J Neurosurg 115:387–397, 2011

Segmental anatomy of cerebellar arteries:

a proposed nomenclature
Laboratory investigation
Ana Rodríguez-Hernández, M.D.,1 Albert L. Rhoton Jr., M.D., 2
and Michael T. Lawton, M.D.1
1
Department of Neurological Surgery, University of California, San Francisco, California; and 2Department
of Neurological Surgery, University of Florida, Gainesville, Florida

Object. The conceptual division of intracranial arteries into segments provides a better understanding of their
courses and a useful working vocabulary. Segmental anatomy of cerebral arteries is commonly cited by a numerical
nomenclature, but an analogous nomenclature for cerebellar arteries has not been described. In this report, the micro-
surgical anatomy of the cerebellar arteries is reviewed, and a numbering system for cerebellar arteries is proposed.
Methods. Cerebellar arteries were designated by the first letter of the artery’s name in lowercase letters, distin-
guishing them from cerebral arteries with the same first letter of the artery’s name. Segmental anatomy was numbered
in ascending order from proximal to distal segments.
Results. The superior cerebellar artery was divided into 4 segments: s1, anterior pontomesencephalic segment;
s2, lateral pontomesencephalic segment; s3, cerebellomesencephalic segment; and s4, cortical segment. The anterior
inferior cerebellar artery was divided into 4 segments: a1, anterior pontine segment; a2, lateral pontine segment; a3,
flocculopeduncular segment; and a4, cortical segment. The posterior inferior cerebellar artery was divided into 5
segments: p1, anterior medullary segment; p2, lateral medullary segment; p3, tonsillomedullary segment; p4, telovelo-
tonsillar segment; and p5, cortical segment.
Conclusions. The proposed nomenclature for segmental anatomy of cerebellar artery complements established
nomenclature for segmental anatomy of cerebral arteries. This nomenclature is simple, easy to learn, and practical.
The nomenclature localizes distal cerebellar artery aneurysms and also localizes an anastomosis or describes a graft’s
connections to donor and recipient arteries. These applications of the proposed nomenclature with cerebellar arteries
mimic the applications of the established nomenclature with cerebral arteries. (DOI: 10.3171/2011.3.JNS101413)

Key Words      •      anterior inferior cerebellar artery      •

posterior inferior cerebellar artery      •      superior cerebellar artery      •      segmental anatomy

A
rteries are critical landmarks for microsurgi-
cal dissection in the subarachnoid spaces, pro-
viding reliable guidance when opening fissures,
navigating through a clot after subarachnoid hemorrhage,
and exposing aneurysms or a variety of other patholo-
gies.10,11,17,21,25–28 Individual arteries have been divided
conceptually into segments based on their curvature and
course.18,20 The resulting segmental anatomy has helped
neurosurgeons learn and appreciate an artery’s unique
characteristics, branches, and relationships to adjacent
neuroanatomy. Segmental anatomy has also provided a
working vocabulary that clinicians apply to patients’ spe-
cific anatomy and pathology.
Segmental anatomy of supratentorial cerebral arteries
has been described in detail by Rhoton et al.18,20 through
cadaveric dissection. Furthermore, a numeric nomencla-
Abbreviations used in this paper: ACA = anterior cerebral artery;
AICA = anterior inferior cerebellar artery; CN = cranial nerve; MCA
= middle cerebral artery; PCA = posterior cerebral artery; PICA =
posterior inferior cerebellar artery; SCA = superior cerebellar artery;
STA = superficial temporal artery; VA = vertebral artery.
ture is established for the segments of the ACA, MCA,
and PCA (Table 1).6,7,14–16,22–24,29 This numbering system
is easy to use and more widely practiced than the actu-
al names of arterial segments. For example, a proximal
MCA aneurysm is more likely to be described as an M1
segment aneurysm than as a sphenoidal segment aneu-
rysm, just as a distal MCA aneurysm is more likely to be
described as an M2 segment aneurysm than as an insular
segment aneurysm.
Segmental anatomy of infratentorial cerebellar ar-
teries has also been described by Rhoton and colleagues
through cadaveric dissection,8,9,12,13,18,24 but a numerical
nomenclature has not been established for the segments
of the SCA, AICA, and PICA. Recognizing the educa-
tional and practical value of such a nomenclature, we pro-
pose a numbering system for cerebellar arteries that is
analogous to the numbering system for cerebral arteries.
Methods
Cerebellar arteries were designated by the first letter

J Neurosurg / Volume 115 / August 2011 387

 A. Rodríguez-Hernández, A. L. Rhoton Jr., and M. T. Lawton
TABLE 1: Established nomenclature of cerebral arteries, carotid TABLE 2: Proposed nomenclature of cerebellar arteries
arteries, and VAs*
Artery Segment
Artery Segment
SCA
ACA  s1 anterior pontomesencephalic
 A1 precommunicating or horizontal  s2 lateral pontomesencephalic
 A 2 postcommunicating or infracallosal  s3 cerebellomesencephalic
 A3 precallosal  s4 cortical
 A4 supracallosal AICA
 A5 postcallosal  a1 anterior pontine
MCA  a2 lateral pontine
 M1 sphenoidal  a3 flocculopeduncular
 M2 insular  a4 cortical
 M3 opercular PICA
 M4 cortical  p1 anterior medullary
PCA  p2 lateral medullary
 P1 precommunicating  p3 tonsillomedullary
 P2 postcommunicating  p4 telovelotonsillar
 P2A crural  p5 cortical
 P2P ambient
 P3 quadrigeminal
 P4 calcarine brainstem and the cerebellum (cerebellomesencephalic,
ICA cerebellopontine, and cerebellomedullary), and the sur-
 C1 cervical faces of the cerebellum (tentorial, petrosal, and suboccipi-
 C2 petrous tal). When examining these relationships, 3 neurovascu-
lar complexes are defined: an upper complex related to
 C3 lacerum
the SCA, a middle complex related to the AICA, and a
 C4 cavernous lower complex related to the PICA. Each neurovascular
 C5 clinoidal complex includes one of the 3 parts of the brainstem, one
 C6 ophthalmic of the 3 surfaces of the cerebellum, one of the 3 cerebel-
 C7 communicating lar peduncles, and one of the 3 major fissures between
VA the cerebellum and the brainstem. In addition, each neu-
rovascular complex contains a group of CNs. The upper
 V1 pretransverse
complex includes the oculomotor, trochlear, and trigemi-
 V2 transverse nal nerves that are related to the SCA. The middle com-
 V3 atlantoaxial plex includes the abducent, facial, and vestibulocochlear
 V4 intracranial nerves that are related to the AICA. The lower complex
includes the glossopharyngeal, vagus, accessory, and hy-
*  ICA = internal carotid artery. poglossal nerves that are related to the PICA.
In summary, the upper complex includes the SCA,
of the artery’s name: s denotes the SCA; a, the AICA; midbrain, cerebellomesencephalic fissure, superior cer-
and p, the PICA. Lowercase letters were used to distin- ebellar peduncle, tentorial surface of the cerebellum, and
guish cerebellar arteries from cerebral arteries with the the oculomotor, trochlear, and trigeminal nerves. The
same first letter of the artery’s name (specifically, ACA SCA arises in front of the midbrain and passes below the
and PCA). The segmental anatomy was numbered in as- oculomotor and trochlear nerves and above the trigeminal
cending order from proximal to distal segments. The pro- nerve to reach the cerebellomesencephalic fissure, where
posed nomenclature for cerebellar arteries is summarized it runs on the superior cerebellar peduncle and terminates
in Table 2 and Fig. 1. by supplying the tentorial surface of the cerebellum. The
middle complex includes the AICA, pons, middle cere-
Results bellar peduncle, cerebellopontine fissure, petrosal surface
of the cerebellum, and the abducent, facial, and vestibu-
Optimizing operative approaches to the posterior locochlear nerves. The AICA arises at the pontine level,
fossa requires an understanding of the relationship of the courses among the abducent, facial, and vestibulocochle-
cerebellar arteries. The 3 cerebellar arteries bear a con- ar nerves to reach the surface of the middle cerebellar
sistent relationship to other structures occurring in parts peduncle, where it courses along the cerebellopontine fis-
of three in the posterior fossa including the brainstem sure and terminates by supplying the petrosal surface of
(midbrain, pons, and medulla), the cerebellar peduncles the cerebellum. The lower complex includes the PICA,
(superior, middle, and inferior), the fissures between the medulla, inferior cerebellar peduncle, cerebellomedul-

388 J Neurosurg / Volume 115 / August 2011

Nomenclature of cerebellar arteries
Fig. 1.  Overview of segmental anatomy of infratentorial arteries, as seen in lateral (A), anterior (B), superior (C), and inferior
(D) views. Printed with permission from Albert L. Rhoton Jr.
lary fissure, suboccipital surface of the cerebellum, and
the glossopharyngeal, vagus, spinal accessory, and hypo-
glossal nerves. The PICA arises at the medullary level,
encircles the medulla, passing close to the glossopharyn-
geal, vagus, accessory, and hypoglossal nerves to reach
the surface of the inferior cerebellar peduncle, where it
dips into the cerebellomedullary fissure and terminates
by supplying the suboccipital surface of the cerebellum.
Superior Cerebellar Artery
The SCA or its branches are exposed in surgical ap-
proaches to the basilar apex, tentorial incisura, trigeminal
nerve, cerebellopontine angle, pineal region, clivus, and
the upper part of the cerebellum. The SCA is intimately
related to the cerebellomesencephalic fissure, the superior
half of the fourth ventricular roof, the superior cerebellar
peduncle, and the tentorial surface (Figs. 1 and 2). The
SCA arises in front of the midbrain, usually from the bas-
ilar artery near the apex, and passes below the oculomo-
tor nerve, but may infrequently arise from the proximal
PCA and pass above the oculomotor nerve. It dips cau-
dally and encircles the brainstem near the pontomesen-
cephalic junction, passing below the trochlear nerve and
above the trigeminal nerve. Its proximal portion courses
medial to the free edge of the tentorium cerebelli, and its
distal part passes below the tentorium, making it the most
J Neurosurg / Volume 115 / August 2011
rostral of the infratentorial arteries. After passing above
the trigeminal nerve, the SCA enters the cerebellomesen-
cephalic fissure, where its branches make several sharp
turns and give rise to the precerebellar arteries, which
pass to the deep cerebellar white matter and the dentate
nucleus. On leaving the cerebellomesencephalic fissure
where its branches are again medial to the tentorial edge,
its branches pass posteriorly under the tentorial edge and
are distributed to the tentorial surface. The SCA usually
arises as a single trunk, but may also arise as a double
(or duplicate) trunk. The SCAs arising as a single trunk
bifurcate into a rostral and a caudal trunk. The SCA gives
off perforating branches to the brainstem and cerebellar
peduncles. Precerebellar branches arise within the cer-
ebellomesencephalic fissure. The rostral trunk supplies
the vermian and paravermian area, and the caudal trunk
supplies the hemisphere on the suboccipital surface. The
SCA frequently has points of contact with the oculomo-
tor, trochlear, and trigeminal nerves.
Segments. The SCA is divided into 4 segments: an-
terior pontomesencephalic, lateral pontomesencephalic,
cerebellomesencephalic, and cortical (Figs. 1 and 2).
Each segment may be composed of one or more trunks,
depending on the level of bifurcation of the main trunk.
Anterior Pontomesencephalic Segment, s1. This seg-
389
 A. Rodríguez-Hernández, A. L. Rhoton Jr., and M. T. Lawton

Fig. 2.  Segments of the SCA.  A: Superior view. The SCA arises at the level of the midbrain and dips caudally along the
pontomesencephalic junction to enter the cerebellomedullary fissure and supply the tentorial surface of the cerebellum. The s1
courses anterior to the midbrain, the s2 lateral to the upper brainstem, the s3 in the cerebellomesencephalic fissure (Cer. Mes.
Fiss.), and the s4 is formed by the cortical branches.  B: Lateral view of the right pontomesencephalic junction showing s1 to s3.
The s2 loops downward toward the trigeminal nerve.  C: Anterior view. The s1 arises anterior to the midbrain, and the s2 loops
downward to the level of the junction of the trigeminal nerve with the midpons.  D: The SCA bifurcates early and both the rostral
and caudal trunks dip in to the cerebellomesencephalic fissure to form the s3.  E: The superior lip of the cerebellomesencephalic
fissure has been removed to expose the s3 within the fissure where it gives branches that continue down the superior cerebel-
lar peduncle (Sup. Cer. Ped.) to the dentate nucleus.  F: Superior view of the s4 formed by the cortical branches supplying the
tentorial surface of the cerebellum. Bas. A. = basilar artery; Ca. Tr. = caudal trunk; Perf. A. = perforating artery; Ro. Tr. = rostral
trunk; Vert. A. = vertebral artery.

ment is located between the dorsum sellae and the upper
brainstem. It begins at the origin of the SCA and extends
below the oculomotor nerve to the anterolateral margin of
the brainstem. Its lateral part is medial to the anterior half
of the free tentorial edge.
Lateral Pontomesencephalic Segment, s2. This segment
begins at the anterolateral margin of the brainstem and
frequently dips caudally onto the lateral side of the upper
pons. Its caudal loop projects toward and may reach the
root entry zone of the trigeminal nerve at the midpon-
tine level. The trochlear nerve passes above the midpor-
tion of this segment. The anterior part of this segment
is often visible above the tentorial edge, but the caudal
loop usually carries it below the tentorium. This segment
terminates at the anterior margin of the cerebellomesen-
cephalic fissure.
Cerebellomesencephalic Segment, s3. This segment
courses within the cerebellomesencephalic fissure. The
SCA branches enter the shallowest part of the fissure
located above the trigeminal root entry zone and again
course medial to the tentorial edge with its branches in-
tertwined with the trochlear nerve. The fissure in which
the SCA proceeds progressively deepens medially and
is deepest in the midline behind the superior medullary
velum. Through a series of hairpin-like curves, the SCA
loops deeply into the fissure and passes upward to reach
the anterior edge of the tentorial surface, the surface fac-
ing the lower margin of the tentorium. The trunks and

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Nomenclature of cerebellar arteries
branches of the SCA are held in the fissure by branches
that penetrate the fissure’s opposing walls. Identification
of individual branches of the SCA within this fissure is
made difficult by the sharp curves of the branches and by
the large number of intermingled arterial loops.
Cortical Segment, s4. This segment includes the
branches distal to the cerebellomesencephalic fissure that
pass below the tentorium and are distributed to the tento-
rial surface.
Operative Exposure. The SCA is exposed when deal-
ing with neoplasms involving the cerebellum, posterior
cavernous sinus, tentorial incisura, and cerebellopontine
angle and when dealing with aneurysms arising at the
basilar apex, origins of the SCA and PCA, and, although
rare, on the distal SCA. It is less common when dealing
with arteriovenous malformations, during vascular de-
compression of the trigeminal nerve in trigeminal neural-
gia, and during a revascularization bypass procedure for
posterior fossa ischemia.
Selecting an operative approach to a lesion involving
the SCA requires that the arterial segments involved be
accurately defined. The only supratentorial approach that
provides exposures to the SCA origin, anterior and later­
al pontomesencephalic and cerebellomesencephalic seg-
ments, and the proximal cortical branches is a temporal
craniotomy with elevation of the temporal and occipital
lobes combined with division and retraction of the ten-
torium. Extending this approach backward to the quad-
rigeminal cistern often necessitates obliteration of some
of the veins draining the lower surface of the temporal
and occipital lobes, with the risk of venous infarction and
edema. A similar or even greater exposure of the SCA is
achieved with the combined supra-/infratentorial presig-
moid approach with tentorial splitting, but this is a much
more extensive operation. When the tentorium is divided
in either of the above approaches, care must be taken to
prevent injury to the trochlear nerve that passes between
the lateral pontomesencephalic segment and the tentorial
edge. The SCA origin, along with the basilar apex, if lo-
cated above the dorsum sellae, can be reached through
a pterional or orbitozygomatic craniotomy with opening
of the Liliequist membrane. Exposing a low SCA origin
by the pterional route may require that the dura roof of
the cavernous sinus be opened, a so-called transcavern-
ous approach, in which the anterior and posterior clinoids
and upper part of the dorsum sellae must be removed.
Resecting the petrous apex in the subtemporal anterior
petrosectomy approach will also aid in exposing a low
SCA origin, if it cannot be exposed by dividing the ten-
torium. A retrosigmoid craniotomy, extending to the edge
of the transverse and sigmoid sinuses, provides excellent
exposure of the SCA in the region of the trigeminal nerve
and the anterior part of the cerebellomesencephalic fis-
sure. This approach provides satisfactory exposure of the
lateral pontomesencephalic segment, but not of the ori-
gin or of other segments. A supracerebellar-infratentorial
approach provides satisfactory exposure of the cortical
branches, the lateral part of the cerebellomesencephalic
fissure, and lateral part of the midbrain. The occipital
transtentorial approach provides a more favorable angle
J Neurosurg / Volume 115 / August 2011
for exposing the branches ipsilateral to the craniotomy
near the midline, below the pineal within the cerebel-
lomesencephalic fissure, and in the posterior part of the
ambient cistern.
Anterior Inferior Cerebellar Artery
The AICA courses through the central part of the
cerebellopontine angle near the facial and vestibuloco-
chlear nerves (Figs. 1 and 3). It or its branches may be
exposed in surgical approaches to the cerebellopontine
angle, basilar artery or VA, clivus, the fourth ventricle
and cerebellum, and during approaches directed through
the temporal and occipital bones. The AICA is intimately
related to the pons, lateral recess, foramen of Luschka,
cerebellopontine fissure, middle cerebellar peduncle, and
petrosal cerebellar surface. The AICA originates from
the basilar artery, usually as a single trunk, and encircles
the pons near the abducent, facial, and vestibulocochlear
nerves. After coursing near and sending branches to the
nerves entering the acoustic meatus and to the choroid
plexus protruding from the foramen of Luschka, it passes
around the flocculus on the middle cerebellar peduncle
to supply the lips of the cerebellopontine fissure and the
petrosal surface. It commonly bifurcates near the facial-
vestibulocochlear nerve complex to form a rostral and a
caudal trunk. The rostral trunk sends its branches later-
ally along the middle cerebellar peduncle to the superior
lip of the cerebellopontine fissure and the adjoining part
of the petrosal surface, and the caudal trunk supplies the
inferior part of the petrosal surface, including a part of
the flocculus and the choroid plexus. The AICA gives rise
to perforating arteries to the brainstem, choroidal branch-
es to the tela and choroid plexus, and the nerve-related
arteries, including the labyrinthine, recurrent perforating,
and subarcuate arteries.
Segments. The AICA is divided into 4 segments: the
anterior pontine, lateral pontine, flocculopeduncular, and
cortical segments. Each segment may include more than 1
trunk, depending on the level of bifurcation of the artery
(Figs. 1 and 3).
Anterior Pontine Segment, a1. This segment, located
between the clivus and the belly of the pons, begins at
the origin and ends at the level of a line drawn through
the long axis of the inferior olive and extending upward
on the pons. This segment usually lies in contact with the
rootlets of the abducent nerve.
Lateral Pontine Segment, a2. This segment begins at
the anterolateral margin of the pons and passes through
the cerebellopontine angle above, below, or between the
facial and vestibulocochlear nerves and is intimately re-
lated to the internal auditory meatus, the lateral recess,
and the choroid plexus protruding from the foramen of
Luschka. This segment gives rise to the nerve-related
branches that course near or within the internal acoustic
meatus in close relationship to the facial and vestibulo-
cochlear nerves. This segment is divided into premeatal,
meatal, and postmeatal portions, depending on their re-
lationship to the porus of the internal acoustic meatus.
These nerve-related branches are the labyrinthine artery,
which supplies the facial and vestibulocochlear nerves
391
 A. Rodríguez-Hernández, A. L. Rhoton Jr., and M. T. Lawton

Fig. 3.  Segments of the AICA.  A: Anterior view. The a1 arises at the pontine level and passes below CN VI. The s2 begins
at the level of a rostrocaudal line extending along the most prominent part of the olive and courses along the lateral medulla.
The a3 begins where the artery passes above the flocculus to run on the middle cerebellar peduncle, which forms the floor of
the cerebellopontine fissure.  B: Enlarged view. The cerebellopontine angle, also called the cerebellopontine fissure (Cer. Pon.
Fiss.), is formed by the cerebellum, folding around the pons to form an angular cleft with the flocculus and CNs VII and VIII in the
center. The fissure has upper and lower limbs that meet at a lateral apex.  C: View through a retrosigmoid craniotomy. The a2 is
the site of a loop directed toward or into the internal acoustic meatus. The a3 courses above the flocculus (Flocc.) and along the
middle cerebellar peduncle toward the apex of the cerebellopontine fissure. The a4 is formed by the cortical branches supplying
the petrosal surface of the cerebellum.  D: Posterior view with the posterior meatal lip removed to show the a2 looping into the
porus of the meatus and the a3 passing above the floccus.  E: Right anterolateral view of a1 to a4.  F: Anterolateral view of
another brainstem and cerebellum showing a1 to a4. Inf. = inferior; Nerv. Intermed. = nervus intermedius; Sup. = superior; Vest.
N. = vestibular nerve.

and vestibulocochlear labyrinth; the recurrent perforating
arteries, which pass toward the meatus but turn medially
to supply the brainstem; and the subarcuate artery, which
enters the subarcuate fossa. This segment not uncom-
monly dips below the pontomedullary junction, especial-
ly if it is tortuous.
Flocculopeduncular Segment, a3. This segment begins
where the artery passes rostral or caudal to the flocculus
to reach the middle cerebellar peduncle and the cerebel-
lopontine fissure. The trunks that course along the pe-
duncle may be hidden beneath the flocculus or the lips of
the cerebellopontine fissure.
Cortical Segment, a4. This segment is composed of
the cortical branches to the petrosal surface of the cer-
ebellum.
Operative Exposure. The AICA is most commonly
exposed in operations for tumors of the cerebellopon-
tine angle. Aneurysms involving the AICA are rare and
if not located at the origin, are most likely located at or
near the internal acoustic meatus. The displacement and
management of the nerve-related arteries with vestibular
schwannomas are reviewed elsewhere.19 Arteriovenous
malformations located infratentorially are uncommon
compared with those in supratentorial locations, and not
infrequently involve the other cerebellar arteries in addi-
tion to the AICA and the brainstem, thus increasing the
management risk. Compression of the facial and vestib-
ulocochlear nerves by tortuous arteries is postulated to
cause dysfunction of these nerves, a concept that is re-
viewed elsewhere.
The AICA may be approached through a retrosig­
moid, middle fossa, translabyrinthine, or combined su­pra-/
infratentorial presigmoid approach. The retrosigmoid ex-
posure is excellent for lesions involving the meatal and
postmeatal segments of the AICA, the lateral part of the
mid and lower brainstem below the trigeminal nerve, and
the area near the internal acoustic meatus. A subtemporal
middle fossa approach, with division of the tentorium and
possibly combined with a medial petrosectomy, may be
selected for lesions in which the AICA has a high ori-
gin, or also involves the SCA and basilar arteries. In the
middle fossa approach to the internal meatus, only a short
segment of the artery located near the meatus is exposed
and sometimes only if the artery loops into the meatal
porus. The translabyrinthine approach exposes the AICA

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Nomenclature of cerebellar arteries
at, and for a short distance proximal and distal to, the
internal acoustic meatus, and along the anterior part of
the petrosal surface. The supra-/infratentorial presigmoid
approaches with various degrees of resection of the semi-
circular canals, vestibule, and cochlea may be selected
for lesions located deep in front of the brainstem, espe-
cially those located near the AICA origin. The AICA ori-
gin may be exposed in the anterior approaches directly
through the clivus only if the origin is near the midline,
but not if the origin is from a tortuous basilar artery that
loops far laterally into the cerebellopontine angle.
Posterior Inferior Cerebellar Artery
The PICA has the most complex, tortuous, and vari-
able course and area of supply of the cerebellar arteries.
It may be exposed in surgical approaches to the foramen
magnum, fourth ventricle, cerebellar hemisphere, brain-
stem, jugular foramen, cerebellopontine angle, petrous
apex, and clivus. The PICA is intimately related to the
cerebellomedullary fissure, the inferior half of the ven-
tricular roof, the inferior cerebellar peduncle, and the
suboccipital surface (Figs. 1 and 4). The PICA, by defi-
nition, arises from the VA near the inferior olive and
passes posteriorly around the medulla. At the anterolat-
eral margin of the medulla, it passes rostral or caudal to
or between the rootlets of the hypoglossal nerve, and at
the posterolateral margin of the medulla it courses ros-
tral to or between the fila of the glossopharyngeal, vagus,
and accessory nerves. After passing the latter nerves, it
courses around the cerebellar tonsil and enters the cer-
ebellomedullary fissure and passes posterior to the lower
half of the roof of the fourth ventricle. On exiting the cer-
ebellomedullary fissure, its branches are distributed to
the vermis and hemisphere of the suboccipital surface.
Most PICAs bifurcate into a medial and a lateral trunk.
The medial trunk supplies the vermis and adjacent part of
the hemisphere, and the lateral trunk supplies the corti-
cal surface of the tonsil and the hemisphere. The PICA
gives off perforating, choroidal, and cortical arteries. The
cortical arteries are divided into vermian, tonsillar, and
hemispheric groups.
Segments. The PICA is divided into 5 segments: an­
terior medullary, lateral medullary, tonsillomedullary,
telovelotonsillar, and cortical (Figs. 1 and 4). These
seg­ments are often longer than the distance around the
medulla or the tonsil because the PICA frequently has a
tortuous course and forms complex loops on the side of
the brainstem among the lower CNs, near the tonsil, and
caudal to the roof of the fourth ventricle. Each segment
may include more than one trunk, depending on the level
of bifurcation of the artery.
Anterior Medullary Segment, p1. This segment lies an-
terior to the medulla. It begins at the origin of the PICA
anterior to the medulla and extends backward past the
hypoglossal rootlets to the level of a rostrocaudal line
through the most prominent part of the inferior olive
that marks the boundary between the anterior and lateral
surfaces of the medulla. Those PICAs arising lateral to
rather than anterior to the medulla do not have an ante-
rior medullary segment. An anterior medullary segment
is more likely to be present if the PICA arises from the
J Neurosurg / Volume 115 / August 2011
superior part of the VA, because the VA courses from the
lateral side of the medulla below to the anterior surface
of the medulla above. An anterior medullary segment is
present if the VA at the level of origin of the PICA has
passed to the anterior surface of the brainstem. From its
origin, the PICA usually passes posteriorly around or
between the hypoglossal rootlets, but occasionally loops
upward, downward, laterally, or medially before passing
posteriorly around or between the hypoglossal rootlets.
Lateral Medullary Segment, p2. This segment begins
where the artery passes the most prominent point of the
olive and ends at the level of the origin of the glossopha-
ryngeal, vagus, and accessory rootlets. Its course varies
from passing directly posterior to reach the glossopha-
ryngeal, vagal, and accessory rootlets to ascending, de-
scending, or passing laterally or medially to form one or
more complex loops in the cistern on the side of the brain-
stem before passing between these nerves.
Tonsillomedullary Segment, p3. This segment begins
where the PICA passes posterior to the glossopharyngeal,
vagus, and accessory nerves and extends medially across
the posterior aspect of the medulla near the caudal half of
the tonsil. It ends where the artery ascends to the midlevel
of the medial surface of the tonsil. The proximal portion
of this segment usually courses near the lateral recess and
then posteriorly to reach 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 loop
passing near the lower part of the tonsil, referred to as the
caudal or infratonsillar loop, may also course superior or
inferior to the caudal pole of the tonsil without forming
a loop. In some cases it dips below the caudal margin of
the tonsil and even below the level of the foramen mag-
num. A caudally convex loop is not present if the PICA
passes directly medial between the tonsil and medulla, if
the PICA ascends along the lateral surface of the tonsil to
reach the hemispheric surface, or if the artery has a low
origin from the VA and ascends posterior to the medulla
to reach the tonsil.
Telovelotonsillar Segment, p4. This is the most com-
plex of the segments. It begins at the midportion of the
PICA’s ascent along the medial surface of the tonsil
toward the roof of the fourth ventricle and ends where it
exits the fissures between the vermis, tonsil, and hemi-
sphere to reach the suboccipital surface. In most, but
not all, hemispheres, this segment forms a loop with a
convex rostral curve, called the cranial loop. This loop
is located caudal to the fastigium between the cerebellar
tonsil below and the lower half of the fourth ventricular
roof formed by the tela choroidea and posterior medul-
lary velum above. This segment gives rise to branches
that supply the tela choroidea and choroid plexus of the
fourth ventricle.
Cortical Segment, p5. This segment begins where the
trunks and branches leave the groove between the vermis
medially and the tonsil and the hemisphere laterally, and
includes the terminal cortical branches. The bifurcation
of the PICA often occurs near the origin of this segment.
The cortical branches radiate outward from the superior
and lateral borders of the tonsil to the remainder of the
vermis and hemisphere.
393
 A. Rodríguez-Hernández, A. L. Rhoton Jr., and M. T. Lawton

Fig. 4.  Segments of the PICA.  A: Left posterolateral view. The cerebellum was removed by dividing the cerebellar pe-
duncles. The p1 arises anterior to the level of the inferior olive. The p2 courses between the most prominent part of the olive and
the origin of CNs IX–XI from the medulla. The p3 courses along the posterolateral medulla and inferior cerebellar peduncle. The
p4 courses within the telovelotonsillar cleft and forms the cranial loop, and the p5 is composed of the cortical branches.  B: Pos-
terior view. The p2 courses between the most prominent part of the olive and the origin of CNs IX–XI. The p3 courses along the
posterolateral medulla and inferior cerebellar peduncle (Inf. Ped.).  C: Superior view of an axial section through the medulla. The
p1 arises along the anterolateral margin of the medulla and is related to the rootlets of the hypoglossal nerve. The p2 is situated
between the most prominent part of the olive and the origin of CNs IX–XI from the medulla.  D: Posterior view of the relationship
between the p1 to p3 and to the lower CNs. The p1 arises anterior to the midportion of the olive and passes by the rootlets of CN
XII. The p2 courses along the lateral medulla and the p3 along the posterolateral medulla and inferior cerebellar peduncle.  E:
The right half of the cerebellum has been removed to show p3 to p5.  F: Posterior view of the suboccipital surface of the cerebel-
lum. The p3 courses along the caudal margin of the tonsil, and the p5 is composed of the cortical branches. Caud. = caudal; Chor.
Plex. = choroid plexus; Cran. = cranial; Vent. = ventricle.

Operative Exposure. The PICA is exposed when deal-
ing with neoplasms involving the cerebellopontine angle,
foramen magnum, cervicocranial junction, clivus, jugu-
lar foramen, fourth ventricle, and cerebellum; aneurysms
arising at the PICA origin, the most common site in the
posterior fossa below the basilar apex, and less frequent-
ly from the distal segments; arterial dissections at the
PICA-VA junction; arteriovenous malformations, which
also commonly involve the other cerebellar arteries and
the brainstem as well as the cerebellum; posterior fossa
ischemia requiring bypass because of the PICA’s easy
accessibility through a suboccipital craniotomy and the
proximity to the occipital artery; anomalies at the cranio-
cervical junction, such as the Chiari malformation and
osseous deformities; and dysfunction of the lower CNs
such as glossopharyngeal neuralgia.
The PICA can arise outside the dura, and at any point
from along the intradural course of the VA. The origin
can be located along the lateral side of the medulla, if
the artery arises near the passage of the VA through the
dura, or in front of the brainstem if the origin is high near
the vertebrobasilar junction. Exposing a low-lying PICA
origin, either extradurally or immediately intradurally, at
the level of the foramen magnum can be achieved by a
midline suboccipital or a far-lateral approach. If an artery
with a low-lying origin has to be followed upward into the
cerebellopontine angle or there is a need to mobilize the
site of the VA’s passage through the dura, a far-lateral or a
limited transcondylar approach may be considered. A ret-
rosigmoid craniotomy may be sufficient to expose a PICA
arising from the midportion of the VA on the lateral side
of the brainstem in the lower part of the cerebellopon-
tine angle. If there is a need to expose the origin deep in
the midline near the vertebrobasilar junction, a supra-/in-
fratentorial presigmoid approach with some added degree
of labyrinth resection may be required, depending on the
depth of the PICA origin and the pathology. A midline
suboccipital craniectomy, possibly combined with re-
moval of the posterior atlantal arch, is usually sufficient
to expose pathology involving the tonsillomedullary and
telovelotonsillar segments of the artery. Lesions involv-
ing the PICA in the walls in the fourth ventricle, vermis,
and paravermian areas are usually exposed by a midline
suboccipital approach. Lesions involving the hemispheric
branch can be exposed through a suboccipital craniotomy
centered over the pathology.
Discussion
A nomenclature for segmental anatomy of cerebral

394 J Neurosurg / Volume 115 / August 2011

Nomenclature of cerebellar arteries

arteries is established, numbering the segments of the
ACA, MCA, and PCA in a manner that is easy to learn,
easy to communicate, and useful intraoperatively during
microsurgical dissections along arteries in the subarach-
noid space. A similar nomenclature for segmental anat-
omy of cerebellar arteries is lacking. In this report, we
propose such a nomenclature that numbers the segments
of the SCA, AICA, and PICA in a manner that is also easy
to learn, easy to communicate, and useful intraoperative-
ly during microsurgical dissections along arteries in the
subarachnoid space. Vascular pathology associated with
cerebellar arteries is less prevalent than with cerebral ar-
teries, but this nomenclature might be valuable with distal
aneurysms. Distal cerebellar artery aneurysms are often
described generically without specifying the exact aneu-
rysm location. The nomenclature localizes these aneu-
rysms more precisely (Fig. 5), which currently is lacking
in published reports and spoken communications. Simi-
larly, the nomenclature localizes a bypass anastomosis
precisely or describes a graft’s connections to donor and
recipient arteries. Alternative names of posterior circu-
lation bypasses are possible using the nomenclature. For
example, the PICA-PICA bypass joins the p3 segments
with a side-to-side anastomosis (p3-p3 bypass), and the
PICA reimplantation onto the VA is a p2-V4 end-to-side
anastomosis. These applications of the proposed nomen-
clature with cerebellar arteries mimic the applications of
the established nomenclature with cerebral arteries.
Better description of posterior circulation bypasses
would clarify important technical nuances (Fig. 6). For
example, the STA-to-SCA bypass is performed classi-
cally to the lateral pontomesencephalic segment, which
is exposed subtemporally. This bypass can also be per-
formed just lateral to the oculomotor nerve on the distal
anterior pontomesencephalic segment, which is exposed
pretemporally.28 The description “STA-SCA bypass”
does not differentiate these anatomical and technical dif-
ferences. Applying the nomenclature, the STA-SCA by-
pass performed through a subtemporal approach using
an s2 recipient segment might alternatively be described
as an STA-s2 bypass. The STA-SCA bypass performed
through a pretemporal approach using an s1 recipient

Fig. 5.  Case example: distal a1 AICA aneurysm. This 27-year-old woman presented with progressive headaches, nausea,
imbalance, and vertigo. A: Axial T2-weighted MR image demonstrating a 1.5-cm-diameter mass indenting the right antero-
lateral pons.  B and C: The initial digital subtraction angiogram does not show an aneurysm (left VA injection, anteroposterior
view [B]), but an angiogram obtained 3 months later demonstrates a subtle filling of the aneurysm in the arteriolar and capillary
phases of the angiogram (right VA injection, anteroposterior view [C]), indicating recanalization of a thrombotic a1 segment AICA
aneurysm. D: The aneurysm was exposed through a right extended retrosigmoid approach, working between CNs VII and VIII
superiorly and IX and X inferiorly. E: The aneurysm was located on the a1 (anterior pontine) segment, originating on the AICA
as it courses above the abducent nerve entering the Dorello canal. The aneurysm’s thick walls and dolichoectatic morphology
prevented direct clipping, and the aneurysm was trapped.

J Neurosurg / Volume 115 / August 2011 395

 A. Rodríguez-Hernández, A. L. Rhoton Jr., and M. T. Lawton

Fig. 6.  Case example: s1 SCA bypass.  A and B: This 55-year-old woman presented with subarachnoid hemorrhage from a
multilobulated left SCA aneurysm, seen on digital subtraction angiography (VA injection, anteroposterior view [A]) and rotational
angiography with 3D reconstruction (B). The superior lobule was coiled and residual neck preserved blood flow in the SCA. The
patient was referred for surgery to treat the residual aneurysm. Intraoperatively, it seemed unlikely that the aneurysm could be
clipped without occluding SCA and likely that a bypass would be needed to preserve it. C: The s1 (anterior pontomesence-
phalic) segment was prepared as the recipient site, just lateral to the oculomotor nerve. The anterior temporal artery was used
as the donor artery. D: The anterior temporal artery was transected distally and reimplanted onto SCA with an end-to-side
anastomosis. After bypass patency was confirmed, the aneurysm neck was dissected and clipped. The patient tolerated anterior
temporal artery sacrifice without neurological sequela.

segment might alternatively be described as an STA-
s1 bypass. Similarly, description of PICA bypasses with
the nomenclature adds technical nuance to their names.
These names for posterior circulation bypasses are analo-
gous to those for anterior circulation bypasses, like the
A2-A2 ACA bypass and the C3–5 cavernous carotid artery
bypass.7,17
The proposed nomenclature uses the arterial seg-
ments already defined by Rhoton and colleagues.8,9,12,13,18,24
The segmental anatomy of the VA and its numbered sys-
tem were defined previously.1–5 Anatomical descriptions
are clear and logical, but these names for cerebellar ar-
terial segments are cumbersome and can be forgettable.
A numbered system for arterial segments is easier to re-
member and easy to apply. A numbered system will, if
nothing else, encourage a more thorough appreciation of
the anatomy of cerebellar arteries. Arteries are critical
landmarks that guide microsurgical dissection in the sub-
arachnoid spaces to vascular lesions. The exact location
of a cerebellar arteriovenous malformation may not be
clear by inspecting the lateral cerebellar surface through
an extended retrosigmoid approach, but correlating ob-
served anatomy with angiographic segmental anatomy
can guide the dissection (Fig. 7). The dissection of brain-
stem cavernous malformations relies on frameless stereo-
tactic navigation, but overlying arterial anatomy can also
confirm the point of access to the underlying malforma-
tion, particularly when there are registration inaccuracies,
brain shift, or minimal hemosiderin staining.
Lowercase letters were used to distinguish infraten-
torial arteries from supratentorial arteries with the same
first letter of the artery’s name. Although the nomencla-
ture is clear in written communication, it may not be clear
in verbal communication. An “a3 segment” aneurysm
could be interpreted verbally as a distal AICA or a peri-
callosal aneurysm. The simplicity of using the first letter
of the artery’s name outweighs the potential confusion in
spoken communication, and verbal context should clarify
infra- versus supratentorial location. In addition, segmen-
tal nomenclature is easily combined with the name of the
parent artery, as in “a3 segment AICA aneurysm.”
Arteries in the posterior fossa are susceptible to nor-
mal anatomical variations, tortuosity, and underlying dis-
ease such as atherosclerosis. Segmental definitions may
not be clear in these cases. For example, a PICA that orig-
inates proximally, just beyond the VA’s dural penetration,
may be lateral to the medulla and not have a p1 (anterior
medullary) segment. An elongated and tortuous basilar
artery can displace the AICA’s origin lateral to the line
drawn through the long axis of the inferior olive, confus-

Fig. 7.  Case example: cerebellar arteriovenous malformation.  A: This 55-year-old man presented with a left cerebellar
hemorrhage and a small cerebellar arteriovenous malformation, seen on CT angiography (axial view).  B: A digital subtraction
angiogram (left VA injection, anterior oblique view) confirms a small arteriovenous malformation arising from the flocculopedun-
cular (a3) segment of the AICA.  C and D: Dissection into the cerebellopontine angle traced the AICA along its cortical and
subarachnoid segments to reach the nidus (C), which was removed through a left extended retrosigmoid approach (D).

396 J Neurosurg / Volume 115 / August 2011

Nomenclature of cerebellar arteries
ing the naming of its proximal a1 (anterior pontine) seg-
ment. There will undoubtedly be ambiguities in nomen-
clature with cerebellar arteries, but it should be applicable
with most vascular pathology.
Conclusions
The proposed nomenclature for segmental anatomy
of cerebellar arteries complements established nomencla-
ture for segmental anatomy of cerebral arteries. This no-
menclature is simple, easy to learn, and practical. The no-
menclature localizes distal cerebellar artery aneurysms,
and also localizes an anastomosis or describes a graft’s
connections to donor and recipient arteries. These ap-
plications of the proposed nomenclature with cerebellar
arteries mimic the applications of the established nomen-
clature with cerebral arteries.
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Lawton, Rhoton.
Acquisition of data: Lawton, Rodríguez-Hernández. Analysis and
interpretation of data: Lawton, Rodríguez-Hernández. Drafting the
article: Lawton, Rodríguez-Hernández. Critically revising the article:
all authors. Approved the final version of the paper on behalf of all
authors: Lawton. Administrative/technical/material support: Lawton,
Rhoton. Study supervision: Lawton.
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Manuscript submitted August 17, 2010.
Accepted March 29, 2011.
Please include this information when citing this paper: pub-
lished online May 6, 2011; DOI: 10.3171/2011.3.JNS101413.
Address correspondence to: Michael T. Lawton, M.D., Depart-
ment of Neurological Surgery, University of California, San Fran-
cisco, 505 Parnassus Avenue, M780, San Francisco, California
94143-0112. email: lawtonm@neurosurg.ucsf.edu.
397