6 Basal Cisterns Anatomy



10.1055/b-0036-141981

6 Basal Cisterns Anatomy

Yoshua Esquenazi Levy, Thomas Frank, and Arthur L. Day


6.1 Introduction


With the rapid expansion and utilization of endoscopy during cranial neurosurgery, detailed anatomical knowledge of the arachnoid membranes and the basal cisterns and their contents is essential for safe navigation within these structures. In this chapter, we present a general overview of the anatomy, nomenclature, and classification of the basal cisterns.



6.2 Overview of the Basal Cisterns


Comprehensive descriptions of the arachnoid cisterns were begun in 1875 by Key and Retzius.1 Pneumoencephalography allowed neuroradiologists to further describe the arachnoid membranes and cisterns, and in 1959 Liliequist described the cistern bearing his name.2,3 In 1976, professor Yaşargil reported his intraoperative observations on the microsurgical anatomy of the cisterns and used the access gained through these structures to revolutionize the field of microneurosurgery.4 Since Yaşargil′s observations, additional endoscopic and microsurgical reports of cistern anatomy have followed.5,6,7,8,9 Recent improvements in endoscopic technology permit safe navigation within the ventricles and subarachnoid cisterns, providing an open pathway to deep areas within the brain, which allows neurosurgeons to manage a broad range of diseases including infections, complex hydrocephalus, intraventricular tumors, and disorders of the cranial nerves.10,11,12,13



6.2.1 Normal Anatomy


The meninges that surround the brain are divided into three layers, the dura mater, arachnoid mater, and pia mater. The dura mater is thick, leathery, and adherent to the inner surface of the skull, acting as an inner layer of periosteum. The pia mater is densely adhesive to the brain surface and can harbor no potential space beneath it (entering the “subpial space” means entering the brain parenchyma). The arachnoid mater lies between the dura mater and pia mater. These three membranes create three spaces, including the epidural and subdural spaces (which are potential spaces) and the subarachnoid space (which contains cerebrospinal fluid [CSF]). The arachnoid mater derives its name from its spider weblike appearance, observed by anatomists in the eighteenth century. The arachnoid mater is avascular, easily separated from the dura mater by the subdural potential space, surrounding the entire brain and spinal cord, but unlike the pia mater, it traverses sulci and fissures.14 The subarachnoid space varies in thickness and may be absent when the pia mater and arachnoid mater are in direct contact at sites where nerves and vessels enter or exit the brain. This space is filled with CSF, blood vessels, cranial nerves, and solid or porous trabeculated fibers connecting the arachnoid mater and the pia mater. The subarachnoid space receives CSF via communications with the ventricles, principally at the foramina of Luschka and Magendie from the fourth ventricle. Focal enlargements within the subarachnoid space occur and are termed subarachnoid and basal cisterns. Trabeculations within the subarachnoid space can either divide the cisterns discretely or allow communication with various sized pores.4 The trabeculated membranes and their relationships to the locations of the cisterns help direct CSF flow from its production by the choroid plexus within the ventricles to its absorption by the arachnoid villi and granulations over the convexity.



6.2.2 Classification


The extent of the subarachnoid space surrounding the brain shows local variations. Cisterns can be divided into those that lie over the convex surface where the space is narrow, and those that lie near the skull base, where more voluminous CSF chambers are encountered. The basal cisterns surround the structures lying on the floor of the skull and mid-brain and communicate with the convex surface via three different routes:




  • 1. Anteriorly: between the hemispheres and along the rostrum of the corpus callosum.



  • 2. Anterolaterally: along the sylvian fissure over the insula.



  • 3. Posteriorly: from the quadrigeminal cistern up around the splenium of the corpus callosum, and from the quadrigeminal cistern posteriorly over the vermis and dorsal cerebellar surfaces.


Basal cisterns are named and classified according to the major anatomical structure they bathe or anatomical location.14 Yaşargil divided the subarachnoid cisterns into two categories, supratentorial and infratentorial, and then subdivided those into anterior, lateral, posterior, and superior (Table 6.1, Animation 6.1). Fig. 6.1 is a midline sagittal illustration of the brain with the major subarachnoid cisterns labeled, and Fig. 6.2 shows the relevant vascular contents of the subarachnoid cisterns at the skull base.

Fig. 6.2 The basal cisterns at the skull base, demonstrating the major vessels within the basal cisterns, axial illustration. (Abbreviations: A1, first segment of the anterior cerebral artery; P1–P4, segments of the posterior cerebral artery.)












































































Table 6.1 Classification and contents of the subarachnoid cisterns

Supratentorial (anterior)


Cistern


Contents


Chiasmatic


Perforating carotid branches, superior hypophyseal and infundibular arteries, optic nerve, optic chiasm, hypophyseal stalk, optic venous plexus


Lamina terminalis


Anterior cerebral arteries (A1 and proximal A2 segments), anterior communicating artery, Heubner′s artery, hypothalamic arteries, origin of the orbitofrontal arteries, venous system of lamina terminalis


Carotid


Internal carotid artery, origin of anterior choroidal artery, posterior communicating artery, ophthalmic artery


Olfactory


Fronto-orbital and olfactory arteries, olfactory vein, orbital vein, olfactory bulb and tract


Sylvian


Middle cerebral artery; origins of lenticulstriate, temporopolar, and anterior temporal arteries; middle cerebral artery bifurcation; superficial and deep sylvian veins


Supratentorial (lateral)


Crural


Anterior choroidal and medial posterior choroidal arteries, basal vein of Rosenthal


Ambient


Anterior choroidal arteries, posterior cerebral arteries, basal vein, superior cerebellar arteries, CN IV


Supratentorial (posterior)


Quadrigemenal


Medial posterior choroidal arteries, quadrigeminal artery, great vein of Galen, posterior pericallosal arteries, third portion of the superior cerebellar artery, perforating branches of the posterior cerebral and superior cerebellar artery, third portion of the posterior cerebral artery, CN IV origin


Velum interpositum


Medial posterior choroidal artery, splenothalamic branches of pericallosal arteries, dorsal callosal artery, internal cerebral veins


Supratentorial (superior)


Callosal


Anterior portion: proximal medial striate artery, recurrent artery of Heubner, medial fronto-orbital artery origin, olfactory artery origin, A2, MCA, frontopolar artery origin, callosomarginal arteries origin, anterior cerebral veins, orbital veins.


Posterior portion: posterior pericallosal arteries, pericallosal veins, occipital veins


Infratentorial (anterior)


Interpeduncular


Basilar artery bifurcation, origins of posterior cerebral artery, origins of superior cerebellar arteries, medial posterior choroidal artery, thalamogeniculate arteries, basal veins of Rosenthal, CN III


Prepontine


Basilar artery, AICA origin, pontine veins, CN VI


Premedullary


AICA, auditory artery, anterior spinal artery, pontomesencephalic vein, anterior medullary vein, CN V, VII, and VIII


Infratentorial (lateral)


Cerebellopontine


AICA, PICA, petrosal veins, CN V–XII


Infratentorial (posterior)


Cisterna magna


Vertebral artery, origin of PICA, cranial nerves IX–XII, lateral medullary vein, postolivary vein, choroid plexus


Superior cerebellar


Terminal branches of superior cerebellar artery, superior cerebellar vein, vermian vein


Infratentorial (superior)


Vermian and hemispheric


Medial and lateral terminal branches of superior cerebellar artery, venous branches to straight sinus, precentral cerebellar veins



6.3 Supratentorial Cisterns



6.3.1 Chiasmatic Cistern


The chiasmatic cistern is a midline structure that surrounds the optic nerves and chiasm; it borders the lamina terminalis cistern superiorly, the carotid cistern laterally, and the interpeduncular cistern posteriorly (Fig. 6.3). The medial carotid membrane forms the lateral wall, the outer arachnoid membrane forms the anteroinferior wall, and the diencephalic membrane forms the posterior wall. Anteriorly, the cistern is limited by the limbus sphenoidale, which is positioned at the posterior edge of the planum sphenoidale. The chiasmatic cistern contains the optic nerves and chiasm, pituitary stalk, and optic venous plexus and perforating carotid branches including the superior hypophyseal and infundibuar arteries.4,15 It continues anterosuperiorly as the cistern of the lamina terminalis.14



6.3.2 Lamina Terminalis Cistern


The lamina terminalis (LT) cistern is located at the midline of the deep cerebrum adjacent to the lamina terminalis, situated above the optic chiasm. The lamina terminalis forms this cistern′s posterior and posterioinferior walls, and the optic chiasm forms its inferior wall (Fig. 6.3). The septal area and medial surface of the posterior gyrus rectus form the lateral walls. The anterior boundary is formed by the pia and arachnoid mater in front of the anterior communicating arteries. The cistern is bordered by the pericallosal cistern superiorly, the chiasmatic cistern inferiorly, the carotid cistern laterally, and the olfactory cistern anterolaterally. It contains the anterior cerebral arteries (A-1 and proximal A-2 segments), the anterior communicating artery, the recurrent branch of Heubner′s artery, the hypothalamic arteries, the origin of the orbitofrontal arteries, and the venous system of the lamina terminalis.4,15,16 Understanding this cistern′s anatomy and its relationship with the anterior cerebral artery complex is crucial to avoid complications during endoscopic fenestration of the LT.17 (See Chapter 26 Lamina Terminalis Fenestration.)

Fig. 6.1 The major subarachnoid cisterns of the brain, midline sagittal illustration.
Fig. 6.3 Midline sagittal high-resolution, T2-weighted magnetic resonance image (MRI) of the brain demonstrating the major subarachnoid cisterns.

Abbreviations: AICA, anterior inferior cerebellar artery; CN, cranial nerve; MCA, middle cerebral artery; PICA, posterior inferior cerebellar artery.


Source: Data from Yasargil et al 1976.3

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Jun 1, 2020 | Posted by in NEUROSURGERY | Comments Off on 6 Basal Cisterns Anatomy

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