Anatomy of Trigeminal nerve

Great sensory cranial nerve of head and face, motor nerve for muscles of mastication. Four segments: Intra-axial Cisternal Interdural Extracranial.

Intra-axial segment

Main sensory nucleus in lateral pons. Spinal nucleus from pons to upper cervical cord (C2-C4 level). Mesencephalic nucleus from pons to midbrain. Motor nucleus lies anteromedial to main sensory nucleus.

Cisternal segment
Exits ventral pons as a larger sensory and smaller motor root. Root entry zone (REZ) Courses anterosuperiorly to the apex of petrous temporal bone through prepontine cistern. Passes through an opening in dura (porus trigeminus) to enter Meckels cave.

Interdural segment
Meckels cave CSF filled space continuous with prepontine cistern, located at a depression in petrous apex. Nerve trunk expands to form Gasserian ganglion from which branches arise.

Postganglionic
Ophthalmic nerve: Courses in lateral cavernous sinus wall below CN4. Exits skull through superior orbital fissure. Enters orbit, divides into lacrimal, frontal and nasociliary nerves. Sensory innervation scalp, forehead, nose, globe.

Maxillary nerve: Courses in cavernous sinus lateral wall below ophthalmic nerve. Exits skull through foramen rotundum. Traverses roof of pterygopalatine fossa. Continues as infraorbital nerve. Exits orbit through infraorbital foramen. Sensory to cheek and upper teeth.

 Branches Infraorbital nerve Zygomatic nerve Nasal Branches Superior alveolar nerves Palatine Nerves Pharyngeal nerve

Mandibular nerve: Exits directly from Meckel cave, passing inferiorly through foramen ovaIe into masticator space. Carries both motor and sensory fibers. Motor root bypasses ganglion, joins mandibular nerve as it exits through foramen ovale. Divides into masticator (muscles of mastication) and mylohyoid nerves (mylohyoid and anterior belly of digastric muscles).

 The mandibular nerve gives off the following branches: From the main trunk of the nerve
nervus spinosus(meningeal branch) medial pterygoid nerve

From the anterior division

masseteric nerve deep temporal nerves buccal nerve lateral pterygoid nerve

From the posterior division

auriculotemporal nerve lingual nerve inferior alveolar nerve motor branch to mylohyoid and anterior belly of digastric muscles

Imaging
Standardized brain MRI protocol- T1W spin echo, proton density, T2W fast spin echo sequences acquired in axial plane with turbo STIR sequence in coronal plane. For trigeminal neuralgia- T1W 3D-FISP (fast inflow with steady state precession). Pitfall: enhancement of ganglia and branchesnormal variant/ abnormal ?

Axial T2W MR

Coronal T1 C+ MR
Nonenhancing crescentshaped trigeminal ganglion and the prominent perineural venous plexus superior to it.

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