S265
36. Sekhar LN, Jannetta PJ, Burkhart LE, Janosky JE: Meningiomas 41. Sen CN, Sekhar LN: The subtemporal and preauricular infratem-
involving the clivus: A six-year experience with 41 patients. Neuro- poral approach to intradural structures ventral to the brain stem.
surgery 27:764–781, 1990. J Neurosurg 73:345–354, 1990.
37. Sekhar LN, Schessel DA, Bucur SD, Raso JL, Wright DC: Partial 42. Shiobara R, Ohira T, Kanzaki J, Toya S: A modified extended
labyrinthectomy petrous apicectomy approach to neoplastic and middle cranial fossa approach for acoustic nerve tumors. J Neuro-
vascular lesions of the petroclival area. Neurosurgery 44:537–550, surg 68:358–365, 1988.
1999. 43. Tator CH, Nedzelski JM: Facial nerve preservation in patients with
38. Sekhar LN, Schramm VL Jr, Jones NF: Operative management of large acoustic neuromas treated by a combined middle fossa
large neoplasms of the lateral and posterior cranial base, in transtentorial translabyrinthine approach. J Neurosurg 57:1–7, 1982.
Sekhar LN, Schramm VL Jr (eds): Tumors of the Cranial Base: 44. Tedeschi H, Rhoton AL Jr: Lateral approaches to the petroclival
Diagnosis and Treatment. Mount Kisco, Futura Publishing Co, 1987, region. Surg Neurol 41:180–216, 1994.
pp 655–682. 45. Wen HT, Rhoton AL Jr, Katsuta T, de Oliveira E: Microsurgical
39. Sekhar LN, Schramm VL Jr, Jones NF: Subtemporal-preauricular anatomy of the transcondylar, supracondylar, and paracondylar
infratemporal fossa approach to large lateral and posterior cranial extensions of the far-lateral approach. J Neurosurg 87:555–585,
base neoplasms. J Neurosurg 67:488–499, 1987. 1997.
40. Sekhar LN, Schramm VL Jr, Jones NF, Yonas H, Horton J, 46. Yasargil MG, Mortara RW, Curcic M: Meningiomas of basal pos-
Latchaw RE, Curtain H: Operative exposure and management of terior cranial fossa, in Krayenbühl H (ed): Advances and Technical
the petrous and upper cervical internal carotid artery. Neuro- Standards in Neurosurgery. Wien, Springer-Verlag, 1980, vol 17, pp
surgery 19:967–982, 1986. 3–115.
Anatomy of the human ear, a drawing by Max Brödel using Wolff’s carbon pencil and dust on Ross stippleboard.
Courtesy, W.B. Saunders Co. (Also see pages S210 and S266.)

Max Brödel’s drawing showing intracranial tumors and abscesses causing communicating hydrocephalus. In another article by
Walter Dandy, Brödel shows the tumor spreading over the brain stem in the foreground. Courtesy, Annals of Surgery 81, 1925.
(Also see pages S210 and S265.)
CHAPTER 9
Jugular Foramen

Key words: Cranial base, Cranial nerves, Jugular foramen, Microsurgical anatomy, Occipital bone, Skull base, Temporal bone, Venous sinuses
T
he jugular foramen is difficult to understand and to usually larger than the left. In a previous study, we observed
access surgically (3, 11, 15, 19, 24, 28). It is difficult to that the right foramen was larger than the left in 68% of the
conceptualize because it varies in size and shape in cases, equal to the left in 12%, and smaller than the left in 20%
different crania, from side to side in the same cranium, and (24). The foramen is configured around the sigmoid and in-
from its intracranial to extracranial end in the same foramen, ferior petrosal sinuses. It can be regarded as a hiatus between
and because of its complex irregular shape, its curved course, the temporal and the occipital bones. The structures that
its formation by two bones, and the numerous nerves and traverse the jugular foramen are the sigmoid sinus and jugu-
venous channels that pass through it (Fig. 9.1). The difficulties lar bulb, the inferior petrosal sinus, meningeal branches of the
in exposing this foramen are created by its deep location and ascending pharyngeal and occipital arteries, the glossopharyn-
the surrounding structures, such as the carotid artery anteri- geal, vagus, and accessory nerves with their ganglia, the tym-
orly, the facial nerve laterally, the hypoglossal nerve medially, panic branch of the glossopharyngeal nerve (Jacobson’s nerve),
and the vertebral artery inferiorly, all of which block access to the auricular branch of the vagus nerve (Arnold’s nerve), and the
the foramen and require careful management. cochlear aqueduct.
The jugular foramen is divided into three compartments: The foramen is situated so that its long axis is directed from
two venous and a neural or intrajugular compartment. The posterolateral to anteromedial, giving it an anterolateral mar-
venous compartments consist of a larger posterolateral ve- gin formed by the temporal bone and a posteromedial margin
nous channel, the sigmoid part, which receives the flow of the formed by the occipital bone. From the intracranial end, it is
sigmoid sinus, and a smaller anteromedial venous channel, directed forward, medially, and downward. One cannot see
the petrosal part, which receives the drainage of the inferior through the foramen when viewing the skull from directly
petrosal sinus. The petrosal part forms a characteristic venous above or below because of its roof, formed by the lower
confluens by also receiving tributaries from the hypoglossal surface of the petrous part of the temporal bone. The foramen,
canal, petroclival fissure, and vertebral venous plexus. The when viewed from the intracranial side in a posterior to
petrosal part empties into the sigmoid part through an open- anterior direction, has a large oval lateral component, referred
ing in the medial wall of the jugular bulb between the glos- to as the sigmoid part, because it receives the drainage of the
sopharyngeal nerve anteriorly and the vagus and accessory sigmoid sinus, and a small medial part, called the petrosal
nerves posteriorly. The intrajugular or neural part, through part, because it receives the drainage of the inferior petro-
which the glossopharyngeal, vagus, and accessory nerves sal sinus. The view through the foramen from directly below
course, is located between the sigmoid and petrosal parts at reveals the part of the temporal bone forming the dome of the
the site of the intrajugular processes of the temporal and jugular bulb, rather than a clear opening.
occipital bones, which are joined by a fibrous or osseous The junction of the sigmoid and petrosal parts is the site of
bridge. The glossopharyngeal, vagus, and accessory nerves bony prominences on the opposing surfaces of the temporal
penetrate the dura on the medial margin of the intrajugular and occipital bones, called the intrajugular processes, which
process of the temporal bone to reach the medial wall of the are joined by a fibrous, or less commonly, and osseous bridge,
internal jugular vein. The operative approaches that access the intrajugular septum, separating the sigmoid and petrosal
various aspects of the foramen and adjacent areas are the part of the foramen.
postauricular transtemporal, retrosigmoid, extreme lateral Although the margins of the jugular foramen are formed by
transcondylar, and preauricular subtemporal-infratemporal the petrosal part of the temporal bone and the condylar part
approaches. of the occipital bone, the other parts of these bones also have
important relationships to the jugular foramen. The petro-
clival fissure, the fissure between the lateral edge of the clival
OSSEOUS RELATIONSHIPS part of the occipital bone and the petrous part of the temporal
The jugular foramen is located between the temporal bone bone, intersects the anteromedial edge of the foramen, and the
and the occipital bone (Figs. 9.1 and 9.2). The right foramen is occipitomastoid suture, the suture between the mastoid por-

S268 Rhoton
FIGURE 9.1. A–D. Osseous relationships. A, the jugular foramen is located between the temporal and occipital bones. One can-
not see directly through the foramen from above, as shown, because it is directed forward under the temporal bone. The sigmoid
groove descends along the mastoid and crosses the occipitomastoid suture where it turns forward on the upper surface of the jugu-
lar process of the occipital bone and enters the foramen by passing under the posterior part of the petrous temporal bone. B, the
view directed from posterior and superior shows the shape of the foramen, which is not seen on the direct superior view. The fora-
men has a larger lateral sigmoid part through which the sigmoid sinus empties and a smaller anteromedial petrosal part through
which the inferior petrosal sinus empties. The two parts are separated by the intrajugular processes of the occipital and temporal
bones. The glossopharyngeal, vagus, and accessory nerves pass through the intrajugular portion of the foramen located between
the sigmoid and petrosal parts. The foramen is asymmetric from side to side with the right side often being larger as shown. The
cochlear aqueduct opens just above the anterior edge of the petrosal part. The vestibular aqueduct opens into the endolymphatic
sac, which sits on the back of the temporal bone superolateral to the sigmoid part of the jugular foramen. C, jugular foramen
viewed from directly below. One cannot see directly through the foramen from below because the foramen is covered above by
the part of the petrous temporal bone forming the jugular fossa, which houses the jugular bulb. The entrance into the carotid canal
is located directly in front of the medial half of the jugular foramen. The stylomastoid foramen is located lateral and the anterior
half of the occipital condyle medial to the jugular foramen. The posterior condylar foramen is transversed by an emissary vein,
which joins the sigmoid sinus. The hypoglossal canal passes above the middle third of the occipital condyle and opens laterally into
the interval between the jugular foramen and carotid canal. D, the view directed from anterior and backward reveals the shape of
the jugular foramen. The roof over the foramen formed by the jugular fossa of the temporal bone is shaped to accommodate the
jugular bulb. The posterior margin of the foramen is formed by the jugular process of the occipital bone, which connects the basal
(clival) part of the occipital bone to the squamosal part. The petroclival fissure intersects the anteromedial margin of the petrosal
part of the foramen. Ac., acoustic; Car., carotid; Coch., cochlear; Cond., condyle; Fiss., fissure; For., foramen; Hypogl., hypoglossal;
Int., internal; Intrajug., intrajugular; Jug., jugular; Mast., mastoid; Occip., occipital; Pet., petrous; Petrocliv., petroclival; Post., poste-
rior; Proc., process; Sig., sigmoid; Squam., squamosal; Stylomast., stylomastoid; Temp., temporal; Vest., vestibular.
tion of the temporal bone and the condylar part of the occip- between the sigmoid and petrosal parts. The intrajugular
ital bone, intersects its posterolateral edge. process of the temporal bone protrudes farther into the jugu-
The intrajugular processes of the temporal and occipital lar foramen than the opposite process from the occipital bone,
bones divide the anterior and posterior edges of the foramen and may infrequently reach the smaller intrajugular process

Jugular Foramen S269
FIGURE 9.1. E–H. E and F, another jugular foramen. Left side: E, the sutures have been forced open to show the relationship
of the foramen to the petroclival and occipitomastoid sutures. The jugular foramen has a larger lateral part, the sigmoid part,
which receives the drainage of the sigmoid sinus, and a smaller medial part, the petrosal part, which receives the drainage of
the inferior petrosal sinus. The intrajugular process of the occipital bone is somewhat more prominent than shown in C and
projects forward toward the intrajugular process of the temporal bone. The hamate process normally extends along the
medial edge of the petrosal part of the foramen to the adjacent part of the temporal bone, but in this case the sutures were
forced open, leaving an interval between the hamate process and the temporal bone. F, enlarged view. G and H, another jug-
ular foramen. G, the intrajugular process of the temporal bone projects into the interval between the sigmoid and petrosal
parts of the foramen. A ridge, the intrajugular ridge, extends forward from the intrajugular process along the medial side of
the jugular bulb. The glossopharyngeal nerve passes forward along the medial side of the intrajugular process and ridge. The
vagus and accessory nerves enter the dura on the medial side of the process, but quickly descend and do not pass forward
along the medial edge of the ridge as does the glossopharyngeal nerve. The jugular process of the occipital bone often has a
small prominence on its surface that projects toward the intrajugular process of the temporal bone, and in some foramina,
the intrajugular processes of the two bones are joined by an osseous bridge that converts the foramen into two osseous
foramina. In this case, the intrajugular process of the occipital bone is absent. H, enlarged view. The cochlear aqueduct
opens above the petrosal part of the foramen and the site where the glossopharyngeal nerve enters the intrajugular part of
the foramen on the medial side of the intrajugular process. The vestibular aqueduct opens onto the posterior surface of the
temporal bone superolateral to the jugular foramen.
of the occipital bone, dividing the jugular foramen into two form a canal, which surrounds the glossopharyngeal nerve as
bony foramina. A ridge, the intrajugular ridge, extends for- it passes through the jugular foramen.
ward from the intrajugular process of the temporal bone The drainage of the sigmoid sinus is directed forward into the
along the medial edge of the jugular bulb (Fig. 9.1). The sigmoid portion of the foramen, where a high domed recess,
glossopharyngeal nerve courses along its medial edge. Occa- the jugular fossa, forms a roof over the top of the jugular bulb
sionally, the edge of this ridge extends medially toward the (Figs. 9.1 and 9.3). This recess, which has its summit slightly
adjacent part of the temporal bone to create a deep groove in lateral to the entrance of the sigmoid sinus, is usually larger on
which the nerve courses or it may reach the temporal bone to the right side of the skull, reflecting the larger sigmoid sinus on

S270 Rhoton
FIGURE 9.2. Osseous relationships. A, lateral view.

The styloid process projects downward and the facial
nerve exits the stylomastoid foramen on the lateral
side, and both block lateral access to the jugular
foramen. The mandibular condyle blocks access to
the foramen from anteriorly and the vertebral artery
ascending through the C1 transverse process limits
access from behind. The transverse process of C1 sits
behind and often indents the posterior wall of the
internal jugular vein. B, inferior view of the jugular
foramen. The jugular foramen is located lateral to the
anterior half of the occipital condyle. The temporal
bone forms the dome over the jugular bulb. The
jugular process of the occipital bone forms the
posterior margin of the jugular foramen. The jugular
foramen and carotid canal are separated by a narrow bony ridge, which is penetrated medially by the tympanic
canaliculus through which passes the tympanic branch of the glossopharyngeal nerve (Jacobson’s nerve). This branch
of the nerve passes forward across the promontory in the medial part of the tympanic cavity, then crosses the floor of
the middle fossa as the lesser petrosal nerve, and eventually reaches the otic ganglion, providing parasympathetic
innervation to the parotid gland. The anterior wall of the sigmoid part of the foramen is the site of a shallow groove across
which the auricular branch of the vagus nerve (Arnold’s nerve) passes to enter the mastoid canaliculus. It exits the mastoid
through the tympanomastoid suture. C, lateral view of the left temporal bone. A small fiber (arrow) placed in the tympanic
canaliculus, shown in B, exits the canaliculus in the middle ear where the fibers of the tympanic branch of the glossopharyngeal
nerve cross the promontory, and then regroup to cross the floor of the middle fossa as the lesser petrosal nerve. The styloid
process projects downward lateral to the jugular foramen. Aur., auricular; Br., branch; Canalic., canaliculus; Car., carotid; CN,
cranial nerve; Cond., condyle; Ext., external; Fiss., fissure; For., foramen; Jug., jugular; Mandib., mandibular; Occip., occipital;
Petrotymp., petrotympanic; Proc., process; Trans., transverse; Tymp., tympanic.
that side. The dome of the recess is usually smooth as it conforms foramen. The external aperture of the cochlear canaliculus,
to the jugular bulb, but the summit may also be ridged and which houses the perilymphatic duct and a tubular prolongation
irregular. A small triangular recess, the pyramidal fossa, extends of the dura mater, opens into the anterior apex of the pyramidal
forward on the medial side of the intrajugular process of the fossa. The glossopharyngeal nerve enters this fossa below the
temporal bone along the anterior wall of the petrosal part of the point at which the cochlear aqueduct joins its apex.

The jugular process of the condylar portion of the occipital fissure. A more detailed review is included in the chapter on
bone, which extends behind the jugular foramen and connects the far-lateral approach.
the clival and squamosal parts of the occipital bone, forms the The anterior margin of the jugular foramen, when viewed
posteromedial wall of the foramen. This process extends lat- extracranially, is formed by the narrow ridge of temporal
erally from the area above the posterior half of the occipital bone, the carotid ridge, which separates the foramen and the
condyle and is penetrated by the hypoglossal canal. The upper carotid canal (Figs. 9.1 and 9.2). The tympanic canaliculus opens
surface of the jugular process of the occipital bone in the area on or near the medial part of the carotid ridge. The styloid
superomedial to the foramen presents an oval prominence, the process and the stylomastoid foramen are located lateral to the
jugular tubercle, which is located above the hypoglossal canal. outer orifice of the jugular foramen, with the styloid process
The jugular tubercle often has a shallow furrow marking the site being located slightly anteromedial to the stylomastoid foramen.
of passage of the glossopharyngeal, vagus, and accessory nerves The facial nerve exits the stylomastoid foramen approximately 5
across its surface. The terminal end of the sigmoid sinus courses mm lateral to the lateral edge of the jugular foramen. The ante-
forward on the superior surface of the jugular process in a deep rior margin of the jugular foramen is located just behind the part
hook-like groove, the sigmoid sulcus, which is directed medially of the tympanic bone that forms the posterior wall of the tem-
into the sigmoid portion of the jugular foramen. poromandibular joint and the anterior and inferior wall of the
On the lateral wall of the jugular foramen, a few millimeters external auditory canal. The vaginal process of the tympanic
inside the external edge, just behind the point at which the bone, which separates both the carotid canal and sigmoid part of
occipitomastoid suture crosses the lateral edge of the foramen, the foramen from the glenoid fossa, is the site of attachment
is a small foramen, the mastoid canaliculus, and a shallow of the styloid process to the skull base. The styloid process
groove leading from medial to lateral across the anterior wall of projects downward from the vaginal process of the tympanic
the sigmoid part to the mastoid canaliculus (Figs. 9.2 and 9.3). bone, lateral to the foramen. The digastric groove is directed
The auricular branch of the vagus nerve (Arnold’s nerve) posteriorly from the styloid process along the medial margin of
courses along the groove and enters the canaliculus. The nerve the mastoid process. Access to the jugular foramen is blocked
passes through the mastoid and exits the bone in the inferolateral laterally by mastoid and styloid processes, the transverse process
part of the tympanomastoid suture. At the site where the intra- of the atlas, and the mandibular ramus (Figs. 9.3 and 9.4).
jugular ridge of the temporal bone meets the carotid ridge, a The tympanic cavity, which is located medial to the tym-
small canal, the tympanic canaliculus, is directed upward, lead- panic membrane, is situated above and lateral to the jugular
ing the tympanic branch arising from the inferior glossopharyn- bulb and the sharp right-angled curve, called the lateral bend, at
geal ganglion (Jacobson’s nerve) to the tympanic cavity (Figs. the junction of the vertical and horizontal segments of the pe-
9.2). Looking from below at the extracranial orifice of the jugular trous carotid artery (Fig. 9.4). Several structures that may be
foramen, it can be recognized that the glossopharyngeal nerve exposed during surgery for lesions in the jugular foramen are
courses along the medial side of the intrajugular process and the vertical and horizontal segments of the petrous portion of the
ridge to reach the area below the tympanic canaliculus. internal carotid artery, the eustachian tube, and the tensor tym-
pani muscle. Both the cochlea and semicircular canals are located
in the petrous part of the temporal bone above the dome of the
ADJACENT BONY STRUCTURES jugular bulb (Fig. 9.4). The facial nerve in the temporal bone,
On the intracranial side, the petrosal part of the foramen is which often blocks access to lesions in the jugular foramen,
located approximately 5 mm below the porus of the internal descends through the mastoid lateral to the jugular bulb. The
canal and 5 mm above the intracranial orifice of the hypoglos- endolymphatic sac is situated on the posterior surface of the pe-
sal canal (Figs. 9.2 and 9.4). The lateral edge of the foramen is trous bone between the two layers of the dura in the corner at
located below and in approximately the sagittal plane which the sigmoid sinus changes its course from a vertical
through the lateral end of the internal acoustic meatus. The direction to a horizontal one (Figs. 9.3 and 9.5).
jugular tubercle, a rounded prominence located at the junction
of the basal and condylar parts of the occipital bone, is situated
approximately 8 mm medial to the medial edge of the jugular Dural architecture
foramen. The otic capsule, which is situated in the petrous part At the intracranial orifice, the jugular foramen is divided
of the temporal bone and which contains the semicircular canals into three compartments by the dura mater: the petrosal com-
and cochlea, is located superior to the dome of the jugular bulb. partment situated anteromedially, the sigmoid compartment
The occipital condyle is located along the lateral margin of situated posterolaterally, and the intrajugular or neural com-
the anterior half of the foramen magnum in the area below partment situated between the petrosal and sigmoid parts at
and medial to the jugular foramen. the site of the intrajugular processes of the temporal and
The hypoglossal canals, which pass through the condylar occipital bones, the intrajugular septum, and the glossopha-
part of the occipital bone in the area above the occipital ryngeal, vagus, and accessory nerves (Figs. 9.3 and 9.5). The
condyles, are located medial to the jugular foramina (Figs. 9.1 dura over the intrajugular part of the foramen, which is
and 9.3). The intracranial end of the hypoglossal canal is located anteromedial to the sigmoid part, has two character-
situated below the jugular tubercle approximately 5 mm in- istic perforations, a glossopharyngeal meatus, through which
feromedial to the petrosal part of the jugular foramen and the glossopharyngeal nerve passes, and a vagal meatus,
several millimeters below the lower part of the petroclival through which the vagus and accessory nerves pass (Figs. 9.5

S272 Rhoton
FIGURE 9.3. A, posterior superior view of the jugular foramen. The sigmoid sulcus makes a sharp turn just before emptying
into the sigmoid portion of the jugular foramen. The inferior petrosal sinus extends along the petroclival fissure and enters
the petrosal part of the foramen. The nerves enter the intrajugular part of the foramen located between the sigmoid and
petrosal parts. The outlined area shows the approximate site from which B to F were taken. B, the sigmoid sinus descends in
the sigmoid sulcus and makes a sharp anterior turn to enter the jugular foramen. The jugular bulb extends upward under the
petrous temporal bone toward the internal acoustic meatus. The endolymphatic sac is located above the lower portion of the
sigmoid sinus on the back of the temporal bone and opens above through the vestibular aqueduct into the vestibule. The
glossopharyngeal, vagus and accessory nerves penetrate the dura on the medial side of the intrajugular process. C, the dura
covering the jugular foramen and the jugular bulb have been removed. The nerves penetrate the dura on the medial side of
the intrajugular process of the temporal bone. The intrajugular ridge extends forward along the medial side of the jugular
bulb. D, enlarged view. The glossopharyngeal nerve passes forward along the medial side of the intrajugular ridge, but the
vagus and accessory nerves, although entering the dura on the medial side of the intrajugular process, almost immediately
turn downward and do not course along the medial edge of the intrajugular ridge in the medial wall of the jugular bulb, as

and 9.6) (24). Both meatus are located on the medial side of the medial side of the intrajugular ridge. After the nerve exits the
intrajugular processes and septum. The glossopharyngeal and jugular foramen, it turns forward, crossing the lateral surface
vagal meatus are consistently separated by a dural septum of the internal carotid artery deep to the styloid process. As the
ranging in width from 0.5 to 4.9 mm (13). The only intradural nerve transverses the jugular foramen, it expands at the site of its
site at which the glossopharyngeal nerve is consistently dis- superior and inferior ganglia (Fig. 9.5). At the external orifice
tinguishable from the vagus nerve is just proximal to this of the jugular foramen, it gives rise to the tympanic branch
dural septum. The close origins of the glossopharyngeal and (Jacobson’s nerve), which traverses the tympanic canaliculus to
vagus nerves at the brainstem, and the arachnoidal adhesions enter the tympanic cavity where it gives rise to the tympanic
between the two in their course through the subarachnoid plexus, the fibers of which course in shallow grooves on the
space may make separation difficult except in the area just promontory and regroup to form the lesser petrosal nerve, pro-
proximal to the dural septum. The superior glossopharyngeal
viding parasympathetic innervation by way of the otic ganglion
ganglion is easily visible intracranially in about one-third of
to the parotid gland.
nerves. The superior ganglion of the vagus can be seen in-
The vagal rootlets enter the dural subcompartment, called
tracranially in only one-sixth of nerves. Although the cranial
the vagal meatus, inferior to the glossopharyngeal meatus
and spinal portions of the accessory nerve most frequently
enter the vagal meatus together, a dural septum may separate from which it is separated by a dural septum (Figs. 9.5 and
them. 9.6). It is joined by the accessory nerve as it enters the dura.
The upper and lateral margins of the intrajugular part of the After its rootlets gather in the intracranial orifice of the fora-
foramen are the site of a characteristic thick dural fold that men, the vagus nerve expands at the superior ganglion, which
forms a roof or lip that projects inferiorly and medially to is about 2.5 mm in length, and ends below the extracranial
partially cover the glossopharyngeal and vagal meatus (Figs. orifice of the foramen. It sits on the dura, covering the jugular
9.5 and 9.6). This structure, called the jugular dural fold, was foramen, and there, along the medial side of the intrajugu-
ossified on both sides in one specimen (13, 16, 17, 24, 31). The lar process of the temporal bone, it turns downward. At the
lip projects most prominently over the glossopharyngeal me- superior ganglion, the vagus nerve communicates with the ac-
atus and is comparable to, but smaller than, the posterior lip cessory nerve, a portion of which blends into the ganglion.
of the internal acoustic meatus. It is either predominantly The auricular branch (Arnold’s nerve) arises at the level of the
bony or fibrous and may project a maximum of 2.5 mm over superior vagal ganglion and is joined by a branch from the in-
the margin of the glossopharyngeal meatus. The vagal lip is ferior glossopharyngeal ganglion (Fig. 9.3). The auricular
less prominent, projecting a maximum of 1 mm over the branch passes laterally in a shallow groove on the anterior
lateral margin of the vagal meatus. wall of the jugular bulb to reach the lateral wall of the jugular
fossa, where it enters the mastoid canaliculus and ascends
Neural relationships toward the vertical (mastoid) segment of the facial canal,
giving off an ascending branch to the facial nerve as it crosses
The glossopharyngeal, vagus, and accessory nerves arise
lateral to it before turning downward to exit the temporal
from the medulla as a line of rootlets situated along the
posterior edge of the inferior olive in the postolivary sulcus bone through the tympanomastoid fissure.
(Figs. 9.3 and 9.5). The hypoglossal nerve arises as a line of The main trunk of the vagus nerve (or, more accurately, the
rootlets that exit the brainstem along the anterior margin of superior ganglion) courses anterior and inferior as it crosses
the lower two-thirds of the olive in the preolivary sulcus, a below the midportion of the intrajugular process of the tem-
groove between the olive and medullary pyramid. poral bone (Figs. 9.3 and 9.5). At the intracranial orifice of the
The glossopharyngeal nerve, at the point at which it pene- foramen, the intrajugular process of the temporal bone sepa-
trates the dural glossopharyngeal meatus, turns abruptly for- rates the ganglion from the sigmoid sinus. In most cases, in
ward and then downward and courses through the jugular the area immediately below the dura at the level of the intra-
foramen in the groove leading from the pyramidal fossa be- jugular processes, there are no fibrous bands between the
low the opening of the cochlear aqueduct and along the glossopharyngeal nerve and the vagal ganglion.
Š
does the glossopharyngeal nerve. The auricular branch of the vagus nerve (Arnold’s Nerve) arises from the vagus nerve,
passes along the groove in the anterior wall of the jugular fossa, and penetrates the mastoid canaliculus in the lateral wall of
the fossa. E, the nerves entering the jugular foramen have been displaced downward. The intrajugular process of the temporal
bone projects backward to join the intrajugular process of the occipital bone, thus forming an osseous bridge that divides the
foramen into two parts. The vagus and accessory nerves pass lateral to the osseous bridge and the inferior petrosal sinus
descends below the bridge to open into the internal jugular vein. F, the hypoglossal nerve has been exposed on the lateral
side of the occipital condyle. It exits the hypoglossal canal and joins the glossopharyngeal, vagus, and accessory nerves below
the jugular foramen in the interval between the internal carotid artery and internal jugular vein. A., artery; Ac., acoustic;
Aur., auricular; Br., branch; Car., carotid; CN, cranial nerve; Cond., condyle; Endolymph., endolymphatic; Gang., ganglion;
Inf., inferior; Intrajug., intrajugular; Jug., jugular; Occip., occipital; Pet., petrosal, petrous; Petrocliv., petroclival; Proc., pro-
cess; Sig., sigmoid; Sup., superior; Temp., temporal; Vert., vertebral; Vestib., vestibular.

S274 Rhoton
FIGURE 9.4. A–D. Stepwise dissection

of the structures superficial to and
surrounding the jugular foramen. A,
the skin and scalp around the ear have
been reflected to expose the area
lateral to the jugular foramen. The
sternocleidomastoid is exposed behind
and the parotid gland in front of the
ear. The greater occipital nerve and
occipital artery reach the subcutaneous
tissues by passing between the
attachment of the trapezius and
sternocleidomastoid muscles to the
superior nuchal line. The external
acoustic meatus is located a little
forward of the deep site of the jugular
bulb. B, removal of the superficial
muscles and parotid gland exposes the
facial nerve, temporalis and masseter
muscles, posterior belly of the
digastric, and the internal jugular vein.
The sternocleidomastoid muscle has
been reflected backward to expose the
accessory nerve entering its deep
surface. C, the mandibular ramus and
condyle, medial and lateral pterygoid
muscles, and posterior belly of the
digastric have been removed to expose
the styloid process, which is located
lateral to the jugular foramen. The
internal carotid artery ascends to enter
the carotid canal in front of the jugular
foramen. Both the jugular foramen and
carotid canal are situated behind the
tympanic part of the temporal bone,
which forms the posterior wall of the
condylar fossa. The tensor and levator
vela palatini muscles are attached to
the eustachian tube in the area below
the horizontal segment of the petrous
carotid. The infratemporal fossa is
located below the greater wing of the
sphenoid. The mandibular nerve passes through the foramen ovale to enter the upper part of the infratemporal fossa. Branches of the
ascending pharyngeal artery pass through the jugular foramen to supply the surrounding dura. The hypoglossal nerve passes forward
across the external and internal carotid artery. D, the styloid process has been removed to expose the glossopharyngeal, vagus, accessory,
and hypoglossal nerves descending between the internal carotid artery and the internal jugular vein in the area immediately below the
jugular foramen. The glossopharyngeal nerve descends along the lateral side of the internal carotid artery. The accessory nerve passes
backward across the lateral surface of the internal jugular vein. The hypoglossal nerve passes through the hypoglossal canal, which is
located below and medial to the jugular foramen, and descends with the nerves exiting the jugular foramen. The occipital artery gives
rise to a meningeal branch, which passes through the jugular foramen to supply the surrounding dura, and to the stylomastoid artery,
which passes through the stylomastoid foramen with the facial nerve. A., artery; Asc., ascending; Aur., auricular; Br., branch; Cap.,
capitis; Car., carotid; Chor. Tymp., chorda tympani; CN, cranial nerve; Cond., condylar; Dors., dorsal; Eust., eustachian; Ext., external;
Fiss., fissure; Gl., gland; Gr., greater; Inf., inferior; Int., internal; Jug., jugular; Laryn., laryngeal; Lat., lateral, lateralis; Lev., levator; Long.,
longus; M., muscle; Mast., mastoid; Men., meningeal; N., nerve; Obl., oblique; Occip., occipital; Pal., palatini; Pet., petrosal, petrous;
Pharyn., pharyngeal; Post., posterior; Proc., process; Pteryg., pterygoid; Rec., rectus; Retromandib., retromandibular; Scap., scapulae; Seg.,
segment; Semicirc., semicircular; Sig., sigmoid; Squamotymp., squamotympanic; Sternocleidomast., sternocleidomastoid; Stylogloss.,
styloglossus; Stylomast., stylomastoid; Stylophar., stylopharyngeus; Submandib., submandibular; Sup., superior; Temp., temporal; Tens.,
tensor; TM., temporomandibular; Trans., transverse; Tymp., tympanic, tympany; V., vein; Vel., veli; Vent., ventral; Vert., vertebral.

FIGURE 9.4. E–H. E, the superior

and inferior oblique have been
exposed by reflecting the more
superficial muscles. The C1
transverse process and rectus
capitis lateralis rest against the
posterior surface of the internal
jugular vein. The rectus capitis
lateralis attaches to the jugular
process of the occipital bone at the
posterior margin of the jugular
foramen. Retracting the levator
scapulae exposes the segment of
the vertebral artery ascending
through the C2 transverse foramen
in front of the ventral ramus of the
C2 nerve root. The vertebral artery,
as it passes medially along the
upper surface of the posterior arch
of the atlas, is situated in the floor
of the suboccipital triangle located
between the superior and inferior
oblique and rectus capitis posterior
major. F, the internal carotid artery
has been displaced posteriorly to
expose the branches of the
ascending pharyngeal, which pass
through the foramen lacerum,
jugular foramen, and hypoglossal
canal to supply the surrounding
dura. The chorda tympani exits the
skull in the medial part of the
condylar fossa by first passing
through the petrotympanic and
then along the squamotympanic
sutures. G, the tympanic bone
forming the lower and anterior
margin of the external meatus has
been removed, but the tympanic
sulcus to which the tympanic mem-
brane attaches has been preserved.
The surface of the temporal and occipital bones surrounding the jugular foramen and carotid canal have an irregular surface that
serves as the attachment of the upper end of the carotid sheath. The mastoid segment of the facial nerve and the stylomastoid fora-
men are situated lateral to the jugular bulb. The chorda tympani arises from the mastoid segment of the facial nerve and courses
along the deep side of the tympanic membrane crossing the neck of the malleus. It exits the skull by passing through the petrotym-
panic and squamotympanic sutures and joins the lingual branch of the mandibular nerve distally. The carotid ridge separates the
carotid canal and jugular foramen. Meningeal branches of the ascending pharyngeal and occipital arteries enter the jugular fora-
men. The glossopharyngeal, vagus, and accessory nerves pass through the jugular foramen on the medial side of the jugular bulb.
H, the tympanic ring and bone lateral to the tympanic cavity have been removed. The internal carotid artery has been displaced
forward out of the carotid canal to expose the carotid sympathetic nerves that ascend with the artery. The glossopharyngeal, vagus,
accessory, and hypoglossal nerves exit the skull on the medial side of the internal carotid artery and jugular vein. The glossopha-
ryngeal and hypoglossal nerves pass forward along the lateral surface of the internal carotid artery, and the accessory nerve de-
scends posteriorly across the lateral surface of the internal jugular vein. The vagus nerve descends in the carotid sheath.
The vagus nerve exits the jugular foramen vertically, retain- teromedial wall of the internal jugular vein. As the vagus
ing an intimate relationship to the accessory nerve (Figs. 9.3– nerve passes lateral to the outer orifice of the hypoglossal
9.5). At the level the two nerves exit the jugular foramen, they canal, it is joined by the hypoglossal nerve medially. The
are located behind the glossopharyngeal nerve on the pos- vagus nerve begins to expand at the site of the inferior vagal

S276 Rhoton
FIGURE 9.4. I–N. I, lateral view of mastoid and tympanic cavity before removing the tympanic ring. The tympanic segment of the facial
nerve passes below the lateral semicircular canal and turns downward as the mastoid segment to exit the stylomastoid foramen. The
stylomastoid foramen and the mastoid segment are located lateral to the jugular bulb. The semicircular canals are located above the jugu-
lar bulb. J, a probe has been placed in the eustachian tube, which passes downward, forward, and medially from the tympanic cavity and
across the front of the petrous carotid. The third trigeminal division passes through the foramen ovale on the lateral side of the eustachian
tube. K, enlarged view of the tympanic ring with the tympanic membrane removed. The tensor tympany muscle passes backward above
the eustachian tube and gives rise to a tendon that turns sharply lateral around the trochleiform process to attach to the malleus. The
chorda tympani crosses the inner surface of the tympanic membrane and neck of the malleus. The round window opens into the vesti-
bule. The stapes sit in the oval window. The promontory is located lateral to the basal turn of the cochlea. L, the floor of the middle fossa
and the tympanic sulcus have been removed to expose the jugular bulb and petrous carotid. The greater petrosal nerve courses along the
floor of the middle fossa on the upper surface of the petrous carotid. The deep petrosal nerve arises from the sympathetic bundles on the
internal carotid artery. The deep and greater petrosal nerves join to form the vidian nerve, which passes forward through the vidian canal
to join the maxillary nerve and pterygopalatine ganglion in the pterygopalatine fossa. The pharyngobasilar fascia and upper part of the

ganglion just below the foramen and is approximately 2.5 cm glossopharyngeal nerve is located laterally and the vagus,
in length. accessory, and hypoglossal nerves medially.
After the internal carotid artery enters the carotid canal
Accessory nerve with the carotid sympathetic nerves and surrounding venous
Although the cranial and spinal portions of the accessory plexus, it ascends a short distance (the vertical segment),
nerve most frequently enter the vagal meatus together, they reaching the area below and slightly behind the cochlea,
may infrequently be separated by a dural septum. The spinal where it turns anteromedially at a right angle (the site of the
portion ascends toward the foramen magnum by crawling lateral bend) and courses horizontally (the horizontal seg-
along the surface of the dura and may even be buried in the ment) toward the petrous apex (Fig. 9.4). At the medial edge
dura below the foramen magnum (Figs. 9.3, 9.5, and 9.6). At of the foramen lacerum, it turns sharply upward at the site of
the dural orifice of the jugular foramen, the nerve is often the medial bend to enter the posterior part of the cavernous
indistinguishable from the vagus nerve. The accessory nerve sinus.
usually enters the same dural subcompartment as the vagus
nerve and often adheres and blends into the vagus nerve at External carotid artery
the level of the superior vagal ganglion. The accessory nerve
departs the vagal ganglion after it exits the jugular foramen The external carotid artery ascends anterior to the internal
and descends obliquely laterally between the internal carotid carotid artery. Proximal to its terminal bifurcation into the
artery and internal jugular vein and then backward across the maxillary and the superficial temporal arteries, it gives rise to
lateral surface of the vein to reach its muscles. Approximately six branches, which can be divided into anterior and posterior
30% of nerves descend along the medial, rather than the groups according to their directions. The latter group is re-
lateral, surface of the internal jugular vein (8). lated to the jugular foramen.
The ascending pharyngeal artery, the first branch of the
Hypoglossal nerve posterior group, often provides the most prominent supply to
the meninges around the jugular foramen (Fig. 9.4) (18). It
The hypoglossal nerve does not traverse the jugular fora- arises either at the bifurcation or from the lowest part of the
men (Figs. 9.3–9.5). However, it joins the nerves exiting the external or internal carotid arteries. Rarely it arises from the
jugular foramen just below the skull and runs with them in origin of the occipital artery. It courses upward between the
the carotid sheath. The nerve exits the inferolateral part of the internal and the external carotid arteries, giving rise to nu-
hypoglossal canal and passes adjacent to the vagus nerve, merous branches to neighboring muscles, nerves, and lymph
descends between the internal carotid artery and the internal nodes. Its meningeal branches pass through the foramen
jugular vein to the level of the transverse process of the atlas, lacerum to be distributed to the dura lining the middle fossa
where it turns abruptly forward along the lateral surface of and through the jugular foramen or the hypoglossal canal to
the internal carotid artery toward the tongue, leaving only the supply the surrounding dura of the posterior cranial fossa.
ansa cervicalis to descend with the major vessels. The ascending pharyngeal artery also gives rise to the inferior
tympanic artery, which reaches the tympanic cavity by way of
ARTERIAL RELATIONSHIPS the tympanic canaliculus along with the tympanic branch of
the glossopharyngeal nerve.
The arteries that may be involved in pathological abnor-
The occipital artery, the second and largest branch of the
malities at the jugular foramen include the upper cervical and
posterior group, arises from the posterior surface of the ex-
petrous portions of the internal carotid artery, the posteriorly
ternal carotid artery and courses obliquely upward between
directed branches of the external carotid artery, and the upper
the posterior belly of the digastric muscle and the internal
portion of the vertebral artery (Fig. 9.4).
jugular vein (Fig. 9.4). Its meningeal branches, which enter the
posterior fossa through the jugular foramen or the condylar
Internal carotid artery canal, may make a significant contribution to tumors of the
The internal carotid artery passes, almost straightly up- jugular foramen.
ward, posterior to the external carotid artery and anterome- The posterior auricular artery, the last branch in the poste-
dial to the internal jugular vein, to reach the carotid canal (Fig. rior group, arises above the posterior belly of the digastric
9.4). At the level of the skull base, the internal jugular vein muscle and travels between the parotid gland and the styloid
courses just posterior to the internal carotid artery, being process. At the anterior margin of the mastoid process, it
separated from it by the carotid ridge. Between them, the divides into auricular and occipital branches, which are dis-
Š
longus capitis have been reflected downward to expose the lower margin of the clivus. M, the jugular bulb has been removed from the
jugular fossa located below the vestibule and semicircular canals. The vertical segment of the petrous carotid has been removed. The
cochlea, which has been opened, is located above the lateral genu of the petrous carotid. The tympanic segment of the facial nerve
passes posteriorly below the lateral semicircular canal. N, the retrosigmoid and presigmoid dura have been opened. The lateral wall of
the vestibule and cochlea have been removed. The vestibule, semicircular canals, and cochlea are exposed above the jugular bulb and
lateral genu of the petrous carotid.

S278 Rhoton
FIGURE 9.5. A, posterior view of the intracranial aspect of the left jugular foramen. The glossopharyngeal, vagus, and accessory nerves
pierce the dural roof of the jugular foramen. The glossopharyngeal nerve is separated from the vagus nerve by a narrow dural septum.
The jugular dural fold projects downward and medially from the lateral and upper margin of the jugular foramen over the site at which
the nerves enter the dura roof of the foramen. The facial and vestibulocochlear nerves and labyrinthine artery enter the internal acoustic
meatus. The subarcuate branch of the anteroinferior cerebellar artery enters the subarcuate fossa. The endolymphatic sac is located
between the dural layers lateral to the jugular foramen. A bridging vein from the medulla joins the inferior petrosal sinus on the medial
side of the jugular bulb. B, the dura has been removed from the posterior surface of the temporal bone. The intrajugular processes of the
temporal and occipital bones, which are connected by a fibrous bridge, the intrajugular septum, separates the sigmoid and petrosal parts
of the foramen. The glossopharyngeal, vagus, and accessory nerves enter the intrajugular part of the foramen by penetrating the dura on
the medial side of the intrajugular process of the temporal bone. C, the glossopharyngeal nerve enters the jugular foramen below the
cochlear aqueduct. The vagus nerve enters the jugular foramen behind the glossopharyngeal nerve. The auricular branch of the vagus
nerve (Arnold’s nerve) arises at the level of the superior ganglion and passes around the anterior wall of the jugular bulb. The acces-
sory nerve is formed by multiple rootlets, which arise from the medulla and spinal cord. The accessory rootlets collect together to form a
bundle that blends into the lower margin of the vagus nerve at the level of the jugular foramen. The lower vagal and accessory roots pass
across the surface of the jugular tubercle. D, enlarged view. The glossopharyngeal nerve expands at the site of the superior and inferior
ganglia. The superior ganglion of the vagus nerve is located at the level of or just below the dural roof of the foramen, and the infe-
rior ganglion is located below the foramen at the level of the atlanto-occipital joint. A., artery; Atl., atlanto-; Aur., auricular; Br., branch;
Bridg., bridging; Car., carotid; CN, cranial nerve; Coch., cochlear; Cond., condyle; Endolymph., endolymphatic; Gang., ganglion; Glosso-
phar., glossopharyngeal; Hypogl., hypoglossal; Inf., inferior; Int., internal; Intrajug., intrajugular; Jug., jugular; Labyr., labyrinthine; Lat.,
lateral; Occip., occipital; Pet., petrosal; Proc., process; Sig., sigmoid; Subarc., subarcuate; Sup., superior; Temp., temporal; Vert., vertebral.
tributed to the postauricular and the occipital regions respec- it anastomoses with the petrosal branch of the middle men-
tively. The stylomastoid branch, which arises below the stylo- ingeal artery. The posterior auricular branch may share a
mastoid foramen, enters the stylomastoid foramen to supply common trunk with the occipital artery, or sometimes it is
the facial nerve. Its loss can lead to a facial palsy even though absent, in which case, the occipital artery gives rise to the

FIGURE 9.6. Retrosigmoid approach to jugular foramen. A, the detail shows the site of the vertical scalp incision and right
retrosigmoid craniotomy. The cerebellum has been elevated to expose the nerves in the right cerebellopontine angle. The
glossopharyngeal and vagal nerves are separated by the dural septum at the level of the dural roof of the jugular foramen.
The glossopharyngeal nerve enters the glossopharyngeal meatus and the vagus nerve enters the vagal meatus with the
branches of the accessory nerve. Both meatus are very shallow compared with the internal acoustic meatus. The superior and
lateral margins of both meatus project downward and medially over the nerves entering the meatus. The vertebral artery dis-
places the hypoglossal rootlets of Cranial Nerve XII posteriorly so that they intermingle with the rootlets of the accessory
nerve. B, another specimen showing the relationship of the rhomboid lip and choroid plexus protruding from the foramen of
Luschka to the glossopharyngeal and vagus nerves. The choroid plexus protrudes laterally behind the glossopharyngeal nerves.
The rhomboid lip is a thin layer of neural tissue that forms the ventral margin of the foramen of Luschka at the outer end of
the lateral recess. C and D, enlarged view of two jugular foramina. The glossopharyngeal and vagus nerves are consistently
separated by a dural septum at the level of the roof over the jugular foramen. The jugular dural fold projects downward and
medially over the lateral edge of the glossopharyngeal and vagal meatus and over the site at which the nerves penetrate the
dura. A., artery; A.I.C.A., anteroinferior cerebellar artery; Chor., choroid; CN, cranial nerve; Glossophar., glossopharyngeal;
Jug., jugular; Plex., plexus; Vert., vertebral.
stylomastoid artery. Members of the anterior group, whose the meningeal, posterior spinal, and posteroinferior cerebellar
origins may be visualized in exposing lesions of the jugular artery.
foramen, include the superior thyroid, lingual, and facial
arteries.
VENOUS RELATIONSHIPS
Vertebral artery The jugular bulb and adjacent part of the internal jugular
The vertebral artery, as it ascends to reach and pass vein receives drainage from both intracranial and extracranial
through the transverse foramen of the atlas, is located below sources, which include the sigmoid and inferior petrosal si-
and behind the jugular foramen (Fig. 9.4). Branches encoun- nuses, the vertebral venous plexus, the venous plexus of the
tered in approaches to lesions of the jugular foramen include hypoglossal canal, the posterior condylar emissary vein, and

S280 Rhoton
the vein coursing along the inferior aspect of the petroclival MUSCULAR RELATIONSHIPS
fissure (Figs. 9.4 and 9.5).
Several muscles that are encountered in the surgical ap-
proaches to the jugular foramen and that provide important
Sigmoid sinus and jugular bulb
landmarks in the approach are reviewed in detail in the
The sigmoid sinus is the largest channel emptying into the chapters on the foramen magnum and temporal bone (Fig.
jugular foramen (Figs. 9.1 and 9.3–9.5). After coursing down 9.4). These include the sternocleidomastoid, situated superfi-
the sigmoid sulcus, the sinus turns anteriorly toward the cially in the lateral neck, and the splenius capitis, longissimus
jugular foramen, crossing the occipitomastoid suture imme- capitis, levator scapulae, and scalenus medius muscles in a
diately proximal to the foramen. From there, the sinus is deeper muscular layer.
directed forward below the petrous temporal bone at the site More anteriorly is the posterior belly of the digastric mus-
of the jugular bulb. The upward bulging of the superior cle, which arises in the digastric groove located medial to the
margin of the jugular bulb creates a rounded fossa in the mastoid process and the longissimus capitis. The styloid pro-
lower surface of the temporal bone below the internal audi- cess and its attached muscles appear in the triangular zone
tory canal. The dome of the jugular bulb may extend upward bounded by the posterior belly of the digastric, the external
in the posterior wall of the internal auditory canal to the level auditory canal, and the mandibular ramus. Reflecting the
of the upper margin of the canal. The bulb is usually larger on digastric muscle exposes the transverse process of the atlas,
the right side, reflecting the larger diameter of the sigmoid which is covered by the attachments of numerous muscles,
sinus on that side. From the level of the jugular bulb, flow is including the superior and inferior obliques, which form the
directed downward behind the tympanic bone and the carotid upper and lower margin of the suboccipital triangle. The
canal into the internal jugular vein. rectus capitis lateralis muscle is the muscle most intimately
related to the jugular foramen. It extends vertically behind the
Inferior petrosal sinus and venous confluens internal jugular vein from the transverse process of the atlas
The foramen also receives the inflow from the inferior to the jugular process of the occipital bone.
petrosal sinus and the venous confluens in the petrosal part of On the posterior neck are the trapezius muscle, splenius
the foramen. The inferior petrosal sinus, which courses on the capitis, and semispinalis capitis. Beneath the semispinalis ca-
intracranial surface of the petroclival fissure, communicates pitis muscle, three muscles arise between the inferior nuchal
the cavernous sinus and basilar venous plexus at its upper line and the margin of the foramen magnum: the rectus capitis
end and with the jugular bulb at its lower end (Figs. 9.3 and posterior major and minor and the superior oblique muscle.
9.5). The inferior petrosal sinus, as it enters the petrosal part of The suboccipital triangle, an area defined by the opposing
the jugular foramen, forms a plexiform confluens with the margins of the rectus capitis posterior major and the superior
venous plexus of the hypoglossal canal, the inferior petro- and inferior oblique muscles, is the site at which the vertebral
clival vein, and tributaries from the vertebral venous plexus artery courses along the upper posterior surface of the atlas.
and posterior condylar emissary vein. This confluens, which
fills the petrosal part of the foramen, usually consists of a SURGICAL APPROACHES
main channel, 2 to 3 mm in diameter, and several smaller
channels, less than 1 mm in diameter. It empties into the Postauricular transtemporal approach
medial aspect of the jugular bulb through one or two open- The postauricular transtemporal approach accesses the re-
ings in the venous walls between the glossopharyngeal and gion from laterally, through the mastoid, and from below,
vagus nerves or into the internal jugular vein below the through the neck (Fig. 9.7) (2, 4, 5). A C-shaped postauricular
extracranial orifice. skin incision provides the exposure for a mastoidectomy and
The inferior petroclival vein courses along the extracranial the neck dissection. The external auditory canal is either pre-
surface of the petroclival fissure and is a mirror image of the served or transected, depending on the anterior extent of the
inferior petrosal sinus, which courses along the intracranial pathological abnormality. The neck dissection is completed
surface of the fissure (Fig. 9.5). It empties into the venous initially to gain control of the major vessels and the branches
confluens at the lower end of the inferior petrosal sinus at or supplying the tumor. The internal carotid artery, branches of
just below the extracranial orifice of the jugular foramen or the external carotid artery, internal jugular vein, and lower
even above it, through bony clefts between the temporal and cranial nerves are exposed in the carotid sheath. A mastoid-
occipital bones. ectomy with extensive drilling of the infralabyrinthine region
accesses the jugular bulb. A limited mastoidectomy confined
Bridging veins to the area behind the stylomastoid foramen and mastoid
A bridging vein, which courses posterior to the glossopha- segment of the facial nerve, combined with removal of the
ryngeal, vagus, and accessory nerves from the dorsolateral adjacent part of the jugular process of the temporal bone, will
medulla to the lower end of the sigmoid sinus, is present in provide access to the posterior and posterolateral aspect of the
about one-third of cerebellopontine angles (Fig. 9.5, also see jugular foramen. Three obstacles to exposure of the full lateral
Fig. 3.12). Infrequently, a bridging vein extends from the half of the jugular foramen, the facial nerve, styloid process,
ventral medulla to the lower margin of the inferior petrosal and rectus capitis lateralis muscle are dealt with by transpos-
sinus in front of the nerves. ing the facial nerve, removing the styloid process, and divid-

FIGURE 9.7. A–D. Postauricular exposure of the jugular foramen. A, the detail shows the site of the scalp incision. The
C-shaped retroauricular incision provides access for the mastoidectomy, neck dissection, and parotid gland displacement. The
scalp flap has been reflected forward to expose the sternocleidomastoid and the posterior part of the parotid gland. B, the
more superficial muscles and the posterior belly of the digastric have been reflected to expose the internal jugular vein and
the attachment of the superior and inferior oblique to the transverse process of C1. A mastoidectomy has been completed to
expose the facial nerve, sigmoid sinus, and capsule of the semicircular canals. C, enlarged view of the mastoidectomy. The
jugular bulb is exposed below the semicircular canals. The chorda tympani arises from the mastoid segment of the facial
nerve and passes upward and forward. The tympanic segment of the facial nerve courses below the lateral canal. D, enlarged
view of the caudal part of the exposure shown in C. The facial nerve and styloid process cover the extracranial orifice of the
jugular foramen. The facial nerve crosses the lateral surface of the styloid process. The stylomastoid artery arises from the
postauricular artery. The rectus capitis lateralis attaches to the jugular process of the occipital bone behind the jugular fora-
men. A., artery; Aur., auricular; Cap., capitis; Car., carotid; Chor. Tymp., chorda tympani; CN, cranial nerve; Coch., cochlear;
Gl., gland; Gr., greater; Inf., inferior; Int., internal; Intrajug., intrajugular; Jug., jugular; Laryn., laryngeal; Lat., lateral, latera-
lis; M., muscle; Med., medial; Mid., middle; N., nerve; Obl., oblique; Occip., occipital; Pet., petrosal, petrous; Post., posterior;
Proc., process; Rec., rectus; Semicirc., semicircular; Sig., sigmoid; Sternocleidomast., sternocleidomastoid; Stylomast., stylo-
mastoid; Sup., superior; Symp., sympathetic; Tr., trunk; Trans., transverse; V., vein.
ing the rectus capitis lateralis muscle. Anterior extensions of sure can be extended by opening the otic capsule (translaby-
the pathological abnormality are reached by sacrificing the rinthine approach).
external and the middle ear structures. Sensorineural hearing
can be preserved by maintaining the foot plate of the stapes in
the oval window to avoid opening the labyrinth. Intracranial Retrosigmoid approach
extensions of the lesion are reached by the retrosigmoid or A pathological abnormality located predominantly intra-
presigmoid approaches after adding a suboccipital craniec- durally can be resected by the retrosigmoid approach (Fig.
tomy. The lesion can be removed by a transtemporal infral- 9.6). A lateral suboccipital craniectomy exposes the dura be-
abyrinthine approach directed through the temporal bone hind the sigmoid sinus. The dura is opened, and the cerebel-
below the labyrinth without the neck dissection, if the ex- lum is gently elevated away from the posterior surface of the
tracranial extension of the lesion is not prominent. The expo- temporal bone to expose the cisterns in the cerebellopontine

S282 Rhoton
FIGURE 9.7. E–H. E, the external auditory canal has been transected and the middle ear structures have been removed,
except the stapes, which has been left in the oval window. The lateral edge of the jugular foramen has been exposed by com-
pleting the mastoidectomy, transposing the facial nerve anteriorly, and fracturing the styloid process across its base and
reflecting it caudally. The rectus capitis lateralis has been detached from the jugular process of the occipital bone. The
petrous carotid is surrounded in the carotid canal by a venous plexus. F, a segment of the sigmoid sinus, jugular bulb, and
internal jugular vein have been removed. The lateral wall of the jugular bulb has been removed while preserving the medial
wall and exposing the opening of the inferior petrosal sinus into the jugular bulb. Removing the venous wall exposes the glos-
sopharyngeal, vagus, accessory, and hypoglossal nerves, which are hidden deep to the vein. The main inflow from the petro-
sal confluens is directed between the glossopharyngeal and vagus nerves. G, the medial venous wall of the jugular bulb has
been removed. The intrajugular ridge extends forward from the intrajugular process, which divides the jugular foramen
between the sigmoid and petrosal parts. The glossopharyngeal, vagus, and accessory nerves enter the dura on the medial side
of the intrajugular process, but only the glossopharyngeal nerve courses through the foramen entirely on the medial side of the
intrajugular ridge. The vagus nerve also enters the dura on the medial side of the intrajugular process, but does not course along
the medial side of the intrajugular ridge. H, the intrajugular process and ridge have been removed to expose the passage of the
glossopharyngeal, vagus, and accessory nerves through the jugular foramen. The tip of a right-angle probe identifies the junction of
the cochlear aqueduct with the pyramidal fossa, just above where the glossopharyngeal nerve penetrates the dura.
angle and the intracranial aspect of the cranial nerves entering magnum in front of or lateral to the lower brainstem (10, 30, 32,
the jugular foramen, hypoglossal canal, and internal acoustic 33). In this approach, the jugular foramen is opened from be-
meatus. hind. The dura is opened and the cerebellum elevated to expose
the intracranial extension of the pathological abnormality at the
lower clivus and at the foramen magnum. Several variations,
Far-lateral approach depending on the location and extent of the pathological abnor-
An extended modification of the retrosigmoid approach, the mality, include drilling the jugular tubercle extradurally and
far-lateral approach, the subject of another chapter in this issue, removing bone above without disturbing the condyle (21, 33).
may be selected if the tumor extends down to the foramen The extradural reduction of the jugular tubercle aids in minimiz-

ing the retraction of the brainstem needed to reach the area Neuromas arise either from the glossopharyngeal, vagus, or
anterior to the medulla and pontomedullary junction. the accessory nerves, and meningiomas from arachnoid gran-
ulations in the jugular bulb or venous sinuses. Although each
Preauricular subtemporal-infratemporal approach tumor has characteristic patterns of invasion and destruction,
the basic anatomic environment is similar to that of the glo-
The preauricular subtemporal-infratemporal approach, re-
mus jugulare tumor.
viewed in detail in the chapter on the temporal bone (see Figs.
8.10 and 8.18), exposes the jugular foramen anteriorly. It may
be selected for tumors that extend along the petrous portion of Selection of surgical approach
the internal carotid artery, through the eustachian tube, or The approaches to the jugular foramen can be categorized
through the cancellous portion of the petrous apex (29). A into three groups: 1) a lateral group directed through the
preauricular hemicoronal scalp incision is extended down to mastoid bone, 2) a posterior group directed through the pos-
at least the level of the tragus and possibly into the cervical terior cranial fossa, and 3) an anterior group directed through
region, depending on the extent of the pathological finding the tympanic bone. This categorization is based on the ana-
and whether a neck dissection is needed. The zygomatic arch tomic fact that the block of the temporal bone, excluding the
is removed or reflected downward with the temporalis mus- squamous part, is regarded as an irregular pyramid, having
cle, taking care to preserve the frontal branch of the facial its base on the mastoid surface. In addition, the middle fossa
nerve. A frontotemporal bone flap, which may include the approaches could be categorized as in the “superior group”
superior or lateral orbital rim, is elevated, and the glenoid and the neck dissection upward to the jugular foramen as in
fossa and the mandibular condyle with the joint capsule are the “inferior group.” However, the latter approaches are usu-
either dislocated inferiorly or removed. The dura is elevated, ally not suitable when used alone for pathological abnormal-
and the bone of the middle fossa medial to the glenoid fossa ities of the jugular foramen.
is removed until the carotid canal is opened. The eustachian
tube and the tensor tympani muscle, which course anterior to Lateral approach
the carotid canal, are sacrificed during this procedure, taking The lateral approach directed through a mastoidectomy,
care to protect the lower cranial nerves as they exit the jugular used alone or in combination with other approaches, is the
foramen. The styloid process is divided at its base, and the route most commonly selected for lesions extending through
internal carotid artery is reflected anteriorly to gain access to the jugular foramen (7, 12, 22). Because the jugular foramen is
the clivus and anterior aspect of the jugular foramen. Drilling situated under the otic capsule, the approach basic to this
can be extended to the posterior fossa through Kawase’s group is called the infralabyrinthine approach. The facial
triangle or through the clivus to the contralateral internal nerve is frequently transposed anteriorly to drill the bone
carotid artery (14). inferior to the labyrinth. Avoiding injury to the facial nerve is
one of the key points in the lateral approaches (1). Even with
DISCUSSION special care, some degree of transient facial palsy is common,
possibly because of disturbance to the nerve’s vasculature.
Pathologies The surgical field can be widened anteriorly by sacrificing the
Tumors are the most common lesions to affect the jugular external auditory canal and middle ear structures or medially
foramen; the majority are chemodectomas (glomus jugulare by drilling away the otic capsule (translabyrinthine approach)
tumor), neurinomas, and meningiomas, with a small percent- or cochlea (transcochlear approach).
age of other tumors, such as chondrosarcomas and chordo- The postauricular transtemporal approach, when combined
mas (12, 25). The glomus jugulare tumor arises either in the with a neck dissection, provides satisfactory exposure of the
adventitia of the jugular dome or from the intumescences jugular foramen, mastoid air cells, tympanic cavity, and the
along the tympanic branch of the glossopharyngeal nerve or extracranial structures in and around the carotid sheath. Re-
the auricular branch of the vagus nerve in the jugular foramen moval of the styloid process along with transposition of the
(9). Tumors of the same nature that arise in the tympanic facial nerve facilitates wide opening of the extracranial orifice
cavity or in the mastoid on branches of these nerves are of the jugular foramen and provides access to the lower part
referred to as glomus tympanicum tumors. Small glomus of the petrous portion of the internal carotid artery. A wider
jugulare tumors remain confined within the jugular foramen. exposure for the extracranial tumor can be obtained by re-
However, the tumor can extend as follows: 1) along the eu- moving the transverse process of the atlas or dislocating or
stachian tube into the nasopharynx and through the foramina resecting the mandibular condyle. The intracranial extension
at the base of the skull, 2) along the carotid artery to the of the tumor is approached either retrosigmoidally or presig-
middle fossa, 3) through the intracranial orifice of the jugular moidally after adding a lateral suboccipital craniectomy or
foramen or along the hypoglossal canal to the posterior fossa, craniotomy (4, 6, 10, 26, 27).
4) through the tegmen tympani to the floor of the middle
fossa, 5) through the round window and the internal acoustic Posterior approach
meatus to the cerebellopontine angle, and 6) through the This group includes the retrosigmoid approach and its
extracranial orifice of the jugular foramen to the upper cervi- more extensive far-lateral and transcondylar variants. These
cal region. approaches are suited to the intracranial portion of the tu-

S284 Rhoton
mors. The conventional retrosigmoid approach provides access 4. Fisch U, Fagan P, Valavanis A: The infratemporal fossa approach for
to the cerebellopontine angle and the intracranial orifice of the the lateral skull base. Otolaryngol Clin N Am 17:513–552, 1984.
jugular foramen. However, extensions of the tumor through 5. Gardner G, Cocke EW, Robertson JT, Trumbull ML, Palmer RE:
the foramen magnum or medially into the clivus are beyond the Combined approach surgery for removal of glomus jugulare tu-
reach of this approach. The far-lateral and transcondylar modi- mors. Laryngoscope 87:665–688, 1977.
fications access these areas, providing an upward view from 6. Gardner G, Robertson JT, Robertson JH, Cocke EW, Clark WC:
Glomus jugulare tumors: Skull base surgery, in Schmidek HH,
below by opening the posterolateral quarter of the foramen
Sweet WH (eds): Operative Neurological Techniques. Philadelphia,
magnum and removing the posterior part of the occipital con-
W.B. Saunders Co., 1988, ed 2, pp 739–752.
dyle. The posterior and posterolateral margin of the jugular
7. Goldenberg RA, Gardner G: Tumors of the jugular foramen:
foramen can be accessed by removing the part of the jugu- Surgical preservation of neural function. Otolaryngol Head Neck
lar process of the occipital bone located behind the jugular Surg 104:129, 1991.
foramen and the portion of the mastoid located behind the 8. Grant JCB: An Atlas of Anatomy. Baltimore, Williams & Wilkins, 1951.
mastoid segment of the facial nerve and stylomastoid fora- 9. Guild SR: Glomus jugulare in man. Ann Otol Rhinol Laryngol
men. A flatter view toward the midline clivus is obtained by 62:1045–1071, 1953.
additional extradural drilling of the jugular tubercle, although 10. Hakuba A, Hashi K, Fujitani K, Ikuno H, Nakamura T, Inoue Y:
drilling in front of these nerves risks damaging the nerves as Jugular foramen neurinomas. Surg Neurol 11:83–94, 1979.
they cross the jugular tubercle (21, 23). 11. Hovelacque A: Osteologie. Paris, G Doin and Cie, 1967, vol 2, pp
155–156.
12. Jackson CG, Cueva RA, Thedinger BA, Glasscock ME III: Cranial
Anterior approach
nerve preservation in lesions of the jugular fossa. Otolaryngol
The preauricular subtemporal-infratemporal approach is a Head Neck Surg 105:687–693, 1991.
major variant of this group of approaches. It uses the pathway 13. Katsuta T, Rhoton AL Jr, Matsushima T: The jugular foramen:
anterior to the external auditory canal and through the tym- Microsurgical anatomy and operative approaches. Neurosurgery
panic bone, which are exposed by removal or displacement of 41:149–202, 1997.
the glenoid fossa and the temporomandibular joint. The ap- 14. Kawase T, Toya S, Shiobara R, Mine S: Transpetrosal approach for
proach alone can access the anterior part of the jugular fora- aneurysms of the lower basilar artery. J Neurosurg 63:857–867, 1985.
men after reflecting the petrous portion of the internal carotid 15. Kveton JF, Cooper MH: Microsurgical anatomy of the jugular
artery anteriorly. Further extensive drilling will expose the foramen region. Am J Otol 9:109–112, 1988.
16. Lang J: Anatomy in and on the jugular foramen, in Frowein RA,
middle to upper clivus anteriorly. However, this approach is
Brock M, Klinger M (eds): Advances in Neurosurgery. Berlin,
most often combined with a lateral approach to access an
Springer-Verlag, 1989, vol 17, pp 125–132.
anterior extension of the pathology (22). Fisch et al. call this 17. Lang J: Clinical Anatomy of the Posterior Cranial Fossa and its Foram-
combined approach the infratemporal fossa approach, Type B ina. New York, Thieme Medical Publishers, 1991, pp 92–95.
or C according to the anterior extension of the exposure (4). 18. Lang J: Anatomy of the posterior cranial fossa, in Sekhar LN,
The selection of the optimal approach requires an under- Janecka IP (eds): Surgery of Cranial Base Tumors. New York, Raven
standing of the nature and the extension of the lesion. The Press, 1993, pp 131–146.
combination of two or three approaches may be needed either 19. Lang J, Weigel M: Nerve-vessel relations in the region of the
in stages or in combination in one operative procedure (4, 25). jugular foramen. Anat Clin 5:41–56, 1983.
Preoperative embolization will often reduce the blood loss 20. Leonetti JP, Brackmann DE, Prass RL: Improved preservation of
with a vascular tumor. Intraoperative electrophysiological facial nerve function in the infratemporal approach to the skull
monitoring is of great help in avoiding nerve injury, in locat- base. Otolaryngol Head Neck Surg 101:74–78, 1989.
ing the neural trajectory in and around the tumor, or in 21. Matsushima, T, Ikezaki K, Nagata S, Inoue T, Natori Y, Fukui M,
predicting postoperative neural function (3, 20). Carefully Rhoton AL Jr: Microsurgical anatomy for lateral approaches to the
foramen magnum: With special reference to the far-lateral ap-
planned reconstruction is required to reduce postoperative
proach and the transcondylar approach, in Nakagawa H (ed):
complications, especially leakage of cerebrospinal fluid, and
Surgical Anatomy for Microneurosurgery VII. Tokyo, SciMed Publi-
to achieve a satisfactory cosmetic result. cations, 1995, pp 81–89.
22. Patel SJ, Sekhar LN, Cass SP, Hirsch BE: Combined approaches
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro- for resection of extensive glomus jugulare tumors: A review of 12
logical Surgery, University of Florida Brain Institute, P.O. Box 100265, cases. J Neurosurg 80:1026–1038, 1994.
100 S. Newell Drive, Building 59, L2–100, Gainesville, FL 32610-0265. 23. Perneczky A: The posterolateral approach to the foramen mag-
num, in Samii M (ed): Surgery in and around the Brain Stem and the
Third Ventricle. Berlin, Springer-Verlag, 1986, pp 460–466.
REFERENCES
24. Rhoton AL Jr, Buza R: Microsurgical anatomy of the jugular
1. Brackmann DE: The facial nerve in the infratemporal approach. foramen. J Neurosurg 42:541–550, 1975.
Otolaryngol Head Neck Surg 97:15–17, 1987. 25. Samii M, Bini W: Surgical strategy for jugular foramen tumors, in
2. Brackmann DE, Arriaga MA: Surgery for glomus tumors, Sekhar LN, Janecka IP (eds): Surgery of Cranial Base Tumors. New
in Brackmann DE (ed): Otologic Surgery. Philadelphia, W.B. York, Raven Press, 1993, pp 379–387.
Saunders Co., 1994, pp 579–593. 26. Samii M, Draf W: Surgery of the middle skull base, in Samii M,
3. DiChiro G, Fischer RL, Nelson KB: The jugular foramen. J Neuro- Dwarf W (eds): Surgery of the Skull Base: An Interdisciplinary Ap-
surg 21:447–460, 1964. proach. New York, Springer-Verlag, 1989, pp 234–359.

27. Samii M, Babu RP, Tatagiba M, Sepehrnia A: Surgical treatment of 31. Silverstein H, Willcox TO, Rosenberg SI, Seidman MD: The jug-
jugular foramen schwannomas. J Neurosurg 82:924–932, 1995. ular dural fold: A helpful base landmark to the cranial nerves.
28. Schwaber MK, Netterville JL, Maciunas R: Microsurgical anatomy of Skull Base Surg 5:57–61, 1995.
the skull base: A morphometric analysis. Am J Otol 11:401–405, 1990. 32. Spetzler RF, Grahm TW: The far-lateral approach to the inferior
29. Sekhar LN, Schramm VL Jr, Jones NF: Subtemporal-preauricular clivus and the upper cervical region: Technical note. Barrow
infratemporal fossa approach to large lateral and posterior cranial Neurol Inst Q 6:35–38, 1990.
base neoplasms. J Neurosurg 67:488–499, 1987. 33. Wen HT, Rhoton AL Jr, Katsuta T, de Oliveira E: Microsurgical
30. Sen CN, Sekhar LN: An extreme lateral approach to intradural anatomy of the transcondylar, supracondylar, and paracondylar
lesions of the cervical spine and foramen magnum. Neurosurgery extensions of the far-lateral approach. J Neurosurg 87:555–585,
27:197–204, 1990. 1997.
Cranial cavity with posterior fossa structures, including cerebellum and cranial nerves, from, Andreas Vesalius, De
Humani Corporis Fabrica. Basel, Ex officina Ioannis Oporini, 1543. Courtesy, Rare Book Room, Norris Medical Library,
Keck School of Medicine, Los Angeles, California. (Also see pages S27, S68, and S209.)

CHAPTER 10
The Posterior Fossa Cisterns

Key words: Brainstem, Cerebellum, Cranial nerve, Posterior cranial fossa, Subarachnoid cistern
T
he subarachnoid space, situated between the pia mater B. Paired cisterns
and the outer arachnoid membrane, expands at the base 1. Cerebellopontine cistern
of the brain, around the brainstem, and in the tentorial 2. Cerebellomedullary cistern
incisura to form compartments filled with cerebrospinal fluid.
Numerous trabeculae, septa, and membranes cross the space
between the pia mater and the outer arachnoid membrane to
INTERPEDUNCULAR CISTERN AND
divide the subarachnoid space into smaller compartments
LILIEQUIST’S MEMBRANE
called cisterns. All of the cranial nerves and major intracranial The interpeduncular cistern straddles the anterior portion
arteries and veins pass through the cisterns. The cisterns of the tentorial incisura (Figs. 10.1 and 10.2). It is situated
provide a natural pathway through which most operations for between the cerebral peduncles and the leaves of Liliequist’s
intracranial aneurysms, extraaxial brain tumors, and disor- membrane at the confluence of the supra- and infratentorial
ders of the cranial nerves are directed. Some cisterns have parts of the subarachnoid space. The posterior wall of the
sheet-like membranes, whereas others have indistinct porous cistern is formed by the posterior perforated substance. Its
trabeculated walls with openings of various sizes. upper border is situated at the posterior edge of the mamillary
The arachnoid membrane that separates the posterior fossa bodies. Its lower border is situated at the junction of midbrain
cisterns includes Liliequist’s membrane, which separates the and pons. It is also bordered rostrally and caudally by Lilieq-
chiasmatic and interpeduncular cisterns; the anterior pontine uist’s membrane.
membrane, which separates the prepontine and cerebellopon- Liliequist’s membrane arises from the outer arachnoid
tine cisterns; the lateral pontomesencephalic membrane, membrane covering the posterior clinoid processes and dor-
which separates the ambient and cerebellopontine cisterns; sum sellae (11, 12). As this membrane spreads upward from
the medial pontomedullary membrane, which separates the the dorsum and across the interval between the oculomotor
premedullary and prepontine cisterns; and the lateral pon- nerves, it gives rise to two separate arachnoidal sheets (Fig.
tomedullary membrane, which separates the cerebellopontine 10.3). One sheet, the diencephalic membrane, extends upward
and cerebellomedullary cisterns. The three cisterns in which and attaches to the diencephalon at the posterior edge of the
the arachnoid trabeculae and membranes are the most dense mamillary bodies and separates the chiasmatic and interpe-
and present the greatest obstacle at operation are the interpeduncular cisterns. The other sheet, called the mesencephalic
duncular and quadrigeminal cisterns and the cisterna magna. membrane, extends backward and attaches along the junction
Numerous arachnoid membranes were found to intersect the of the midbrain and pons to separate the interpeduncular and
oculomotor nerves. prepontine cisterns. The lateral edge of the diencephalic and
The subarachnoid cisterns are divided into supratentorial mesencephalic membranes attaches to the arachnoidal sheath
and infratentorial groups. The cisterns located in the posterior surrounding the oculomotor nerves. The diencephalic mem-
cranial fossa or that communicate through the tentorial inci- brane is the thicker of the two and is more frequently without
sura are described here (Fig. 10.1) (15). They include paired perforations so that it acts as a barrier to the passage of air or
and unpaired cisterns. other substances through the subarachnoid space. The mes-
encephalic membrane is thinner, more frequently incomplete,
I. Posterior fossa cisterns and contains an opening through which the basilar artery
A. Unpaired cisterns ascends to reach the interpeduncular fossa. The mesence-
1. Interpeduncular cistern phalic membrane may form a tight cuff around the basilar
2. Prepontine cistern artery, but it more commonly has a large opening through
3. Premedullary cistern which the basilar artery ascends. Many arachnoid trabeculae
4. Quadrigeminal cistern fan out from the superior edge of the diencephalic membrane
5. Cisterna magna to attach to the stalk of the pituitary gland, the mamillary

S288 Rhoton
FIGURE 10.1. A–D. Posterior fossa cisterns. A, midsagittal section; B, anterior view; C, lateral view; D, inferior view.
The cisterns in the posterior fossa are the interpeduncular (red ), the prepontine (dark blue), the cerebellopontine
(orange), the premedullary (purple), the cerebellomedullary (yellow), the quadrigeminal (light green), the superior
cerebellar (brown), and the cisterna magna (light blue). The anterior spinal (light gray) and posterior spinal (dark gray)
cisterns communicate through the foramen magnum with the posterior fossa cisterns. The ambient cistern
(dark green) is a supratentorial cistern. The quadrigeminal cistern opens inferiorly into the cerebellomesencephalic
fissure. The cerebellopontine cistern extends laterally to the cerebellopontine fissure. The latter fissure has superior
and inferior limbs. The cisterna magna opens into the cerebellomedullary fissure. The apex of the basilar artery, the
origin of the PCA, and the oculomotor nerves are situated in the interpeduncular cistern. The SCAs arise at the
junction of the interpeduncular and prepontine cisterns. The trigeminal, abducens, facial, and vestibulocochlear nerves
arise in the cerebellopontine cisterns. The basilar artery gives off the AICAs in the prepontine cistern. The SCAs and
AICAs pass through the cerebellopontine cisterns. The vertebral arteries give rise to the PICAs and anterior spinal
arteries in the premedullary cistern. The hypoglossal nerves pass through the premedullary cistern. The
glossopharyngeal, vagus, and spinal accessory nerves arise in the cerebellomedullary cisterns. The PICAs pass through
the cerebellomedullary cisterns and the cisterna magna. The basal vein empties into the vein of Galen in the
quadrigeminal cistern. The carotid and posterior communicating arteries are in the supratentorial cisterns. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Car., carotid; Cer., cerebellar; Cer. Med.,
cerebellomedullary; Cer. Mes., cerebellomesencephalic; Cer. Pon., cerebellopontine; Cist., cistern, cisterna; Comm.,
communicating; Fiss., fissure; Inf., inferior; Interped., interpeduncular; P.C.A., posterior cerebral artery; P.I.C.A.,
posteroinferior cerebellar artery; Post., posterior; Premed., premedullary; Prepon., prepontine; Quad., quadrigeminal;
S.C.A., superior cerebellar artery; Sp., spinal; Sup., superior; V., vein; Vert., vertebral.

Cisterns S289
FIGURE 10.2. A. Anterior view.

The arachnoid membrane has been
removed to expose the following
cisterns: olfactory, carotid,
chiasmatic, ambient, crural,
interpeduncular, prepontine,
premedullary, cerebellopontine, and
cerebellomedullary and the cisterna
magna. The oculomotor nerves
course in an arachnoidal
intersection situated in the junction
of the walls of the carotid,
chiasmatic, prepontine,
interpeduncular, and
cerebellopontine cisterns. The
medial carotid membrane separates
the carotid and chiasmatic cisterns.
The crural membrane separates the
crural and ambient cisterns. The
anterior pontine membrane
separates the prepontine and
cerebellopontine cisterns. The
lateral pontomesencephalic
membrane separates the ambient
and cerebellopontine cisterns. The
medial pontomedullary membrane
separates the prepontine and
premedullary cisterns, and the lateral pontomedullary membrane separates the cerebellopontine and cerebellomedullary cisterns.
The interpeduncular cistern is situated between the diencephalic and mesencephalic leaves of Liliequist’s membrane. The
bifurcation of the basilar artery is in the interpeduncular cistern. The carotid and posterior communicating arteries course within
the carotid cisterns. The anterior choroidal artery arises in the carotid cistern and courses through the crural cistern. The optic
nerves and chiasm and the stalk of the pituitary gland are situated in the chiasmatic cistern. The olfactory cisterns enclose the
olfactory tracts. The SCAs arise at the junction of the interpeduncular and prepontine cisterns. The PCAs and trochlear nerves
course through the ambient cisterns. The AICAs arise in the prepontine cistern. The premedullary cistern contains the hypoglossal
nerves and vertebral arteries and the origin of the PICAs and anterior spinal arteries. The abducens, trigeminal, facial, and
vestibulocochlear nerves and a segment of the SCA and AICA pass through the cerebellopontine cisterns. The cerebellomedullary
cisterns contain the glossopharyngeal, vagus, and accessory nerves and a segment of the PICAs. The veins that course through
the cisterns include the peduncular, transverse pontine, transverse medullary, lateral medullary, and median anterior
pontomesencephalic veins and the veins of the pontomedullary sulcus, cerebellopontine fissure, and middle cerebellar peduncle.
The veins in the cerebellopontine or cerebellomedullary cisterns join to form the superior petrosal veins. A., artery; A.C.A., anterior
cerebral artery; Ant., anterior; Arach., arachnoid; Bas., basilar; Car., carotid; Cer., cerebellar; Cer. Med., cerebellomedullary; Cer.
Pon., cerebellopontine; Chiasm., chiasmatic; Chor., choroid; Cist., cistern, cisterna; Comm., communicating; Fiss., fissure; Front.,
frontal; Interped., interpeduncular; Lat., lateral; Lilieq., Liliequist’s; M.C.A., middle cerebral artery; Med., medial, medullary;
Memb., membrane; Mid., middle; N., nerve; Olf., olfactory; P.C.A., posterior cerebral artery; Ped., peduncular; Pet., petrosal;
P.I.C.A., posteroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary; Pon. Mes., pontomesencephalic; Premed.,
premedullary; Prepon., prepontine; S.C.A., superior cerebellar artery; Sig., sigmoid; Sp., spinal; Sulc., sulcus; Temp., temporal;
Tent., tentorium; Tr., trunk; Trans., transverse; V., vein; Vert., vertebral.
bodies, and the posterior cerebral and posterior communicat- branes that converge on and form a sleeve around the nerves
ing arteries. The interpeduncular cistern communicates with are the mesencephalic membrane, which separates the inter-
the crural and ambient cisterns, which are situated in the peduncular and prepontine cisterns; the diencephalic mem-
tentorial area between the temporal lobe and midbrain. brane, which separates the interpeduncular and chiasmatic cis-
The oculomotor nerves course in the lateral wall of the terns; the anterior pontine membrane, which separates the
interpeduncular cistern and form the pillars to which the cerebellopontine and prepontine cisterns; the lateral pontomes-
leaves of Liliequist’s membrane attach. In addition, the ocu- encephalic membrane, which separates the ambient and cerebel-
lomotor nerves are the site of attachment of other arachnoid lopontine cisterns; the medial carotid membrane, which sepa-
membranes that separate the cisterns of the junction of the rates the chiasmatic and carotid cisterns; and the lateral carotid
supra- and infratentorial areas (Figs. 10.2 and 10.3). The mem- membrane, which forms the lateral wall of the carotid cistern.

S290 Rhoton
FIGURE 10.2. B. Cisterns

exposed through a
unilateral suboccipital
craniectomy. The insert
(upper left) shows the site
of the skin incision (solid
line) and craniectomy
(interrupted line). The
arachnoid membrane
forming the posterior wall
of the cerebellopontine and
cerebellomedullary cisterns
has been opened. The
anterior pontine membrane
is medial to the abducens
nerve. The lateral
pontomedullary membrane
separates the
cerebellopontine and
cerebellomedullary cisterns.
The flocculus and choroid
plexus protrude into the
junction of the
cerebellomedullary and
cerebellopontine cisterns
near the foramen of
Luschka.
The interpeduncular cistern contains the posterior thalam- were found in the prepontine cistern. The basilar artery
operforating arteries, the bifurcation of the basilar artery, the courses through and gives rise to the anteroinferior cerebellar
origins of the posterior cerebral artery (PCA), superior cere- artery (AICA) within this cistern (14).
bellar artery (SCA), and medial posterior choroidal arteries,
the peduncular, posterior communicating, and median ante- CEREBELLOPONTINE CISTERN
rior pontomesencephalic veins, and the vein of the pontomes-
encephalic sulcus (3–5, 16, 24). The cerebellopontine cistern lies between the anterolateral
surface of the pons and cerebellum and the arachnoidal mem-
brane that rests on the posterior surface of the petrous bone
PREPONTINE CISTERN (Figs. 10.1–10.4). Superiorly, at the level of the tentorium, this
The prepontine cistern lies between the arachnoid mem- cistern is separated from the ambient cistern by the lateral
brane resting on the clivus and the anterior surface of the pons pontomesencephalic membrane. This membrane is attached
(Figs. 10.1–10.4). The upper end of the cistern is wider than the to the brainstem at the junction of the midbrain and pons and
lower. The prepontine cistern is separated from the interpe- to the outer arachnoidal membrane near the free edge of the
duncular cistern by the mesencephalic leaf of Liliequist’s tentorium. Anteriorly, it intersects the oculomotor nerve. This
membrane. The lower boundary of the cistern is situated at membrane spans the interval between the PCA and SCA.
the level of the pontomedullary sulcus, the site of a less Inferiorly, the cerebellopontine cistern is separated from the
well-defined membrane called the medial pontomedullary cerebellomedullary cistern by the lateral pontomedullary
membrane. This membrane is formed by the thick trabeculae membrane, which crosses the subarachnoid space between
that surround the junction of the vertebral and the basilar the vestibulocochlear and glossopharyngeal nerves. The latter
arteries. The lateral edges of the prepontine cistern are sepa- membrane stretches from the junction of the pons and me-
rated from the cerebellopontine cisterns by the paired anterior dulla to the outer arachnoidal membrane. Medially, the cer-
pontine membranes. These membranes cross the interval be- ebellopontine cistern is separated from the prepontine cistern
tween the pons and the outer arachnoid membrane that rests by the anterior pontine membrane. Laterally, the cerebel-
on the clivus. The anterior pontine membranes intersect the lopontine cistern extends to the edge of the cerebellar surface
oculomotor nerves superiorly and extend downward along that wraps around the pons to form the cerebellopontine
the medial side of the abducens nerves. The anterior pontine fissure.
membranes become progressively thinner as they extend cau- The trigeminal nerve arises from the midpons and courses
dally and may disappear on the lower pons. No cranial nerves through the superolateral portion of the cistern. The abducens

Cisterns S291
FIGURE 10.2. C. Cisterns in

the tentorial incisura. View
through a right
frontotemporal craniotomy.
The insert shows the
direction of view. The
inferior surface of the
temporal lobe has been
elevated. The arachnoid
membrane medial to the
free edge of the tentorium
has been opened to expose
the carotid, ambient, crural,
cerebellopontine,
interpeduncular, and sylvian
cisterns. The lateral carotid
membrane is on the lateral
side of the carotid artery,
and the medial carotid
membrane separates the
carotid and chiasmatic
cisterns. The crural
membrane extends from the
optic tract to the uncus and
between the origins of the
posterior communicating
and anterior choroidal
arteries.
nerve arises at the level of the pontomedullary sulcus and part of the clivus (Figs. 10.1, 10.2, and 10.4) (2). Its upper border
ascends just lateral to the anterior pontine membrane. The is located at the junction of the pons and medulla. It is separated
facial and vestibulocochlear nerves arise in the inferior part of from the prepontine cistern by the medial pontomedullary mem-
the cerebellopontine cistern just above the lateral pontomed- brane. Laterally, its border with the cerebellomedullary cistern is
ullary membrane. The outer arachnoid membrane extends located at the dorsal margin of the inferior olive in front of the
into the internal auditory canal and surrounds the intracanal- glossopharyngeal, vagus, and accessory nerves, at the site where
icular segment of the facial and vestibulocochlear nerves. The the density of the arachnoid trabeculae crossing the subarach-
flocculus projects into the cerebellopontine cistern behind the noid space increases (1). Inferiorly, the premedullary cistern is
facial and vestibulocochlear nerves. continuous (without obstruction) with the anterior spinal cistern.
The SCA and AICA course through the cerebellopontine The rootlets forming the hypoglossal nerves arise in the posterior
cistern (5, 14). The SCA enters the cerebellopontine cistern by wall of this cistern between the medullary pyramids and the
passing through the junction of the anterior pontine mem- inferior olives.
brane and the oculomotor nerve. It courses below the troch- The vertebral arteries enter this cistern by ascending through
lear nerve and the lateral pontomesencephalic membrane, and the foramen magnum. They ascend obliquely through this cis-
above the trigeminal nerve in its passage through this cistern. tern and join at the junction of the premedullary and prepontine
The bifurcation of the SCA into rostral and caudal trunks may cisterns. The paired anterior spinal arteries arise from the verte-
be situated in either the prepontine or the cerebellopontine bral arteries and join to form a single trunk that courses in the
cisterns. The AICA enters the lower part of the cerebellopon- midline on the anterior surface of spinal cord.
tine cisterns by passing through or below the anterior pontine
membrane. It commonly bifurcates into its rostral and caudal
trunks within this cistern. The veins in this cistern converge CEREBELLOMEDULLARY CISTERN
on the area around the trigeminal nerve, where they unite to
form the superior petrosal veins, which empty into the supe- The cerebellomedullary cistern lies caudal to the junction of
rior petrosal sinus (16). the pons and medulla (Figs. 10.1, 10.2, and 10.4). It is separated
from the cerebellopontine cistern by the lateral pontomedul-
lary membrane and from the premedullary cistern by the
PREMEDULLARY CISTERN trabeculae in front of the glossopharyngeal, vagus, and acces-
The premedullary cistern lies between the anterior surface sory nerves. Its inferior border is located at the level of the
of the medulla and the arachnoid membrane covering the lower foramen magnum. The cistern extends backward from the

S292 Rhoton
FIGURE 10.3. Liliequist’s membrane and the cisterns and membranes intersecting the oculomotor nerve. A, parasagittal section to
the left of the midline. Liliequist’s membrane arises from the part of the outer arachnoid membrane that rests against the dorsum
sellae and splits into the diencephalic and mesencephalic membranes. The diencephalic membrane is a complete membrane that
attaches to the maxillary bodies and separates the chiasmatic and interpeduncular cisterns. The mesencephalic membrane,
which attaches along the junction of the midbrain and pons, forms an incomplete wall between the interpeduncular and prepon-
tine cisterns with an opening through which the basilar artery ascends. B–D, cisterns and membranes intersecting the oculomotor
nerves. B, the ventral arachnoidal wall of the chiasmatic, carotid, interpeduncular, prepontine, and cerebellopontine cisterns has
been removed. The lateral carotid membrane forms the lateral wall of the carotid cistern. The medial carotid membrane separates
the carotid and the chiasmatic cisterns. The interpeduncular cistern is situated behind the mamillary bodies and the diencephalic
membrane. The cerebellopontine cistern opens into Meckel’s cave (arrow). The anterior pontine membrane separates the prepon-
tine and cerebellopontine cisterns. C, the arachnoid membrane covering the cerebellopontine cistern has been stretched laterally
to show the lateral pontomesencephalic membrane. The lateral pontomedullary membrane separates the cerebellomedullary and
cerebellopontine cisterns. D, the arachnoidal cuff around the right oculomotor nerve has been opened. The medial and lateral
carotid, mesencephalic, diencephalic, lateral pontomesencephalic, and anterior pontine membranes converge on and form a cuff
around the oculomotor nerve. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Arach., arachnoid; Bas., basilar; Car.,
carotid; Cer. Med., cerebellomedullary; Cer. Pon., cerebellopontine; Cist., cistern; Comm., communicating; Dien., diencephalic;
Infund., infundibulum; Interped., interpeduncular; Lat., lateral; Mam., mamillary; Med., medial; Memb., membrane; Mes., mesence-
phalic; N., nerve; P.C.A., posterior cerebral artery; P.I.C.A., posteroinferior cerebellar artery; Pit., pituitary; Pon., pontine; Post.,
posterior; Prepon., prepontine; S.C.A., superior cerebellar artery; Sphen., sphenoid; Tr., trunk; V., vein, venous; Vent., ventricle.
dorsal margin of the inferior olive around the dorsolateral through this cistern to reach the jugular foramen. The spinal
medulla to the biventral lobule of the cerebellum. portion of the accessory nerve ascends from the posterior
The glossopharyngeal and vagus nerves and the medullary spinal cistern to reach the cerebellomedullary cistern. The
portion of the accessory nerve arise within and course lateral recess of the fourth ventricle communicates with this

Cisterns S293
cistern through the foramen of Luschka. The choroid plexus rior part is formed by the part of the occipital cortex located
that projects from the foramen of Luschka sits on the posterior below the splenium. Below the colliculi, the cistern extends
surface of the glossopharyngeal and vagus nerves. into the cerebellomesencephalic fissure.
The vertebral artery enters the dura mater at the lower The roof of the cistern is formed by the lower surface of the
border of this cistern and immediately leaves it to enter the splenium and the broad membranous envelope that sur-
premedullary cistern. The posteroinferior cerebellar artery rounds the great vein and its tributaries. This envelope is
(PICA) enters this cistern by reaching the anterior surface of applied to the lower surface of the splenium and is continuous
the rootlets of the glossopharyngeal, vagus, and accessory anteriorly with the tela choroidea surrounding the velum
nerves (13). From here, the artery passes dorsally between the interpositum. It is within this envelope in the superomedial
rootlets of these nerves and pursues a posterior course around part of the cistern that the intracisternal venous structures are
the medulla to enter the cisterna magna. found in the greatest density (16). The superomedial location
of the veins contrasts with the location of the arteries, which
CISTERNA MAGNA are found in the greatest density in the inferolateral part of the
cistern.
The cisterna magna lies dorsal to the medulla and cerebel-
The quadrigeminal cistern communicates with the posterior
lar vermis (Fig. 10.1). Its posterior wall is formed by the
pericallosal cistern, which extends around the splenium. It
arachnoid membrane that conforms to the inner surface of the
opens inferolaterally below the pulvinars into the ambient
occipital bone above the foramen magnum. A characteristic
feature of the cisterna magna is the dense, mesh-like trabec- cisterns, which are located between the midbrain and the
ulated arachnoid that extends from the cerebellar tonsils to temporal lobes. It may communicate with the velum inter-
the medulla and the margin of the foramen of Magendie. positum. The trochlear nerves arise in the quadrigeminal cis-
The lower part of the cisterna magna is situated behind the tern just below the inferior colliculi and course forward
medulla (17). Superiorly, the cisterna magna projects both around the midbrain and below the pulvinars to enter the
anterior and posterior to the cerebellar vermis. Anteriorly, it ambient cisterns.
opens into the cerebellomedullary fissure. The cisterna magna The trunks and branches of the PCA and SCA enter the
also opens behind the vermis into the posterior cerebellar lower-anterior part of the cistern and course below and lateral
incisura. The arachnoid membrane covering the incisura is to the arachnoidal envelope around the vein of Galen and its
reflected around the falx cerebelli. The upper limit of the tributaries (5, 16, 29). The PCAs commonly bifurcate into their
extension behind the vermis is the tentorium. If the falx cer- calcarine and parieto-occipital branches within the cistern.
ebelli is absent or small, the upper part of the cistern may be Some of the lateral posterior choroidal arteries arise from the
quite large. A median sheet of arachnoid may extend from the PCAs within this cistern (4). The medial posterior choroidal
dorsal surface of the medulla to the outer arachnoid mem- arteries arise from the PCAs in front of the midbrain and
brane to divide the cistern into sagittal halves. Inferiorly, the encircle the brainstem to enter the quadrigeminal cistern,
cisterna magna communicates without obstruction with the where they turn forward beside the pineal body to reach the
posterior spinal cistern. velum interpositum. The SCAs course through the part of the
The PICAs pass posteriorly around the medulla. They enter cistern that extends into the cerebellomesencephalic fissure.
the cisterna magna near the point where they commonly The perforating branches of the PCAs supply the walls of the
divide into a lateral trunk, which supplies the hemisphere and cistern situated above the shallow groove separating the su-
tonsil, and a medial trunk, which supplies the vermis (3, 13). perior and inferior colliculi, and the SCAs supply the walls of
the cistern below this groove.
QUADRIGEMINAL CISTERN The venous relationships in the cistern are the most com-
plex in the cranium because the cistern is the site of conver-
The quadrigeminal cistern encloses a space that corre-
gence of the internal cerebral and basal veins and multiple
sponds to the pineal region (Fig. 10.1) (18, 19, 22, 26). The
other tributaries of the vein of Galen (18, 19). The internal
quadrigeminal plate is located at the center of the anterior
cerebral veins exit the velum interpositum and the basal veins
wall of the cistern. In the midline, the anterior wall rostral to
the colliculi is formed by the pineal gland. The suprapineal exit the ambient cisterns to reach the quadrigeminal cistern,
recess of the third ventricle bulges into the cistern above the where they join the vein of Galen. The latter vein passes below
gland. Laterally, the anterior wall is formed by the part of the the splenium to enter the straight sinus at the tentorial apex.
pulvinar that lies medial to where the crus of the fornix wraps The veins that converge on the cistern to empty into the great,
around the pulvinar. The fornix crosses the pulvinar midway basal, or internal cerebral veins include the posterior perical-
between the medial and lateral edges of the pulvinar. The losal veins, which course around the splenium; the atrial
medial half of the pulvinar forms the anterior wall of the veins, which drain the walls of the atria; the internal occipi-
cistern and the lateral half of the pulvinar forms the anterior tal veins, which originate on or near the calcarine and parieto-
wall of the atrium of the lateral ventricle. occipital sulci; and the vein of the cerebellomesencephalic
Each lateral wall of the cistern has an anterior and a poste- fissure, which originates on the superior cerebellar peduncles
rior part. The anterior part is formed by the segment of the and terminates with the superior vermian vein in the great
crus of the fornix that wraps around the pulvinar. The poste- vein.

S294 Rhoton
FIGURE 10.4. A, prepontine, cerebellopontine, cerebellomedullary, and premedullary cisterns. The arachnoid membrane that forms the
anterior wall of the cerebellopontine, cerebellomedullary, prepontine, and premedullary cisterns has been removed. The lateral pon-
tomedullary membrane separates the cerebellopontine and cerebellomedullary cisterns. The thick arachnoid trabeculae around the junc-
tion of the vertebral arteries form the median pontomedullary membrane that separates the premedullary and prepontine cis-
terns. The anterior pontine membrane separates the prepontine and cerebellopontine cisterns. The premedullary cistern
extends backward to the anterior surface of the glossopharyngeal, vagus, and accessory nerves. B, the anterior pontine mem-
brane, which separates the prepontine and cerebellopontine cisterns, passes forward from the pons to the clivus. The lateral
pontomesencephalic membrane, which forms the floor of the ambient cistern and the roof of the cerebellopontine cistern,
stretches across the interval between the PCA and SCA. A small flap of dura has been elevated to expose the trigeminal nerve
in Meckel’s cave. C, posterior view. The arachnoid membrane forming the posterior wall of the cerebellopontine and
cerebellomedullary cisterns has been opened. The lateral pontomedullary membrane separates the cerebellopontine and

Cisterns S295
SUPERIOR CEREBELLAR CISTERN arachnoid membrane is opened below the oculomotor nerve,
the intact arachnoid membrane above the nerve will draw the
This cistern is situated between the superior part of the vermis
nerve upward. After opening the arachnoid membrane be-
and the arachnoid membrane that rests against the lower border
low the oculomotor nerve, elevating the temporal lobe will
of the straight sinus. Anteriorly, it opens into the quadrigeminal
elevate the oculomotor nerve and aid in exposing the struc-
cistern (Fig. 10.1). Posteriorly, it communicates below the torcu-
tures below the nerve because the arachnoid above the ocu-
lar with the cisterna magna. Laterally, it blends into the sub-
lomotor nerve is tethered to the temporal lobe. Opening the
arachnoid space over the cerebellar hemispheres. The cistern
arachnoid above the nerve will allow the nerve to retract inferi-
contains the median and paramedian branches of the SCAs and
orly and facilitate the exposure of structures above the nerve.
the superior vermian vein.
The second site at which the arachnoid trabeculae are es-
pecially dense is in the superomedial part of the quadrigem-
DISCUSSION inal cistern, where the dense arachnoidal envelope surround-
Key and Retzius’s excellent illustrations in 1875 accurately ing the vein of Galen and its tributaries blends with the tela
display the anterior pontine, medial and lateral pontomedul- choroidea forming the walls of the velum interpositum. The
lary, and lateral pontomesencephalic membranes and the part of the cistern situated below the vein of Galen that
membrane now called Liliequist’s membrane (9). Liliequist contains the PCA and SCA is less densely trabeculated.
noted that the membrane bearing his name, in pneumograms, The third site where the arachnoidal web is especially dense
is often seen as a fine line with a forward convexity extending is in the cisterna magna, where the trabeculae bind the me-
from the dorsum sellae to the mamillary bodies (11, 12). In our dulla and cerebellar tonsils to the branches of the PICA. It is
study, this membrane was found to have two leaves: an upper commonly necessary to divide numerous trabeculae to re-
leaf, called the diencephalic membrane, which attaches to the move a cerebellar tonsil and to expose and mobilize the
posterior edge of the mamillary bodies, and a caudal leaf, infratonsillar loop of the PICA.
called the mesencephalic membrane, which attaches to the Opening a cisternal wall, with the resultant escape of cere-
junction of the pons and the midbrain. The completeness and brospinal fluid, facilitates the approach to lesions in front of
position of the diencephalic membrane favor its definition the brainstem and cerebellum. Allowing cerebrospinal fluid
after lumbar subarachnoid injections of air, whereas a mem- to escape from the cisterna magna during posterior fossa
brane like the mesencephalic membrane would not be seen on operations facilitates the exposure of lesions in the cerebel-
air studies because the large perforation in it, through which lopontine, cerebellomedullary, prepontine, and premedullary
the basilar artery ascends, does not block the passage of air. cisterns. In some operations in which excessive retraction
The oculomotor nerve is the site of intersection of multiple would be necessary to reach a cistern, opening the arachnoid
arachnoidal membranes (9). Six arachnoid membranes con- over several surface folia and applying suction through a
verge on the oculomotor nerve: the diencephalic, mesence- cottonoid laid over the arachnoidal opening will remove
phalic, anterior pontine, lateral pontomesencephalic, and medial enough cerebrospinal fluid to relax the cerebellum and allow
and lateral carotid membranes. The medial carotid membrane the operation to proceed.
separates the chiasmatic and carotid cisterns. The lateral carotid Pathological processes in the subarachnoid space may con-
membrane, which is situated lateral to the carotid artery, extends form to cisternal boundaries. The arachnoid septa and trabec-
from the optic to the oculomotor nerve (10, 25). ulae separating the cisterns may prevent the spread of blood
The three sites in the posterior fossa where the normal to adjacent cisterns after aneurysm rupture. The resulting
arachnoidal trabeculae and membranes present the greatest location of the blood, as seen on computed tomographic scans
obstacle at operation are the interpeduncular and quadrigem- and magnetic resonance imaging, often provides information
inal and the cisterna magna. The multiple membranes that pinpointing the site of a ruptured aneurysm. The thickening
converge on the walls of the interpeduncular cistern make the and staining of the arachnoid membranes that follow sub-
operative exposure of lesions in this cistern more difficult. The arachnoid hemorrhage may make the approach to an aneu-
tendency for the arachnoidal membranes and the nerves and rysm more difficult. Yasargil notes that aneurysms may be-
arteries to which they attach to retract away from the site of an come invested with the arachnoidal walls of the cisterns and
arachnoidal incision can be utilized to aid in exposing lesions that tension on the arachnoid membranes may be transmitted
in the interpeduncular cistern and also at other sites. If the to the fundus of the aneurysm, even when dissection is being
Š
cerebellomedullary cisterns. The PICA and hypoglossal nerves arise in the premedullary cistern. Choroid plexus protrudes into
the junction of the cerebellomedullary and cerebellopontine cisterns. D, anterior view. The lateral pontomedullary membrane
separates the cerebellopontine and cerebellomedullary cisterns. The anterior pontine membrane separates the prepontine and
cerebellopontine cisterns. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Arach., arachnoid; Bas., basilar;
Car., carotid; Cav., cavernous; Cer. Med., cerebellomedullary; Cer. Pon., cerebellopontine; Chor. Plex., choroid plexus; Cist.,
cistern; Comm., communicating; F., foramen; For., foramen; Infund., infundibulum; Jug., jugular; Lat., lateral; Med., medial,
medullary; Memb., membrane; N., nerve; P.C.A., posterior cerebral artery; Pet., petrosal; P.I.C.A., posteroinferior cerebellar
artery; Pon., pontine; Pon. Mes., pontomesencephalic; Post., posterior; Premed., premedullary; Prepon., prepontine; S.C.A.,
superior cerebellar artery; Sulc., sulcus; Temp., temporal; Trans., transverse; V., vein; Vert., vertebral.

S296 Rhoton
carried out some distance away (27, 28). In dissecting an during tumor removal. Meningiomas may be removed with-
aneurysm, it is helpful to know which membranes may be out opening the outer arachnoid membrane. These tumors
attached to the aneurysm. Aneurysms arising at the basilar frequently displace the arachnoid membrane around their
apex and at the origin of the SCA may project into the leaves inner surface. The arachnoid membrane provides a barrier to
of Liliequist’s membrane; aneurysms arising at the origin of injury of adjacent arteries and nerves during the removal of
the AICA may have the anterior pontine membrane stretched these tumors.
around their surface; aneurysms arising at the origin of the The arachnoid membranes surrounding the cerebellopon-
PICA from the vertebral artery may project upward into the tine and cerebellomedullary cisterns are best seen in decom-
lateral pontomedullary membrane; and aneurysms arising at pression operations on the cranial nerves (6–8, 20). During
the junction of the vertebral with the basilar arteries may be these operations, the membranes are commonly found to be
enmeshed in the thick trabeculae that form the medial pon- displaced by tortuous arteries. When one exposes the trigem-
tomedullary membrane (21). inal nerve by the retrosigmoid route, the trochlear nerve is
An understanding of the arachnoidal membranes is espe- usually seen just above the trigeminal nerve. Placing the
cially important in dealing with aneurysms pointing in the arachnoidal incision to expose the trigeminal nerve below the
direction of the oculomotor nerves. Traction on any of the caudal edge of the trochlear nerve will allow the arachnoidal
membranes converging on the oculomotor nerve may rupture trabeculae inserting on the upper edge of the trochlear nerve
these aneurysms. The outer surface of the arachnoidal mem- to draw it upward, away from the operative site. After the
branes that are adherent to an aneurysm may provide a plane outer arachnoidal membrane beside the trigeminal nerve is
of dissection that allows easier separation of the aneurysm opened, the lateral pontomesencephalic membrane will come
from adjacent structures. It may be necessary to leave some of into view in the interval above the SCA. To complete a de-
the arachnoid membrane attached to the fundus and wall of compression operation on the trigeminal nerve, one rarely
the aneurysm to prevent rupture of the aneurysm before a clip must expose the SCA as far medial as the point where it
is applied. penetrates the anterior pontine membrane.
A knowledge of the anatomy of the cistern will aid in dissect- In completing an operation at the junction of the cerebel-
ing some tumors. The arachnoidal walls of a cistern containing a lopontine and cerebellomedullary cisterns for hemifacial
tumor may protect the neural and vascular structures in adjacent spasm, one sees the lateral pontomedullary membrane in the
cisterns from operative injury. Tumors may be classified into five interval between the glossopharyngeal nerve and the nerves
categories on the basis of their relationship to the cisterns. These entering the internal acoustic meatus. One of the more com-
are: 1) growth within a single cistern; 2) growth within one mon findings in hemifacial spasm is that the PICA has looped
cistern with compression of adjacent cisterns; 3) growth within upward to compress the caudal surface of the facial nerve.
multiple cisterns; 4) growth in adjacent structures with extension This loop commonly pushes the lateral pontomedullary mem-
into the cisterns; and 5) growth in adjacent structures with com- brane ahead of it.
pression of, but not extension into, the adjacent cisterns. A small
pinealoma or acoustic neurinoma will be situated entirely within Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro-
a single cistern. As it enlarges, it will stretch the arachnoidal logical Surgery, University of Florida Brain Institute, P.O. Box 100265,
walls of the cistern around its borders. Epidermoid tumors grow 100 S. Newell Drive, Building 59, L2–100, Gainesville, FL 32610-0265.
within multiple cisterns. These tumors, when situated in the
posterior fossa, commonly involve the cerebellopontine, cerebel-
lomedullary, and prepontine cisterns, and they may spread into REFERENCES
the premedullary, interpeduncular, ambient, and quadrigeminal
cisterns. Choroid plexus papillomas and ependymomas of the 1. Amundsen P, Newton TH: Subarachnoid cisterns, in Newton TH,
fourth ventricle may extend through the foramen of Magendie Potts DG (eds): Radiology of the Skull and Brain. St. Louis, CV
Mosby, 1974, vol 4, pp 3588–3711.
into the cisterna magna or through the foramen of Luschka into
2. de Oliveira E, Rhoton AL Jr, Peace DA: Microsurgical anatomy of the
the cerebellomedullary cistern. Some gliomas of the cerebellum region of the foramen magnum. Surg Neurol 24:293–352, 1985.
and brainstem may develop exophytic extensions into the cis- 3. Fujii K, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the
terns. Meningiomas commonly arise external to and compress choroidal arteries: Fourth ventricle and cerebellopontine angles.
the cisterns without extending directly into them. J Neurosurg 52:504–524, 1980.
Acoustic neurinomas may stretch the anterior pontine, lat- 4. Fujii K, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the
eral pontomedullary, and lateral pontomesencephalic mem- choroidal arteries: Lateral and third ventricles. J Neurosurg 52:
branes around their borders (23). Preserving the arachnoid 165–188, 1980.
membrane that lies posterior to the tumor and extends into 5. Hardy DG, Peace DA, Rhoton AL Jr: Microsurgical anatomy of
the internal acoustic meatus during removal of the posterior the superior cerebellar artery. Neurosurgery 6:10–28, 1980.
6. Jannetta PJ: Microsurgical approach to the trigeminal nerve for tic
meatal wall with a drill will prevent bone dust from entering
douloureux, in Krayenbühl H, Maspes PE, Sweet WH (eds): Progress
the subarachnoid space. A large tumor will displace the ab- of Neurological Surgery. Basel, Karger, 1976, vol 7, pp 180–200.
ducens nerve and anterior pontine membrane toward the 7. Jannetta PJ: Cranial nerve vascular compression syndromes (oth-
midline. The lateral pontomedullary membrane crosses the er than tic doulourex and hemifacial spasm), in Carmel PW (ed):
interval between the tumor and the glossopharyngeal and Clinical Neurosurgery. Baltimore, Williams & Wilkins, 1981, vol 28,
vagus nerves and provides some protection for these nerves pp 445–456.

Cisterns S297
8. Jannetta PJ, Abbasy M, Maroon JC, Ramos FM, Albin MS: Etiol- 18. Ono M, Ono M, Rhoton AL Jr, Barry M: Microsurgical anatomy of
ogy and definitive microsurgical treatment of hemifacial spasm. the region of the tentorial incisura. J Neurosurg 60:365–399, 1984.
Operative techniques and results in 47 patients. J Neurosurg 19. Ono M, Rhoton AL Jr, Peace DA, Rodriguez RJ: Microsurgical
47:321–328, 1977. anatomy of the deep venous system of the brain. Neurosurgery
9. Key A, Retzius G: Studien in der Anatomie des Nervensystems und 15:621–657, 1984.
des Bindegewebes. Stockholm, Norstad 1875, vol 1, pp 111–123. 20. Rhoton AL Jr: Microsurgical anatomy of the posterior fossa cra-
10. Lewtas NA, Jefferson AA: The carotid cistern: A source of diag- nial nerves. Clin Neurosurg 26:398–462, 1979.
nostic difficulties with suprasellar extensions of pituitary ade- 21. Rhoton AL Jr: Anatomy of saccular aneurysms. Surg Neurol
14:59–66, 1980.
noma. Acta Radiol Diagn (Stockh) 5:675–690, 1966.
22. Rhoton AL Jr: Microsurgical anatomy of the third ventricle: Part
11. Liliequist B: The anatomy of the subarachnoid cisterns. Acta
2—Operative approaches. Neurosurgery 8:357–373, 1981.
Radiol 46:61–71, 1956.
23. Rhoton AL Jr: Microsurgical anatomy of the brain stem surface
12. Liliequist B: The subarachnoid cisterns: An anatomic and roent-
facing an acoustic neuroma. Surg Neurol 25:326–339, 1986.
genologic study. Acta Radiol 185:1–108, 1959.
24. Saeki N, Rhoton AL Jr: Microsurgical anatomy of the upper
13. Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical basilar artery and the posterior circle of Willis. J Neurosurg
anatomy of the posterior inferior cerebellar artery. Neurosurgery 46:563–578, 1977.
10:170–199, 1982. 25. Wackenheim A, Braun JP, Babin E, Megret M: The carotid cistern.
14. Martin RG, Grant JL, Peace DA, Theiss C, Rhoton AL Jr: Microsurgical Neuroradiology 5:82–84, 1973.
relationships of the anterior inferior cerebellar artery and the facial- 26. Yamamoto I, Rhoton AL Jr, Peace DA: Microsurgical anatomy of
vestibulocochlear nerve complex. Neurosurgery 6:483–507, 1980. the third ventricle: Part 1—Microsurgical anatomy. Neurosurgery
15. Matsuno H, Rhoton AL Jr, Peace DA: Microsurgical anatomy of 8:334–356, 1981.
the posterior fossa cisterns. Neurosurgery 23:58–80, 1988. 27. Yasargil MG: Microneurosurgery. New York, Thieme-Stratton,
16. Matsushima T, Rhoton AL Jr, de Oliveira E, Peace DA: Microsur- 1984, vol 1, pp 5–53.
gical anatomy of the veins of the posterior fossa. J Neurosurg 28. Yasargil MG, Kasdaglis K, Jain KK, Weber HP: Anatomical ob-
59:63–105, 1983. servations of the subarachnoid cisterns of the brain during sur-
17. Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the gery. J Neurosurg 44:298–302, 1976.
fourth ventricle: Part 1—Microsurgical anatomy. Neurosurgery 29. Zeal AA, Rhoton AL Jr: Microsurgical anatomy of the posterior
11:631–667, 1982. cerebral artery. J Neurosurg 48:534–559, 1978.
Key to various anatomic structures for an 18th century wax model in the Ceroplastica Laboratory of La Specola,
Florence, Italy. The anatomic model reached its peak expression during this period. Courtesy, Ceroplastica Laboratory,
La Specola, Florence, Italy.

Superficial dissection showing anterior musculature, from, Bartolommeo Eustachio, Tabulae anatomicae. Rome,
Sumptibus Laurentii & Thomae Pagliarini, 1728. Courtesy, Rare Book Room, Norris Medical Library, Keck School of Medicine,
Los Angeles, California. (Also see pages S2, S28, S130, S154, and S194.)

The Posterior Cranial Fossa

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

The Posterior Cranial Fossa

Uploaded by

Copyright:

Available Formats

Neurosurgery, Vol. 47, No.

3, September 2000 Supplement S1

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement S3

Surgical instruments as shown in

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement