Atlas of

Neurosurgical Anatomy
 John L. Fox

Atlas of
Neurosurgical
Anatomy
The Pterional Perspective
With a Contribution by Bengt Ljunggren
Illustrated by David M. Klemm

With 171 Illustrations in 329 Parts, 133 in Full Color

Springer-Verlag New York Berlin Heidelberg

London Paris Tokyo
JNtN L. Fox, M.D.
Clinical Professor of Surgery. Division of Neurosurgery, Uni"ersity of Nebraska Medical
Center, Omaha, NE68105, USA

H ENGT LJUNGGREN, M.D.

Professor. Department of Neurosurgery, Uni,'e rsity Hospital, Uni,'c rsity of Lund, 22185
Lund,Sweden

Illttilmtor
D AV ID M. K L EMM
Medical lIIustralOr. Ed ucational l\ledia Production and Services. GeorgelOwn University
Medical Center, Washington, DC 20007, USA

Portions of the wor k on this atlas were carried OUI by Dr. J. L. Fox at the following institu-
tions: Universi ty of Zurich, Zurich, Swiuerland (1973-1974); West Virginia University Med·
ical Center. Morgantown. West Virginia (1975-1982); King Faisal Specialist Hospital and Re-
search Centre, Ri yadh, Saud i Arabia (1983-1985); Georgetown Unil'ersity Medical Center,
Washington. D.C. (1985-1987); and University of Nebras ka 1-.ledica l Center. Omaha, Ne-
braska (1987 -1988). The senior author is grateful for their support in this academic en·
d eavor.

On IM/TQnl coveT: Fig. 7. 13/p. 138.

Library of Congress Cataloging-in-Publication Data

Fox, J ohn L., 1934-
Atlas of neurosurgical anatomy: the plerional perspective f J ohn
L. Fox with a contribution by Hengl Ljunggren ; illustrated by David
M. Klemm.
p. cm.
Includ es bibliographies and index.
\. Brain-Anatomy-Atlases. 2. Brain-Surgery- Atlases.
[. Ljunggren, SengI. II. Title.
[DNLM: !. Nervous Syslem-anatomy & histology-atlases.
2. Nen'ous System-surgery-atlases. WL 17 F792aJ
QM455. F65 1989
61 1.8-dcl9
DNLMIDLC 88·39319
Printed on add·free paper
o3:l 1989 by Springer-Verlag New \orlo: Inc.
Softcovcr repri nt oTlllc hardcover 1st edition 1989
All rights reserved. This work may not be trans lated or copied in wbole or in pan without
the writlen permission or the publisher (Springer-Verlag, 175 Fifth A"enue, New York, NY
100 [0. USA), except for brief excerpts in connection with reviews or scholarly analysis. Use
in connection with any form of information storage and retrieval, electronic adaptation,
computer software, or by similar or d issimilar methodology now known or hereafte r de·
"e1oped is forbidden.
The use of general descriptive names, trade names, trademarks, etc. in this publication,
even if the former are not especiaJl ~' identified, is not to be taken as a sign that such names,
as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used
freely by anyone.
While the advice and information in this book are believed to be trueand accurate althe date
of going to press, neilher the authors nor the editors nor the publisher can acce pt any legal
responsibility for any errors or omissions that may be made. The publisher makes no ,,'ar·
ranty, express or implied. wi th respect to the material contained herein.

Typeset, printed, and bound by Universitatsdruckerei H. Sturtz AG. Wunburg, Federal

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9 8 765 4 3 2 1
lSBN- 13: 978-1-4613-8825-8 e-[SBN-1 3: 978-1-4613-8823-4
00[: 10. 1007/978-1-46 13-8823·4
 Dedicated to James Winston Watts, M.D., Professor Emeritus,
Department of Neurological Surgery, George Washington University
Medical Cente'r, Washington, D.C.
 Foreword

During the past 15 years, several publications on neurosurgical tech-

niques, often with special emphasis on surgical anatomy. have appeared
in the literature. Howevel; this book by J ohn L. Fox goes far beyond an
ordinary effort. This extraordinary work, Allas of Neurosurgical Anat011o/:
The Pte1'ional Perspective, has its or igins in the author's many years of devo-
tion, exhaustive labors, and experience as a teacher in the operating
theater (to wh ich his many residents will attest). This surgeon, born in
Billings, Montana, in the ycar of 1934, authored one of his first publica-
tions as a senior resident in 1964. The tide, " Differentiation of Aneurysm
from Infundibulum of the Posterior Communicating Artery," presaged
his future recognition as an intracran ial aneu rysm surgeon. Now Profes-
sor Fox is known throug hout the world not only for h is many publica-
tions on su bjects in neuroscience and clinical neurosurgery, but also for
his teaching methods, which utilize both television demonstrations a nd
color slides of live neurosurgical anatomy in realistic depth and clarity.
Such talents as a teacher have led J ohn Fox to be called forth as an in-
structor and lecturer in many neurosurgical seminars and courses both
here and abroad, East a nd West. His presentations with color photo-
graphs showi ng true visual images now are captured with perfection in
this atlas. Such photographs, with accompanying instructions and de-
scriptions on approaches to aneurysms and tumors, have left a promi-
nent and lasting impression on everyone who has had the opportunity to
attend his lectures.
This book gives us images in livin g color, images curremly unsur-
passed by any other work and well illustrated as the su rgeon actually sees
them. The excellent accompanying and instructive drawings help carry
the reader and observer step by step through the intricacies of cisternal
anatomy and pathways of intracranial surgery. This publication is di-
vided into e ight chapters, starti ng with the history of the pterional ap-
proach in neurosurgery. The inclusion of this interesting and instructive
chapter gives us an added evolutionary insight. It is co-authored by Pro-
fessor Bengt Ljunggren, whose interest and expertise in neurosurgical
history and aneurysm surgery are well known. Professor Ljunggren,
from the University Hospital of Lund in Sweden, fascinates the reader
with his accounts of the early evolution of techniques for turning the cra-
nial fl ap. The next three chaplers by Dr. Fox carry us through in strumen-
tation and positioning, photographic technique, and cranial anatomy.
His final four chapters take us from the sylvian fissure into and thro ugh
VIII Foreword

the carotid, chiasmatic, and inter pedu ncu lar cisterns and their en virons.
Such anatomy could never be so well illustrated before the days of the
operating microscope.
I have followed the career of john Fox for nearly 30 years, includ ing
the time since his days as a student and resident at the George
Washington Un iversity Medical Cen ter through his appointment as Pro-
fessor of Neurological Surgery at the same institution in Washington,
D.C., on Ju ly I, 1974. Subseque nt yea rs have shown that Professor Fox
not only is singularly and eminently qualified and gifted as an author of
such an atlas, but also continues to have the energy and drive to give fu-
ture students, anatomists, neurologists, and neu rosu rgeons such a last-
ing work on intracranial surgery via the pterional perspecti ve.

L UDW IG G. K EMPE, M.D.

Professor of Neurological Su rgery and
Research Professor of Anatomy
University of South Carolina
Charleston , South Carolina
 Preface

After completing a three-volume book entitled inlmcranial Aneurysms

published by Springer-Verlag in 1983, this authorcomin ued to compile a
set of surgical photographic slides that served well for teaching anatomy
at neurosurgical rounds, meetings, and workshops. But preservation of
these images for futu re sLUden ls required their publication in a more
permanent form. The plerional approach to cenain imracranial prob-
lems is being used with increasing frequency, and the photographs pre-
sented here give us the plerionai, or frontolatera l, perspective - a per-
spective that is turned upside-down and obliqued in comparison with
most standard anatomical illustrations. Yet, th is is the vlew as seen by the
neurosurgeon. For ease of comparison, all photOgraphs are oriemed as
if a right-sided operation is being performed.
In one sense, this atlas becomes "volume 4" of Intracmnial Aneurysms.
However, em phasis is on live anatomy and its variations rather than on
pathology. h is for this reason that this author omitted cases with basal
tumors, for such masses often distort and compress the vessels and cra-
nial nerves beyond dear recogni tion .
The earthly finality of death is mitigated by the deeds one does during
his or her life. One then leaves behind the results of interaction with
others. As physicians we hope to have mostly benefined our patients.
Sometimes we fail. This atlas nOl only is in memory of those failures. but
also is a photographic epitaph of some of those very patiems, however
few in number. For the many patients who survive the neurosurgeon's
hand and return home to family, the surgeon can gain more than any
ephemeral fame, fonune , or feeling of "well done." The neurosurgeon,
more importantly, can be both a catalyst inspiring younger surgeons to
greater heights and a teacher leaving behind works upon which others
can build. The author, the con tributor to the chapter on history, and the
artist hope that this atlas will serve such lasting purposes.
J owe a debt of gratitude to my friend and colleague Professor Bengt
Ljunggren at the Departmem of Neurosurgery of the University Hospi-
tal, The University of Lund, Sweden. Begin ning with the 1889 work of
the German surgeon Wilhelm Wagner. Professor Ljunggren contributes
a vital perspective to the history in Chapter 1. Special credit is due to
David M. Klemm , medical ill ustraLOr at the Georgetown University Med-
ical Cemer in Washington , D.C., where I carried out part of the work on
this book. He drew and labeled all the illustrations that accompany the
color photographs.
JOHN L. Fox
 Contents

Foreword by LUDWIG C. KEMPE. VII

Preface . . . . . . . . . IX

H istory of the Pterional Approach

BENGT LJUNCGREN and JOHN L. Fox

2 Instrumentation and Positioning 11

3 Photographic Technique . . . 33
4 Cranial Anatomy and the Cranial Flap 37
5 The S),lvian Fissure 55

6 The Carotid Cistern and Environs. 93

7 The Chiasmatic Cistern and Environs 123

8 The Ambient and I nterpeduncular Cisterns 165

Ind ex 20 1
 1
History of the Pterional Approach
BENGT LJUNGGREN and JOH N L. Fox

Introduction today's microsurgical instrume nts, the

Many surgical a pproaches have been proposed
in order to facilitate exposure of lesions in the
skull-base region wi th a minimum of brain re-
traction [I, 3, 12, 15, 18, 19,24,29,32-34,37,
39, 40, 49]. The pterional a pproach [0 th e cir-
cle of Willis and its environs is routinely used by
many surgeons. A pterional approach implies
that a small skull flap is raised with the pterion
(Creek pterion, wing [ II ]) - the craniometric
point located undern eath the tcmporalis mus-
cle and form ed by the junction of the fronta l,
parietal , and te mporal bones with the g reat
sphe noid wi ng bone - in the center of the base
of the flap (Fig. 1.1 ). Additional drillin g down
of the sphe noid ridge allows a low basal expo-
sure along the skull base. Equipped with
ne u rosu rgeon finds that the pterional ap-
proach to skull-base lesions is a more natural
and easier procedure than earl ier-day opera-
tions. Yet, there is a fascinating hiSlOrica l back-
ground over the last 100 years, that form s the
basis o f the present-day pterional approach.
There are several pioneers who made mo nu-
mental contributions to the development of
this access to deep-seated cran ial-base lesions.
Wilhelm Wagner and His
Osteoplastic Method
followin g studies on human cadavers for sev-
eral years, Wilhelm Wagner (1848 -1900) be-
came the first su rgeon in the world to raise a

Fig. 1.1. Close-u p view of left

side of dry skull with sutures
between the frontal (F),
parietal (P), temporal (1),
sphenoidal (S), and zygomatic
(l) bones outlined by black
ink.
2 I. HislOry of the Pterional Ap proach
bone flap (temporal in site) out of the cranial
vault in a living person , kee p it attached to the
overlying soft tissue (perioste um, tempora l
muscle, and scalp), a nd then replace the fla p
(after evacuation of a la rge epidu ral
hematoma) [4, 44]. Wagner used hammer and
chisel to raise the bone flap. The patient, a 27-
year-old man with skull-base frac tures a nd the
clinical picture of increasin g intracranial pres-
sure, underwent su rgery on the second day fol -
lowing a seve re head injury. He was in a poor
condition p rior to the ope ratio n. Following
evacuation of the hematoma, it was appa rent
thal the intracranial pressure had become nor-
malized , bUl the patient did not recove r a nd
d ied 24 hou rs after surger y. At a uto psy
Wagne r fou nd no signs of di st urbed nutrition
in the te mporal, omega-sha ped fl ap that he
had raised to allow e vacuation of the now-ab-
sent hematoma. He concluded that his osteo-
plastic method was an excellen t procedu re that
resulted in a good ex posure of lace rations of
the middle me ningeal artery in the middle cra-
nial fossa. He also suggested that his osteo-
plastic method could be used to ex plore and re-
sect other intracra nial lesions such as brain
abscesses, e pile ptic scars, a nd brai n tumors
[44].
Two years later (1891 ) Wagne r rightly
claimed priority for the introduction of the use
of the above-described , intraoperative osteo-
plastic bone flap to ex plore intracran ial le-
sions. He e mphasized that such fl aps appea red
to heal quickly and withou t compl ications
when attachme nt to the soft tissue was retained
during surgery [45]: "The osteoplastic method
of trepanation is no morc difficult or da nge r.
ous than an explorative laparotomy. "
In 1895 Wagner publi shed two cases of suc-
cess ful evacuation of e pidural hematomas
throu gh his then innovative osteoplastic proce-
dure. In this paper [46) he again e mphasi;r.ed
th e adva ntages associated with tempora ry re-
sect ion of a large bone fl ap for cx ploration of
the middle meningeal bra nches.
In 1909 Ha rvey Cushing [5] described
Wagne r's original procedure to explore and
decompress cerebral lll mors, which otherwise
proved to be inoperable, using" the usua l os-
teoplastic method of exploration ." He sum-
marized [5]: '~ n osteoplastic resection, what-
ever tools may be e mployed , has doubtless
come to be made, in the hands of all , unde r
some form of tourniquet, with the omega-
sha ped fl ap broken off across the thin squa-
mous wing of the temporal bone."
Wagner was a self-educated surgeon who,
like his great conte mporary colleague from
Berlin , Ernst von Bergman n ( 1 836 ~ 1907),
had been in volved in the Fra nco- Prussion War
in 1870. He devo ted his life to working in the
local hospi tal of Kon igshoue, a small tow n in a
mining d istrict in Upper Silesia, which in 1880
cou nted 27,600 in habitan ts. Silesia at this time
was incorporated into the newly founded Ger-
man Re ich. In this small place Wagner became
a n absolute master surgeon, and like von
Be rgmann he ex hibited a pa rticula r interest in
cran ial and spina l surgery. While von
Bergmann strongly objected to the use of
o pening the skull with chisel a nd mallet. this
was the technique superbly practiced by
Wagner. T he lattcr also publ ished important
contributions concerning the operative man-
agement of complicated skull fractlll"es [4 3]
a nd on fracture di slocations in the cervical
spine [47]. His re port on the cli nical diagnosis
a nd o perative evacuation of e pidural
he ma tomas is a masterpiece [46] . The same ca n
be said of the remarkable volume, " Die Verlet-
zu ngen der Wirbelsaule und des Rocken-
ma rks" [47] whic h he published in collabora-
tion with his colleague Stolpe r from nearby
Bresla u (Wroclav). Despi te a heavy clinical
dail), practice, he not only kept abreast with the
surgical litera tu re of the lim e but also followed
the litera tu re in general med ici ne and other re-
lated bra nches . Wagner was beloved by his pa-
tie nts, for he rad iated secu rity a nd goodness
and was widely recognized in the whole of
Silesia not onl y for his supreme skill but also
for his vast medical knowledge and his good reo
sui ts in the treatment of nonsurgical d iseases.
Crania] Saws
In 1891 Professor (" professeur a la Facuitc
libre") J ean Toison from Lille in France re-
pon ed on his use of a chain saw to divide the
bone between burr holes from within outward
to facilitate raising of osteoplastic skull fl aps
[38]. This saw could replace ha mme r and
chisels previously used in o pening the cranial
va ult. I n his pape r Toison paid much attention
to Wagner (already in his title) as the true
 de Martel's Skull Trephine and Metal Gu ide 3

pionee r behind the revolutionizing method of Heidelberg, Cermany, Kocher from Bern,
raising cranial flaps. He described Wagne r's Swi tzerla nd , Simpson from Edinburgh, Scot-
" historical con tribution which he first per- land , and Sklifassowsk i from SL Petersburg,
formed on a li vin g human on October 1st Russia. In his pioneer pa per Oba linski gives
1889" and continu ed [38], .. Aussi la nou vell e credit to Karl Dahlgren (1864 - 1924), a
methode opCraloire inauguree par W Wagne r Swed ish pioneer who, in 1896, had designed a
(de Konigshuue) qu i permetde creer une vaste new bone-cutting forceps fo r making linear
ouverture a la boite ossellse du crane et de re- cuts in the skull bone and which cut from the
fermer, a la fin de I'ope ration, avec de I'os, inside out [6]. With the increasing interest in
J'ouvertu re rendue tcmporaire de la trepana- cranial surgery in the first decade of this cen-
tion, constilUe-t-ci le un grand progres chirur- tury. the Cigli saw later became recognized also
gical. Ce chirurgie n a donne a celle methode in the United States by Harvey Cushing, who
operatoire Ie nOIll de rcseClion temporaire du adopted the use of this simplc instrument to di-
crane . ., vide the skull bone betwee n two burr holes
Toison's saw was fairl y cl umsy and was there- [36].
fore not much used [48]. T hree years later
(1894) Leonardo Gigli from Florence, Italy, de-
scribed his simple yet clever instrumem, a wire de Martel's Skull Trephine and
saw to divide bone between two open ings, This Metal Guide
tool has come to bea r his name, being called the
Gigli saw [ 16, 17). Origina lly, Gigli imemed his In 1908 Count Thierry de Manel (1875- 1940)
wire saw to facilit.·ue sym physiotomy in obstetri- presented lhe perfect solution to the rest of the
cal surgery. He fini shed his origi nal re port {16], problem of trephinin g wi thout risk of produc-
emphasizing that one dozen saws could be or- in g intracranial damage. As a bo)' de Martel
dered from the Hermann HarLel Compa ny in was alread y very inquisitive and enjoyed taking
Breslau at the price of 3 German marks plus mechanical things apart to learn how the), op-
40 pfe nnig for shipping com to an)' forei gn erated [31]. Frequently he dissected the fowl
country. He also added that chiefs of clinics being pre pared in the kitchen, and he bought
could obta in free samples by just sending in a a skeleton that he displayed as an amiable com-
request. pan ion, de Martel, a dcscenda nt of the
Professor Alfred Obalinski from the Jagicl- Mirabeau fa mil)' who played an olltstanding
Ionian University of Cracow in Galicia (the role in the French Revolution, was an aristocrat
haven of Polish culturc at the time, although fully conscious of his ancestry. At fi rst he was
under the government of Vienna) had in- enrolled in a school for the training of en-
tended to describe the use of the Gigli saw for gi neers and later was trained by several French
cranial trepanations at the Imernational Con- master surgeons . He beca me especially in-
gress in Moscow in August 1897. However, he terested in neurosurgical instrumentation . At
was prevemed from going and instead pub- the age of 33 he published an article [28] de-
lished his innovative a pplication in the Cen- scri bing two new neurosu rgical instruments.
tro/blatt [il r Chimrgie that same ),ea r [30]. In his Today, 80 ),ears later, both are in dail y use by
paper Obalinski stated that it had occurred to many thousands of neurosurgeons all over the
him that by using a slightly bcnded cannu la as world. In his milestone paper the two instru-
an inserter, the fl ex ible Gigli saw was ideal for ments he described were (a) a motor-driven
introduction between burr holes. He em- tre phine equipped with an automatic disen-
phasized that the use o f the Gigli saw permits gaging gear that stopped the trephine as soon
the safest method of dividing the skull bone as it has penetrated the skull and (b) the metal
from the inside to the outside without th e type gu ide for the introduClion of the Gigli saw be-
of trauma usually seen from the use o f ham- tween separate burr holes.
mer and chisel [30]. In Moscow, Emile Doyen When in Paris, de Martel presented his new
from Paris demonstrated his own method for automatic trephine, but it was received with de-
performing a cra niectomy in front of many rision. He then performed a demonstration
prominent professors of surger)" including lI sing a dried skull with a balloon 0 11 the inside
von Bergmann fro m Berli n, Czerny from as an im itaLion of the dura mater. With his au-
4 I. History of the Pterional Approach
Fig. 1.2. The " hypop hyseal 0' a pproach of Heuer and
Dand y. From Dandy WE (1936) The braill , in Lewis
D (cd): WF Prior, P roc/ice of SUrgfly, vol 12.
LOmatic trephine he drilled a hole in this sk ull
without puncturing the balloon a nd com-
mented [31 ], "Well, as yo u call see, this
treph ine can be operated by a n imbecile" ("ct
bien comme valis voycz, Messieurs, cc trepan
pellt manie meme par un imbecile"). Amer-
ican neurosurgeons were even more reluctant
to accept de Mart.e1's e lectric dri ll. By the late
1930$ it was used routinely in Sca ndinavia,
France, Germany, a nd Central Europe. Yet in
Boston in 1948 its lise was rejected even at the
Massachuseus General Hospital. The burr
holes were done ma nuall y (and laboriously!)
with Hudson drills. It was said that electric
drills were not used because Cushing had once
stated that such drills caused too much vibra-
tion transmitted to the brain (Bakay L, per-
sonal communication, 1974).
Hagerstown, Maryland, pp 145, 583-585. Re-
printed with permission of Practice of Surgery Ltd .
[71 .
de Martel a lso had designed a hemostatic
forceps, a self-reta ining cerebral retractor, and
a specia l surgical chair supporting the patient
for operatin g on posterior fossa tumors with
the patient in the siuing position. He was the
pioneer neurosurgeon in France who fou ght
a nd overcame the difficulties of blood loss and
inadequate posterior Fossa visualization com-
mon to neurosu r ger y during the first qua rter
of this centu ry. He had lost his only son in
World War I. In 1938, at the Annual Cong ress
of the De utsche Gesellschaft fUr Chirurgie. de
Martel gave an impassioned speech about the
necessity of continued friend ship between
French and German su rgeons, a speech that
was followed by thunderous applause. Two years
later, on Ju ne 14, 1940, as Hitler's troops occu-
pied Paris, de Martel commited suicide [31].
 From a "Hypophyseal" to a More Pterional Approach
Fig. 1.3. Another view of the "concealed incision"
(behind the hairline) of Heuer and Dandy. From
Dand y WE (1936) The brain, in Lewis D (ed): WF
From a .. H ypophyseaJ" to a More
Pterional Approach
In 1918 Waller Dandy took the liberty to report
for George Heuer, one of his younger col-
leagues, on a " hypophyseal" a pproach to
pituitary tumo rs [23]. Heuer later described
this approach in more detail and used it for sel-
IaI' and suprasellar LUmors [21, 22]. In the
1940s Dandy made some modifications [7 - 10]
and this lype of cranial opening became popu-
larly known in the United States as the " Dandy
nap " (Figs. 1.2-1.4). This hypophyseal ap-
proach used a skin incision concealed behind
the hairline.
5
Prior, Practice of Surgery, \'01 12. Hagerstown, Mary·
land, pp \45.583-585. Reprinted with permission
of Practice of Surgery Ltd . [7].
In 1962 George "{ayes, one of Dandy'S stu-
d ents and former chief of neurosurgery at The
Walter Reed Army Medical Center 111
Washington, D.C., briefly illustrated his fron-
totemporal approach in a publication with
Slocum [20]. One of their figures showed " ...
the visualization of an aneurysm of the an-
terior communicating artery as exposed
through a small Dandy pituitary lype o f flap. "
Hayes and his colleagues commonly used this
approach to the base of the brain (Hayes GJ ,
personal com munication, 1974).
In 1963, before the period of micro-
neurosurgery, Lougheed and co-workers [27]
stated that their operative procedure was car·
ried out "through a fronto temporal bone flap
6 L History of the Plerional Approach

A.

I
OpenonS .r.·chnldl ~r
betw~~ ,
optic n.
ad
GJrotid L ;- )mal\cr

Fig. 1.4. Dandy's approach to an intracranial Copyright ]944 by Comstock Publishing Company,
aneurysm. Fro m Dandy WE (1944 , reprilHcd 1969) Inc. Re printed by permission of Cornell University
Intracranial Arterial Aneurysms. New York, Hafner. Press [9].

with removal o f the pterion and a bit of the

Ski n irn:: i$ion
Fig. 1.5. The ptcrional craniotOmy flap as o utlined
by Kempe. From Kempe LG [25] .
outer third of the lesser wing ohhe sphenoid. "
Ludwig Kempe. who succeeded Hayes at T he
Walter Reed Army Medical Ce nter, Ilicely illus-
trated various features of the plcrional ap-
proach (Fig. 1.5) in his 1968 two-volume alias,
OPerative Neurosurgery [25] . Of interest is the de-
scription given to the critical burr hole placed
at the junction of the temporal line, the
zygoma tic process of the frontal bone, and the
orbital ridge. At The Walter Reed Army Hospi-
tal this became known as the " psychopathic
poi m " [14, 26, 4 1], probabl y in reference to the
disposition of the surgeon should the residem
fail to place the burr hole correctly! Sub-
seque mly Fox learned the pterionaltcchnique
of cran ial ope ning [ 13, 14] by observing or as-
sisting George Hayes, Lud wig Kempe, and
Hugo Rizzoli , Dand y'S last neurosurgical resi-
de m o Barnes Woodhall, a nother of Da ndy'S
trainees, simila r! y used the pte rional a pproach
at Duke University (Woodhall B, personal com-
municatio n, 1980).
With the imroduction of microncurosurg i-
cal techniques, Gazi Ya~argil illustrated his
 Bibliography
Fig. 1.6. Diagram of skull with area
usually included in a pterional flap
although modified by various surgeons.
From Fox JL [14].
microtechnical pterional approach [51, 54],
which was a refinement of his 1969 frontotem-
poral descri ption [50]. He emphasized the
sma ll , low basal expos ure by drilling down the
sphenoid bone. At that time the basic differ-
ence between his published description and
that of Ke mpe's [25] was the use of micro-
technique, sphenoid bone dri lling, a wider
opening of the sylvian fi ssu re, the placement
of the posterior burr holes more a nteriorly
(making it a frolHos phenoidal craniotomy),
a nd the avoidance of retraction on the tem-
porallobe [54]. Ya~argil and co-workers used
the pterional approach for lesions in the inter-
peduncular cistern [52], in which situation the
posterior clinoid process is a landmark that, on
occasion, may hinder a clear ex posure [35].
The skin incision likewise has changed with
the needs and preference ofth e individual sur-
geon. Dand y's original incision is illustrated
in Figs. 1. 2 through 1.4. Kempe's incision
(Fig. 1.5) permitted greater exposure of the
temporalis mu scle as well as a more basal expo-
sure . Various surgeons at times extend the
fronta l limb a shon distance into the skin of the
forehead above the junction of the medial twO
thirds and lateral one third of the eyebrow.
This might permit a shorter scal p incision, but
itdid make part of the surgical sca r visible after
hair regrowth . Ya~arg il 's incision was longer
but re ma ined concealed beh ind the hairli ne
while descending low enough to perm it a
lower, basal a pproach [53, 54]. The pterional
approaches at times can inju re the fromalis
7
"
branches of the facial nerve, a point of recent
discussion [2, 55].
Throughout the years neurological sur-
geons have altered and modified the a pproach
to the middle fossa and sellar region. In one
form or anOlher the pterion has been incorpo-
rated within the reflected bone fl ap in modifi-
cations of the "pterional fl a p " (Fig. 1.6). Its
evolution from the Heuer-Dand y flap to the
Hayes- Kempe flap posteriorly and basally and
then to the Yaprgi l nap a nteriorl y a nd basall y
has been accompanied by parallel advances in
imaging, anesthesia, magn ification, lighting,
retraction, instrumentation, and intraopera-
tive e nergy transfer (by laser, ultrasound, elec-
trocautery, and the like). The pterional ap-
proach is now finding its place as an important
surgical route to t he circle of Wi llis and itsenvi-
rons. T he pioneers who laid the fund amental
cornerstones to this procedure include
Wilhe lm Wagner, Leonardo Gigli, Alfred
Obali nski, Thierry de Martel , George He uer,
and Walter Dand y. T hese are the men of years
long past to be r emembered by all ne urosur-
geons who today regard the pterional ap-
proach to the skull base as a n elementary and
most obvious and fund a me ntal principle.
Bibliography
1. AI-Mefty 0 (1987) Supraorbital-ptcrional ap-
proach to skull base Icsions. Neurosurgery
21: 474-477
2. Aoki N (1987) Incision offacial nerve bra nch al
8 I. History of the Plerionai Approach
aneurysm surgery. (Leuer to the Editor) J
Neurosurg 66: 482
3. Brock M, Dietz H (1978) The small frontolateral
approach for the microsurgical treatment of
intracranial aneurysms. Neu rochirurgia (Stultg)
21: 185- 191
4. Buchfeldcr M, Lju nggren B (1988) Wilhelm
Wagner (1848- 1900). Surg Neural, in press
5. Cushing H (1909) A method of combiningexplo-
ratio n and decompression for cerebral tumors
which prove to be inoperable. Surg Gynecol
Obstet 9: 1-5
6. Dahlgren K (1896) Ein neues Trepanations-
instrument. Centralbl Chir 23: 217 -220
7. Dandy ,-\,IE (\936) The brain, in Lewis 0 (ed):
PracliceofSurgery, Hagerstown, Md, WI<- Prior, vot
12, pp 145,583-585
8. Dandy WE ( 1938) Intracranial ane urysm of in-
ternal carotid artery. Cured by operation. An n
Surg 107:654-659
9. Dandy WE (1944, reprimed 1969) Intracranial
ArterialAneurysms. New York, Hafner
10. Dandy WE (1945) Intracranial arterial
aneurysms, in: The Brain. New York, Harper &
Row (Reprinted 1969 from WF Prior, Lewis Prac-
tice o/Surgery, Hagerstown, Md)
II. Dorland's Illustrated Medical Dictionmy (1974) cd
25. Philadelphia, WB Saunders Co, p 1284
12. Dotl NM (1933) Intracranial aneurysms: cere-
bral arterio-radiography: surgical treatment.
Edinb Med J 40: 219-234
13. Fox JL (1979) Microsurgical exposurc of intra-
cran ial ancurysms. J Microsurg I: 2-31
14. "oX JL (1983) Intracranial Aneurysms. Ncw York,
Springer-Verlag
15. Frazie r CH (1913) An approach to the
hypophysis through the anterior cranial fossa.
AnnSurg57: 145-150
16. Gigli L (1894) Ober ein neues Instrument wm
Durchtrenncn dcr Knochen, die Drahtsage.
Centralbl Chir 21: 409-411
17. Gigli L (1897) Z UI" praktischen Vcrwertung der
Drahtsage. Cemralbl Chir 24: 785-788
18. Hakuba A, Liu S, Nish imura S (1986) The or-
bitozygomatic infratcmporal approach: A new
surgical technique. Surg Neurol 26: 27 1-276
19. Harris P, Udvarhelyi GB (1957) Aneurysms aris-
ing at the internal carotid-postcrior com-
municating artery junction. J Neurosurg
14: 180- 19 1
20. Hares GJ , Slocum HC (1962) The achievement
of optimal brain relaxation by hypervemilation
technics of anesthesia.] Neurosurg 19: 65-69
21. Heuer GJ (1920) Surgical experiences with an
intracrall ial approach to chiasmallesions. Arch
Surg I: 368-381
22. Heuer G] (193 1) The surgical approach and
treatment of tumors and other lesions about the
optic chiasm. Surg Gynecol Obstet53: 489-5 18
23. Heuer C] , Dand y WE (1918) A new hypophysis
operation. ] o hns HopkillS Hosp Bu ll 29: 154
24. Jane JA, Park TS, Pobereskin LH et al (1982)
T he supraorbital approach: Technical note.
Neurosurgery 11:537-542
25. Kempe LG (1968) Operative Neurosurgery, wl/.
Cranial, Cerebral, and Intracm71ial Vascular Disease.
Berlin, Springer-Verlag
26. Kcmpe LG, VanderArk GO (197 1) Anteriorcom-
municating artery aneurysms. Gyrus rectus ap-
proach. Neurochirurgia (Stultg) 14: 63-70
27. Lougheed WM. BOltereH EH, r..lo rley TP (1963)
Results of the direct attack in the surgical man-
agement of internal carotid and midd le cerebral
aneurysms. Clin Neurosurg9: 193-200
28. de Martel T (1908) Un point de technique
operaLOire dans la craniectomie. Presse Med
16:641-643
29. McArthur LL (1912) An aseptic surgical access to
the pituitary body and its neighborhood. J AMA
58:2009-2011
30.0balinski A (1897) Zur Technik del' Schadel-
trepanation. Centralbl Chir 24: 857-859
31. Pecker ] (1980) T hierry de Martel, 1875-1940.
Surg Neurol 13: 40 1-403
32. PiteHi SO, Almeida GGM, Nakagawa EJ etal
(1986) Basilar aneurysm surgery. The subtem-
poral approach with section of the zygomatic
arch. Neurosurger y 18: 125- 128
33. Pool] L (196 1) Aneurysms of the anterior com-
municating artery. Bifrontal cranioLOmy and
routine use of temporary dips. ] Neurosurg
18:98-112
34. Pool ] L (1962) T iming and techniques in the
intracranial surgery of ruptured aneurysms of
the anterior communicating artery.] Neurosurg
19: 378-388
35. Samson OS, Hodosh RM, Clark WK (1978)
Microsurgical evaluation of the ptcr ional ap-
proach to aneur ysms of the distal basilar circula-
tion. Neurosurgery 3: 135- 141
36. Seeger W (1973) Allgemeine neurochirurgische
Operations tech nik, in Sailer FX, Gierhake FW
(cds): Chirurgie histQrisch gesehen. Deisenhofen bei
t.H.inchen, Dustri Verlag: pp 237 -238
37. Sugita K (1985) MiC1"01liurosurgical Atlas. Berlin,
Spri nger-Verlag
38. Toison] (189 1) De la trepanation du crane par
resection temporaire d'un lambeau osteoplas-
tique (procede de Wagner et procede person-
nel). Cong Fr Chir 5: 325-338
39. Tonnis W (1936) Erfolgreiche Behandlungeines
Aneurysma der Art. commun. ant. cerebri. Zen-
tralbl Neurochir I: 39-42
40. Tonnis W, Walter W (1960) Ein neuer operativer
Zugang zu den sackrormigen Aneurysmen der
basalen Hirngef.isse. Wien med Wochellschr
110: 145-147
41. VanderArk CD, Kempe LG, Smith DR (1974) An-
 Bibliography
terior communicating aneurysms: the gyrus
rectus approach. Clin Neurosurg 21: 120 - 133
42. Wagner W (1885) Uber Halswirbellu xationen.
Ard,iv fur klinische Chirurgie. Berlin, Verlag von
August Hirschwald , pp 192-2 16
43. Wagner W (1886) Die Behandlung der kompli-
cirten Schadelfrakturen . Centralbl Chir
26: 2405-2510
44. Wagner W (1889) Die temporare Resektion des
Schadeldaches an Stelle der Trepanation. Ein
Vorschlag. Celllralbi Chir 16: 833-838
45. Wagner W (1891 ) Zwei Faile von temporarer
Schadelresektion. Ccmralbl Chir 18: 25 - 29
46. Wagner W (1895) Zwei Faile von HaematOm der
Dura mater geheilt durch temporare Schadel-
resektion. Berl klin \-I/ochenschr32 (7) : 13i - 140
47. Wagner W, Stolper P (1898) Die Verletzungen der
Wirbelsaule und des Riickenmarks, in von
Bergmann E, von Bruns P (eds): DeutscM Chirur-
gie, No 40, Stuttgart, Verlag von Ferdinand Enke,
pp 1-564
48. Walkcr EA (1951) A His/ory of Neu.rological Su.rgery.
Baltimore, Williams & Wilkins Co, p 50
9
49. Wolff J (1863) Die Osteoplasti k in ihren Be-
zieh ungen zur Chirurgie und Physiologic. Arch
klin Chir 4: 183-294
50. Ya~argil MG (1969) Microsurgery Applied 10
Neurosurgery. Stuttgart, G Thieme, pp 119- 143
51. Ya~a rgi1 MG (1984) Microneurosurgery. Stuttgart,
GThieme
52. Ya~argil MG, Antic J , Laciga R et a1 (1976) Micro-
surgical pterional approach to aneurysms of the
basilar bifuf(:ation. Surg Neurol6: 83-91
53. Ya~argil MG, FoxJL(1975)The microsurgical ap-
proach to intracranial aneurysms. Surg Neurol
3:7-14
54. Ya~argi l MG, FoxJL, Ray MW (1975) The opera-
tive approach to aneurysms of the anterior com-
municating artcry, in Krayenbiihl H (cd): Ad-
vances and Technical Standards in Neurosurgery.
Vienna-New York, Springer-Verlag, pp 11 3- 170
55. Yaprgil MG, Re ichman MV, Kubik S (1987) Pre-
servation of the frontotemporal branch ofthe fa-
cial nerve using the inter fasc ialtcmporalis nap
for pterional craniotOmy. Technical article. J
Neurosurg 67: 463-466
 -- 2
Instrumentation and Positioning
Introduction
This chapter describes the surgical instru-
menlS and equipment uti lized by the author
during the plcrional approach to intracranial
lesions. Since part of the instrumentation is
used to maintain the proper position and align-
ment of the patient, positioning is an inti-
mately related subj ect.
The Japanese samumi was a dedicated and
courageous warrior skilled in battle. He and hi s
sword or bow-and-arrow were a si ngle fighting
unit. They were such an integral pan of each
other that activation of cerebral and muscle
memory effected ra pid and nearly subcon-
scious communication, resu lting in precise,
"computerized" delivery of the weapon upon
its targeted foe.
The above simile is meant to emphasize the
conceptual and real changes occurring in the
modern ne urosurgical operating room. The
neurosurgeon (samurai), the instrumentation
(bow-and-a rrow), and the patient's lesion (foe)
are no lon ger separate en tities. Through ex-
tensive laboratory and clinical training, un-
learning old habits, and learning new methods
of hand-brain-eye coordination , the modern
neurosurgeon now develops cerebral and mus-
cle memory a kin to that of the samurai . The
operating microscope and microsu rgical in-
strume nts become an in tegral part of the sur-
geon who must deftly deliver his therapeutic
arrow on target. If this is to be done with mini-
mal disturbance to the patient's brain, the
arrow's trajectory is limited to narrow pathways
between cran ial and intracranial structures.
It now ca n be appreciated that, in addition to
being able to work in small, optically magnified
spaces with delicate and long dissecting instru-
ments, thc position of the neurosurgical pa-
tient nowadays is critical to the "stereotaxic"
alignment of the su rgeon's eye, the micro-
scope, the dissecting instruments, and the
ta rgeted lesion. The surgeon must supervise
the positioning of the patient so that when the
target is reached later in the day, the surgeon is
comfonably situated for delicate dissection of
the tumor or vascular anomaly within very nar-
row spaces. As the patienland instrumentation
are being set up, the surgeon reviews a mental
check list(much as an airplane pilot does) based
on past experience and endeavors to control in-
terlocking events with in the operating room.
Inexact patient posi tioning or imperfect align-
ment of the patient's head in the historical past
could be compensated by more brain retrac-
tion or by rotation of the patient's head resting
on a cranial "donut." Nei ther is acceptable in
most modern-day microneurosurgical proce-
dures where the patient'S cranium is im-
mobilized by a skull-fixation apparatus and the
brain is supported by self-retaining retractors
usually attached to the operating table. Thus,
an incorrect pos itioning of the skull-fixation
a ppa ratus, for ex.ample, may cause part of th is
a pparatus to intcrfer with later placeme nt of a
smail , self-retaining retractor 0 11 the in ternal
carotid artery and thereby hinder the sur-
geon's line-of-sight to the interpeduncu lar cis-
tern . It is in this context that "interlocking
events" must be well thought out and control-
led.
Because the neurosurgeon is working within
very narrow confines, it is even more incum-
bent upon the surgeon not on ly to have a
thorough knowledge of normal and aberrant
 12 2.lnstrumemation and Positioning

Fig. 2.1. A. Top of skull with

burr hote at right coronal su-
tu re and small hole (arrow)
just behi nd burr hole. B.
View with camera lens at
burr hole. Anterior clinoid
processes (triangles), poste-
rior clinoid processes, and
left foramen ovale (wroed
arrow) are ,",'ell seen at skull
base. Small arrow lies on right
posterior clinoid processand
poims toward metal pin pro-
jecting up\\'ard from noorof
sella turcica. C. Similar but
morc restricted view with
camera lens at smaller cra-
nial hole (behind burr hole
A in A). Arrow crosses left pe-
trous pyramid and intracra-
nial opening o f carotid canal
and poinL~ LO the foramen
ovale. Figures 8 and Care
rotated 90 0 counter clock-
wise compared with A.

c
 Head Holder
neuroanatomy but also to be able to concep-
tualize the anatomy in its three dimensions
(stereoimage concept). The tomographic plan-
es of computed tomography (CT) and magnet-
ic resonance imaging (MR I) detract from such
conceptua lization (whereas stereoscopic im-
ages and pneumoencephalography [45J en-
courages it). The medical student lea rns his
anatomy from sta ndard cadaver dissections
a nd textbooks. The surgeon, at least in the
pterional approach illu strated in this atlas,
must view the patient's anatomy from an ob-
lique a nd upside down oriemation (wi th re-
spect to the patient).
Cranial openin gs have become smaller as
microsurgical techniques have advanced. In
theory, an intracranial lesion could be operated
on via a tiny (eg, I mill) cranial opening
(Fig. 2.1). In a sense, the operating microscope
brings the surgeon's eye closer to the cran ial
opening. If the surgeon's eye were at the ope n-
ing like peering through a keyhole, a full view
of the intracranial spaces could be seen - if re-
tractors cou ld fit through the opening - and
the lesion cou ld be removed or corrected - if
dissectOrs, like a laser beam, could fit through
the opening. Thus, among the factors limiting
the use of very small cranial openings in most
cranial operations are intracranial instrumen-
tation and maneuverability.
Instrumentation continues to change, de-
pending on surgical needs. There are va ri-
ations among specific types of instruments (eg,
retractor systems, cranial-fixation systems,
operating tables) , and an individual surgeon
often uses the system that he was trained in or
that fits his particular approach. T he instru-
ments and equipmem herein described have
been the author's personal preference for the
pterional approach to various intracranial le-
sions. Much of the following is reproduced
from a previous publication [16].
External Instrumentation
Operating Room Table
We place the patient on the American Sterilizer
operating room (OR) table so that the patient'S
head is at the foot end of the table (Fig. 2.2).
This has several advantages: (a) the table ped-
als are not in the way of the sitting surgeon's
feet (the anesthesiOlogist or circulating nurse
manipulates these as needed); (b) there is more
13
room for the base of the microscope (which we
position to the left of the surgeon) ; (c) the nor-
mal opening in the OR table lies under the lum-
bar region of the patient's back, facilitating
lumbar cerebral spinal fluid (CSF) drainage
without turning the patient. The only disad-
vantage of this alignment is that the main
weight of the patient is off the center of gravity
for the OR table. An assistant often must assist
in elevation of the surgeon's end of the table by
lifting lip the table under the patient's shoul-
ders when the patient'S head is raised (table
fl exed) to its final position (aboma 10- to 15-de-
gree elevation of the patient'S head). This ac-
lion lightens the unbalanced load on the table
wh ile the table is flexed. One must becareful to
avoid sliding the bUllocks into the opening,
which would risk sciatic nerve pressu re in short
patients.
Head Holder
In this era of minosurgical technique and self-
retaining retractors, it usually is essential that
the head be immobilized by three-poim skull fi-
xation. We use the Mayfield-Kees skull clamp
(Kees Surgical Specialty Company). T his clamp
(Fig. 2.3) is inserted into the normal foot end
of the American Sterilizer table. The horizon-
tal part of the head holder should be nearly
parallel wi th the fl oor. We prefer to have the
two-point side of the clamp on the side of the
surgery, as the opposite one-point side may
project Out tOO fal: All joints are tightened se-
curely (from above downward), a nd the head is
immobilized throughout the operation.
A study group sta ted (17):
Under the surgical microscope, the slightest
movement of the patient's head is magnified con-
siderably. Microsurgery demands a precisely
maintained position of the firmly fixed cranium
throughout the entire opel'ation, whether one op-
crates with the patient in the sitting. supine, or
prone position. This is beSt achieved by a pillion
head holder in which the essclllial clemem is a
clamp made to accommodate three relatively
sharp pins. The pins penetrate the scal p and are
then firmly fixed to the outer (able of the skull.
\Vhen placing the pins, the surgeoll shou ld take
care to avoid a spinal fluid shunt, surface vessels,
thin bone (such as over the frontal and mastoid
sinuses), and the thick temporal muscle where the
position of the pin tends to remain unstable, how-
ever tightly the clamp is applied. A pin on the
forehcad should , of course, be well away from the
eyc; and when the clamp is positioned too close to
 14 2. Instrumentation and Positioning

"

c

fig. 2.3. A. Mayfield-Kees head holder with demon-
stration skull (bone flap re moved) in position for
rig ht fron(Oiatcrai craniotomy. 8 . Pa tient in position
~~------------------------------------------------------
Fig. 2.2. A. Sketch of American Sterilizer OR table.
The usual head end is to the observer's lefl. The
head rest has been rCII1O\'cd from this end and
placed at the normal foot e nd on the observer's
right. T he patient'S head initially rests on the head
rest on the observer's righ t with that end c!evated
10°_ 15° and with the lu mbar region oflh e patient's
back res ting Mer the open ing (arrow) in the table.
B. Same after specially mad e maltress is in place with
opening for lumbar CS F drainage. A model skull
(see Fig. 2.3) is held by the skull damp (replaci ng the
head res t). An "ether screen" (bar with knob project-
ing toward observer) p rojects away from the le ft sid c
of the paticlll to late r ho ld the d ra pes alld suction
A
with head turned 40° to left, tilted 15° to left. and
d ro pped back 15°, From Fox [16].
tubes. The Leyla self- retaini ng retractor bar (see
Fig. 2. 11 ) atl<lchcs (aITow) to the O R table just
cephalad to the ether screen attach me nt. The micro-
scope stands JUS t cephalad to lhe ether screen , and
the anest hesiologist is positio ned caudal LO lhe et he r
screen. C. Preli mina ry dra ping of paticnt. Instru-
ments are placed o n the overhead ins trume nt ta ble
(Phelan Manu fact uring Corporatio n, Minnea polis).
Note the steralized "C-clam ps" at each end with rub-
ber tubing st retched between . T hese are covered
after fi nal draping and prel'cnt instruments from
falling offinto the a ncsthesiologist's no nsterilc field.
From Fox [ 16].
15
16 2. Instrumentation and Positio ning
the incision, a pin·casing can be a hinderance.
Special smaller pins available for infants can also
be used for patients who have thin skulls. Pa rticu-
lar attention should be given to patie nts who have
had a long history of hydrocephalus. Having se-
cured the clamp. the surgeon holds the head in
the desi red position wh ile the final attach ment to
the operating table is made. Man ipulation of the
head holder accurately and with safety may bcdi f·
ficull at first, but with experience any obstacles e n-
counlcred can usually be surmounted. This
method of skull fixation avoids the pressure in-
juries that may occu r to the scaJp or face when the
head has been resting on rubber pads for long
periods.
The time of insertion of the poinlS imo the
scalp and skull is a critical period . T he head
must be perfectly posiLioned accordin g to the
approach used by the surgeon . Any deficiency
wi ll cause defective alignment of the target,
cranial opening, microsco pe, and surgeon's
eyes. The alignment must be such that there
will be a dear view of the aneu rysm a t the focal
poim of the microscope with the surgeon in a
comfortable position. Upon insertion of the
Fig. 2.4. Pneumatic lift chair (C.C. R. Medical Corpo-
ration, Pittsburgh). The dark cush ion is added for
extra height. From Fox [ 16] .
poinlS, the patient's blood pressure and intra-
cranial pressure will rise unless he is properly
anesthetized and his blood pressure is under
control. The surgeon must notify the anes-
thesiologist before he inserlS the poims. Colley
a nd Dunn (6] recomme nded local anesthesia
in the scalp at the point-insertion sites.
Surgeon's Chai r
Surgeons' chairs are available from various
companies, eg, Storz Instrument Compa ny,
Aesculap Company, Stryker Corporation, and
V. Mueller Company. Ya~a rgil el al [57] re-
ported on their special chair; we have found
the rece nt modification sold by the Aescu lap
Company to be qu ite satisfactory. \Ve also have
used the pneumatic lift chair (style P390244)
available from lheC.C.R. Medical Corporation
of PitlSbu rgh (Fig. 2.4). A hard cushion may be
placed on the seal to give the surgeon a bit
more height. The stool height is adjustable by
pressing on the foot bar.
Operating Microscope
After years of experience with neurosurgery
sa ns microscope fo llowed by microneurosurgi-
cal ex per ience in his operating room, Cha rles
Drake concluded [12]:
The remarkable new surgical world revealed
under the operating microscope and the beauti-
ful instruments available to work in it have un-
d oubtedly played a m.yor role in placing the
safety and scope of aneurysm su rgery \\'here they
are today.
And Gazi Ya ~argil had advised [55]:
However, it should never be forgotten that the re is
much more to microtech niquc in neurosurgery
than the possession of a highly perfectcd optica l
instrument. This alone is o f little value without
special methods of bipolar coagulation, carefull y
ad apted instru ments, and, above all, atraumatic
operation techniques.
In 1865 Bischo ff [4] published his work on
dissections of the cranial nerves. He began wi th
lou pes and later graduated to the dissecting
microscope with up to 50x power. The evolu-
tion of the use of the operating microscope in
surgery is detailed in other publications [9, 17,
36,4 1, 43 ,55].
In 1978 a stud y grou p concluded the follow-
;ng [In
 Operating Microscope
The use of the operating microscope and micro-
technique is only one part ofthe modern trend in
the surgical treatment of certain cerebrovascular
problems. Coincidentally, a team of experts has
evoh'cd, each of whom is specially trained to carry
Out his or her wsk in this type of surgery ... Al-
though we place major emphasis upon the micro-
surgical tedmi<lues, advances have occurred as
well in anesthesiology, nursi ng care, radiological
diagnostic methods, pharmacology, and available
monitori ng systems. Certainly the jud icious use of
vascular hypotension and of techniques to control
intracranial pressure has helped greatly to reduce
patient morbidity. Some operations would be ex-
tremely difficult if not impossible to perform
without today"s sophisticated personnel ... Both
reports in the recent literature and the increasing
use of the microscope by neurosurgeons confirm
the opin ion and experience of stud y group mem-
bers that the application of the operati ng micro-
scope and microtechnique has markedly reduced
the mortality and morbidity associated with intra-
cranial aneurysm surgery. Parallel improvements
in equipment have contributed additionally to
these results. The cardinal factors , however, arc
the training, experience, and expertise of the
operating surgeon who utilizes these new
tech niques and the capabilities of his operative
team.
Some of the technical as pects of optics, su p-
ports, accessories, use, care, and sterilization of
the microscope and its accessories are given
elsewhere [10, 14, 15, 17,3 1, 35, 37, 40, 43, 55,
57]. The Zeiss operating microscope (Carl
Zeiss, Inc) is the unit most commonl y used at
this time (Figs. 2.5-2.7).
We have been using (he counterbalanced
Zeiss-Contraves unit (Figs. 2.6 and 2.7) with
electronic switches that release magnetic locks,
immobilizing the microscope in any desired po-
sition [57]. Our preference has been the OPM I
No. I Zeiss magn ification system rather than
the zoom lens system attached to the Contraves
stand . We also prefer the floor mount to the
ceiling mount. In our OR the television came ra
is attached to the left side of the beam spl itter,
and the binocular observation lUbe or still cam-
era is attached to the right side. The newer in-
clinable binocular tube (Fig. 2.8) has improved
the versatility of this in strumenl.
With ex perience, the counterbalanced Zeiss-
Contraves microscope and the surgeon be-
come a single entity, working comfortably
"hand-in-glove" in attacking the lesion. Nor-
mally we have one surgical assistant on the
right sid e of a right-handed surgeon. Thus,
17
this surgeon's left hand is his first assistant and
the other surgeon, in effect, is his second assis-
tant. The counterbalanced Zeiss-Contraves
microscope, first used by Ya~a rg il [57] in
Zurich, can be auached to laser systems or used
in conjunction with an ultrasonic aspirator.
With the former, the mobile microscope comes
over the left shoulder of the surgeon while the
attached laser unit is off to the surgeon's direCt
left and siLS between the microscope stan d and
the anesthesiologist's equipment. Other excel-
lent o perating microscope syste ms arc avail-
able. For exa mple. Kenichiro Sugita in Mat-
sumoto, Japan, h as develo ped a highl y sophis-
ticated system [48].
Although agreement is not universal as to
whe n the microscope should be brought into
the operative field, ex perience shows that a
more gentle, accurate, a nd rapid dissection ca n
be carried out if, once the dura is opened, the
entire approach to the a ne urysm and its dissec-
tion are carried out under the microscope.
With the patient supine, the angled position of
the incl inable binocula r lUbe is used most
often. This now can be easi ly altered to a
straighte r position when drilling the sphenoid
wing a nd to a sharper angle when dissection is
in the sylvian fi ssure or antcrior perforated
substance. With ex perience, the surgeon often
finds that he routinely uses the same highe r
magnification (eg, 6x or 8x true magnifica-
tion) for the approach to the tumor or
aneurysm as he d oes for its dissection.
Several disadvantages to the o perating micro-
scope have been mentioned [ 17]: Special tra in-
ing is required for using the microscope.
microtools. a nd microsllture; it necessitates
o perating in a deep, narrow gap ; it requires
longer adaptation time ; it does not permit
good tissue palpation (i nstrume nts are used ,
not fingers) and requires visual manipulation ;
work is indirect; work is tiring to the eyes; stiff
neck, should ers, a nd back generall y result; dis-
tractions are poorly toleraLCd; equipme nt and
training a re expensive; it lakes up space in the
o perating room; and the operating time for
most surgeons is longer.
The advantages for the ne urosu rgeon far a
outweigh any drawbacks, however [17]: Fewer
parallax problems occur because the objective
le ns brings the largetcloser to the surgeon's vi-
sion; binocular vision is improved; ill umination
is incrcased ; the foc us is sharper; a nd magnifi-
cation permits a smaller cran iotomy, less brain
18 2. Instrumelllation and Positioning
retraction, a smaller cortical incision , and bet-
ter delineation of normal a nd abnormal
anatomy. Structures that are beller idcmified
by the microscope are the arachnoid space,
compartments, and bands; the perforating ar·
tcries; vascular variations in the circle of Willis;
aneurysmal anatomy; microaneurysms; the im-
pending rupture of an aneurysm; small bleed-
ing points for bipolar coagulation; and the
nerves [17]. The advantages to the patienlarc a
smaller wound, beller repair or nerves a nd ves-
sels, the fact that some inoperable lesions be-
come operable, optimal hemostasis, fewer sur-
gicallcsions, and fewer postoperative compli-
cations [ 17 ]. Educational advantages include
Fig. 2.5. Standard Zeiss operating micro-
scope with zoom lens system. f\lounted on
Zeiss Universal S3B noorstand. Counesy
of Carl Zeiss, Inc.
use of the observer tube, television with tape
recording, and cinematogra phy or still photo-
graphy. I n addition, the television system al-
lows the scrub nurse and anesthesiologist to
know the state of the surgery from moment to
moment.
As the microsu rgical era began, Drake in
1965 stated [11]:
The ability to see the minute details of the struc-
tures about an aneurysm has been, in my opinion,
the source of much trouble in this as ill other
fields of neurosurgery ... There is a new world
waiting for us. The dissecting microscope with its
superb illumination is ideal.
 Operaling Microscope 19

fig. 2.6. A. CoUi ltcrixliallccd 7..ciss-Collt ra\cs

o llCrat ing micrOKope. B. Close·up of microscope.
From Fox [ 16]:courlCsy ofC:lrI Zeiss. Inc. B
20 2. Instrumenta tion and Positioning

Fig. 2.7. A. Zeiss-Contravcs o perating microscope in
position at surgery. The bone flap has been turned.
Note the rubber wbi ng that holds the drapes firm ly
down and caudally. Abo\'c arc two suction tubes in
readiness. In the background is a telc\·isio n monitor.
B. Close-u p of microscope and alLach ments. Left:
Sony lclc\·ision camera and microphone. Cn!Ur:
binocular system and beam-spiller. RighI: assistant's
observation tube. The lauer is rcmo\'cd when still-
camera photographs arc made. From Fox [ 16].
 Operating ~" icroscope 21

Fig. 2.8. Inclinable billoclliartube (Carl Zeiss. Inc) flanked by SonyT V camerit on left and Contax still camera
on right. A. In straight positiull . B. 111 angled positiun.
22 2. Instrumentation and Positioning
Gillingham cautioned , however [22]:
This is a moment 1O reflect on the use of magnifi-
cation. [\ may make us len times morc gentle but
it leads to obsessive over dissection in an endeavor
to find the neck ofa sac which is nonexistent orcx-
cessivc manipulation in the region oftbe neck.
Television
As memioned above, television has imponant
ed ucational adv3mages (live visualization of
microanatomy and taping procedures for fu-
lure teaching) as well as practical advantages
[17,32]. Operating room physicians and nurses
alter their anesthetic techniques a nd ongoing
activities as wel l as morc efficiently prepare for
anticipated operative CVClllS based on informa-
tion received from the television monitor.
Color television systems (see Fig. 2.7 B) for
the microscope arc in a state o f rapid evolution
in terms of image clarity and brighmess,
weight, durability, and freedom from need for
frequem repa irs. Hence, il is pointless to rec-
ommend specific systems allhis time.
Many of the newer television cameras can
operate at a lowe r light level. Yct it is still advan-
tageous to obtai n good lighting to allow a smal-
ler diaphragm ope ning and consequently a
greater de pth of fie ld and sharper focus.
Table 2. 1 su mmarizes some methods to im-
prove lighting for the surgeon and for the tele-
vision or pho1.Ographic cameras.
Overhead Table
In our experie nce, the overhead table (sec
Fig. 2.2 C) made by the Ph elan Manufacturing
Corporation (Minneapoli s) has provided
maxi mum advantages for the surgeon, anes-
thesiologist, scrub nurse, and patien t. The cra-
nial e nd of the table should bejustcaudal to the
patien t's shoulder (more caudal if the cervical
carotid a rtery needs 1.0 be exposed). The table
height is easily adjusted , and the nurse or tech-
nician has clear and rapid access to in stru-
mems a nd the su rgeon's hanet.
I ntraoperative Instrumentation
Fishhooks
The use of improvised tissue-retraction hooks,
or "fishhooks," connected to rubber bands has
Table 2.1 . Methods of improvi ng lighti ng for the sur-
geon and/or camer<ts."
I. I ncrease voltage in transformer (s hortcns bulb life).
2. Use an cfficiem lighting system (currently in state ofim·
pnll'ement).
3. Keep hull>s and optical system clean.
4. Discard bulbs ",it h blue or dark spots in light image.
5. Usc add-on light sources.
6. Usc short focal length objecti\'e lens.
7. Avoid zoom !ens system. which absorl>s more light.
8. Turn off bright lights in opcr.lting room (bener con-
u'ast; surgeon's pupils arc d il'lIcn. rcrruiring less light ).
9. ~ I ake use of inlernal rencctions in surgical wound;
a,-oid rencclions back in to the microscope.
10_ Remo" e black paint border aruund glass light dencctor
behind objecti ve lens (present in some microscopes).
II. Usc 30-70 beam splitrer (70% to side arms. onl), 30%
(0 surgeon) inslead of 50-50 beam spliuer.
12. Use greater magnification in e)'cpicces. thercby requ ir-
i n~ less rnagn.i fic3tion (hence less light loss) inside
mrr.ros<;ope unll.
13. OllCn diaphragm to camera (with loss of sharpness and
depth of focus).
14. l'rollCrI}, adjust TV camera power supply and TV
monitor.
15. SeleCl efficient TV camera or film that can OllCrale wit h
less light.
Certain mClhods listen ha\'e particular \'"Iue in some cir-
cumstances, whereas in others they may pro\'e unneces-
sary or impractical. Items I through 10 also increasc
brightness for the surgeon . Item II decrease~ image
brightness to the surgeon. From Fox et al [ 171.
been used by many surgeons to retract scalp,
muscle, and du ra. More recently a fi shh ook re-
tractor device using springs (Aesculap Instru-
melll Co.) instead of rubber bands has been
suggested [57]. We prefer the "disposable"
Week Durahooks (Edward Week and Com-
pany), a lthoug h one can remove their rubber
bands fo r repeated usc.
The hooks a re used to retract the froillolem-
poral scalp flap tlIrned over the patient's
forehead as follows (Fig. 2.9): The sterile
drapes between the overhead table (neu rosur-
gical instrume ll t table; Phelan Manufactllring
Corporation, Minneapolis) and the patient's
head are -held firml y downward and caudall y
by standard rubber suction tubing of appro-
priate length. The looped e nds of this tubing
arc secured LO stirrup cla mps on each side of
the OR table. This lube (a) firmly holds the
drapes in place and (b) allows a convenient site
of allachmem fo r the rubber bands that retract
both the scalp hooks and the bone flap. I n this
way the drapes of the pcrioperalive field are
 Intraoperati\"e Instrumentation
Fig. 2.9. Close-up view of ru bber tube holding
drapes firm ly (sec Fig. 2.7 A). Here the samc tubi ng
is used to attach the rubber b..1nds hold ing thc fish-
hooks. T hese fis hhooks retract thc oxrccllu lose-co-.
vcred scalp nap forward . The rig ht fromolateral
smooth , firm , and dear of unnecessary damps
and other retractors.
SUClion an d SUClion- l rrigation Devices
SUClion tubes usually are sized (diameter) by
the "French" (Fr) designation: a 3- Fr size has
an oLlterdiameter of 1 mm ; a 9- Fr size is 3 mm ;
ctc. Standard sizes for aneurysm surgery are
3- Fr, 7-Fr, 9-Fr, and II -Fr, al though there are
many other variations. There are a multitude
of types of suction lubes with variation s in
length. angulation, tip co nfi guration, and vac-
uum pressure [3, 5, 17,28,29,44,56, 57J.
A SUClion system with a mechanism to con-
trolthe negative pressure at ve ry low levels is
essential . The suction should be finel yadjusled
to eliminate the ha7...1nl of small anatomica l
structures bein g entrapped and damaged.
Many neurosurgica l suction tubes are con-
23
bonc nap is attachcd to the lcm poralis musclc (at
cemcr of figure). Dural lack-up sutures and bonc-
nap sutures are in place in the cranium before the
dura is opened. From Fox [ 16].
slruCled to allow regulation of suction strength
by adjusting the degree to which the thumb
occludes the ai r ho le. T hese ho lcs ca n be en-
larged [5, 29]. and/or venting needles can be
placed in rubber suction tubes. T he trap bot-
tles ca n have pressure-regu lating gauges.
When dissecting delicate SlnlClUres, it may be
helpful to use specia l smooth-tipped suction
tubes and negative pressures o f about 2 m of
WaleI' (a pproximatel y 0.2 alln) [57]. I n place of
wa ll sllction, some sllrgeons prefer an electric
suction pump, easily regulated by adjusting the
dia ls on the pum p.
Irrib'<lting flu id in cunjunction with the suc-
tion apparatus is essential during the surgical
proced ure. In addition to keeping tissues from
drying and the aneu rysm wall from becom ing
briule, it discourages the formalion of small
blood clots and their.ad herence to the dissect-
ed surfaces; it also increases the effectiveness
24 2. Instrumentation and Positioning

of bipola r coagulation and reduces tissue adhe- We commonl y use the Le ksell, Echlin , a nd
siveness. Constant bathing with CSF has the Lempert rongc urs for frontotemporal
same effect. Some surgeons prefer a combina- craniolOmy, where bone is rongeured away at
tion suctio n-irrigation unit. the base. The fl at-j awed Lempert rongeur is
We usuall y use a n angulatcd Frazier suction especiall y helpful for removing that portion of
tube of varyi ng lengths. The II-Fr a nd g-Ff the sphenoid wing sticki ng Out as a ridge to-
sizes are used for cra nial work and the 7-Fr for ward the sylvian fissue.
aneurysm dissection. We use the 7- Fr size The neurosurgeon needs a small , high-
rathe r than smaller suction tubes because of its speed electric or pneumatic drill for removing
usc as a dissector and retractor as well as a suc- the sphenoid ridge, the clinoid process, and
tion device. Moreover, the large r diameter pro- other protrusions of the cranial base; however,
vides less air a nd liquid veloci ty for the same only after he has become acquainted with a nd
vacuum pressu re. The metal suction tube can skilled in its application in the laboratory
also be used for resting microscissors or other sho uld he use a h igh-speed drill in a neurosur-
instruments to reduce tremor when making a gica l operation [17J . A drill that ca n reve rse its
delicate d issection . The suction lube is held in direction is pre fe rred by some to one that cuts
the su rgeon's left hand , often with his ha nd or in only one di rection . A constantsuctioll-irriga-
fifth finger resting on the Leyla retractor bar tion system with physiological saline ca n be
of the skull. (This "resting fi nger" serves more used to cool the drill ; o therwise, heat is trans-
to provide proprioceptive feedback rather mitted to nearby neural structures. One ob-
than comfol"( to the su rgeon. ) The SUClion is mins a more accurate a nd controlled use of the
often used against small dental cotton balls drill when it is operated at high speeds; o nly
(Richmond Dental Colton Company, Char- very slight pressure shou ld be used to remove
lo tte, North Carol ina) or small cottonoids for the bon e. Dangero us skiddi ng may OCClll" at
suction protection and retraction. Rubber tub- slow speed s or with dull drill bits because of the
ing is preferred to plastic tubing, the latter greater pressure needed to cut bone. When
being too stiff for com fo rtable usc. We using lightweight drills or burrs, steel burrs are
routinely put 1,000 units of he parin in each used when the drilling is remote from the
liter of irrigating solution 1.0 limit dotting, dura. Diamond burrs are sa fer close to the
which could cause o bstruction within the tub- du ra or vital structures, for they tend less to
ing; this practice may retard undesirable d Ol- tea r SOfllissue. We use oxycellulose rather than
ting in the basilar ciste rns as well. The on ly cotton sponges to cover the nearby galea, mus-
time we use a suction-irrigation apparatus cle, and bone fl a p , as no harm occurs if these
(House-Radpour unit) is during bone get caught in the drill. Couon , on the mher
(sphenoid wing or clinoid process) drilling. hand , may cause serious damage if caught in
the drill.
When using bonewax under the micro-
Bone-Removal Instruments scope, we have fo und the fo llowing to be help-
In 1930 Rogers [46] gave an excellent historica l ful: The scrub nu rse applies a small bit of
account of cra niotomy methods. He noted that bonewax to one side of a small , d ry COllonoid
the Horsley trephine had its origins in the time a nd hands it by bayonet forceps to the center of
of Hippocrates (ca 400 years Be) . The the surgeon's operative field. The surgeon
technique of bone flap removal made a signifi- then can use his bipolar forceps (without cur-
cam ad vance with C igli's applicatio n of the rent applied ) or his finger to push the C01-
wi re saw (the C igli saw) in 1894 [19, 20]. This tonoid against the wax, which is pressed into
saw is still routinely used by many surgeons - the bleeding bone. Usually we use this
especially in elderly patients where the dura tech nique on the sphenoid wing a fter drilling
may be stuck to the inner table of the skull . T he it under magnification.
present-d ay use of power (pneumatic or elec-
tric) drill s a nd cran iotomy for lifting skull fl aps
Electrocautery
is well known and requires no further discus-
sion here. Electrocautery for coagulation of vessels and
Ro ngeu rs for biting away the base of the vascular tissues has been an in1.egral pa rt of
bone flap are standard in a ny cra nio lOmy set. neurosurgery ever since the advent of the
 Imr3oper.uivc Instrumentation
Fig. 2. 10. Fox bipolar elec-
trocautery forceps in three
lengths: 16, 18, and 20 em.
Each of the straight forceps
cOl11es in 0.5- and 1.0-111111
diameter tips; curved and
angled tips also are available.
From Fox [ 16]; counesy of V.
Mueller Compau)'. Chicago.
.. Bovie" electrosurgical un it, reponed by
Cushing and Bovie in 1928 [7]. Light [38] gave
a good historical ove rview of the subject in
1945. In 1967 Malis [39] reviewed the de,'elop-
ments and evolution of bipolar cle<.:trocoagula-
tion since thc ti me of Grcenwood in 1940 [23].
" Monopolar" elcctrocoagulation has been
and continues to be commonly used to coagu-
late or cut tissues. (Of course, it is reall y bipo-
lar: One pole is the "ground plate" and the
other is the hand-hcld electrode.) Bi pola r elec-
trocoagulation of the type whcre both poles
arc in the forceps was developed by Grcen-
wood [23-26] to cauterize small blood vessels
on the spinal cord , whcre minimal heat and
electrical spread ,.,rere essential. Accordin gly.
the bipolar force ps basically consists of a mod-
ification of ordinary bayo net forceps or jewel-
ers' force ps in which each blade of the forceps
is one of the electrodcs or poles; the blades are
isolat.ed from each Other by insulation, which
separates them at thei r base.
For microvascular and intracran ial
aneurysm surgery and ford issection of tumors
fro m the bra instclll , bipolar electrocautery
un its have become essential. There have been
many mod ifica tions in both the fo rceps and the
po"crsupply [8, 13, 18,23-27,33,34,39,47,
52.53, 56,57]. Malis [39] improved th e power
supply ( 0 provid e a damped wave spark un it
that was electricall y bener isolated. This un it
(Cod man and Shurtleff Company) has bee n
one of the more popular and reliable un its for
neurosurgery (and is preferred by us). The
unit was designed specificall y to provide the
best coagulation at the lowest voltage with the
least muscle stimulation. At the same time, it re-
stricts the current to the shon cst path between
the tips of the twO blades of the forceps, with
no currenL of consequence nowing from tip to
ground or tip to patient. The greater safety of
bipolar coagulation compat'ed with monopolar
coagulation around brain stem structures was
demonstrated by Gestring et al [ 18].
Some tried to provide a single unit for both
mono polar and bipolar electrocoagulation [ 18,
27]. Sugita et al (52, 53] uscd a thermister at
the tip of their forceps to aUlomaticaliy cut o rf
the eleclriccurren t when a preset temperature
was rcached . Oth ers developed a suction [47]
or irrigation [13, 34] systcm attached to one
blade of their forceps. Del ong and Fox [8] de-
scribed an automalic cyclin g on-off bipolar
electrocautery power supply.
We used to prefer the Ya~a rgi l bipolar for-
cc ps [56, 57] (Mathys & Sohn, Zurich), but we
now use the stai n less-steel Fox bi polar bayonet
force ps (V. Mu eller Company, Chicago)
(Fig. 2.10). T hesc forccps come in 16-, 18-, and
20-cm lengths and with 0.5- and I.O-mm tip
diametcrs . Other popu lar bipolar forceps fo r
surge ry include the Rhoton round-handled
forceps and the Malis forceps with the blades
slightly angled downward rather than parallel
lO the hand le. Titan ium or stai nless steel are
commonly used metals, the former being
liglllcr. We prefer the heavier weight of the
stainless-steel for ceps for bettcr balance, com -
fo rt, and proprioceptive feedback. It is impor-
tant nOl to sterilize titanium and stain less-steel
instruments in the same package, for the dif-
ferent. metals in close proxi mity may create an
26 2. Instrurnentation and Positioning
electrical potcmial conductive to rusting a nd
corrosive activit),.
De Long and Fox [8} recommended the fol - longed or illlensh'C use, even in one patie nt,
lowing care of t hese forceps to lim it thc slicking may res ult in a need for a n elCClrical overhaul.
oftisslICS to thei r tips:
I. Do not short-circuit the electric curre nt by
touching the forceps lips together.
2. Clea n the lips frequemly only with a damp
d oth (not with the sca lpe!!)
3. Polish the lips periodically (or obtain new
force ps) when the tips become pitted a nd
rough.
4." Knead " the tissue between the forceps tips
by gelltly squee zing and releasing the for-
ceps blades.
5. Lift lhe force ps from tissue contact fre-
quentl y.
6. Kee p the tissue moist with CSF or saline.
7. Avoid high current settings.
8. Apply t he currCIll in shon bursts to allow
heat dissipation.
Wc usc the bipola r forccps as the principal
d isscCling a nd tissuc-separating instrument
intracranially. Fo r this reason the blades o f the
fo rceps must have proper spreading tcnsion,
yct not be so tense as to ma ke tip approxima-
tion uncomfortable. T hey must not rotatc in-
appropriately in the surgcon's hand. In terms
of timc, its actual a pplication for e lec-
troca utcri zation is quite short compared with
its use as a tissue dissector, pcrforator,
spreader, separatet; a nd grasper. It is uscd to
place a nd remove cotlonoids , cotton balls, gela-
tin sponge, gelatin paste, oxycellu lose, and I'LIb-
bel' or plastic sheclS. On tcrms of frequenc ),
a nd duratio n of usc, for us the suction lube (in
the surgeon's left hand) and the bipolar elec-
trocautcry forceps (in the right hand) havc be-
come thc main micros urgical inSlrulllcnlS dur-
ing intracranial surgcr)',
For most of o ur extracra nial cauterization
we usecither the monopolarorthe bipolar unit
with the Malis powcr supply dial set at 30 or 35.
On cerebral cOrtcx wc use the Malis bipolar
power supply d ial al the 25 to 30 seuings: on
the brainstem we use the 15 to 25 settings.
"iner-tipped force ps increase thc cun'ent den-
sity at the tips. If higher settin gs are required,
lhe spark ga p in the unit probabl y needs reset-
tin g. With faulty spark gap distances or other
electrical proble ms, o ne ca n use hig her power
settin gs to obtai n more current, but the qualit y
(waveforms) of the e lectrica l OLitput will be
pOOl; resu lting in poor coagu lation and a tcn-
de ncy for vcssels to ex plode or be incised. Pro-
Thcre fore, twO o r more such bipola r powcr
supplies should be ava ilable. We use a 15-foot
cord between the power supply and the for-
ceps. Longer cord s may cause de fecti ve electri-
ca l o utput at the forceps. We set the power sup-
ply at the foot of the OR L:'l ble. I n this positio n
it does not add to th e instrument cluneI' near
the surgeon, a nd ilS electromagnetic noise
emission is a suffi cie nt di stance from the televi-
sion system so as to not c"eatc any significalll
a udiovisual in tcr ference. For the same reason,
the wa ll socket plug-i n sites for the television
and the bipolar I)()\\'er supply units should be
at a considerabl e dista nce from each o ther. The
" monopolar " a nd bipolar electrocautery cords
sho uld not be dose to each other.
Retractors
In past yea rs mOSt brain retraction wasdonc by
assistant surgeons. Such retraction was often
inconsistcnt, inaccurate, and dangerous, as
brain retraction prcss urc exceeded cerebral
pcrfusion pressure. In 1958 Gi llin gham [21]
warned that bleedin g from an a neurysm at
surgery (causing reve rsal of blood now from
vital brain tissues a nd a drop in blood pressure)
may result in ischem ia of nearby brain tissuc.
He wa rned that thi s wou ld be aggravated by ex-
cess or prolonged brain retraction. Add ition-
all y, he ca utio ned that inaccurate o r excessive
retraction may place traction o n vital per-
forators, producin g vasospasm a nd in-
adequate ce rebral perfu sion. Albin e t al [ I. 2,
17] havc shown that brain retraction pressures
exceeding 20 I.o rr cause underlying brain dam-
age. I f induced hypote nsio n is used, evcn Icss
bra in retraction prcssUl'e is IOlerated .
A number o f authors have described the use
of self-rel.aining b rain retractors [17,29,30,40,
42,57], Various t)'pes, eit her in the literature
or in commercial catalogs, have included the
de Ma nel , Dolt (Edinburgh), Hamby, Green-
berg, Ya ~a rgi l (Leyla), Dohn-Ca rton. Malis,
Clowa rd , Enker, Miskimon, and J annclta re-
tractor syste ms.
Self-reta inin g retractors also have become
indispensablc to aneurys m surgery because
they allow th e surgeon to work in a relativel y
 Other Microsurgical Instruments
confined space unhinde red by the presence of'
an assistant's hands, which are less dependable
for maintain ing constant retraction of the
brain . Sel f-reta ining brain retractors arc of two
basic types [ 17]. One is composed of a series of
stra ight shafts attached by small clamps to give
the co rrect arm length and con fi guration re-
qu ired for holding the brain spatula in place.
T he otherconsislS of a series of ball-and-socket
un its resembling a cha in of peads with an inter-
nal cable that when tightened, remai ns in the
desi red position .
Of greatest impon a nce in intracranial
surge ry is the minimal brain retraction neces-
sary (Table 2.2), ascribable not on ly to use of
the su rgical microscope and microtechnique
bu t also to improvemenls in exposure tech-
niq ues that allow a lowel; basal, and ta ngential
approach to the base of the sk ull and the circle
of Wi llis, which is partly aided by removal of a
portion of the sphenoid wing and lhe use of
special self-retaini ng brain retractors. How-
ever, these aids wo uld be totall y useless without
a relaxed brain effected by proper timing of
surgery and by supe rior anesthetic a nd life-
support methods.
T he selection of a self-retaining retraClor
system is up to the ind ividual surgeon's prefer-
ellce and habit. Many prefer systems that at-
tach on ly to the sku ll . T hey are concerned that
table-mounted retractors may move relative to
the brain even if the skull is immobilized by
three-point fixa tion [40]. We have foun d that
the Aescu l a p -Ya~argi l (Lcyla) retractor system
(Fig. 2. 11) is ideal for most cases of intracran ial
aneurysm surgery. We auach the bar to the left
Table 2.2. Minimal brain retraction.
I'crmincd by:
I. Usc of microS(ope. mi<;rotC(;hnique
2. Low oosal. tangemial approach
3. Self-retaining br.lin retractor
4. CSF drainage
:1. Neumanest hetic techniques
Avoids:
I. Removal of significant brain for exposurc of lesion
2. CUlling of Olfactory nCf\'c
3. Dil'iding of SOIllC bridging I'eins
4. Secondary brain contusion o r edema, vascular spasm
5. Vascular compression by retractoror stretched arachnoi-
dal bands
6. Tr.letion on aneurysm
7. UnnC(;essary exposure of A·I and M-I arterial segmcl11s
From Fox et al r17 1.
27
side of the O R table just cran ial to the "ether
screen" attachmen t (wh ich holds drapes that
separate the m icroscope from the anes+
thesiologist; see Fig. 2.2 B). Two or three fl exi-
ble (unless tightened) retractor ar ms are at+
tached to the con nectors on the bar. All joi nts
must be firmly tightened to avoid drift.
Fi rst, set the retractor blade (i n the flex ible
a rm) neal" the planned retraction site. T hen
tighte n the flex ible bar by turning [he screw,
which pulls the internal wire taul. Last, "toe-
in" the retractor blade to its desired position
a nd retraction press ure an d then tighten its
wing nut. Drift is minimal or absent if done
properly. Always have the poi lll of connection
between the retractor blade and flexible bar
away from the cra nial opening. This requires
auaching the flexible arm ncar the end of the
retractor blade and bending the blade at its
proper poi nt for descent into the cranial cavi ty.
T his ma neuver gives better in tracranial expo-
sure wi thout the ends of the fl exible retractor
arms being in the way.
Although these retractors a re usually
ap plied against brai n tissue or its coverings, on
occasion a narrow retractor ca n be used to
gently retract nerves, aneurysms, or aneries
such as the internal carotid anery or the mid-
dle cerebral artery d uring frontotemporal ap-
proaches to the interped uncular cistern [ 16,
48,50,51]. Such retraClion requires d isplace-
ment and protection of these arteries \I'jthout
occluding them.
O the r Microsu rgical Instrume nts
T here are now a large number of microsurgi-
ca l instruments in the fie ld of neu rosu rgery.
We ca nnot review all of them in this rapidly
changi ng field .
Figures 2. 12 and 2. 13 ill ustrate some of the
instruments we most commonly use for micro-
dissection. The j ewelers' fo rceps is used to pick
up the arachnoid over the sylvian fiss ure to in i-
tiate opening of this fissure. T he Aescu lap
bayonet scissors (cu rved and stra ight) come in
three lengths (16 cm for surface work, 18 cm
for work about the anterior circle of Willis, and
20 cm for deeper work, eg, aboulthe posterior
circle of Wi llis). T here is also a 22-cm scissor.
The bipolar forceps have been described in the
earl ier section on electrocautery. T he Rhoton
 28 2. Instrumemation and Positioning

Fig. 2.11. A- D. Leyla (Ya~ar­

gil) retractor system. Cour-
tesy of Aesculap-\'\'erke AG,
TUlli ingen, \Vest Germany.
B. Close-up view of auach-
mCIlt head between the bar
(left) and retractor a rm con-
nector (right). C. Close-u p
view of connector bell,'ceo
bar and OR table. D. Retrac-
tor h.1r and attachment head
in prcliminaryposition.Above
is the draped scalp with an
outline of a righl froruolat-

-
eral cran iotomy incision.
From Fox [ 16] .

A
....

c
 Olher Microsurgical Instruments
fig. 2.11
instruments shown in Fig. 2.13 are the four
types most commonly used by us. The "Iong
flat instrument" (a ,. micro-Penfield No.4 ") is
used to retract nerves, arte ries, and the
aneurysm. The "short fl at instrument" is ideal
for se parating adhesions between an aneurysm
and adjacent tissues because the edges of its
angled, flat end are somew hat sharp. The 40°
hook is sa fer to use than the right-angled hook,
for it will not catch and tear tissues upon iLS re-
moval fro m the field. A ball-tipped hook also is
helpful.
I nstruments and sutu re for reanastomosing
or repairing blood vessels and nerves should
be available along with the expertise to do so.
These are detailed in many articles on micro-
vascular anastomosis.
These microsurgical instruments require
some trai ning and ex perience in their use and
manipulation through a small openi ng and in-
sid e a deep narrow cavi ty. The su rgeon can rest
29
his hand on the skull oron the Leyla retractor
bar (named after the daughter of Ya~argil) ,
which holds the self-retain ing retractors.
Often the surgeon rests only his fifth finger as
a point of proprioceptive feedback. This allows
sensory orientation a nd reduces tremor. One
instrument can also be rested on the suction
tube of the surgeon's left hand to red uce tre-
mor in critical moments.
On occasion a mirror a t the tip of a probe
can be useful for seei ng behind and around
va riou s structu res . Wilson and Spelzler 154]
used a denta l mirmr, Sugi ta et al [49] a 5-mm
mirror, and Ya~argil and colleagues [57J a mir-
ror that changes positions when the grip han-
dle is squeezed.
There now are many types, sizes, and config-
urations of vascu lar and aneurysm dips a nd
clip-appliers. These are in a continual state of
evol Ulion, a nd lhe reader is referred to other
articles on the subject [14, 16]. T he technology
30 2. Instrume ntation and Positio ning

fi g. 2.13. Enlarged view of microsurgical dissecti ng

instruments (Rhoton ty pe: V. Mueller Company).
Ltft nld: No . 7, or "Iong n at instrument." ufl u1!l~r:
No.2, o r "short n at instrument," RigJllullter: No. II ,
or " 400 hook." Righi tl,d: No. 10, o r "right angle
hook." From Fox l I6].

2. Albin MS, Bunegin L. DltiOVIlY M et al ( 1975)

fig. 2.12. uft: J c\\'clc l's' forceps (Ed ward Week &
Co.). C~lIlf'r; Bayonet sha ped microscissors (Aes-
culap Instrume nts). Rig"': Ua),oncI shaped bipola r
electrocautery forceps (Math)'s & Soho). From Fox
116].
of e ne rgy tran sfer (lase r, ultrasound) in the
ope rating room is a large and changing field
that will not be addressed here.
Bibliograp hy
I. Albi n MS, Buncgin L, Be n nclt MH et 31 (19i7)
Clin ical and experimemal brai n retraction pres-
sure monito ring. Acta Ncurol Scand (supp! 64)
56: 522-523
Brain retraction preSS urC during intracranial
procedu rcs. Surg ,"brum 26: 499 - 500
3. ll.1dcr DC H ( 1975) ~'I icro-su rgical treatment of
intracranial ancurys ms. J Neu ros urg Nu rs
7:25 - 27
4. Bischoff EPE ( 1865) Mikrru1wJ!~ht Analyst der
ArwstomoStn der Kopfr!trotrl. Munich , Vcrlag der
JJ Lentnc r'sche n Buch handlung. See 'Hicroscopic
Arw{ysis of tht Allas/olllos;s Up/weer! /IU! emllia{
Nerves, translated by Sachs EJr, Va ltin £W ( 1977)
Hanover, N H , Un i\'ersity Press o r New England
5. Bo ndu ra nt C P ( 1977) Alte ration or suctio n lip
prcssure. J Neuros u rg 46: 559
6. Colley PS, Du n n RC J r (1979) Pre\'ention o r
blood pressu re respo nsc 10 sku ll-pin head hold-
er by local anesthesia. Anesth Analg (Cle\'e)
58:241-243
7. Cushing H , BO" ie WT ( 1928) Electro-su rgery as
,III aid to the rc moval or im rac ra nial tu mors.
Su rg G}'llccol Obstel 4 7: 751- 784
 Bibliography
8. De long \V B, Fo x J L (1977) Automatic q-cling
bipola rcoagulator. Surg Neurol8: 15- 16
9. Donaghy Rfo.·IP (1979) The history of micro-
surgery in neurosurgery. Cli n Neurosurg
26:619-625
10. Donaghy R t\.H~ Ya~argil MG (1967) MicrQ-WSW-
lar Surge/yo Stungart, G T hieme
II. Drake CG (1965) On the surgical treatment of
ruptured intracranial aneurysms. Cl in
Neurosurg 13: 122 - 155
12. Drake CG (l976) Ccrcbral aneurysm surgery-
an uJXIatc, in Scheinberg P (cd): Cerebrqvascular
Disease. Tenth Prineeton Conference. New ' ork,
Ral'en Press, pp 289 - 3 10
13. Dujovny M, Vas R, Osgood CP et al (1975) Au-
tomatically irrigated bipolar forceps. Tech nical
note. J Neurosurg 43: 502-503
14 . Fox J L(1976) Va~cularclips fort he microsurgical
(reat melll of stroke. Stroke 7: 489-500
15. Fox J L (1979) Miu osurgical cxposure of intra-
cranial aneurysms. J Microsurg I: 2- 31
16. Fox J L (1983) Intracranial Aneurysms. New York,
Springer-Verlag, pp 678 - 707
17. Fox .I L, Albin MS, Bader DCH et a1(1978) Micro-
surgical treatme nt of neurovascular d isease.
Neurosurgery 3: 285-337
18. Gestri ng FG, Koos WT , Boeck FW (1972) Bipo la r
coagulation with modified cOtl\'emional elec-
trocoagulators. Technical note . .I Nellrosurg
37:50 1- 504
19. Gigli L (1894) Ober ein neues Instrument zum
Du rchtrcnnen der Knochen, die Drahtsage.
Centralbl ChiI' 21: 409 - 4 11
20. Gigli L (1898) Zur Technik der temporaren
Schadelresektion mit meiner Drahtsiige. Cell-
tralbl Chir 25: 425 - 428
21. Gill ingham fJ (1958) The management of ru p-
tured intracranial aneurysm. Ann R Coli Surg
23:89-1 17
22. Gi llingham FJ (1976) Twent)'-five yea r~' experi-
ence with midd lc ccrcbral aneurysms. Rev Ins[
Nac Ncurol (Mcx) 10; 16-21
23. Greenwood J J r (1940) 1\\'0 point coagu lation. A
new principle a nd instru ment for applying
coagulation current in ncurosurgery. Am J Surg
50:267-270
24. Grecnwood .I JI" (1942) 1\\'0 point coagulation. A
fo llow-u p report on a new techni<llIe and instru-
ment for electrocoagulation in neurosurgcry.
Arch Phys T her 23: 552 - 554
25. Greenwood J J r (1955) Two-point or interpola r
coagulation. Review after a twelve-}'car period
with !lotcs on add ition of sucker tip. J Neul"Osurg
12: 196- 197
26. Greenwood J .I I' (1974) ElcClrocaagulation in
neurOSUl-gcry. Surg Neurol 2: 4
27. Gurdjian ES, Thomas LM, Gurdjian ES (1968) A
singlc unit for bipo lar, rnollopolar coagulation,
and cutting . ./ Ncurosurg 29: 567 -568
31
28. Hamby \VB (1952) Intracranial Anellrysms.
Springfield , IL. Charles C Thomas Publisher
29. Hamby \VB (1969) Intracra nial surgery for
a neurysms. Prog Neurol Surg 3: 1-65
30. Hamby \VB (1970) Remarkscollcerni ng intracra-
nial aneurysm sU I·gery. Clin Neurosurg 17: 1- 17
31. Hocrenz P (1980- 198 1) T he operating micro-
scope. J Microsurg I: 364-369, 419-427;
2: 22-26, 126-139: 3: 179- 182
32. Housepian EM, Ungcr \VH. Scharff TB et al
(1975) Expericnce with videotape monitOring of
microscopic neurosurgical procedu res. J
Ncurosurg 42: 204 - 208
33 . Jacques S, Bullara LA, rudcnz RH (1976) Micro-
vascular bipolar coagliJator. Technical note. J
Neurosurg 44: 523 - 524
34. King TT, Worpo!e R (1972) Sel f-irrigating bi-
lar diathermy forceps. J Neurosurg 37; 246-
247
35. K riegel' AJ (1978) The Use of the Operating Micro-
scope. New York, Carl Zeiss
36. Kurze T (1964) Microtechniques in neurological
surgery. Clin Neurosurg II : 128-137
37. Kurze T, A puzzo Mq , \\'eiss MH et aJ (1977) Ex-
pericnces with sterilization of the operating
microscope. J Neurosurg 47: 861-863
38. Light RU (1945) Hemostasis in neul"Osurger r· .I
Neurosurg 2: 414-434
39. Malis LI (1967) Bipolar coagulation in micro-
surgery. in Dtmaghy RMP, Ya§argil MG (cds) :
Micro-vascular Surgery. Sw ug;m , G Thieme,
pp 126- 130
40. Malis Ll (1979) Instrumentation and techn iques
in microsurgery. Clin Neuros urg 26: 626-636
41. Nylen CO (1954) Thc microscope in aural
surgery. IIS first use a nd later development. Acta
O[olaryngol [Suppl] (Stockh) 116: 226- 240
42. Peerless SJ (1974) The surgical approach to mid-
dle cerebra l and posterior commu nicati ng
,IllC\lI·ysms. Clin Ncurosurg 21: 151- 16.?
43. Rand RW (1985) Micronellrosmgel)i cd 3 SI Louis,
CV Mosby Co
44. Khoton AL, Merz W (1981) Suction lUbeS for con-
\'eI1lional and microscopic neurosurgery. Surg
Neurol 15: 120 - 124
45. Robertson GE (1967) Pllellmoenuphalogm//hy,
ed 2 Springfiel d, 1L, Charles C T ho mas Pub-
lisher
46. Rogers L (1930) T he history or craniotomy: an
account of the methods which have been prac-
ticed and the instruments used for o pening the
hu ma ll sk ull during life. Ann Med Hist 2:49:)-
514
47. ScarffTB (1974) A nell' bipolar suction-camery
forceps fo r microncurosurgical use. Surg
Neurol 2: 213
48. Sugita K (1985) Mic1"01Ie1lrOSlagicai Atlas. Berlin,
Springer-Verlag
49. Sugita K, Hirota T, Tsugane K (1975) Applica-
32 2. I nstrumentation and Positioning
lion of nasopharyngeal mirror for aneurysm op-
eration . Tech nical note. J Neurosurg 43: 244-
246
50. Sugita K, Kobayashi S, Shintani A el al (1979)
fl. licroneurosurgery for aneurysms o f tile basilar
artery.] Ncurosurg 51: 615-620
51. Sugita K, Kobayashi S. TakemaeT et al ( 1980) Di-
rect retraction method in aneurysm surgery. J
Neurosurg 53: 417 -419
52. Sugita K. Tsugane R (1974) Bipolar coagulator
with automatic thcrmocomrol. Technical note. J
Neurosurg 41: 777 - 779
53. Sugita K, Tsuganc R, Kagcyam3 N (1975) Bipo-
lar coagulator with automatic thcnnocontrol
and some impro\'cmciltsofmicrosurgicai insl!"u-
melliS, in Handa H (cd): Microneurosurgery. Balti-
more, University Park Press, p 17
54. Wilson CB, Spetzler RE ( 1979) Operative ap-
proaches to aneurysms. Clin Neurosurg
26:232 - 247
55 . Ya~argil Me ( 1969) MicrosUlgery Applied to
NeuroSllrgery. StUttgart, G Thieme, pp 119 - 143
56. Ya~argi l MG. FoxJL, Ray MW (1975) The opera-
tive approach to aneurysms oflhe anteriorcolll-
municating artery, in Krayenbiihl H (cd): Ad-
Milas and Technical Stlllu/mtis in Neurosurgery,
vol 2. New York, Springer-Verlag, pp 113- 170
57. Y.1.~argil MG, Vise WM, Bader DCH (1977) Tech-
nical adjuncts in neurosurgery_ Surg Neurol
8:33 1-336
 3--
Photographic Technique
Introduction
T he color illustrations of live microsurgical
a natomy as shown in this atlas were re pro-
duced from photographic color slides . The
photogra phs were taken du ring actual ope ra-
tive proced ures per form ed by the author since
1975. They represcnL visual records o f selected
surgical cases treated at the West Virginia Uni-
versity Medical Center in I'vlorgantown, West
Virginia; the King Faisal Specialist Hospital
and Research Centre in Riyadh , Saudi Arabia;
a nd the Georgetown University Med ical
Center in Washin gto n, D.C. T he majority of
these cases were palie nt5 with illlracranial
a ne u rysms, bu t the e mphasis he re is o n live
anato my such as may be seen in the pterio nal
a pproach to many other lypeS of neurosurgical
problems. Pho tog raph ic slides were selected
for demo nstratio n o n the basis of ill ustrating
clarity of features, having absence of signifi-
cant tissue disto rtion by tumo r o r hemo rrhage,
showing no rmal a natomic var iations, and/o r
portraying special neuroa nalOmical points.
From a recent historical stand point, the a u-
thor learned the photographic technique de-
scribed herei n from trial-and-erro r expe ri-
ence a nd fro m lectures given by Leo nard
Malis, Chairman of the De partmen t of
Neurosurgery, Mount Sinai School of
Medicine, New Yor k City. Earl y in his ex pe ri-
e nce the a uthor VLF) was under the miscon-
ception that increased lightin g, a wide opening
of the ca mera d iaphragm (small I-stop
numbe r), and short time exposures were neces-
sary lO gain sufficient ex posure of the image
on the film in the prese nce of moveme nt of
neural and vasc ular intracran ial tissues re-
fl ected by card iac pulsatio ns (directly on the
blood vessels) and res pi ratory pulsations (indi-
rectly via the venous circulation). Many surgi-
cal photogra phers still pho tograph through
the operating microscope with these concepts
in mind . However, in many instances, pholO-
graphs taken with such techniques have lacked
shar pness of image. appeared somewhat flat ,
and fa iled to provide a good de pth of fi eld .
The key lO improving the q uality of the colo r
photographs is to na rrow the le ns a perature
(we use an f -StOp o f 44). T his results in a signif-
icant improvemen t in clarity a nd shar pness of
images and in dep th of foc us (reducing the flat-
ness of image effect). To accomplish th is o ne
must increase the brightness of the ligh t source
and/or increase the du ration of film exposure.
The light inte nsity can be increased to some ex-
tent by overloading (increasing the voltage) the
tra nsfo rmer of the 30- or 50-W tu ngsten bulb.
Stro nger halogen o r xenon lig ht sou tcescan be
used . But excess light ene rgy, even with the use
of fi beroptic trans fe l~ dries out intracranial tis-
sues rapidly and reasonable lim its a re finite.
One can, however, extend the film expos ure
time la, for example. 1 second . Because a rte-
ria l systolic pu lsations are quite brief com-
pared wi th the entire duratio n of one pulse.
this movi ng (blurred) image is not detected by
thc hu man eye o bserving the resultin g photo..
graph . In oth erwords, th is systolic movemem
(or " noise") is ave raged out by the stable image
of relatively much longer duration [4]. The sur-
gical pho tographer muSl ta ke care to avoid any
respiratory- induced move me nt by as king the
anesthesiologist to hold the paticm 's respira-
tions d u ring the du ration of fi lming if possible.
34 3. Photographic Tcch ni<Jue

In the a uthor's early yea rs of fi lming with use the right; the TV came ra is on the left; see
narrow lens aperature and I-second exposu re Fig. 2.7). We have tried using special adapters
limes, excel le nt color slides were obtained with allow in g the TV camera a nd still camera to be
any sim ple came ra bacK (film holder) and with attached to the same side of the microscope's
30-\V incandescen t lig hting (givi ng a 2,800° to beam spl ineI' (permitting an observer's tube to
3,100° K color te mperature). Recen t a nd more be attached LO the other side), but the ca mera
sophisticated ca meras, optics, and microscope lens aperatu re had to be wide ned (smaller [-
lighting systems have not improved the quality stop number) with a res ulti ng degradation of
of the phoLOgraphs, and in many situations the the photographic image.
quality deteriorated. The conve rsion o f some As reported previously [I, 2], the following
Zeiss microscopes to the usc of halogen, were utilized by the author. For photography,
tungsten-filament lam ps (giving a 3,200° to we used a Zeiss OPM I- I operating microscope
3,400° K color temperalUre) has improved the equipped wi th a 275-mm objective le ns, a 160-
lig ht inte nsity without noticeable degradation mm focal-l ength binocular tube, 12.5X
in the photogra phic image on tungsten (ASA eye pieces, a 30-70 beam spli tter (70% of the
o r ISO No. 160) Kodak Ektachrome film (ba- lig ht is deflected and divided equally between
lanced for color temperatures of 3,200° K [4, the film on the right and the camera on the left;
5]). We have been satisfi ed with this light. 30% goes to the surgeon's eyes), a Zeiss came ra
More recently we temporarily switched to adapter and 2x magnification auachment, a
the use of the much brighte r xenon ligh t Contax camera body, a nd ISO (formerl y called
source (shown on microscope in Fig. 2.5). How- ASA) No. 160 (tungste n) Ektachrome 35-mm
ever, its color temperature is aro und 6,000° K. fi lm. T he tungsten- halogen light source was
ils e miued liglll energy is stronger in the blue- used without auxiliary lig htin g but with the
green spectrum (com pared wi th light from trans former constantly on "overload "
tungslen-filamentlamps), and hence one must throug hout the operation. (If the heat is a l-
use daylight color slide film (Kodak's Ekta- lowed to escape directly into the room, the light
chrome fi lm, ISO No. 200, is ba lanced at a bulb usually la sts throughout several opera-
color temperature of 5,500° K). Unfortu - tions.) Before 1980 no drapes were used, but
nately, the heat-absorbing (red-a bsorbin g) the microscope, camera, film, and T V system
path ways of the microscope's optical system were cold-gas-ste rilized for 12 to 18 hours with
further reduced the red speClrum in the lig ht, pure ethylene oxide gas. (New federa l regula-
and the resulting photograph (even with day- tions have now restricted this method of sterili-
lig ht film) portrayed defective color reproduc- zation.) Any black-paint border around the
tion. White or g ray tissues had a yellow-green glass pris m deflecting the light through the ob-
cast a nd red blood vessels had a browni sh cast jective lens was removed. Overhead lights in
(due to the red and g reen color mixture). Al- the operating room were turned offLO provide
though proper filters may improve the colo r, beller contrast and LO facilitate dilation of the
the liglllioss may resu ltin no signi ficant netim- surgeon's pupils.
provemem in bri ghtness with the xenon light Photographs \·...e re made with respirations
source compared wi th the tungsten-halogen temporarily stopped or during the ex piratory
light source. Accordingly, we have return ed to phase of the automatic respi rator and with the
the tungsten-ha logen la mp on the Zeiss-Con- [stop on the Zeiss photoada pter set at44 . With
lI'aves o peratin g microscope. nona utomatic cameras, the ex posure time was
set at I second. Wi th automatic cameras the ex-
posure time approxi mates this duration. We
Current Techniques use the delayed sh utter-release mode so that a ll
camera and microscope movements have
Except for the Zeiss camera adapte r and 2x ceased by exposure time occurring about
magnification attachme nt, the o ptics is that 12 seconds after pressing the exposure button.
which is contained within the Zeiss operating Self-retaining retractors a nd while cottonoid s
microscope system [3]. The still ca mera (cam- were posi tioned to provide lig ht reflcClions
era back to hold and move the film; Fig. 3.1 ) within the wo und while avoid ing refl ectio ns to-
can be any good-quality model and is attached ward the microscope. Unless otherwise indi-
to the rig ht or left side of the beam splitter (we cated, the photographs presented were made
 Currenl Techn iques
Fig. 3.1. Contax camera at-
tached 10 microscope beam
splitter via ad apter (not
seen) alld 2x magnification
attachment (arrow).
with the Zeiss magn ification dial set at its third
magnification selling (the old No. 16 01' the
new No. 1). providing a true 6x magni fication
for the surgeon . Although lhe photographs
lhemselves do not provide stereoscopic vision
and sufficie nt depth of fi eld, which may be
6 em from the skull surface, the reader's know-
ledge of analom), wi ll compensate for this.
Bibliogra phy
L Fox J L (1979) r.,I icrosurgical exposure of imra-
cranial aTleurysms . .1 Microsurg I: 2- 31
35
2. Fox J L (1983) llitracranial Al1eUl ysms. New York,
Springer-Verlag, vol 2
3. Hoerenz P (1980 - 1981) The operati ng micro-
scope, J Microsurg I: 364 - 369, 419-427;
2: 22 - 26, 126 - 139;3: 179- 182
4. Malis LI (1981) Neurosu rgical photography
thro ugh the microscope. Clin Neurosurg
28: 233 - 245
5. MartIn-Rodriguez JG (1985) Colo l' still and mo-
tion pholOgraphy and color tcle\·isioll recording
through the operating microscope, in Rand RW
(00): MicrQrlclI.rosllrgery. SI Louis, CV Mosby Co.
ed 3, pp 83-9)
 --4 --
Cranial Anatomy and the Cranial Flap
Anatomy
The pterion has been defined in Chapter I.
Figure 4. 1 illustrates that the pterion is not a
specific point but rather a general region of the
skull lying under the tcmporalis muscle and in
dose prox im ity to the frontal, parietal, tem-
poral, and sphenoid bones. The frontoparietal
(coronal) sutu re and the sphenoidotemporal
suture do not meet at a common point but in -
stead come to a "T' intersection (Fig. 4. 1) with
the parietotemporal, parietosphenoidal. and
frontosphcno idal sutures (the latter two form-
ing a relatively straight posterior-ta-anterior
extension of the parietotemporal suture). This
anatomical arrangement allows a short com-
mon boundary betwee n the parietal and
sphenoid bones and causes a separation be-
tween the fronta l and temporal bones.
Fig. 4.1_ View of left side of skull model .
TIle suture lines between JX)rtions of the
skull arc outlined in ink. F, frontal;
P parietal; T, temporal; S, sphenoidal; and
Z, zygomatic bones.
Figu re 4.2 shows the anatomical arra nge-
ment of these bones at the inner base of the
skull [I]. Although not prominent on the out-
side, the sphenoid bone represents the "key-
slOne" of cranial-base analOmy. The word
sphenoid is derived from the Greek word
sphenoeides, meaning wedge-like [6]. From its
body this interesting struclllre (Fig. 4.3) sends
out lalerallesser and greater wings, a ppearing
rather like a butterfly in flight [2]. For the sur-
geon operating at the base of the skull and
brain, this hidden keystone contains land-
marks of orientation as well as structures that
may have to be removed by rongeurs and high-
speed drills. The latter structures include the
sphenoid wings, anterior clinoid process, pos-
terior clinoid process, roof of optic canal,
tubercu lum sellae, floor and septum of the
sphenoid sinus, and floor of the sella turcica.
 Fig. 4.2. Base of skull, upper surface. Note that
Ihe anlerior clinoid process is a posterior pro-
jection of the origin of the lesser wing o f the
sphenoid oone. Components of the sphenoid
wing include lu, lesser wing; gu'. greater wi ng;
ls, tuberculum sellae; ae, alilcrior clinoid pro-
cess; sl, sell a lUrcica; pc. posterior clinoid pro -
Iw
ccss;fo, foramen ovate; ds, dors u m sellae. Re-
drawn from Clemente CD (ed) (198S)Al!alomyoj
gw tht H/lInol! Body by H em)' Gmy, 30th American
ed . Philadelph ia, Lea & l<"ebigcr, p 17 1 [ IJ.

"
"
"
po

d.

Fig. 4.3. Vicw of disaniculatcd sphe noid bone o f

sku ll as seen from behind . The dorsum sellae hides
the sella turcica (pituitary fOS5<1) seen best from
aoc·vcin Fig. 4.2. Note the relationship o f the greater
and lesser wings separated by thcsupcriororbil.al fis·
surc. A n o ptic strut separates the superio r o ,'hital fis·
sure from the o ptic canal. From Etter L E (1955) Atlas
of Roentgen AI/atomy of the Skull. Spri ngfield, 1L ,
Charles CThomas Publ isher. p 17 [2).
V

38
 The Cranial Flap
By whatever approach to basal structures, the
surgeon must have intimate knowledge of the
sphe noid bone.
The basal cran ial anatomy ta kes on a differ-
ent pers pective when viewed in the surgica l up-
side-down, oblique position (see Figs. 2.3 and
4.8). Figures 4.4 and 4.5 illustrate a skull model
with a small pterional cra nial opening. T hesc
show the value of removing mu ch of the
sphenoid wi ng (ie, lesser and greater wings) [3,
4]. Before the sphenoid win g is removed , the
surgeon's view of the suprasellar region is
blocked by the latcral projcClion of the win g
unless greater and haza rdous brain retraction
is a ppl ied . Partial removal of thc sphc noid
wing, practiced for years by Walter Dand y's dis-
ciples, pcrmits a lowcr, basal, ta ngential a p-
proach to the circle of Willi s. Once the surgeon
uses this tcchniquc rOUlinely a nd then omits it
from an operative case, he will appreciate its
significant value for permitting easie r visuali -
zation of basa l cistern s. This technique ,
coupl ed with the skilled usc of sel f-ret.'lining
retractors and of the operating microscope on
a relaxed brain , allows thc surgeon to manipu-
late microinstruments in small but sa tisfactor-
il y visualized spaces.
If we take the same dry skull model shown in
Figs. 4.4 a nd 4.5 , one can see the relationship
of the basilar artery to the anterior a nd pos-
terior cl inoid processes as visualized through a
pterional exposu re (Figs. 4.6 and 4.7). One ca n
unde rstand fro m Fig. 4.7 that removal of
much of thc sphc noid wing on one side a nd a
widely opened sylvian fi ssure on the othcr side
arc necessary to approach the midbrain, pons,
and inlerped uncular cislern wilh mi ni mal
brain retraction. T he posterior clinoid process
of the sphenoid bone then becomes a critica l
la ndmark , lying medial to the oculomotor
nerve passing forwa rd from the midbrain .
The Cranial Flap
All surgica l photogra phs in this atlas arc shown
as a right-sided pterional cran iotomy. Those
that originally were left-sided have bee n re-
versed to permit consistency in anatomical il -
lu stration. Much of the following in th is cha p-
ter is mod ified from a previous publication of
the author [4 ].
39
For a right frontola tcral cra niotomy, the
head is held in a t hree~point skull-fi xation ap-
paratus (see Fig.2.3) and lUrned approxi-
mately 300 t045° to the left, tilted 150 to the left ,
and dropped back about 150 (Fig. 4.8). This
brings the " psychopathic poi nt" (see Chap-
te r I) into the center and to thc highest point
of the opc rative field . (When a right-handed
surgeon operates on the left side of the head , a
40 0 to 450 rotation to the riglH is used.) For
aneurysms of the middle cerebral a rtery or the
internal carotid artery bifurcation, the head
is dropped back further so that thc surgeon's
line of vision is as perpendicular as possible
to the M-I portion of the middle cerebral ar-
tcry.
T he skin incisio n is kept behind the hairline
rather than curvi ng for ward into the exposed
forc head. This requi res a long incision, but the
cosmetic resul t is better after the hair grows
back. T he incision (Fig. 4.8) begins at the mid-
line. curves laterally behi nd the hai rline, and
terminates one fingerbreadth in front of the
ear at the level of (or slightl), below) the
zygomatic arch. T he skin flap and galea are
stripped from the temporal is fasc ia a nd perios~
teum, covered with oxycellu lose gauze (colton
may get ca ught in the high-speed drills), and
pu lled fo rward with fi shhook retractors.
An incision is made in the ante rior and pos-
tcrior lim il of the ex posed lemporalis muscle.
T he anterior portion of the temporalis muscle
is stripped posterioriy from the zygomatic pro-
cess of the frontal OOne . Herc one may have to
clectrocoagulate one or two bra nches of the an-
terior deep te mporal artery (from the imc rnal
maxillary a rter y). Also. tiny art.eries pe rforat-
ing the frontal bone just behind its zygomatic
process may have to be coagulated (wilh cut-
tin g current) and/or sealed with bonewax . The
periosteum is stripped along the line of inci-
sion from the exposed fronta l, parietal, and
lemporal bones. Howe,'er, a tria ngle of perios-
leum (Fig. 4.9) is preserved a nteriorly for later
suturing to the te mporalis fasc ia, thereby cov-
erin g the anterior frontal burr hole at the end
of the operation. This piccc of periosteum ,
with its base anteriorly, is laid on the galea of
the skin flap, covered with oxycellu lose, a nd
held by a fi shhoo k retractor.
The frontotempo ral bone fl ap itself is simi-
lar to that illustrated by Lud wig Kempe (sec
Fig. \.5) with the fo llowing modifications
(Fig. 4.10) ,
40 4. Cranial Anatomy and the Cran ial Flap
I. The first burr hole is just behind the
"psychopathic point" and its anterior ed ge
touches on that point.
2. The second burr hole is also in the frontal
bone. This hole lies more medial than that il-
lustrated by Kempe (see Fig. 1.5). There are
three advantages to this: (a) It allows more
room for frontal lobe retraction without the
retractor striking the fron tal bone. (b) It per-
mils ple nty of room for maintenance oftem-
poralis muscle attachment to the frontOlcm-
perosphenoparietal bone flap, thereby re-
ducing the incidence of later temporalis
muscle atrophy. (c) T here is enough ex-
posed bone flap for placement of flap-edge
holes for suturclrubber band retraction of
the bone fl a p.
3. The third burr hole is placed in the parietal
bone just inferior to the temporal line.
4. The fourth burr hole is drilled in the tem-
poral bone just in front of the ear a nd above
the zygomatic arch. If placed too far back,
temporal bone air cells may be encou ntered.
The bone dust is saved and used to fill the
burr holes after closure of the bone flap ,
thereby helping to preven1. a ny future inde n-
tations of the scalp into the burr holes.
In patients younger than 55 years, the dura
is not usually tightly adherent to the skull bone.
In these cases we often utilize the ai r-driven
craniotome to cut the sk ull fl ap in a similar de-
sign between two holes: only the most a nterior
and the most inferoposterior burr holes.
Otherwise a Gigli saw is used to cut the skull
bone between the four burr holes. Prior to
either of these techniques of craniotomy,
rongeurs are used (we usually use the Echlin
ronge ur) to bite away as much of a channel in
the fronto-spheno-temporal bone as possible
between the two basal burr holes under the
temporalis muscle. Doing this before sawing
the bone between the upper calvarial burr
holes allows this inferior bony channel to be cut
without the bone flap inad vertently fracturing
too high above the base.
After the bone fl a p is cut free, its inferior
edge is rongeured (Leksell rongeur) until it
presents a smooth , nonprojecti ng surface.
Heavy si lk sutures are passed through two of
the small edge holes (already drilled for future
reattachment of the bone fl ap to the cal-
varium). The sutures are each connected to a
rubber band that has been wrapped around
the rubber tubing shown previously in
Figs. 2.7 A and 2.9. In this manner, the bone
fl ap, still attached to the te mporalis muscle, is
retracted over the zygomatic arch, thereby ex-
posing the du ra (Fig. 4.11). The bone flap is
waxed at its edges and then covered with wet
oxycellulose. T he calvarial ed ges are also
waxed . The dura is the n tacked up with sutures
that are passed through the calvarial edge
holes (also to be used for reattachmen t of the
bone fl ap. T he sphe noid wing is rongeured in-
fe riorly as far as possible and then waxed . In
cases where an even more basal ex posure is re-
quired , we cut the zygomatic arch anteriorly
and posteriorly. It can be left attached to soft
tissues while the b ulk of the temporalis muscle
is d isplaced inferiorly. The zygoma is reat-
tached at the en d of the surgery.
The superficial temporal artery runs in
fron t of the ear and j ust su perficial to the
galea. Preservation of this arte ry is useful,
especially if the su rgeon pla ns an extracranial-
to- intracranial anastomosis . This may be neces-
sary if one pla ns on a trapping procedure or an
arterial occlusion. In such a circumstance,
meticulous technique is needed to prevent su-
perficial temporal arter y injury.
The frontalis branches of the facial nerve
pass forward between the galea a nd lemporalis
fascia a nd are usually seen passing anteroin-
fe rior to the first burr hole. They can some-
times be preserved by turning a superfical
layer of the temporalis fascia forward over the
zygomatic process of the fro ntal bone before
incising the tcmporalis muscle a nte riorly. Elec-
trocoagu lation in the area must be ke pt at a
minimum. T he ner ves a r e ofte n injured, and
the patient may have an immobile forehead on
the ipsilateral side foll owing surgery. In most
such cases, frontalis mu scle function returns
wi thin 6 month s.
Sphenoid Wing Removal
The operating microscope is now brought into
the surgical field and used unti l dural closure.
The Leyla self-retaining retracto rs are at-
tached to the operating table (see fig. 2.1 1).
The dura of the frontal and temporal lobes are
retracted gently from the sphe noid bone and
the lateral roof of the orbit. If necessary, some
cerebrospinal fluid (CSF) ca n be drained by
 Sphenoid Wing Removal
lumbar puncture to relieve pressure on the
brain. Release only a sufficient amount of CS F
to perm it a relaxed brain, as excess removal
risks premaLUre rupture of an aneurysm, tear-
ing of vcin s bridging the dura and the brain , or
downward hern iation in cases with mass le-
sions. The dura of the temporal lobe is often
quite vascular and will require bipolar elec-
trocoagulation, oxycellulose application, and
occasionally th e use of malleable dips.
With a suction-irrigation apparatus in the
left ha nd and a high-speed drill in the right
ha nd (of a right-handed surgeon), the surgeon
removes projections of the sphenoid win g and
latera l orbital roof. Keep all couonoid s out of
the immediate field to avoid injury by their
being caught in the drill. The steel drill bit is
used in itially because ofiLS more ra pid removal
of bone. As the base of the anteriordinoid pro-
cess is approached, the drill bit is changed to
the d iamond type, which tends less to tear the
nearby dura. The Lempert rongeur is very
helpful in removing sliver-like projections of
the sphenoid wing. A tiny bit of bonewax on a
small , dry couonoid is a pplied against the bone
with the bipolar forceps to stop bone bleeding.
One mllst be careful to avoid drilling into the
orbital cavity. I f this occurs, the patien t will
have greater temporary swelling a nd ec-
chymosis of orbital tissues during the post-
operative period. In some patiellLS there is a
partial, congeni tal absence of the greater wing
of the sphenoid bone behind the orbi t.
The sphe noid wing is removed with a
rongeur and then burred down with the high-
speed drill dose to the base of the anterior
clinoid process, a medial depth of about 5 cm
(Figs. 4.12 and 4.13). As one approaches this
point, the meningo-orbital artery (su praorbital
branch of middle men ingeal artery) is a land-
mark seen in the dura; it passes from the mid-
dle men ingeal artery through its own "lacri-
mal" forame n (Hyrtl's canal) in the sphe noid
wing or through the lateral corner of the
su perior orbital fissure to communicate with
the lacrimal a rtcry in the orbit. (This artery is
one of the remnanLS of the e mbryonic stapedial
arterial system [5]). The meningo-orbital ar-
tery usually is electrocoagulated and severed,
allowing further drilli ng ofthe sphenoid wing.
41
At this point the faster steel drill bit is swi tched
fo r a d iamond bit. The base of the amerior
cl inoid process appears as a glistening while
bone often contain ing a single small vascular
channel (Fig. 4.13).
The dural ope ning is considerably smaller
than the craniotomy defect. The bony open ing
is larger for the reasons stated earlier in this
cha pter. The dura is perm itted to cover the
brai n as much as possible to protect the brai n
from the drying effecLS of air a nd light. T he
dura is opened in a modified, shallow horse-
shoe-shaped man ner (Fig. 4. 14). The dural
na p is retracted over the smoothed-out
sphenoid bone by suturing it to the galea.
Often a secondary dural inci sion over the syl-
via n fissure is needed if the fi ssure is to be
opened widely. At this point, some CS F can be
removed by lumbar drai nage or by aspiration
from the chiasmatic and adjacent ciste rns
under a minimally elevated frontal lobe
(Figs. 4.14 and 4.15). Auention must be paid to
the one or more veins bridging the temporal
lobe and the sphenoparietal sin us. Although it
is good practice to preserve venous drainage
where possible, we have not seen any com plica-
tions from electrocoagu lating and severin g
these vei ns. I n cases where minimal temporal
lobe retraction is necessary, these veins may be
preserved . The following chapter details the
anatomy of the sylvian fissure in the approach
to the basal cisterns.
Bibliography
I. Clemente C D (ed) ( 1985) Anatomy of Ille Human
Body by Henry Gmy, 30th American ed. Philadel-
phia, Lea & Febigcr, p 171
2. Etter Lf. ( 1955) A/las of Roentgen Anatomy of lhe
Skull. Springfield, 1L, Charles C Thomas Pub-
lisher, pp 16-44
3. FoxJL (1979) Microsurgical exposure of intracra-
nial aneurysms.J Microsurg I : 2-31
4. Fox JL (1983) Intracranial Aneurysms, vol 2. New
York, Springer-Verlag, pp 877-887, 1030
5. Lie TA (1983) Variations in cerebrovascular
anatomy, in Fox J1. (ed): Intracranial Aneurysms,
\'01 I. New York, Springer-Verlag, pp 432-489
6. Sin/man's Medical DicliOl!l1ry, ed 24. (1982) Balti-
more, Williams & Wilkins Co, p 1312
42 4. Cranial Anatomy and the Cranial Flap

Fig. 4.4. View of dry skull in the same surgical posi- pel, pClrous pyramid; ac, anterior clinoid proces; pc,
tion as in figs. 2.3 and 4.8 prior to removal of the tip of ]X>sterior clinoid process; crossed an-ow, ex-
sphe no id \~il\g. The right orbit is at the upper left posed lOp of red rubber eraser ("lUmor" or
corner. spit, L1.leral aspect of greater sphenoid wing; ",jllcurysm").
 Analo my 43

""'It

Fig. 4.5. Same dry skull as in Fig. 4.4. The sphenoid clino id processes. ac, Right amerior clinoid process;
wing (sPh) has bee n drilled away. Crossed arraw: red pel, right petrous pyra mid ;,,£;, righl posterior clino id
rubber eraser ("tumo r" or "aneu rys m") sitting on process. From Fox [3] .
lhe tuberculum sellae n anked by both ame rior
44 4. Cranial Anatomy and the Cranial Flap

Fig. 4.6. Same dry skull as in '-igs. 4.4 and 4.5. Skull flank ing tubercu lum sellae (ts); PC. right posteriur
is in upright, oblique position with view over lateral clinoid process; 00, red pen representing basilar ar-
roof of orbil. zy. Frontal processofzygoma;pet. right tery. (Behind the latter would be the midbrain and
petrous pyramid; ac, anterior clinoid processes pons.)
 AnalOmy 45

Fig. 4.7. Same dry skull as in Figs. 4.4-4.6. Sku ll
now is in surgical upside-down, oblique position.
Thesurgeon's view is more caudal to view the region
of the "basilar artery" (00, a red pen) as seen via the
pterional approach. The orbit is in the upper left
corner of the figure. pc, Right posterior clinoid pro-
cess; pel, petrous pyramid; *, right anterior clinoid
process: sph, drilled down sphenoid wing. From Fox
[3).
46 4. Cranial Anatomy and the Cranial Flap

Fig. 4.8. Patient's head in a skull clamp. The incision (triallgle) isoudincd to stay behind the hairline. ret allows
the bone nap to remain auached to the temporalis muscle. From I-ox [3).
 The Cranial Flap 47

Fig. 4.9. Scalp nap turned for right pterional tal bone; fb. fronta l bone; If, tClllporalis fasc ia; pt.
craniotomy. Paticnt in position shown in Fig. 4.8. perioste um ; re, raney clips on scal p edgc; s, suction
Ga/~a exposed. Crosstd 01'7'01/,\ junction of tcmpo""dl tube: If, thumb forceps elevating triangular patch of
line with orbital ridge a nd zygomatic process of f ron- perioste um offfrontal bone Vb).
48 4. Cranial Anatomy and the Cranial Flap

Fig. 4.10. The oxycellulosc (ox) covered galea and frontal if) burr holes have been drilled and covered
scalp flap arc held by fishhook retraCLOrs (fit). A re- with bonewax. fe, Periosteum; el, elevator; if, tern-
tractor (ret) is pulling the incised lcmporalis m uscle poralis fascia.
forward. One parietal (P). one temporal (I), and lWO
 The Cranial Flap 49

Fig. 4.11. The bone flap (bj), covered byoxycell ulose (t1ll). lph, Sphenoid ....,ing;td. temporal dura;fd. fron-
(ox), has becn turned laterally o\·e r the zygomatic tal dura : su, suture for later reattachment of the
arch. It rcmains attached to the temporalis muscle bone flap .
 ;0 4. Cranial AnatOmy and the Cranial Flap

,
/CO;
Id

.1
Fig. 4.12. The sphenoid wi ng (sph) prior to removal. hII, Amcrior fronta l burr holc;fd, fron ta l dur<t;sf, dura
over sylvian fissure; It!, temporal dura.
 Sphenoid Wing Removal 51

Fig. 4. 13. The right sphenoid wing (spl!) has been tractor on the dura of the tempo ral lobc (/d). On left
burred away. Crossed arrow, vascular channel ill lesser is a suction tube (5) and retractor (ret) 0 11 the dura of
wing of sphe noid wing near base of anterior clinoid the right frOlllallobe ifd). Zeiss dial SCl at magnifica-
process; mo, mcningo-orbital artery. On right is a re- tion Hu mber 0.6 (old no. 10). From Fox [3].
52 4. Cranial Anatomy and the Cranial Flap

Fig. 4. 14. Initial exposure of carotid cistern. Magnifi- down dural flap (dura), The sylvian fissure (sf) is not
catio n reduced. Retractors (rtt) elc\'ating the right yet opened. 2, Optic nerve; ica, ime rnal carotid af-
Ic mporallobe (about') and frontal lobe (below) I em tcry. Zeiss magnificatio n dial set at number 0.4 (old
frOIl1 right spheno id wing co\'c red by the turned- no. 6). From Fox [3].
 Sphenoid Wing Removal 53

Fig. 4.15. View along sphenoid wing to the right an- nerve (2) are covered by arachnoid. J, Right olfac-
teriorclinoid process (*). ti. "I"emporal lobc;j1, fronlai tory tract ; s. suction lube. Zeiss dial set at 0.6 (old
lobe. The internal carotid artery (ica) and optic no. 10). From Fox (3).
 5--
The Sylvian Fissure

Introduction Figure 5. 1 is a computed tomography (CT )

Even though the pterional approach to skull-
base lesions has become more widely used by
neurosurgcons, significam separation of the
frontal and tcmporal lobes by opcning the syl-
vian fissure is often not done. However, as we
have gained morc experience. we have o pened
the sylvian fissure more and morc. This has
seve ral benefits [3, 5): (a) small vessels arc not
compressed by arachnoidal bands during re-
traction of the brain; (b) there is less resistance
(and he nce less bra in-retractor pressure) to re-
traction of the fronta l lobe; (c) traction 011 onc
lobe does not pull and injure Lhe other lobe;
(d) fewer bridging veins need be sacrificed; (e)
the olfactory nerve usually can be preserved;
and (f) there is minimal traction on perforating
arteries and on a n a neurysm.
scan that nicel y ill ustrates the significant cere-
bral spinal fluid (CSF) space (sylvian cistern)
between noncom pressed frontal and temporal
lobes. This space, containing the midd le cere-
bral artery and its branches. is quite prominent
in the older 01" the atrophied brain. h may be
minimal in the edematous or compressed
bra in. The sylvian cistern is larger near its basal
zone, as seen in Fi g. 5.1. and becomes smalle r in
the more peripheral zones. At the surface the
sylvia n fi ssure may appear to be absent (i t is
not) owin g to the close approximation of the
froma l pia and temporal pia mater. This zone
is covered by fi r mly adhering arachnoid
strelched over th e pia, and at first observation
the untutored observor may be mislead into be-
liev ing that an opening of the sylvian fi ssure is
too difficult to wa rrant performing. Indeed.

Fig. 5.1. CT scan after injec-

tion of iopamidol into CS F.
Arrow runs from posterior
cerebral artery (at junction of
ambient cistern with inter-
pedu ncular cistern) to optic
tract. Arrowhead. middle cere-
bral artery in sylvian fissure.
Section is at level of midbrain
and optic chiasm. Note an·
tcrior cerebra l arteries in
chiasmatic cistern (trianglt)
and interhemispheric fi ssure.
56 5. The Sylvian Fissure
the difficulties e ncountered with opening the
sylvian fissure compressed by sofland edemat-
ous brain contai ning friable , nonautoregulat-
ing vessels may make the procedure LOa
hazardou s. But in most circumstances the fis-
sure can be widely opened, thus pe rmitting ex-
cellent exposure of basal anatomy between a
drilled-down sphenoid wing and a widely ex-
posed sylvian fissure.
Anatomy
Figures 5.2 thro ug h 5.8 illustrate the initial
opening of the sylvian fi ssure in five cases (all
photographs in this alias a re presented as view-
ing the right side). With initia l elevation of the
frontal and temporal lobes (Fig. 5.2), the sur-
geon will see fine arachnoid bands passing in
the subdural space between the arachnoid and
dura (both being mesodermal le ptomeningeal
tissue of similar embryonic origin). I n some
cases the arachnoid over the sylvian fi ssure is
distended by contained CS F (Fig. 5.3). This
often occurs when the brain has been mildly
shrunken as water is transferred from the
brain into the CS F space owi ng to controlled
hyperve ntilation [7] .
The sylvian fissure is usually opened on the
frontal lobe side of the sylvian veins (Figs.
5.4-5.8). Initially, we use ajeweler's forceps to
pick up the arachnoid (Fig. 5.6), which is incis-
ed with microscissors . The self-retaining re-
tractor blades are e mployed to separate the
frontal and temporal lobes, thus gently stre tch·
ing the arachnoid in the fi ssure. This facilitates
exposure of the next, dee per layer of arach-
noid and its con tai ned peripheral branches of
the middle cerebral arter y (Fig. 5.7). Close in-
spection via the operating microscope reveals
the eve r-present, fine arachnoid bands or fi-
bers supporting the arteries within their bath
of CS F. This anatomical phenomenon, to be
emphasized throughout this atlas, has been
stressed by Arutiunov an d colleagues in their
drawings [1]. They related mechanical distor-
tion of these supporting fi bers to the evolution
of vasospasm after aneurysmal subarachnoid
hemorrhage.
We no longer hesitate to coagulate and incise
veins and supe rficial arteries passing between
the two lobes. In this manner the surgeon, with
the suction tu be in his left hand and the bipolar
forceps o r microscissors in his right hand ,
works his way down toward the base of the syl-
vian fissure (Figs . 5.8-5.12). Meticulous ca re is
taken with the small a rach noid adhesions and
bands adjacent to middle cerebral artery
branches deeper in the fi ssure. When released ,
these bands will not compress a nd compromise
vessels as the lobes are se parated, and the sur-
geon will find the fissure sudden ly opening up
to sign ificant advantage. A small cotton paddy
or dental cotton ball (counted ) is hel pful for
compressing bleed ing vessels with the suctio n
tube prior to their electrocoagulation.
One finally reaches the much tougher
arachnoid fibe rs at the base of the sylvian fis-
sure (Figs. 5.9-5.1 1). When these arc cut, the
surgeon ga ins immediate entra nce into the
carotid cistern and more CSF is released. Dur-
ing this approach, the surgeon must decide
whether or not to electrocoagu late a nd cutone
or more bridg in g veins between the sylvian
vei ns of the lemporal lobe and the dural
sphenoparietal sin us (Figs. 5. 10-5 .1 3). Preser-
vation of bridging veins generall y is a good pol-
icy, bUllheir presence may lim it adequa te expo-
su re in some cases. Also, these veins may lear,
resulting in venous bleeding at a difficult time
during the operation. We rarely, if ever, had a
complication due to removal of these particu-
lar veins. Figure 5.13 shows the preliminary
anatomy in one patient after opening the syl-
vian fissure.
The following figures ill ustrate va riatio ns in
surgical anatomy of the right sylvia n fissure.
Figures 5.14 a nd 5. 15 are twO separate cases
where on ly the d istal zone of the sylvian fissure
(similar to site of jeweler's forceps in Fig. 5.6)
has been o pened. In each case branches of the
middle cerebral a rtery project out and
arach noid bands a re noted. In Fig. 5.15 the
morc superficial part of the sylvian fissure has
been obliterated la terally by adhesions (from
previous hemorrhage) between the frontal a nd
temporal lobes. Figures 5.16 and 5. 17 are illus-
trations (at different magnifications) of middle
cerebral arterial bra nches projecting outward
after the lateral portions of the frontal and
te mporal lobes in Fig. 5.15 have been scpa-
rated. Emphasis is placed on the arachnoid
bands of Arutiunov ( I], which are clearly re-
vealed in these photographs. Of course, nor-
mally they are bathed in CS F within the sylvian
cistern .
Figure 5.18 indicates a later state of dissec-
tion where the tough arachnoid between the
base of the frontal lobe a nd the base of the tem-
poral lobe is being severed by microscissors
(compare with Fig. 5. 11 ). Figure 5. 19 shows a
 Anatomy
variation in the M-I and M-2 arterial anatomy
after cutting basal arachnoid fibers. Figure
5.20 is an example of a long M-I artery project-
ing laterally through an early superficial open-
ing of the sylvian fissure. Figure 5.21 illustrates
another long M-I artery ta king the more usual
course deep in the sylvian fissure. Figures 5.22
and 5.23 are exam ples of a long M-l artery and
a short M-l artery, respectively. In both in-
stances, the M-1 a rtery is best seen with the su r-
geon's view aimed perpendicular to the axis of
the artery, and this is best obtained by a greate r-
than-usual extension of the patient's head
when lesions along the M- l artery and internal
carotid anery bifurcation are treated surgi-
call y.
As the sylvian fissure is opened more widely
at the base, the bifurcation of the internal
ca rotid artery into its M-J and A- I branches
comes into view. A structu re often seen but not
commonly recognized here is the optic tract
(Figs. 5.23-5.29). In this region the optic tract
forms the lateral border of the lamina ter-
minalis and its cistern , is crossed by the A-I ar-
tery, a nd lies deep to perforators passing to the
a nterior perforated substance from A- J, M-I,
a nd the carotid bifurcation vasculatu re. Fig-
ures 5.24 and 5.25 a re good examples of im-
portant anatomy seen at and just beyond the
widely opened sylvian fi ssure. In addition to
that described above. this anatomy includes the
anterior choroidal artery, stria thalamic per-
forators. reCUITent artery of Heubncl; and the
anterior temporal artery. Figures 5.26and 5.27
are additional examples where the internal
carotid artery is short. The multitude of stria
thalamic perforators as seen in Figu re 5.28 will
be obscured by a n a neurysm at the bifurcation
of the internal carotid artery (Fig. 5.29).
In a n occasional case, gentle retraction to
separate the fromal and temporal lobes will ex-
pose middle ce rebral artery branches usually
deeply hidden in the sylvian fissure (Fig. 5.30).
With microlechnique to open the arachnoid
membrane and to sever the fine arachnoid
bands supportin g the a rteries, the arteries (dis-
tended a nd pulsating with blood) may project
outward toward the surgeon (Fig. 5.31). Usu-
ally a seco nd layer of arachnoid me mbrane is
found covering the larger M-2 branches and
must be removed to see these branches clearly
(Fig. 5.32). These arteries then can be followed
down to the M- I artery and its pe rforators
(Fig. 5.33). It is thi s author's opinion that the
brain is covered by a double layer of arachnoid
57
as if the brain had settled down onto a balloon
made of arachnoid membrane. As the brain
"settled," the opposing arachnoid walls ap-
proximated, leav ing an inner layer (wrapped
around and supporting the arleries at the base
of the brain) a nd a n outer layer (covering the
brain and stretched between neu ral protru-
sions so as to form CS F-comaining cisterns and
fi ssures). Ju st as fine arachnoid ba nd s and fib-
ers run between the dura a nd the arachnoid
(see Fig. 5.2), similar ba nds and fibers (of
Arutiunov) run from the inner arachnoid layer
(surrounding arteries) to other nearby inner or
outer arachnoid layers (see Fig. 5.17). Often
the inner layer of arachnoid el1\'elops not only
the conduit arteries but also the perforators
running in the CSF space between the artery
and the brain (the anterior thalamic per-
forators from the posterior communicating ar'-
tery shown in Cha pter 8 bein g the best exam-
ple). Thus, these perforators a ppear to be
lined on both sides by a layer of inner
arachnoid membrane [4]. This membrane be-
comes stretched, perforated, and discontinu-
ous with growth of the child.
Figures 5.34 and 5.35 are two illustrations of
a leash of stria t halamic perforators passing
from the M-I artery, through the base of the
sylvia n cistern , over the optic tract, and into the
a merior perforated substance. Figure 5.36 is
an angiographic example of such perforators.
The nex t chapter will ta ke the obser ver deeper
into the carotid and adjacent cisterns.
Bibliography
I. Arutiunov A, Baron MA, Majorova NA (1974)The
role or mechanical ractors in the pathogenesis or
short-term and prolonged spasm or the cerebral
ancries. J Neurosurg40: 459 - 472
2. Fox JL (1979) Microsurgical exposure orintracra-
nial aneurysms.] Microsurg I: 2-31
3. Fox JL (1983) Intmcrallial Aneurysms. vol 2. New
York, Springer-Verlag, pp 877 - 1069
4. Fox JL, J erez A (1974) An unusual aCOustic
neurinoma loca lized between brain stem and basi-
lar arlery using emulsified Pantopaque cisternog-
raphy. Surg Neurol 2: 329- 332
5. Fox JL, Albin MS, Sader DCH et al (1978) Micro-
surgical treatment of neurovascular disease.
Neurosurgery 3: 285-337
6. )<ox JL, Nugent GR (1976) Recent advances in
intracranial aneurysm surgery. \V Va Med J
72: 104- 106
7. Hayes GJ , Slocum HC (1962) The achievemem of
optimal brain relaxation by hypervcntilation
technics or anesthesia.J Neurosurg 19: 65-69
58 5. The Sylvian Fissure

Fig. 5.2. In itial intradural exposure down rig ht d ura and a rachnoid mcmbranc;jf, frolllal lobe; 1l1,
sphenoid wing. dum, Dura rencctcd over drillcd- brain rClraClOrs; II. tcrnporallobc; ~ \'cin.
dowlJ sphenoid wing: tlr, arach noid hands between
 Anatomy 59

r· •

"
.. ".
• •
,
-. , ....~,
"' •

..f-,
<
•
.

- .
" •• • • ~

,
, •

....., . ..
~

)'.

fig. 5.3. Arachnoid membrane (ar) in sylvian fi ssure sphenoparietal si nus. clp. Malleable clips on d ural
d istended by CS F. Prom inent sylvian vein (v) cov· ed ge; If. lem porallobc;jl. fro ntal lobe; (lolJbie-crossed
ered by this arachnoid and divides peri pherally into arrau~ a rachnoid on fronta l lobc side of sylvian veins.
twO branches (single-crossed arrows) entering
60 5. The Sylvian Fissure

Fig. 5.4. In itial incision into sylvian fissure (arrows). a peripheral branch (a, bottom) of the middle cerebral
This is 0 11 the fronta l lobe (jl) side of the syl\·jan veins artery. Abo\'c is a surface branch (a, toP) of the mid-
(v). Arachnoid membrane (ar, lOP) is stretched over dle cerebral artery on the temporal lobe. rei, Retrac-
the sylvian fissure. A rach noid bands (ar. bottom) cross LOr ; cot, cOllonoid.
 AnaLOmy 61

Fig. 5.5. Same case ("ig. 5.4). Distal ponion of right anery (rn -2, loP). ica , Imernal carolid ancry (oU( of
sylvian fissure widely opened, exposing a large fron· focu s) ;col,COltonoid u nder rClracLOr;j1, frontal lobe;
tal M-2 arlery (m-2, bottom) and a smali lemporal M-2 If, lc mporal lobe;ar, arachnoid band.
62 5. The Sylvian Fissure

II -'
(
"-

dura

Jf

Fig. 5.6. Anothe r case illustrating jeweler"s forceps (jj) grabbing arachnoid over Syh,j.Ul fissure (arrow). fl.
Fromallobe; II, temporal Jobc;d1lra, dural margi n;$, suction lU be; t', vein. From tox [3).
 Anatomy 63

tl-ret

fI-ret

(
,

Fig. 5.7. Furthe r opening or syJvian fissure comain- JolJe re tral:tor; v, syl vian veins. Note arachnoid bands
ing entwining vessels. ar (toP), Arach noid on (ar, bottom) octween sylvian vessels and pia. From Fox
atherosclerotic internal carotid artery (ica); Ie, te nto- [3].
rial edge; li·ret, temporal lobe rei ractor;jl-rel, rrontal
64 5. The Sylvian Fissure

I\

tl.f'et

II-ret

Fig. 5.8. Another case to illustrate use of forcep rct ractor;jl-rel, fro ntal lobe retracLOr; col, small cot-
blades ifcPl to open and separate arachnoid (ar) o n t Oil ball (from dental supply house).
frontal lobe side of syl\'ian veins. /l-ret, Temporal lobe
 Amllomy 65

Fig. 5.9. Arachnoid at base of sylvia n fissure is usu· carotid artery; dum, dura o,'cr sphenoid wi ng; 3,
ally thicke ned (ar) and needs to be cut to expose basal oculomotor nerve; v, veins;ti, temporallobe;fcp. for-
cisterns. gr, Gyrus rectuS; 2, optic ne .... ej ita, illlernal ceps.
66 5. T he Sylvian fissure

Fig. 5.10. Another case after partial opening of fl. frontal lobe; 2, optic nerve; ica, internal carotid ar-
arachnoid (ar, lOP) over sylvian fissure. Arachnoid tery; pc, posterior clinoid process; v, sylvian veins; It,
bands (ar, hottom) connect branch (a) of middle cere· temporal lobe. T h e vei n (v, lOP) is entering the
bral artery with pia. cot, Cottonoids under retractors; sphenoparietal sinus.
 Anatom), 67

Fig. 5.11. Same case (Fig. 5.10) after further separa- carotid arrer)' ju ncuon;pc, I>ostenor clino id process;
tion of arachnoid (ar, below) b)' blades of forceps V, vein; I'll, retractor on tcml>oraiiobe.
ifcp}, or (toP), Arachnoid band O\'er optic nen'eJ
68 5. The Sylvian Fissure

-- \
Fig. 5.12. Same case (Fig. 5.10) after clearocoagula- me m, membrane of Liliequisl ill background (pointer
lion of vein (v) to sphenoparieta l sin us. dura, Dura crosses more supe rficial frontal lobe and internal
over drilled-down sphenoid wing; te, tentorial edge; carotid artcry) ;sc, microscissors.
 Anatomy 69

Fig. 5.13. S.. me case (Fig. 5. 10) a rter rurthe r separa- the inter peduncula r cistern. T he uncus (un) is still
lion o r rrontal lobe (j1) and te rn pordl lobe. The adhercnt to thc ocu lo motor nerve (3). s. Suction
a rachnoid membrane or LilicquiSl (mem) has beCI1 tube; 2, optic nervc;pt:. posterior clinoid process; at ,
partially opened. re\'ealing the basilar artcry (ba) in a nterio r clinoid process.
70 5. The Sylvian Fissure

(
I

r
/1- 't

•
, ,
fJ

fig. 5.14. Another case after opening peripheral the middle cerebral artery are projecting out of the
part of right sylvian fissure. Note arachnoid bands depths of the sylvian fissure and toward the ob-
(ar) between arteries and between arterial branches server. rei, Retractor; Il, temporal lobe; fl. frontal
and pia. The temporal (I) and frontal if) branches of lobe.
 Anatomy 71

Fig. 5.15. Anothe r case after partial opening of right trocoagulated) between frontal lobe (jl) and tem-
sylvian fissure (crossed arrow). Branch (a) of middle porallobe (If). col, Coltonoids under brain retractors;
cerebral arter y lies on island of Reil (*) and comes ar, arach noid band .
from depths of sylvian fi ssure. ad, Adhesions (elec-
72 5. The Sylvian Fissure

Fig. 5.16. Same case (Fig. 5. 15) after further opening
of sylvi3n fissure . dura, Dura over drilled-down
sphenoid wing; or, arachnoid membrane stretched
between frontal and temporal lobes; Ii-ret, temporal
lobe retractOr; floret, frontal lobe retractor. Note
many arachnoid bands between branches (a) of lhe
middle cerebral artery and between arteries and pia
(shown under greater magnification in the next fig-
ure).
 AnalOmy 73

Fig. 5.17. Same case (Fig. 5.16) and vicw undcr grcat- arachnoid bands: col, coltonoid under retraclor;fl.
er magnification (old Zeiss dial No. 25 or new Zeiss frontal lobe.
dial No. 1.6). Crossed arrows, examples of the many
74 5. The Sylvian Fissure

Fig. 5.18. Another case where arachnoid at base of
sylvian fissure is being cut by microscissors. A suc-
lion tube (s) is in the surgeon's Jcrt hand and micro-
scissors are in his righl. The optic nerve (2) and the
i/Hernal ca rotid artery (ica) a rc still covered by
arachnoid. cot, Small cOlton ball ; rtt, retractor o n
frontal lobe ; v, vein from temporal lobe to
sphenoparietal si nus; II, temporal lobe. From Fox
[2].
 Anatomy 75

Fig. 5.19. Example of 1\\'0 front..al (I:Mmom) and o ne buried in temporal lobe (If) ; ala, anterior temporal
te mporal (top) M-2 branches (m-2) arising from the artery; v. \·eins;j1. frontal lobe.
M-I artery (m-/). on, Base of aneurysm with dome
76 5. The SyJ vian Fissure

Fig. 5.20. Exampleof middlecerebral arter y pmject- posterior temporal artery: fl, temporal lobe; I, tem-
ing through partial o pening o f sylvian fi ssure. cot, pol-al M-2 branch; G, small artery; v, vcins;f, frontal
Coltonoids under retractor;jl. frontallobc; an , twO 1\'1-2 brauch.
microanc urysms of 1\'1- 1 artery (m - I) bifurcation; pia,
 Anatomy 77

Fig. 5.21. View along a widely opened right sylvian
fissure uncler less magnification (old Zeiss dial
No. 10 or !leI,' Zeiss dial No. 0.6). fl·rel, Fro ntal lobe
retranor; 2, optic nerve; ica, imernal carotid artery;
double-crossed arrfJUl, origin of anterior choroidal ar-
tery; single-crossel{ arrow. crosses dome of ica
aneurysm and poims to posterior com mu nicati ng a r-
tcry dcep to aneurysm; ala, antcrior tcmporal ar-
tcry; Il-,.et, temporal lobe retractor; cot, couonoid ; 1/1-
2, M-2 arteries arisi ng with multilobulated
aneurysms at bifurcation of the M- I artery (m-/); ox,
ox),cellulose (Surgicel);ar, arach noid bands;a-I, A- I
artery. From "ox [3].
78 5. T he Syl\'ian Fissure

,,'

Fig. 5.22. Example of long M-l artery (m-/) bu ried rronlal M-2 artery (bottom). NOle perforators sUlek to
deep in right sylvian fissure. rei, Retractor on the dome of aneurysm. ala , Anterior temporal artery.
tem poral lobe; cot, cOltonoid; v, \'ci ns; an, small From Fox [2].
aneurysm flanked by tempol'a] M-2 artery (loP) and
 AnaLOmy 79

Fig. 5.23. Example of short M· I artery (m.I) at base
of sylvian fissure. slw, Superior hypophyseal artery;
ica, bifurcation of internal carotid artery ; ala, a n·
terior temporal artery; an, small aneurysm nanked
by temporal M·2 artery (t) and frontal ~1 -2 aner), (j);
ar, arach noid fibers enveloping perforators; p, per-
forating arteries ar ising from the A-I artery (a-I)
and entering the a nterior perforated substance; at,
optic tract. The M- I perforators are mostly hidden
behind the M-l arte ry. From Fox [2].
80 5. The S)'lvian Fissure

I
\
~
. r?-
lu
C?,
,

Fig. 5.24. Example of atherosclerotic internal
carotid a rle ry (*) bifufcation seen after a wide open-
ing of the sylvian fissure. mem, Dceply located mem-
brane of Liliequist; a-I, A- I anery; mol, M-I arter),;
ach, amcriorchoroidaJ artcry;ar, arachnoid band be-
tween artery and temporal lobe; I, temporal M-2 af-
tery;f, frontal M-2 artery; p, perforators from A-I
and M-l anerics;o/, optic tract; v, veins; 110., ret:ur reru
artery of Heubner; ch, optic chiasm.
 Anatomy 81

Fig. 5.25. Internal carotid artery (ica) bifurcation at
base of sylvian fissure (at higher magnification: old
Zeiss dial No. 25 or new Zeiss dial No. 1.6). hp,
hypothalamic perforators from internal carotid ar·
lery (ica); acll, anterior choroidal artery; mem, deepl y
located arachnoid membrane of Liliequist; m-l, M-I
artery entering sylvian fissure; p, perforators from
internal carotid and M-J arteries; ho., artery of
Heubner; a-J, A-I artery; ret, frontal lobe retractor;
ot, optic tract; eh, opticchiasm;ar, arachnoid bands.
82 5. The Sylvian Fissu re

\ -,
...,."
'" gel

f[-ret

Fig. 5.26. Transsylvian view of M-J (m-l) and A-I (a-
J) origins from internal carotid artery (ica). CrOSJed
arrow, origin of anterior choroidal anery; pea, min is-
cule posterior communicating artery whose anterior
thalamic perforaLOrs (p) are notable; 00, basila r ar-
tery in backgrou nd; sea, right superior cerebellar ar-
terYi 1'-1, large P_I artery; /l.ret, tcmporallobe retrac-
torian, base of aneu rysm (from bi furcation o f basilar
artery); ot, optic tract (see a<ljacent perforators from
A-I l;jl-ret, frontal lobe retractor; gel, gelatin sponge
(Gclfoam); ch, optic chiasm; 2, optic nerve; Pit, piLUil-
ary stalk. From Fox [3].
 Anatomy 83

Fig. 5.27. Another exam pic of transsylvian view of
A-I (a-I) and M- I (m-l) origins fro m short internal
carotid artery (iea). Note anterior thalam ic per-
forators a nd arachnoid bands coming off posterior
communicating arlcry (pea) . Retraction of the uncus
(unc) causes angulation of the oculomotor ncl"'-'c (3)
lateral to the postel-ior clinoid process (pe).fib, Fibrin
from previous hcmorrhage; ala, anterior temporal
arlery; m-2, M-2 artery; 01, optic tract; p, perforator
fro m anery of Heu bner;jl-ret, fro ntal lobe retractor;
cit, optic ch iasm; 2, optic nerve; ac, anterior clinoid
process. From "ox (3].
84 5. T he Sylvian Fissure

Fig. 5.28. Another case where the internal carotid ar- I (a-I) to the anterior perforated substance. ell, optic
lCry bifurcation (crQSMd arrow) is well seen after the chiasm; Qt, optic tracl; 00, basilar artery;slm, superior
sylvian fi ssure is widely opened. Note leash of hypo physeal arlcry;o7l, aneurysm orica at rakeoffof
arach noid bands and perforators (p) passing from A- anterior choroidal aftery; m-I, M-l artery.
 Anatomy 85

Fig. 5.29. Base of aneurysm (an) at bifurcation of in- terior choroidal artery; pea, posterior commun ic.1.t-
lernal carotid artery (ica), transsylvian view. Artery ing artery; If, temporal lobe; m_l. M- J aner)';cof, cOt-
of He ubner (1m) is adherent to aneurysm. a-I, A- I ar- tonoid ; 1111, rctractoTs;j1, frontal lobe. From Fox [3] .
tcry; If, lamina terminal is; ot, optic tract; adm, a n-
86 5. The Sylvian Fissure

Fig. 5.30. Anothe r case illustrating the anatomy o f arteries arc exposed by separation of the frontal (jl)
the right syJvian fissure. Arachnoid still CQ\'c r s the and temporal (tf) lobes. rei, Retractor; spit, dura rc-
sylvian fissure (between crossed arrows) in which the nected over sphenoid wing; v. vein.
 Anatomy 87

Fig. 5.31. Same case (Fig. 5.30) after the arachnoid branches remain covered by a deeper layer of
(ar) over the sylvian fissure has been opened. arachnoid (crossed arrow). Note strands of arachnoid
Peripheral branches (a) of the middle cerebra l artery fibers supporting the arteries. *, Unseparated
project the mselves toward the surgeon. Deeper M-2 deepe r portions of the froma l and temporal lobes.
88 5. The Syh'ian Fissure

Fig. 5.32. Same case (Fig. 5.30) after removal of the (dQuble-trOSMd an-ow) are seen. ala, Aillcrior temporal
deeper arachnoid layer. The frontal M·2 branch artery.
(single-cros.sed arrow) and the temporal M-2 branch
 Anatomy 89

".

Fig. 5.33. Same easc (Fig. 5.30) aflcrcxposurc of the
M- I arter}' (m-l) deep in the sylvian fiss ure. T he M- I
division into the frontal (single-crossed arrow) and
temporal (double.crossed arrow) is seen. Note leash of
stria thalamic perforators (perf) passing from M-l.
crossi ng the right op tic tract (ot), and enter ing thc an-
tcrior perforated substance under the frontal lobc
retractor (ret). fl, Temporal lobe; an, giant internal
carotid aneurysm; ala, anterior temporal arter y.
90 5. The Sylvian Fissure

Fig. 5.34. Samccase (Fig. 5.30) with more magni fied tractor; 01, optic tract; an, aneurysm; (1.1; linc
view of ]\,1· I (1/1+ 1) perforators. pel[. One of man)' M-l arachnoid fibers from art.eries.
perforaLOrs; m-2, M-2 arteries; rei, fro mal lobe re-
 Anatomy 91

Fig. 5.35. Another case showing arterial anatomy of
base of right sylvian fissure. Note unusually large
perforator (double-crossed arrow) arising from the M-
1 arte ry (m-/). II, Te mporal lobe ; ala, anterior tem-
poral artery; lia, arte ry of Heubner; 01, optic tract;j1,
.I!
fmnla1 lobe; aI; arachnoid fibers; a- I, A- I artery; eh,
o ptic chiasm; iea, internal camtid artery; pea, post-
erior communicating artery; single-crossed arrow. an-
terior choroidal anery.
92 5. The Syh"ian Fissure

Fig. 5.36. Left internal carotid ancriogram illustrating stria thalamic perforators frolll lhe M- I and A-I ar-
teries. Patient had aneurysm (arrow) alorigin of A- I and al origin ofantcl"ior choroidal artery. From Fox and
Nugent [61 with permission from the West Virgin ia State l\Iedical Association.
 6--
The Carotid Cistern and Environs

Introduction tern bounded late rall y by the medial portion of

The carotid cistern, the chiasmatic cistern, and
the cistern of the lamina lcrminalis lie rostral to
the arachnoid membrane of Liliequist (mem-
brane of Key and Retzius). Surgical observa-
tions regard ing the cerebral spinal nuid (CSF)
cisterns and their companmental divisions arc
described elsewhere [3]. Fig ure 6.1 is a coronal
com pUled tomography (CT) image (a cistern-
ogram) that nicely illustrates the rela tions hip
of the illlcrnal carotid artery to the carotid cis-
the temporal lobe. Posteriorly the carotid cis-
tern is separated from the interpeduncular cis-
tern (see Chapter 8) by the arachnoid mem-
brane of Lilicquisl; mediall y the carotid cistern
joins the chiasmatic and lamina terminalis cis-
te rns and superiorly it joins the sylvian cistern
(fi ssure) . In Fig. 6 .1 note the bifurcation of the
internal carotid artery into the middle cerebral
artery (r..'I- 1 segment) and the anterior cerebral
artery (A- I segment). This occurs altheconflu-
ence of thc uppe r pan of the carotid cistcrn,

Fig. 6.1. Cisternogram with iopamidol in CS Fimaged by coronal CTscan LO show anatomyofi mernal carotid
artery (black (/),-ow) wilh cisterns and brain . Open arrow, A-I arter), ; black arrowhead, optic chiasm; while arrow-
head, uncus of temporallobc; wltill' (j/TOU\ contrasl medium in s)'Jvian fissure (cistern). See text.
94 6. The Carotid Cistern and Environs

Fig. 6.2. Tomographic image after ai r has replaced some CSF by pneumoencephalography (patieotin sitting
position). Closed G/'rQW, lies in interpeduncular cistern and poims to arachnoid membrane of Liliequisl (Key
and Retzius). Open arrow, ai r in aqueduct ofSylvius. Sec text.

the lower-medial pan of the sylvian cistern passes from side to side between both
(containing the M- I origi n), a nd the upper-lat-oculomotor nerves (see Fig. 8.1). Normally it is
e ral part of the chiasmatic ciste rn (containing either a solid , translucent sheet with openings
the A- I origin ). This confluence is bounded on either side or a multi perforated membrane
superiorly by the anterior per forated sub- allowing passage of CSF from the posterior
stance of the fronta l lobe . fossa into the anterior cisterns, from whe nce
In earlier years when pneumoencepha log- CSF circulation continues ove r the surface of
raphy was a common intracranial imaging pro- the brain. After subarachnoid hemorrhage or
cedure, the injected gas (usually air), which re- meningitis, ad hesions a long this membrane
placed or displaced some of the CS F. often was may sea l offCSF passageways a nd ca use a com-
temporarily trapped in the interpeduncular municating hydrocephalus. Opening eithe r
cistern (Fig. 6.2). The air was prevented from this mem bra ne or the la mina terminalis at
passing throu gh me mbrane openings and into surgery releases much CSF and may be a per-
the anterior cisterns by the membrane of manent cure for patients with hydrocephalus.
Liliequist until a sufficien t pressure differen- Unless one is approaching a lesion in the inter-
tial developed to overcome adhesive forces be- peduncular cistern or attempting lO release
tween the air bubbles and the moist a rachnoid CS F from the posterior cisterns, it is bette r to
membra nes . leave the Liliequist me mbrane intact. It acts as
The membrane of Liliequist. known origi- an effeCli ve barrier to surgical blood entering
nally as the membrane of Key and Retzius. is an the posterior basal cisterns. Further details are
important arachnoid landmark [2]. The mem- given in anothe r textbook [2].
brane run s from the dorsum sellae and pos-
terior clinoid processes upward toward the
mammillary bodies of the hypothalamus. It
 Anatomy
Anatomy
The surgical anatomy prcscmcd in this alias is
oriented as the surgeon sees it through the
operating microscope at surgery. It is always
de picted on the right side of the patient for ob-
server consistency, and the reader may need to
refe r to the figures in Chapter 4 (especially
Fig.4.8) for occasional orientation of the
supine patie nt's head. T he right olfactory tract
will always head toward the upper-left corner
of the figure (towa rd the paticm's nose), and
the righl lcmporallobc (usually its uncus) will
lie und er a ribbon retractor 011 the right side o f
the field (toward the paliem's riglll ear).
Now that the sylvian fi ssure has been
opened (Cha pter 5), the surgeon recognizes
normal (or abnormal) va riations in surgical
anatomy as seen between the basc of the sylvian
fissu re a nd the dura reflccted ovcr the drilled-
down a nd surgically fl attc ncd sphenoid wing
( ~igs. 6.3 a nd 6.4). The fi rst visible branch of
the internal carotid artcry is usuall}' not lhe
ophthalmic a rtery, for the origin of the
ophthalmic artery invariably is hidden by the
superiorly a nd medially overlapping optic
nerve. The ophthalmic a rtery usually arises on
the medial side of the carotid artery just below.
above. or at the level of the exit of the carotid
a rte ry from thc cavernous sinus. Most com-
monly the surgeon first recognizes the ori gin
o f the posterior communicating artery on thc
latcral , poste rior, or posterolateral side of the
ca rotid artery; but on close inspection onc can
see more proximal (ie. toward the heart) arte-
rial branches, which are the superior hypo-
physeal a rtery (Fig. 6.4) and hypophyseal per-
forators. Throughollt this cha pter the reader
will note how close the internal carotid artery
comes to the posterior clinoid process. and at
times its bifurcation is behind the level of the
dorsum sellae. The oculomotor nerve (third
cra nial nerve) always lies external to the pos-
terior cl inoid process. as this nerve passes for-
ward under thc a nterior reflcction of the ten-
torium and into the top of the cavernous sinus
(sec Figs. 8.2 and 8.3).
T he intracran ial portion of the internal
carotid artery may be fairly long, as noted in
Figs. 6.3 a nd 6.4, or short, as demonstrated in
~igs. 6.5 a nd 6.6. T he shorter this internal
carotid ar tery segment. the more readily the
95
su rgeon can expose the origins of the A-I and
M- I branches.
A leash of vital perforating artcries arises
from the posteroinferior side of the internal
carotid artcry and the posterior communicat-
ing a rtery (Figs. 6.7 and 6.8). Often one has to
retract the carotid artc ry medially or laterall y
to sce thcm. Thcse perforators include the
superior hypoph yseal artcry. hypophyseal per-
forators, and anterior thalamic perforators. As
the surgeon retracts the frontal lobe. the olfac-
tory tract a nd gyrus rectus come into view.
Co mmonly, thc r ecurrcnt artery of Hc ubner
(pc rforator fro m the antcrior cerebral artery)
is seen in the Cl"cvicc between the retracted
frontal lobe and the optic nerve (Fig. 6.7).
Whc n la rge, this may be mistaken for the A-I
artery, which lies behind (o r in front) and
below the artery of Hcubner.
As one retracts the temporal lobe, a major
inte rnal carotid artery branch within the
carotid cistern will be the an tcriorchoroidal ar-
tcry or arteries (frequently there may be two or
evcn three) as illustrated in Figs. 6.9 and 6.10.
This a rtcry arises laterally, postcriorly, or post-
erolatera lly from the internal carotid artery
and passes posteriorl y under the uncus of the
tempora l lobe. II. enters the choroid fi ssure
and passes thence into the temporal horn . As
this a rte ry travels back, it may come in close
proximity to the bifurcation of the internal
ca rotid artcry and its perforators.
The poste rior communicating artery may be
seen dec p to the space between the carotid ar·
tery a nd the optic nc rve (see Figs. 6.6 and 6.9).
or it may bowolltlatc raliy as show n in Figs . 6.11
and 6.12. Even when the posterior CO Ill -
municating artery is small (Figs. 6. 13 a nd 6.14),
it will contain vital a nterior thalamic per-
forators to the brainstem. Ofte n an infun-
dibulum of the posterior communicating ar-
tery is seen, a nd its a ppearance suggests a
prcancurysmal a nomaly (Fig. 6.15) dcveloping
at the d istal angle between internal carotid ar-
tery and the posterior communicating artery,
the classical si tc of such ane urysms (Fig. 6.16).
Although the pituitary stalk lics in the back
of the chiasmatic cistc rn, it often is readily
identificd upon exposure of the carotid cis-
te rn . As shown in Figs. 6.7 and 6. 11, for exam-
ple, the ptcrional approach renders the pituit-
ary stalk visible through the space betwecn thc
96 6. The Carotid Cistern and Environs

Table 6.1. Structures contained within the carotid 6sterns' ,

1. Internal carotid artery

2. Origin of the ophthalmic artery (not always)
3. Origin of the superior hypophyseal anery
4. Origin of the posterior communicating anery
5. Origin of the anterior choroidal artery
6. Origin orlhe middle cerebral artery (M- I)
7. Origin orthe anterior cerebral arte ry (A·l)
8. Origins of the hypothalamic perforators from the carotid artery
9. Origins of the more rostral anterior thalamic perforators
10. Some stria thalamic perforatorll
II. A portion orthe artery of Heubner
12. A portion of Ihe ante rior perfo ralCd substance of the frontal lobe
13. Medial surface orthe temporal lobe
14. Lateral border orlhe optic nerve
15. Sympathetk fibers on the internal carotid artery
16. Rostral edge of the posterior clinoid process (dural covering)
17. Anterio r cli noid process (du ral covering)
18. A portioll of the tentOrial edge between the anterior and postcrior clinoid
processes

Items 12-14 and 16-18 can be considered to form portions of the margins
of the carotid cistern. Sec Fig. 6.1.

oplic apparatus a nd the carotid artery. The
slalk lies between the arachnoid membrane of
Liliequisl posteriorl y and the optic chiasm an-
teriorly. It appears as a reddish, vascu larized
projection passing inferiorl y through the
opening in th e diaphragm sellae. T he su perior
hypophyseal artery a nd hypothalamic per-
forators provide a rich ane rial blood supply,
and the ponal plexu s of veins also are visible
under microscope.
Regard less of the location of the lesion, we
not only open the sylvian fiss ure substantiall y
but we also lyse adhesions and arachnoid
(which separates the carotid and chiasmatic
cisterns) between the ipsilatera l optic nerve
a nd the base of the frontal lobe whe n usi ng the
pterional approach (Figs. 6.1 7 and 6. 18). This
allows: (a) gentle retraction of the frontal lobe
without adhesions pulli ng on the optic nerve,
(b) less brain retraction press ure, (c) occa-
sional inspeClion of the anterior communicat-
ing complex in aneurysm cases, (d ) exposure
of the lamina tcrminalis in cases with hydro-
cephalus, and (e) assessment of local anatomi-
cal variations and e nhance ment of the sur-
geon's knowledge of surgical anatomy. In our
experience the latte r is done at no risk [Q the
patient a nd has bee n extremely important in
honing the surgeon's skills. in patients without
lesions in the anterior communicating region,
actual exposure of the anterior communicat-
ing a nery is not done in pa tients who would re-
quire significant frontal lobe retraction .
Figures 6.19 a nd 6.20 illu strate how, in some
cases, the internal ca rotid artery ca n exte nd or
project above and behind the level of the pos-
te rior clinoid processes and the dorsum sellae.
Here we are looking med ially behind the optic
apparatus (nerve, chiasm, and traCl) ; the lOp
and side of the dorsum sellae are brought into
vIew.
Although not proved histologically in this
case (Fig. 6.21), we believe that sympathetic fi-
bers are seen traveling on the adventitia of the
internal carotid anery in the carotid cistern.
T hey ca n be mistaken for arachnoid bands and
vIce versa.
Upon elevation of the fro ntal lobes in the
nonswollen brain , a view of the medial side of
the opposite carotid cistern can be visualized
(Fig. 6.22). Note how the medial side of the
temporal lobe forms the lateral boundary of
the carotid cistern. Figures 6.23 a nd 6.24 again
show how the carotid cistern is bounded be-
hind by the arachnoid membrane of Lil iequist,
above by the a nte rior perforated substance,
laterally by the tem poral lobe, and mediall y by
the chiasmatic cistern. T he membrane of
Liliequist appears blue whe n CSF remains be-
hind it in the interped uncular cistern. The
 Anatomy
color turns black when the CS F is drained (eg,
by aspiration or lu mbar puncture) so as to leave
only a shadowed space without the reflecting
and refracting water (CSF). Note the unusual
veins (bilateral) from the unseen cavernous
sinus to the unseen basilar vein of Rosenthal ,
the unusual position of the pituitary gland in a
shallow pituitary fossa, the portal veins on the
pituitary stalk , and the opposite posterior com-
municating artery seen through the space be-
tween the optic nerves.
Figures 6.25 and 6.26 represent another
exam ple of the carotid cistern and environs.
Note the su pe rior hypophyseal artery, pituit-
ary stalk, and anterior thalamic perforators
with hypophyseal perforators (displaced me-
97
dially by giant aneu rysm). Table 6.1 sum-
maries the various structures found in the
carotid cistern. The next chapter will take us
i~to the more med ial chiasmatic and adjacent
cIsterns.
Bibliography
I. Fox JL (1979) Microsurgical exposure ofintracra-
nial aneurysms. J Microsurg I: 2-31
2. Fox JL (1983) IntmcranUiI Aneurysms. New York,
Springer-Verlag, frontispiece, pp 877 - \069
3. Ya~argil MG, Kasdaglis K, Jain KK et al (1976)
Anatomical obser vations of the subarachnoid cist-
erns of the brain during surgery. J Neurosurg
44:298-302
98 6. The Carotid Cistern and Environs
Fig. 6.3. View of right carotid cistern and environs.
aI', Arachnoid membrane between the optic nerves;
1, olfactory trdct; gr, gyrus rcctus; 2, right optic
nerve; Ttl, retractor on frontal lobe; crossed arrow, ori-
gin of the posterior communicating artery; ica, inter-
nal carotid artery; 3, oculo motor nerve passing for-
ward uncler the morc lateral tentorial edge (Ie), by
the more medial posterior clinoid process (PC) and
thence imo the C3\'e rn OUS sinus; mem, a refleClion of
Liliequisl's mcmhl<tlle. Between the ocu lomotor
nerve and Liliequisl's membrane is a black, dear CSF
passageway into the interpeduncular cistern. Note
the attachment of Liliequist's arachnoidal mem-
brane to the posterior clinoid and adjacent dors um
sellae. Opening this membrane between the
oculomotor ne rve and the internal carotid artery is
the usual frolllolatcra l route to the interpeduncular
cistern. From ~ox [ I].
 Anatomy 99

Fig.6.4. Carotid cistcrn in another patient. or,
Arachnoid between optic nerves; 2, right optic
nerve; slUJ, superior hypophyseal artery; ica, internal
carotid artery; Ie, anterior reflection of tentorial
edge, 3, oculomotor nerve passing late ral to duraon
posterior d inoid process (PC); pea, posterior com·
municating anery; mem, membrane of Liliequist;fl·
rei , fro mallobe retractor; 1, ol factory tract; v, vein 011
gyrus rectus (gr). From Fox [2].
100 6. The Carotid Cistern and Environs

Fig. 6.5. Right carotid cistern with shon internal
carotid artery (ica). 2, Optic nerve; ac, anterior
clinoid process; mem, membrane of Liliequisl (cover.
ing posterior clinoid process); pea, origin of pos-
terior communicating artery; ), oculo motor nerve;
ad, adhesions between aneurysm (an) and temporal
lobe (/l);cot, couonoid;ata, anterior temporal artery;
crossed arrow, origin of anterior choroidal artery; bif,
bifurcation of carotid artery; fri, origin of A-I ar-
tery;ft. frontal lobe. From Fox [2].
 Anatomy 101

Fig. 6.6. Anotherexample of a short internal carotid
artery (ica) . Note yellow atherosclerotic plaque. pea,
Origin of posterior commun icating artery (lateral
pea) passing behind carotid artery and reappearing
deep to space betwcen optic nerve (2) a nd carotid ar·
{cry; gel, Gelfoam on optic nerve; a-I, right A- I ar-
tcry; bif, bifurcation of carotid artery; ret, temporal
lobe retractor; an, a neurysm ; ad, adhesions between
aneurysm and tentorium (te). From Fox [ I].
102 6. The Carotid Cistern and Environs

Fig. 6.7. Example of long atherosclerotic internal
carotid artery (ica) and environs. Many
hypothalamic (including superior hypo physeal ar-
tery) and anterior thalamic perforators (enclosed in
an envelope of arachnoid) arc seen passing back and
medially from the carotid artery and the posterior
communicating artery (pea). peif, One of these per-
rorators coming off the carotid ancry;), oculomotor
nerve, tl, uncus of temporal lobe;jl. frOlltal lobe; ret,
retractOr ; J, olfaClory tract; ar, arachnoid between
optic nCfI'CS; 2, right optic nerve; JUl, recu rre nt ar-
tery of Heubner;pil, vascular pituitarystalk ;pc, d u ra
on posterior clinoid process. f rom Fox [2].
 Anawmy 103

1(
,, /

I ,
/

Fig. 6.8. Greatly magn ified view between right optic municating artery (pca) are seen. 2, Optic nen-e;
tract (ot) and internal carotid artery (ica). Zeiss dial mem , membrane of Liliequist; pro probe retracting
set at No. 2.5 (old No. 40). Anterior thalamic per- carotid artery laterally. From Fox [I].
fOTawrs(jJeifj from carotid aneryand posterior com -
104 6. The Carotid Cistern and Environs

"',

Fig. 6.9. Carotid cistern with origins of posterior mOLOr ncrvc;ad, adhesions between frontal lobe and
communicating artery (pea) and anterior choroidal optic tract (ot); pit, pituitary stalk; 2, optic nerve; 00,
artery (acha) from internal carotid artery (jea). mem, origin of ophthalmic artery; ret, retractors. From
Membrane of Liliequist; an, aneurysm; 3, oculo- Fox [2].
 Anatomy 105

ha

Fig. 6.10. View of carotid cistern showi ng relation-
ship of anterior choroidal anery (acha) to the uncus
(tine) of the temporal lobe./I(1., Anery of Heubner; J,
olfactory tract; gr. gyrus rectus; 2, optic nerve; iea. in-
lel'llal ca rotid arlery; pea, origin of posterior com·
munica ting anery; Ie, tentorial edge; all, aneurysm
(shrunken and elongated by bipolar electrocoagula-
tion) ; ad, adhesions and fibrin between aneurysm
and temporal lobe and tentorium. Deep to the an-
terior choroidal a n e ry (adUJ) lies the arachnoid
me mbrdne of LiliequisL From Fox [I].
106 6, The Carotid Cistern and Environs

Fig.6. 1I. View o f carotid cistern with laterally d i·
rected posterior communicating artery (pea). mol,
M-l origin;peif, perforators from A-I (a-I); ot, right
optic tract; Jryp, hypothalamic perforaLOrs from
carotid artery; pil, pituitary stalk; ch, optic chiasm; 2,
left and right optic nerves; (-ica, medial side ofleft ill-
lernal carotid artery; dia, diaphragm sellae; pc, left
posterior clinoid process; crossed arrow, superior
hypophyseal artery; r-ica, right internal carotid ar-
tery; r-pc, right posterior clinoid process; ), oculo-
motor !len"e. From Fox [2J.
 AnalOmy 107

Fig. 6.12. A very athcrosclerOlic imcrnal carotid ar-
tery (ica ) with the posterior communicating artery
(fxa) goi ng latcrally. Crosud arr~ crosses dome or
atherosclerotic ane urysm and points to perforator.
adm, Ante rior choroidal artery; 00, basitar arter),
lying in imerpeduncular cistern a nd seen arter re-
mova l of membralle or Lilicquist (In.!m) still attached
to oculomOlOr ncn'e (J) and posterior clinoid pro-
cess (PC), rtt, Retractor on right temporal lobe; te, ten-
lorial edge; at:, anterior clinoid process; 2, optic
nerve,
108 6. The CarOlid Cistern and Environs

~
~ cot
--=- ---

Fig. 6.13. Example of small, short posterior com-
municating artery (crossed arrow) connecting internal
carotid artery (ica) with posterior cerebral artery (p-
2). cot, Cotlonoid; unc, uncus of temporal lobe; an ,
small aneurysm at takeoff of anterior choroidal artery ;
m- I, origin of M-I artery; a- I, origin of A-J artery;lUl,
artery of Heubner; 01, optic tract; 2, optic nerve; ac,
anterior clinoid process; pc, posterior clinoid pro-
cess; te, tentorial edge; ), ocu lomotor nerve. From
Fox (2].
 Anatomy 109

""'

\ ,

Fig. 6.14. Same case as Fig. 6. 13 with probe (pr) dis- municating artery; 01, optic tract; pc, posterior
placing carotid artery medially. Crossed arrow, site of clinoid process; p- J, P-l artery; 3, oculomotor nerve;
anterior thalam ic perforators from posteriOl· com- unc, uncus;p-2, P-2 artery.
110 6. The Carotid Cistern and Environs

Fig. 6.15. Example of prcaneurysmal type of infu n-
dibulum (croSMd af7"ow) of posterio r com municating
artery (pea). perf. Anterior thalamic perfor.uors;
adm, aillcrior choroidal anc!)' ; V, vein; a-l, A-I ar-
tery; Qt, OPlic tract; fl-rt/, frama l lobe retractor ; pro
probe retracting carotid artcl1' i Pit, pituitary stalk; 2,
optic ncn'c;llC, anlcrio r di no id process; un, internal
ca rotid artery; Ie, te ntorial edge; pc. postcriordinoid
process; J, oculomotor Ilcn'c; II-rei, temporal lobe rc-
tractor. From ,"ox [2].
 Anatomy III

mom
oot

Fig. 6.16. Carotid cistern after bipolar eleclrocoagu· (or Kcy and Retzius); ac, autcrior clinoid proccss; ica,
lalion of aneurysm (an) with ad hesions (ad) to internal carotid artery; pc, posterior clinoid process;
ocu lomotor nerve (3) and uncus (unc) of tcmporal pea, origin of postcl'ior communicati ng artcry. From
lobe. col, Cottonoids; mem , membrane of Liliequist Fox [2].
112 6. The Carotid Cistern and Environs

Fig. 6.17. Anatomy of carotid cistern and e nvirons.
Arachnoid membrane of Liliequisl(mem) is well seen
deep to and between the internal carotid artery (ica)
and oculomotor ne rve (3). Crossed arrow, anterior
choroidal artery; IInc, uncus; m·l, origin of M-l ar-
tcr),; an, base of aneurysm at bifurcation of carotid
artery; a-1, righ t A-I al"ter}'; a-a,junction of right A- I
and unseen rig ht A-2 and anterior communicating
(aea) arteries; gr, r ight gyrus rectus; perf, per forators
from anterior communicating artery; hr, bridging ar-
tcry from anterior communicating artery to left A-2
artery (connection out of view); a-2, Icrt A-2 artery;
2, optic nerves; ch. optic chiasm; ft, lamina terminalis;
ot, r ight optic tract; ac, ante rior clinoid process; ds,
diaphragm sel lae; pc, posterior cli noid process; pea,
posterior communicating artery.
 Anatomy 113

Fig. 6.18. Sa me case as Fig. 6.17. Upper internal
carotid artery (ica) and the M- I origin (m- /) are re-
tracted by a probe (pr) to \'iew perforators (crossed ar-
rows) and optic tract (ot) beh ind aneurysm (an) and
bifurcation of carotid artery. pea, Posterior COIll-
municating artery; -UIIC. uncus; acha, anterior choroi-
dal arte ry;s, suction lube; perf. perforators; 00, recur-
rem artery of Heubner;jl, frontal lobe; a-I, A-I ar-
tery; Ma. anterior com municating artery; it, lamina
terminalis.
114 6. The Carotid Cislern and Environs
Fig. 6.19. Ano ther case with view of carOlid cistern
and e nvirons, looking morc medially. Appearing deep
between right internal carotid artery (r-iea) a nd o ptic
apparatus a re seen perforators (peif). pituitary stalk
(Pit), right posterior clinoid process (PC), lOp of lhe
dorsum sellae (ds), le ft superior cerebellar artery (l-
sell), and left oculomotor nerve (3). Lateral to the
right carotid artery 3rc noted the tentorial edge (te),
side of the dorsum sellae (ds), a dural venous si nus
(us) behi nd the dorsum sellae, the posterior com-
municating artery (pea) and its adjacent aneurysm
(crosud arrow), the P-2 artery (p.2). basilar artery (00),
and right oculomotor !len 'c (3). 2, Optic nerves; ch,
o ptic chiasm ; 01, right o ptic tract;foo. right (bottom)
and left (toP) fronto-orbital arteries;gr, right (bottom)
and left (lOP) gyri recti; l-ita, med ial side of left inter-
nal carotid artery; a.-I, A- I artery_
 Anatomy 115

Hg. 6.20. Same case as Fig. 6.19 emphasizing reo
lationship of intcrnal ca rotid artcry (ica) and pos-
ter ior clinoid proccss (PC). Ids. Top of dorsum sellac
covcrcd by dura ;fds, front of dOT5um seUae;sds. side
of dOT5u m sellae; vs, vcnous sinus in dura beh ind
dOT5u m sellae; J, oculomotor ncrve; col , cottonoids;
P01lS, rostral pons; sea, right superior cerebellar ar-
te ry behind 3rd ncrvc;p-2. P·2 artcry in front of3rd
ne rve; une, uncus;a1l. second aneurysm at takeoff of
anterior choroidal a rlery (hidden); CTossed arrow, first
aneurysm at takeoff of posterior communicating ar-
tc ry (hidden); rtf, r ight temporal lobe retractor; m· J,
M- I a rte ry origin; 00, basilar artery ; Iry, hypophyseal
perforator from ica; a- I , A- I a rte ry; 01, optic tract.
Note Icft lateral medu llary pe rfo rator from basilar
;lrtCI,), a nd in shadows behind dorsum sellae.
116 6. The Carotid Cistern and Environs

,.,
Fig. 6.21. Ano ther case illu.n rating sympathetic fi·
bers (5)'"') o n internal carotid artery (ica). ar (]alen]),
Arachnoid band ; Ie, tcnlorial edge; an, aneurys m at
takeoff of [.N)Sterior communicating artery (hidden:
most of aneurysm is below lcnloriu m);cot, cottonoid:
Il t,frontal lobe rclrdctQr; ar (medial), arachnoid
membrane between optic nerves; 2, right optic
ncn'c; mem, membrane o f Liliequist; ac, anterior
clino id process. From Fox [ I].
 Anatomy 117

Fig. 6.22. Another tase showing view of medial side
of opposite (kfl) carotid cistern. reI, Retractor on
right frontal lobe (fl); ch, optic chiasm; 2, both optic
nerves; cot, cotton ball; clp, shank of aneurysm clip ;
ac, right anterior clinoid process; ar, arachnoid fi-
bers; 1.5, tuberculum sellae; unc, medial side of left
uneus;foa, left fronto-orbital artery on left fronta l
lobe; m- I, origin ofleft M- I artery; v. vein ; ica, left in-
ternal carotid artery (medial side near bifurcation);
a- I, origin ofleft A-I a rtery.
liS 6. The Carotid Cistern and Environs
Fig. 6.23. Another case with view of carotid and
chiasmatic cisterns. The pituitary gland (pit) projects
superior to the level of the diaph ragm sellae. Sing/to
crossed arrow, portal veins o f pituitary stalk ; 2, optic
nerves; ell, optic chiasm; r-ica, right internal carotid
artery; hy, hypothalamic perforators from internal
carotid artery; pc. dura of posterior clinoid process;
mem omembrane o f Liliequist; v, unusual vein arising
from cavernous sinus; double-crossed arrow, posterior
communicating artery; aella, one of two alllerior
choroidal arteries;tl-ret, temporal lobe retractor; 111-1,
M- l pordon of midd le cerebral artery; fmi, per-
forators from bifurcation of jea to alllcrior perfo-
rated substance; ot, right o ptic tract; a-I, A-I portion
of anter ior cerebra 1 artery;fl-rel, fro mal lobe retrac-
tor; l-ica, left imernal carotid artery; l-pea, left pos-
terior comm unicating artery. From Fox [2].
 Anatomy 119

Fig. 6.24. Some case as Fig. 6.23. View is looking me-
d ially toward the le ft internal Gl.rotid artery (i-ica). 2,
Optic nerves; Pit, pituitary st.alk; l-pea, le ft posterior
communicating artery; ch, optic ch iasm; a-1 , A- I por-
tion of left anterior cerebral artery; cot, COtton strip;
1/j.-1, M-l portion of left middle cerebral artery;jl-ret,
frontal lobe retractor; v, unusual vein on left arising
from cavernous sinus; pr, probe retracting the vein ;
crossed arrow, medial left temporallobc. ,"'rom Fox [2].
120 6. The Carotid Cistern and Environs

Fig. 6.25. Another case illustrating internal carotid
artery (ita) and environs. pc, Posterior clinoid p ro-
cess; an, giant aneurysm o f right P·1 artery; tl, right
temporal lobe; mol, M-I artery; a-i, A-I artery; ret, re-
tractor on frollla!lobe;a-2, right A-2 artery;gr, gyrus
rectus; am, anterior communicating arter y; 2, optic
nerves; ch, optic chiasm; sha, superior hypophyseal
artery; crossed arrow, one of several hypophyseal and
anterior thalamic per forators in an arachnoid
sheath; Qt, optic tract.
 Anatomy 121

Fig. 6.26. Same case as Fig. 6.25. Probe (pr) is retract- ancurysm; te, telltorial edge; UIIC, uncus; ),
ing right optic nen·c (2) mcdially to show pituitary oculomOlOr llen'c; I'll, temporal lobe retractor; bif,
stalk (pit). pc, Posterior clinoid process; all. giant bifurcation of right internal carotid artery.
 7- -
The Chiasmatic Cistern and Environs
Introduction
As the surgeon d issects medially from the ptcr-
iona l exposure, he or she enco unters a confl u-
ence of cisterns in the ccn ter of which is the
chiasmatic cistern . T he computed tomography
(CT) scans with cerebral spinal fl uid (CSF) con-
trast e nhancement show the ch iasmatic cistern
and adjacent cisterns (Figs. 7. 1 and 7.2). The
ca rotid cisterns are lateral, the cistern of the
Fig. 7. 1. Axial \·icw of CT scan after injection of
iopamidol into the CSF by lu mbar pu ncture: cister-
nogram of chiasmatic cistern containing optic
chiasm (black arrowhead) and medial poI-lions of optic
nerve. Closed black arrow crosses ant.el-im-clinoid pro-
cess and poi nts to lateral portion of optic nerve in
carotid cistern; open arrow lies in confluence of upper
lamina terminalis is behind and above, and the
olfac tory cisterns pass an terior to the chias-
matic cistern. T h e o lfactory cistern lies be-
tween the gyrus rectus and medial orbital
gyrus. I n the mid li ne between the fronta l lobes
is the pericallosai cistern and interhemispheric
fiss ure (cistern).
carotid cistern with med ial chiasmatic cistern from
which arter ial shad ows of A-I (medially) and M-I
(laterally) can be seen 10 originate; white arrow points
to optic tract lying lateral to the laleral portion of the
cistern o f the lamina terminalis and medial to the
confluence of the two cisterns (carotid and sylvian);
while triangle lies on lamina termi nalis.
124 7. The Chiasmatic Cistern and Enviro ns
Fig. 7.2. Coronal (fro mal) view of CT scan after in-
jection o f iopamidol into the CSF by lumbar
puncture: cistcrnogram of olfactory cistern. Black ar-
ruws lie in olfactory cistern and poim to olfaClory
tracts; while triangle, gy rus rectus; while dosed arrow,
Anatomy
As the surgeon elevates the frontal lobe, the ol-
factory tract may be stretched if the brain is
vcry relaxed . If thi s ha ppens, vei ns near the
midline and traversing bcnveen the frontal
lobe (gyrus rectus or adjace nt medial orbital
gyrus) and nearby dural si nuses may lear and
bleed . When such occurs, it will be necessary to
expose the olfactory cistern (Figs. 7.3 and 7.4).
This maneuver is not necessary unless bleed-
ing occurs, requiring bipolar electrocoagula-
tion of these veins.
The olfactory tract appears as a white ba nd
lying in the olfactory cistern. Posteriorly, it
arises from the medial a nd lateral olfacto ry
stria , formin g the from border of the anterior
perforated substance. The tract is adherent to
the fromallobc between the gyrus rectus (me-
dially) and the medial orbital gyrus (laterally).
further anteriorly the olfactory tract se parates
from the brain (figs. 7.2 and 7.5) and passes to-
ward the olfactory bu lb la teral to the crista galli
(Fig. 7.6). From this olfactory bu lb pass the hid-
den fil a me nts of the olfactory nerves down
through the cribiform plate and into the mu-
cosa of the nose.
As the dissection proceeds med ially from
branch of anterior cerebral artery in interhemis-
pheric fiss ure; open arrow, contrast medium in sub·
arachnoid space (optic cistern) surrounding optic
nerve in orbit.
the carotid cistern and into the chiasmatic cis-
tern toward the anterior com municating com-
plex, the surgeon may fo llow the A- I artery ifit
is easily seen. Th is usually occurs if the inte rnal
carotid artery is fairl y short. In cases where the
inte rnal carotid a rtery is long a nd the A- I ar-
tery is hidden posteriorly, the surgeon shou ld
avoid retraction of the frontal lobe to ex pose
the A- I artery. If an anterior communicating
artery aneurysm is the target. the approach is
then directl y through the gyrus rectus [2-4].
T he la ndmarks for the I-cm incision in the
gyrus rectus are illustrated in Figs. 7.7 and 7.8.
The triangular or quadrangular zone inferior
and lateral to the franta-orbita l artery lying on
the gyrus rectus is described in the legends for
these figures.
If the sylvian fissure has been widely
opened, elevation of the frontal lobe will brin g
the optic chiasm, optic tract, and lamina ter-
minalis (betwee n the optic tracts) into view in
cases with a prefixed optic chiasm (ie, short
optic nerves intracran ially). Figures 7.9and 7.10
a re two examples of a prefixed chiasm. The
lam ina termina li s appears as a thin , translu-
cent me mbrane retain ing third ventricular
CS F inside. The CS F on its outer, visible side
lies in the cistern of the lamina terminal is,
 Anatomy
which contains the medial portion of the A- I
arteries, their interconnecting anterior com-
municating artery, and the recurrent artery of
Heubner (Figs. 7.10-7. 12). The cistern of the
lamina terminalis me rges with the chiasmatic
cistern below and a nteriorly a nd with the in-
terhe misphe ric fi ssure (cistern) superiorly.
Laterally, the cistern of the lamina terminalis
me rges with the confluence of the sylvian a nd
carotid ciste rns lateral to the optic tract.
Figures 7.13 and 7.14 are intraoperative
photographs of the same patient. In I-ig-
ure 7.13 we see through the right carotid cis-
tern a nd the lamina terminal is and ch iasmatic
cisterns into the left (opposite) carotid cistern .
The tented la mina tenninalis is prominent.
The medial side of the left internal carotid a r-
tery is seen superior and inferior to the image
of the left optic nerve. The left posterior com-
municating artery is visualized deep to the
pituitary stalk. Pa nicularly important are the
hypophyseal perforators from the carotid a r-
teries. If the A- I arteries are fo llowed medially
and superiorly, the anterior communicating ar-
tery is seen lying in the cistern above a nd a n-
terior to the tented-up lamina terminalis
(Fig. 7. 14).
Figures 7.15 through 7. 18 are four exam ples
of variations in the a natomy of the chiasmatic
and lamina terminalis cisterns. In each case the
inferoanterior zone of the lamina terminalis is
visuali zed . In Figs. 7. 15 and 7. 16 the r ight late ral
margin of the pituitary stal k is seen. This pitu-
itary stalk, along wi th the optic nerves and
chiasm, lies in the chiasmatic cistern (bounded
caudally by the arachnoid membrane of
Liliequist) . However, in many cases the me m-
brane of Liliequist, which lies caudal to the
pituitary stalk, sends an ante rior reflection of
arachnoid membrane in front of the pituitary
stalk. This situation puts the pituitary stalk in-
side its own hypophyseal cistern (Fig. 7.16). In
l'ig. 7.16 note that the frontal lobe retraction is
stretching arachnoid bands at the lateral mar-
gin of the cistem of the lamina terminalis.
Figu res 7.17 and 7.18 add itionally illustrate
the many variations in the pathway of the recur-
rent a rtery of He ubner. Generall y, this artery
a rises from the A-I a rtery or the A-2 arte ry
near the a nterior communicating artery (refer
to Fig. 7.40). There may be two arteries of
Heubner on one side. The artery passes later+
ally and lies superior to and behind or in fron t
of the A-I and medial origi n of the M- ) arteries
125
and sends branches into the anterior perfo-
rated substance. Freque ntly the anery o f
Heubner is seen before the A- I artery is iden+
tified, and it may bequite large (as in Fig. 7. 11 ).
Figures 7.19 and 7.20 are photographs of the
same patient before a nd after per foration of
the lamina terminalis to treat hydrocephalus.
One of the many variations in the anteriorcom-
municating artery complex inside the lamina
terminalis cistern is shown here. Such vari-
ations, with duplications and cross-bridges, are
common (refer to Fig. 7.39). This is a tripli-
cated anterior communicting artery complex
with a bridge between two of the arteries. The
artery of Heubner is well see n.
Figures 7.2 1 through 7.24 de monstrate two
patien ts in whom the artery of Heubner is the
same diameter as the A- I artery (Figs. 7.21 and
7.22) or larger tha n the A- I artery (Figs. 7.23
and 7.24). In Fig. 7.21, the A- I artery is almost
t... .:: size of an adjacent large M-I perforator,
and the M- I arter y is equal in size to the inter-
nal cal"Otid artery. In Fig. 7.22 the pituitary
stalk is surro unded by arachnoid (Liliequist's
me mbrane beh ind and an a nterior reflection
of the same me mbrane in front). He nce the
pituita ry structures are 111 their own cistern
(hypophyseal ciste rn).
The same is true In another patient
(Fig. 7.23) whe re part of the a nterior arachnoid
enclosing this cistern has been opened by the
surgeon . The pituitary stalk is redd ish due to
the marked arterial and portal venous vascular+
ity (which partly accounts for its enhancement
on CT scans with contrast medium). Fig-
ure 7.24 in the same patient shows a ve ry
hypoplastic right A-I artery a nd a large right
artery of Heu bn er. Additional anomalies are
the low takeoff of the frontopolar arteries. The
large left A- I artery supplies this unusual an-
terior commu nicating complex. Because the
anterior communicating a rtery is lifted up by
an a neurysm in the cistern of the lamina tel'-
minalis, descending "hypothalamic" per-
forato rs are well shown .
Figure 7.25 is a n example of a patient with a
prefixed chiasm and short internal carotid ar-
teries. Without the surgeon go in g through the
gyrus rectus, the right A- I, anterior com-
mun icating, and left A- I arteries are seen upon
elevation of the frontal lobe. Im ponan t per-
forators from the right A- I a rtery to the right
optic tract, chiasm, and nerve are seen. I-igure
7.26 also is a photograph of a shon internal
126 7. The Ch iasmatic Cistern and Environs

Thble 7.1. Structu res contained within the chiasmatic cistern'.

I. Optic chiasm
2. Optic ner\'es. medial border
3. Surface of the gyrus rectus of the frontal lobe
4. Tuberculum sellae (dural covering)
5. Arachnoid membrane of Liliequist (Key and Retzills), rostral surface
6. Arachnoid between optic neTl'es
i. Superior hypophyseal artery
8. Hypothalamic perforators
9. A portion of the fronto-orbital artery
10. Pituitary stalk (often lies within its own cistern)
Items 2-5 can be considered to form portions of the margins of the chias-
matic cistern.

Table 7.2. Structures contained ...·ithin the lamina terminalis cistern' .

I. Outer surface of the lamina terminalis
2. Surface of the optic tracts
3. Surface oflhe gy rus rectus of the frontal lobe
4. Anteriorcommunicatingartery
5. Anterior cerebral artery, A-I portion
6. Anterior cerebral artery, origin of A-2 portion
7. Origin of the fronto-orbital artery
8. Artery of Heubner, proximal portion
9. Hypothalamic perforators from A-I and anterior communicatinganeries
10. St.ria thalamic perforators from the A-I arte ry
II . O rigin of an occasional accessory anterior cerebral artery
• Items 1-3 can be conside red to form portions of the margins of the lamina
terminalis cistern.

carotid artery and a prefi xed chiasm . An un- The common ly duplicated a nterior com-
usual arterial anomaly is also illustrated: the ar- municating artery again is seen in Fig. 7. 33. Fig-
tery of Heubner an d th e frolltopolar artery ure 7.34 shows the underside of a n anterior
arise from a common trunk . This arterial com municati ng artery and nearby perforators.
trunk origi nates at the right A- IIA-2 ar terial The optic tract is rarely well seen unless the
junction. Branches from the ascend ing fron- sylvian fiss ure has been opened. Figures 7.35
topolar artery suppl y the territory of the ab- through 7.38 are examples ill ustrating this
sent franta-orbital a rtery. tract in two patients. I n fi gure 7.35 the origin
Figures 7.27 through 7. 30 reveal a common of an accessory anterior cerebral ar tery is seen
variation in the amerior communica ting artery (someti mes mistaken for the base of an
complex . In Figs. 7.27 through 7.29 the an- a ne urysm) . Figur e 7.36 (sa me patient) isa more
terior communicating artery form s a "Y" with magnified view of the la mina terminalis seen
one limb on the right a nd two limbs on the left. between a large artery o f Heubner and the A- I
the superior one a nastomosing higher up on ane ry. A large ve in tur ns posteriorl y and pass-
the left A-2 artery. In Fig. 7.30 the an te rior es along with the optic tract to join the unseen
com municati ng artery is duplicated ; the basilar vein of Rosenthal.
superior one is hidde n by a layer of arachnoid . Figures 7.37 and 7.38 are twO views of the
Figures 7.31 and 7.32 ill ustrate a nothe r right optic tract and chiasm. The A- I arteries
example of a V-shaped anterior communicat- join the anterior communicating artery well
ing arte ry with the common trunk on the right above the lamina terminalis, a nd the left A- I ar-
and the two limbs on the lefl. Additionall y a tery has an unu sua l bridging artery retu rning
large perforalor and an accessory ame rior back to the left A-I. Note the arachnoid band
cerebral artery (a third, midline A-2 artery) (com pare with that in Fig. 7. 16) over the right
arise at the division of this V-shaped anterior A-I artery at the lateral border of the cistern of
communicating a rte ry. the lamina terminalis. Tables 7.1 and 7.2 sum-
 AnalOmy
marize the various structures found in the
chiasmatic and lamina terminalis cisterns.
The duplications and bridges ofte n seen as
the a nterior communicating artery complex
were illustrated by Bremer [1] in 1943
(Fig. 7.39). But it was only with routine use of
the operating microscope that surgeons saw
how commonly such va riations occurred. Fig-
ure 7.40 is Westberg's representation of the
usual course of the recu rrent artery of
Heubner [5]. This large perforator sends
branches illlo the anterior perforated sub-
stance along with the stria thalamic perforators
from the A- I a nd M- l arteries.
127
Bibliography
I. Bremer J L (1943) Congenital aneurysms of the
cerebral arteries. An embryologic study. Arch
Pathol35: 819~83 1
2. Fox J L (1979) Microsurgical exposure of intracra-
nial ane urysms. J Microsurg I : 2 - 31
3. Fox J L ( 1983) Intracranial Aneurysms, vol 2. New
York , Springcr-Vcrlag, pp 877 - 1069
4. Kempe LG (1968) Operative Neurosurgery, vol I : Cra-
nial, Cerebral, ami Intracranial Vascular Disease. New
York, Springer-Verlag, pp 1- 75
5. Westberg G (1963) The recurrent artery of
Heubne r and the arteries of the central ganglia.
Acta Radiol (Diagn) 1: 949-954
128 7. The Chiasmatic Cistern and Environs

'0'

Fig. 7.3. Lower portion of olfactory tract (1). gr, carotid artery (carotid cistern); ac, anterio r clinoid
Gyrus rcclus;2, right optic nerve;dura, dural margin process; v, vein on temporallobe; s, Sliction lube; ret,
of optic canal; ar, arachnoid covering internal retractor on fro ntal lobe.
 Anatomy 129

Fig. 7.4. Same case as Fig. 7.3. Middle portion of dura, dura covering orbital roof (floor of anterior
right olfactory tract (1) in olfactory cistern. V, Vein in fossa) projections; nt, retractor on frontal lobe.
sulcus between frontal lobe (jT) and olfactory tract;
130 7. The Chiasmatic Cistern and Environs

Fig. 7.5. Same case showing olfactory tract (1) pass- (jl) toward cribi form plate and nose. v, Vein; a, ar-
ing through subarachnoid space from frontal lobe tery;cg, dura of crista galli.
 Anatomy 131

Fig. 7.6. Another case demonstrating olfactory bulb retractor;jZ, base of frontal lobe ; dura, dura covering
(ob) and upper olfactory tract (I). cg, Crista galli; ret, orbital roof projections.
132 7. The Chiasmatic Cistern and Environs

Fig. 7.7. Initial exposure of gyrus rectus (gr) during
an approach to an amerior com municating artery
aneurysm where the A-I artery is not followed me-
dially. Note the quadrangular zone bounded by the
edge of the frontal lobe retractor blade (jl-ret), the
fTOlllo-orbital artery fjo), the frontallobe/optic nerve
junction (dQuble-crossed arrow), and the olfactory tract
(/). T he incision in the gyrus rcelusis made here and
the fronto-orbital artery is followed to the aneurysm.
v, Vein; ar, arachnoid between optic nerves; 2, rigln
optic nerve; ica, interna l carotid artery; Ie, anterior
reflection of tentorial edge; Ii, temporallobc; II/em,
membrane of Liliequisl; cot, cotton strip lying on syl-
vian fissure. From Fox [3].
 AnaLOmy
Ag.7.8. Another case illustrating the initial expo-
sure of gyrus rectus on the right (r-gr) where the
right A-I anery (a-I, hottom) is fo llowed medially.
Crossed arrow, interhe mispheric fissure. Note quad-
rangular zone oounded by the frontal lobe and right
A-I j unction, the olfaclOry tract (/), the front.allobc
retractor blade (jI-ret), an d the f!"OOlo-orbital artery
I/o). The initial incision is made within this zone. r-gr,
Right gyrus rectus; lIa, left artel-Y of Heubncr; i-gr,
133
medial surface of left gyrus rct:lus; i-10, left fronlo-
orbital artery; aT, arach noid between optic nerves; 2,
left and right optic nerves; Ii, temporallobc; ch, optic
chiasm;it, lamina terminalis;o/, right optic tract;mca,
branch of middle cerebral aner}, in sylvian fissure;
a-l, left (toP) and right (hoI/om) A-I arteries converg-
ing lOward the hidden anlerior comm unicating ar·
ter y. From Fox [3J.
134 7. The Chiasmatic Cistern and Environs

Fig. 7.9. Another case illustrating prefixed optic
chiasm (ch). Lamina terminalis (it) and its cistern be·
tween the optic tracts (ot) arc seen. Within the cistern
oftbe lami na terminalis is pari of the A- I anery(a- J)
and a duplicated amerior communicating artery
(aca). ar, Arachnoid between optic nerves (2); ica, in-
ternal carotid arte ry; ac, anterior dinoid process; pc,
posterio r clinoid process; »Mm, arachnoid mem-
brane o f Liliequist; te, tentorial edge; ata, anterior
temporal artery; It, temporal lobe; hij, bifurcation o f
iea; tUmble-crossed arrow, origin of hidd en anterio r
choroidal artery; single-crossed arrow, origin of hid-
den posterior com municating artery; /w., artery of
Heubner.
 Anatomy 135

'.

Fig. 7.10. Another case with prefixed chiasm (ch) and tion. ica, Imernal carotid artery; Ii. temporal lobe;
short intracranial optic nerves (2). T he carotid, a·l, A·I artery; !Ia, artery of Heubner;j1, frontal
chiasmatic, and lamina terminalis cisterns appear lobe; 1$, tuberculum sellae; it, lamina terminalis; ot,
here without identifiable boundaries after dissec· optic tract. From Fox [2).
136 7. The Chiasmatic Cistern and Environs

Fig. 7.11. Same case as Fig. 7.10. A short imernal
carotid artery has permitted exposure of the an-
terior communicating artery (aca) by followi ng the
right A- I artery (a-I, bottom). The upper chiasmatic
cistern and the cistern of the lamina tcrminalis are
exposed. ch, optic chiasm; It, lamina terminalis; ot,
optic tract; ha, right (bottom) and left (toP) a rteries of
Hcubner; gr, right gyrus rectus; a- J (lOP), left A-I ar-
terYi/o, left [ront()-orbital artery on left gyrus reclus.
From Fox [2 ] .
 Anatomy 137

Fig. 7.12. Same case after removing about I·em
length of gyrus rectus to expose an anterior com-
mun icating artery aneurysm (an) surrounded by left
(lap) and riglll (bottom) A-2 arteries (a-2). Above are
the left and below are the right A- I arteries (a-I), ar-
teries of Heubner (ha), and frorlLO-orbital arteries
1/0).//, Lamina lerminatis;gr, teft gyrus rectus. These
st ructures lie within the lamina terminalis and in-
terhem ispheric cisterns. From Fox [2].
138 7. The Chiasmatic Cistern and Environs

Fig. 7.13. Another case with exposure of all the an-
terior cisterns bounded by the left and right tem-
poral lobes (l-Il, r-el). s, Suction tube above bifurca-
tion ofleft internal carotid artery (l-ica); (1- 1, both A-I
arteries; ii, lamina terminal is; ot, right optic tract;fl.
right frontal lobe; 2 , both oplic nerves; ky. left and
right hypophyseal perforators; Pit, pituitary stalk
(and its hypophyseal cistern) surrounded by
arachnoid (ar), which splits and surrounds it; pc,
posterior clinoid process; mem, me mbrane of
Liliequist; l-ica and r-ica, both internal carotid ar-
teries;l-pca and r-pea, both posterior communicating
an eries. The left one (i-pea) lies in froOl of Liliequist
membrane and is seen through the space between
the pituitary stalk (pit) and [he right carotid artery
(r-ica). From Fox [3].
 Anatomy
fl-ret
Fig. 7.14. Same case after exposure ofrwo aneurysms
(an) on the anterior communicating artery. The
small one projecting upward is obvious. The large
one projects downward and is hidden by the anterior
communicating artery (aca). Above and below arc
the left and right A-I arteries (a-I) and A-2 arteries
139
-l
Olf
(a-2) . 111. left frontal lobe , Lt, lamina terminalis, 01,
right optic tract; bif, bifurcation of right internal
carotid artery; col. couonoid; JUl, right artery of
Heubner; fl-ret, right frontal lobe retractor. From
Fox [3].
140 7. The Chiasmatic Cistern and Environs
Fig. 7. 15. Another case showing chiasmatic cistern
both rostral and abo\'c (to observer's left) and caudal
a nd behind (to observer's right) the optic ap pa ratus.
$, Suction tube ; l-fl, left frontal lobe; ar, arach noid be·
tween left oplie nerve and frontal lobe and separat-
ing left carotid cistern from chiasmatic cistern; 2.
bolh optic nerves; fo, le ft fronto-orbi ta l ancl}'; ha,
left arteries of Hcubnc r ; ell, optic chiasm; 01, right
optic tract; ac, right anterior clinoid process; Pit,
pituitary gland projecting above (with rcspca to pa-
liem) sella lUl'eica; ita, internal carmid artery; frs,
pituita ry stalk; ft, la mina terminalis; rei, rctractoron
right fro mal lobe; an, aneurysm arising from an-
terior commun icating artery; a-I and a-2, left (toP)
and right (bol/om) A- I and A-2 artcrics:fp, low !.akrofr
of le n frolHopolar artcr)' ;col, small coHon hall. From
Fox [3}.
 Anatomy
Fig. 7.16. Another case showing surgically induced
communication between chiasmatic cistern rostrally
and inter ped uncular cistern caudally. T he latler con-
tains the basilar artery (ha) seen after opening the
membrane of Liliequisl (mem). Note Liliequ ist's
membrane sends an anterior reflection around
pituitary sta lk (pit), thus enclosing the hypophyseal
cistern. Double-crossed arrow, reflections of light from
CS F in interped uncular cistern; ji"gle-crossed an-ow.
14 1
lies on short internal carotid artery and points 10 ori-
gin of posterior communicating artery; /l-ret, tem-
poral lobe retracto r ; m·}, M- I artery; perf, largest of
several perfo ratOrs from A-I artery (a-1); ot, right
optic tract; ar, arachnoid bands at lateral margin of
cistern of the lamina tenninalis; fl, lami na terminalis
(covered by A- I artery);j1-rel, frontal lobe retractor;
ell, optic chiasm; 2, both optic nerves; ac, anterior
clinoid process. FrOIll Fox [2] .
142 7. The Chiasmatic Cistern and Environs

Fig. 7.17. Another example of structures in chiasmat·
ic, carotid, and lamina lerminalis cisterns. 2, both
optic nerves; ch, optic chiasm; ii, lamina terminalis;
Q/, right o ptic tract; ac, aillerior clinoid process; d()U-
ble-cro5Sed arrow, origin of posterior communicating
artery from internal carotid artery; )/1--/, M-l artery;
perf, perforator from A-I artery (a-I); ha, artery of
Heubner;fo, franto-orbital artery; rei, retractor on
frontallobe;sillgle-crossedarrow, interhem ispheric fis-
sure; gr, left gyrus rectus.
 Anatomy 143

Fig. 7.18. Another example of the lamina terminalis
(It). A bilobed anterior communicating artery
ane urysm (an) is surrounded by the lert A-2 artery
(a-2, loP), the anterior com municating artery (aca),
and the rig ht A-2 artery (a-2, boltom). The termina-
tion of the lert A-I artery (a-I, toP) is seen. 2, both
optic nerves; ell, optic chiasm; ot, right optic tract; a-I
(bottom), right A- I artery;ha, artery of Heubner; r-[o,
r ight fronto-orbital artery;Jl, right frontal lobe; ret,
retractors; V, vei n on lert gyrus rectus (gr); l-fo, left
fronto-orbita l artery.
144 7. The Chiasmatic Cistern and Environs

Fig. 7,19. Another case illustrating lamina tcrminalis
(ll), its cistern, and a variation of the anterior com-
municating complex with 3 arteries (uca) and a
bridge (brl between 2 of them. a-I, Left (lOP) and
r ight (bollom) A- I arteries; eh, optic chiasm; ot, righ t
optic tract; single-crossed arrow, origin of posterior
commu nicating artery: douhle-crrused arrow, origin of
anterior choroidal artery; mol, M-I artery; v, vein; r-
JUl, rig ht artery of Hcubncr; ju,junction of anterior
communicating artery and hiddell right A-2 artery;
r-fo, right franto-orbital artery; an, microaneu rysm
on anterior communicating artery; a-2, left A-2 ar-
tery; ar, arachnoid in interhemispheric fissure ; l-fo,
left frollto-orbita.l artery; t-fla, Icrt artery of
I-Ieubnc r. From Fox [3].
 Anatomy 145

Fig. 7.20. Same case as Fig. 7. 19 after putting musli n artery; doublt-cro.s.std arrow. anterior choroidal anery;
(mu) on microaneurysm and open ing (singk-U05Std nt, frontal lobe retractor; ot, optic tract;3v, third ven-
arrow) the lamina terminalis (It); ica, internal carotid tricle; tot, small cotton ball .
146 7. The Chiasmatic Cistern and Environs

Fig. 7.21. Chiasmatic cistern in case with hypoplastic
right A-I artery (a-l). The recurrent artery of
Hcubncr (ha) is as large as the A-I artery. p. Per-
forators; mol, M- I artery; m-2, fronta l (bottom) and
temporal (top) M-2 arteries; aT, arachnoid over syl-
viall fissure; II, temporallobe;jl, frontal lobe; cot, cot-
tonoid; rei, fronta l lobe retractor; ft, lamina lcr-
minalis; ot, right optic tracl jch, opticchiasm;gr, right
gyrus rectus; 2, both optic nen'es; l-ica, left internal
carotid artcrYipit, pituitary stalk; mem, membrane of
Liliequisl j T-ica, right internal carotid artery.
 Anatomy 147

Fig. 7.22. Magnified view of Fig. 7.2 1. Arachnoid
membrane of Liliequist (num) sends anterior sheet in
fro nt of pituitary stalk (pit). ac, Anterior clinoid pro-
cess; r-ica, atherosclerotic right internal carotid ar-
tery; cot, cottonoid; aM, anterior temporal anery
from internal carotid artery; ret, temporal lobe re-
tractor; m-I, M-l artery; a-I, hypoplastic A-I artery;
p, perforator; IUl, artery of Heubner;foa, fromo-or-
bital anery; r-gr, right gyrus reClUS; ihf, interhemis-
pheric fissure ; l-gr, left gyrus rectus; l-ica, left inter-
nal carotid anery; 2, both optic nerves; ch, optic
chiasm; ft, lamina tenninalis; ot, right optic tract.
148 7. The Chiasmatic Cistern and Environs

Fig. 7.23. View of opposite imcrnai carotid cistern
and ch iasmatic cistern. 2, both optic nerves; {-gr, left
gyrus reclUs; i.oa, left ophthalmic artery going
unde r left o ptic nerve; l-iea, atherosclerotic left inter-
nal carotid artery (medial sidc);is, tuberculum sellae;
r-oo, origin of right ophthalmic artery; r-ica. right in-
lernal carotid artery; mem, part of membrane of
Liliequisl (opened) passing in front of pituitary stalk
(pit); p, hypothalamic perforator; ot, right optic tract;
it, lam ina terminalisj ch. optic chiasm; ar, arachnoid
between optic nerves. From Fox [3].
 Anatomy 149

Fig. 7.24. Same case as Fig. 7.23 after removal of ,I
small amount of right gyrus rectus (r-w) to view cist-
e rn of the lamina terminalis. Another example of a
hypoplastic right A-I artery (a-I. !mllom) and a large
right artery of Heubner (r-ha). The left A-2 artery is
hidden by the right A-2 artery (a-2). an. Aneurysm
projecting back against the lamina termi llalis (It); p.
hypothalamic perforators stuck to alllerior COIl1-
1T1unicating ,1I·tcry aneurysm; *, anterior com-
municating artery; r-/pa, right frontopolar artery
(unusually low takeoff from the A-2 artery); I-[pa,
left frontopolar artery; l-gr, left gyrus rectus;[oa, left
fronto-orbital artery; I-ha, left artery of He ubner ; a-
I (loP), le ft A-I artery; 2, both o ptic nerves; ch, optic
ch iasm; Pit, pituitat·y stalk; ot, right optic tract. From
Fox [3].
150 7. The Chiasmatic Cistern and Environs

Fig. 7.25. Example of chiasmatic cistern with pre-
fixed oplic chiasm (short intracranial optic nerves).
gel, Gelfoam on left optic nerve; 2, both optic nerves;
ch, optic chiasm; iCG, internal carotid an ery; elp,
shanks of two aneurysm dips; 01, oplic tract ; a-I,
right (bottom) and left (toP) A-I arteries; aca, anterior
communicating artery; it, lamina terminalis; ha,
right artery of Heubner; T-fl, right fronta l lobe; ihj,
interhemispheric fissure (covered by arachnoid);
l-fl, left f rontal lobe; l-foa, left fronta-orbital artery.
 Anatomy 151

Fig. 7.26. Another case revealing an unusual com-
mon trunk (*) from which arise the right frontopolar
artery (r-fpa) and the artery of Heubner (ha) . gr,
Right gyrus rectus; a-2, right A-2 artery from which
the above-mentioned trunk arises; l-fpa, left fron-
topolar artery; 2, left optic nerve; ch. optic chiasm;
a-I, left (toP) and right (bottom) A- I arteries; it, lamina
terminalis; 01, optic tract; mem, membrane of
Liliequist; ac, anterior clinoid process; ica, internal
carotid artery; col, coltonoid. Note xanthochromic
pigment (bilirubin) from hemoglobin of recent sub-
arachnoid hemorrhage.
152 7. T he Chiasmatic Cistern and Environs

Fig. 7.27. Allother example where chiasmatic,
carotid, and interpedu ncular cisterns arc all seen
(from observer's left to right). 2, Both optic nerves;
ch, optic ch iasm; 01, right optic tract; ito, internal
carotid artery; single-crossed arrow, hidden o rigi n of
poster ior com m u nicati ng artery; dQu.ble-crossed arrow,
hidden ongm of anterior choroidal artery; ac, an-
terior clinoid process; pc. posterior clinoid process;
bo, basilar artery;3.ocu lomotor nerve; un, uncus; rei,
fron tal lobe retractor; 00, artery of Heubner; a-I,
right (bottom) and left (toP) A- I arteries_ See next two
fi gures for anterior communicating artery complex .
 Anatomy 153

Fig. 7.28. Same case as in Fig. 7.27. T}'pical variation
in anterior communicating artery complex illus-
trated . a-I, Left (toP) and right (!mllom) A-I arleries;
a-2, left (top) and right (bol/o.m) A-2 arleries; aea, an-
terior communicating arlcry; co, connecting bridge
fro m anterior communicating arler}, to left A-2 ar-
tery; in!, arachnoid over interhemispher ic fissure;
lIa, arler}' of Heubner; ar, arachnoid fibers; iea, inter-
nal carotid artery; sillgle-crossed arrow, origin of pos-
terior communicating artery; *, bifurcation of inter-
nal carotid artery.
154 7. T he Chiasmatic Cistern and Environs

fig. 7.29. Same case as in Figs. 7.27 and 7.28. An-
terior com municating artery complex magnified .
foa, Franto-orbital artery; ilif, arachnoid over in-
terhemispheric fissure; a-2, left (toP) and right (bot-
10m) A-2 arteries; a-1, le ft (lOP) and right (hoI/om) A-I
arteries; Ma, anterior commun icating artery; co, con-
necti ng branch to the left A-2 artery; 2, both o ptic
ne rves; ch, optic chiasm; ot, optic tract; 1m, artery of
Heubner.
 Anatomy
1' I
)
"
,.1
Fig. 7.30. Another case illustrating relationship of
anterior communicating artery (aca) to chiasmatic
and lamina terminalis cisterns. a- I , Left (toP) and
right (bottom) A-I arteries; a-2 • left (lOP) and right (bot-
10m) A-2 arteries; 00, artery of 1·Il~ ubner and
branches covered by arachnoid and blood ; ar,
arach noid over interhemispheric fi ssure and cover-
155
a-I
ing a second anterior communicating artery; r-gr.
right gyrus rectus; rtl, frontal lobe retraClOr; I, olfac-
tory tract;jl, right frontallobe ;fpa, left frontopo lar
artery (low takeoff); foa, left fronto-orbital artery;
l-gr, left gyrus rectus; 2, both optic nerves; ts, tuber-
culum sellae; ch, optic chiasm; 01, right optic tract; It,
lamina terminalis.
156 7. The Chiasmatic Cistern and Envil"Ons

Fig. 7.31. Another variation o f the anterior com-
municating artery comple x. From the anterior com-
municating artery (aca) arises both a connecting
bridge (co) to the left A-2 (sec Fig. 7.32) and an acces-
sory (third) anterior cerebral artery (ace) ascending
between the two A-2 arteries. a·· I , Left (toP) and right
(bottQm) A- I arlc i-ies; a-2, left (lOP) and right (OOllom)
A-2 arte ries; r-foa, right fronto-orbital artCl-Y; I, right
o lfactory tract; r-gr, right gyrus rectus; l-gr, left gyrus
rectus; i-roa, left fronto-orbital artery; ar, arachnoid ;
2, both optic nerves; at, anterior clinoid p rocess; ica,
internal carotid artery; *', bi furcation of the internal
carotid artery (from wh ich unseen aneurysm arises);
ot, right optic tract; cit, optic chiasm; It, lamina ter-
minalis.
 Anatomy 157

Fig. 7.32. 5."lme case as in Fig. 7.31 with right frontal
lobe d isplaced by retractor (rei). a-1, Left (lOP) and
right (hottom) A-I arteries; a-2, left (loP) and right (bot-
10m) A-2 arter ies; aca, anterior commu nicating ar-
tery; p, perforatOr; co, con necting branch fro m an-
terior communicating artery to the left A-2 artery; V,
\'ei n; ace, accessory (third) anterior cerebral artery;
foa, left fronto-orbita l artery; I-JUl, left artery of
Heubner; 2, right optic nen 'c; ac, right anter ior
clinoid process; ch, optic chiasm (lateral side); ot,
right optic tract; it. lamina terminalis; *, bifurcation
of internal carotid artery from which arises base of
aneurysm (an); m-2, M-2 artery; r-Iw, right a rte ry of
Heubncr.
158 7. The Chiasmatic CiSlern and En"irons

Fig. 7.33. AnOlher case of anterior communicating
artery (aca) duplication. a- I , Right A-I artery; M. ar-
tery of Heubner; 0-2, right (bottom) and left (top) A-2
arteries; Ttl, right frontal lobe retractor; ihf, in-
terhemispheric fissure;gr, le ft gyrus rectus; I , left 01-
faclO ry tract; 2, both o ptic nerves; i-loa, left frolllo-
orbital artery; an, aneurysm; Pit, pituitary stalk ; ica,
internal carotid a rtery; ., bifurCllion of inlernai
carotid artery; 01, right optic tract; ii, lamina ter-
minalis; ch, optic chiasm; p. perforator.
 Anatomy 159

Fig. 7.34. View of underside of an anterior com·
municating artery complex in chiasmatic and lamina
te rminalis cisterns. s, Suction tube; ua, internal
carolid artery; ot, right optic tract; fI, lamina ter·
minalis; p, hypothalamic perforators; a-J , right (001-
tom) and left (toP) A· I arteries; a-2, origin of left A-2
artery; (Ua, anterior communicating arte ry; ha, left
artery of Heubner; 1-[00, left fronto-orbital artery; 1,
left olfactol}' tract; 2, both optic nerves; ts, tuber-
culum sellae.
160 7. The Chiasmatic Cistern and Environs

Fig. 7.35. AnaLOmy o f lhe lamina terminalis and
chiasmatic cisterns. 2, Both optic nerves; ar, vascular
arach noid betweell optic nerves; cit, oplicch iasm;all,
aneurysm a rising from most of the internal carotid
artery; a-I, righ t (bottom) and left (lOP) A- I arteries; it,
lami na tcrminalis; JUI, artery of Heubner; ret, frontal
lobe retrano}"; 0-2, right (boltom) and left (lOP) A-2 ar-
teries; ace, origin o f accessory anterior cerebral ar-
tery; i/l[, arachnoid over interhemisphe ric fissure .
 Anatomy 161

Fig. 7.36. Same case as in Fig. 7.35 with magnified tract (vi). Note arachnoid bands (or) and many PCI~
viel\' of the lamina terminalis (It) between the right forating arteries (P). v, Vein: gr, gyrus reclus; all,
A-I artery (a-I) and artery of Heubner (ha). The aneurysm.
lamina ter minalis is bordcred latcrally by the optic
162 7. The Chiasmat ic Cistern and Environs

Fig, 7.37. Another exa mple of carotid, ch iasmatic,
and lam ina tcnninalis ciSlCrnal analOmy. ica, intcr-
nal carotid artcry; Ie, edge of anterior reflection of
tentori um ; pc. posterior clinoid proccss; /KO, pos-
terior communicating artcry; oclw, anterior choroi-
dal artcry; m-I, M-l ancr)'; QI, optic tract; (1"1, right
(hollom) and Icft (loP) A- I arteries; dr, arachnoid
b<uld ; II, lamina lerminalis; dCd, anterior com-
municating artery; hr, bridging artcry from left A- I
loanterior corn municati ngancry:Joo, left fronto-OI'-
bital artery; gr, left gyrus rectus; lUi, left anery of
Heubner; eh, optic chiasm; 2, both optic ncn'CS; p,
perforators.
 Anatomy 163

Fig. 7.38. Same case as in Fig. 7.37, different view. iea,
Internal carotid artery; pea, posterior com municat-
ing artery: aelta. anterior choroidal anery: mol, M- I
arte ry; (I- I, right (bottom) and left (lOP) A- I arteries; P,
perforator ; ill; arachnoid band; I··IUI, right artery of
Heubner and branches; r{oa . right fronLO-orbita l ar·
tery;a-2, origins of right (bottom ) and left (lOP) A-2 ar-
teries; v, vein; aea, anterior communicating arter),; {-
100, left fronto-orbital artery;gr, left gyrus reclUS; 2,
bOlh optic nerves; '·IUl, left artery of Heubner; 01,
optic tract; fl, lamina tenninalis.
 Fig. 7.39. A historic, diagrammatic example of an alllerior com-
municating arter ial complex form ing duplications and bridges. On
( ither side are the righ t and left A-IIA-2junctions. Fl"Om Bremer JL
( 1943) Congenital aneurysms o f the cerebral ancrics. An em-
bryologic study. Arch Pathal 35: 8 19-83\; copyright 1943, Amer-
ican fo.'leclieal Association [I].

Fig. 7.40. Photograph of a plastic cast (toP) and d ia- interrupted lines. From \Vcstbcrg C (1963) T he re-
gram (bottom) o f the rec ur rent artery of Hcubncr as current artery of Heubner and the ancrics of the
seen in front with two somewhat different p rojec- central ganglia. Acta Radiol (Oiagn) I: 949-954 [5].
tions. In the diagram the artery Heubncr is shown in

164
 --8--
The Ambient and Interpeduncular
Cisterns
Jntroduction
This cha pte r focuses on the pterional ap-
proach toward the ambien t and interpeduncu-
la r cisterns. The surgical orientation of the pa-
tie nt's head (sec Fig. 4.8) is similar to that for
the plerionai approach to the syivian, carotid ,
a nd chiasmatic cisterns . However, the o perat-
ing microscope is shifted from a more rostral
d irection (see Fig. 4.5) to a mo re caudal line-of-
sight (see Fig. 4.7).
T he ambient cistern is a ce rebral spinal flui d
(CS F) compartme nt made u p of the body and
wing of the ambient cistern o n each side. T he
body is borde red laterally by the medial sur-
face of the te mporal lobe and the med ial ed ge
of the te ntorial notch. It is borde red medially
by the lateral surface of the midbrain a nd the
pontomesencephalic junction. T he wing (not
seen anato mically in this atJas) is a lateral exten-
sion of the body a nd lies betwecn the pul vinar
of the thalam us anterio rly and the temporal
lobe posterio rly. The bod y of the ambie nt cis-
tern as seen in this atlas conta ins those struc-
tures following the tentorial edge and lying
within the space between the carotid cistern
rostra ll y and the inter peduncular cistern ca u-
dall y. Some of these structu res (such as the a n-
te rior cho ro idal artery) arc assigned to a sepa-
rate cru ral cistern by some authors [8}. T he
basilar vein of Rosenthal a nd the terminus of
the optic tract ca n be considered eithe r to lie
within the ambient cistern or to make up pan
of the med ial wall of the cistern . The third
(oculo moto r) ne rve lies within both the inter-
peduncu lar cistern a nd the ambient cistern
since the arachnoid membra ne of Lil iequ ist
(separating the rostral chiasmatic cistern from
the caudal interpedu ncular ciste rn) usually is
adherent along its lateral margin to the medial
a nd caudal side o f the oculomo to r nerve. This
me mbrane may sto p at or before the
oculomotor nerve so that CS F in the inter-
pedu ncular cistern mixes with CS F in the am-
bient cistern at a conflue nce lateral o r medial
to the oculo motor nerve (Fig. 8.1; also sec
Fig. 6.3). In some cases the Liliequist mem-
brane ex te nd s la terall y to the tentorial ed ge
(see Fig. 8. 10), a nd CS F fl ow must be through
perforations in th is arach noid membra ne. T he
posterior communicating artery and the P-2
portio n of the posterior cerebral artery as well
as th e fourth (trochlea r) nerve and superior
ce rebellar arter y also are partly within the
body of the ambie nt cistern .
Figure 8.2 shows the anatomy at the le,'el of
the tentorial notch a nd midbrain . Figure 8.3
diagrams the anatomy of the auachmc nts of
the tentorium ante riorly to the poste rior and
a nterior clinoid processes. During the pter-
iOlla l a pproach to the inter peduncular cistern ,
the posterior cli noid process is an imponan t
landmar k latera l to which is the oculomo to r
nerve.
Within the interpeduncular ciste rn lie the
o rigins of the oculomoto r nerves, the tip of the
basilar artery (Fig. 8.4), the origins of the P- I
segments of the posterior cerebral arteries and
the ir poste rior thala mic per forators (Fig. 8.4),
and the origins of the superior cerebellar ar-
te ries. I n the case of a shor t P- l artery, the
caudal e nd of the poster ior communicating a r-
tery also may lie more medially a nd within the
interped uncular cistem.
166 8. The Ambient and Interpeduncular Cisterns

Fig. 8.1. Diagram of sagittal sections of a normal

brain and the sellar regio n , looki ng to the right. M,
Mammillary body; LM, Lilicquist's mern branc(mcm -
bra ne of Key and Retzius); 3. right ocu lomOlOr
Ilene; PC, right po~tc riol' clinoid process; DS, dor-
sum sellae; arrow, normal now o f CSF thro ugh the
prepontine and interpeduncular cisterns. From ~ox
J L, Al-~'Ie fty 0 (1980) Suprasellar arachnoid c)'s\s:
an extension of the membrane of Liliequisl.
Neurosurgery 7: 615 - 618 (4).

"

opt.< <hi"""
1 ,,{ u. ru\.. bulwn.
Ne:rve.
5u.p i-Bo.,ilor rut.,.~
,,-,- 0,," (.e:rt1.Cro..l
a:ftV"!:I
lY NeT""
(m.b..." ou.du.c.t of
p.duncl.

Qu.adriq.miMI
pio.t.

Fig. 8.2. Incisu ra of the te ntorium. The m idbrain
was sectio ned transversely, and the he mispheres
have been removed. Note relation of the bifurcation
of the basilar artery to the environs in terms of a pIer·
iOllal approach lO lhis region. From Taveras Jr-..[
(1960) T he roentgen diagnosis of intracranial in-
cisura l space occupying lesions. Am J Roentgenol
84: 52-69 [7]. Copyright by American Roentgen
R'ly SocielY. 1960.
 Anatomy
A 8
Fig. 8.3. Relatio nship of posterior clinoid p rocess o n
the left (A) and right (B) to the oculo motor nerve
and circle o f Wil lis. Note relation ofposter iorclinoid
process. posterior cOlllm un icating artery. 1'- 1 a rte ry,
and oculo motor nerve t.o tip of basilar artery in
terms of the pterio nal approach \0 the interped un-
cular ciste rn . Reprod uced by permission from Mal-
kasian I) R. Rand RW ( 19i8) 1\'licrosurgical anatomy,
in Ra nd R W (cd ): Microl1tllroslllgtry. cd ~ . St Louis,
CV 1\losby Co, PI' 3i - iO [6]. A. Su perio r view view
o f the le ft sellar and p,uasellar region de mo nstrat-
ing the d ural reneClions and the "oculomotor
trigolle." /.ines wilh adjaunl OfN'11 arrOW.J. boundaries
of the ocu lomotor trigone: .t, medial renections of
the tentorium cerebclli : y.. posterior clinoid process;
~. anterior clinoid p rocess; d. d ia phragm sellae; lal-
tra/ slmighl black arrow. ostium of the ilUernal carotid
a rtc!)' : cw"Vtd (lITOU\ O\'c r o ptic nen'e and under fal-
cifo rm ligamcnt;dolltd Ii/It. o pe ning to the o ptic fora-
mcn; mtdial slmiglit arrow (black cMcurt'd), opening in
d i:l ph ragm sellac fo r pituita ry stalk ; broke71 arr~
oculomotor ostium ; long black arrOW/lead, ostium of
167
the fou rth cranial ner\"c; l'lI/all black arrows. "Y" du ral
fold. B. Su perior view of the sella illustrating the reo
lationship o f the a n le rior clinoid process (11), midd le
cerebr:11 art ery (C). poste rio r communicating arte ry
U), oculo motor Ilc n e (fl, trochlear nerve (D), pos·
te rior ce rebral anery (C) and te ntorium cerebclli
Illed i<l l renectio ll (1-:- /). Note that the oculo motOr
ne rve is slightly lateral a nd inferior to the posterior
commun icati ng an ery at the oculo motor ostium as it
pe netrates the du ra in the oculomotor trigone. How-
e\'er. as the oculomotor nerve P.1SseS inferior to the
posterior communicating artery (prox imal to the
midbrain), it may be im med iately inferior or slightly
medial to the posterior cerebral artery-postcrior
com municali ng artery ju nctio n. The anterior
cho roid,ll artery has not been included . Unl1UJrked
arrou~ falciform liga mell t o\"er the optic ne n 'c as it
e nters the optic ca nal; E, frce edge o f the te ntorium
cerebclli and its medial renection; H, basilar arte ry;
I , posterior clinoid process; K. antc rio r cerebral ar-
tery.
168 8. T he Ambient and Interpeduncular Cisterns

Fig. 8.4. Lateral vicw of vertebrohasilar arteriogram

(subtraction technique) to show example of pos-
terior thalamic pel-foratofs (arrow) arising from the
pol artery and the basilar ancry bifurcation. From
Fox [2].
~

Fig. 8.5. Diagrams illustrating various relatio nships ted S (1954) The relationship between the third ven-
of the basilar artery termination to the dorsum sellae tricle and the basilar artcry. Acta Radiol4 2: 85 - 100
(A) and the th ird ventricle (B). From Greitz T, 1...Of5- [5].
 Anatomy
Fig. 8.6. Two cxamplcsofiopamidol cislcrnography
wilh axia l cr sections at lel·eI of midbrain. Thc cis-
tcrnal CSF is whitc. A. UtIV)' black OrTout. from in·
tcrhcmisphelic fissure to cistern of thc lamina lcr'
millalis (poims to lamina tcrm inalis behind which is
black unenhanced CSF in third ventricle): simigllt
solid black OITOW lies at union of syl\'ian. chiasmatic
and ambient cisterns and points to optic tract; wavy
wllile aITow p<"lSses from lateral syl\'ian cistern (fis-
sure) to medial sylvian cistem; jlmigllt solid wllile
aITow lies on medial temporal lobc and points to the
body of the ambient cistern lateral to midbrain : slum
.wiid wllilt Qrrow lies on vcrm is of cercbellum and
pOill lS 10 (illad rigc milial cistern : shorl o/lell Muck arrow
lics in interpcdu ncular cistern and poims to mam-
169
8
millall' body of hYj>othalamus. B. BfackaITuwhead lics
in j unction of ambient and intcrpedullcular cisterns
and poillts 10 ocu lomotor nerve that separates these
cisterns; doubit-headtd aITOW lies in interpeduncular
cistcrn and points (a) anteriorly to pituitary stalk
(surrounded by arachnoid enclosing less enhanccd
CS F in hypophyscal cistern) and (b) posteriorly 10
ol1e of the two ascending P_I afleries;so/id black aITOW
lies in intcrpeduncu la r cistcrn and extends from
othcr asccnding P·l artery to postcrior clinoid pro-
cess (whiter than tllC enhanced CSF);solid whitton'OW
lies 011 peduncle of midbraill and points to body of
ambient cistern ; opm arrow lies on anterior clinoid
process aud points to internal carotid artery.
170 8. The Ambienl and In terpeduncular Cisterns
Within the interpeduncular cistern , the ter-
minus of the basi lar artery may have various
relationships with the dorsum sellae and its
posterior clinoid processes as well as with the
brainstem (Fi g. 8.5). The imaged anatomy of
the structures about the ambie nt and inter-
peduncular cisterns can be see n in cross-sec-
tion on the computed tomography (CT) scan
after instillation of water-sol uble contrast
medium into the CSF (Fig. 8.6). Figure 8.7 is a
photograph of a plastic model of the brai n
orie nted as the neurosurgeon will sec the
brainstem, basilar a n e ry, superior cerebellar
artery, oculomotor nerve, and poste rior cere-
bral a n e ry (P- I segment) . In Ihis view fro m the
plc riona l perspective, Lhe right temporal lobe
and cerebellar hem isphere have been removed
(a lso see Fig. 4.7).
Anatomy
The surgeon follows th e posterior co m-
municating artery cau dally. Adhes ions be-
tween the uncus of the temporal lobe and
oculomotor nerve are removed. The temporal
lobe and its uncus are retracted. After openin g
the a rachnoid membrane of Li licq uist (mem-
brane of Key and Retzius), the surgeon sees the
follow ing in a caudal-to-rostral direction
(Figs. 8.8 and 8.9): the rostral pons, su perior
cerebellar artery, oculomotor nen'e, posterior
cerebral artery, posterior communicating a r-
tery a nd its anterior thalam ic perforators, a n-
I.erior choroidal artery. inl.ernal carotid artery.
and optic nerve. The oculomotor nerve will be
seen passing imo the dura of the oculomotor
trigone (Fig. 8.3) just latera l to the posterior
clinoid process. From there the oculomotor
nen'e en ters the cavernous si nus.
At this stage ofthe exposure, only the lateral
termination of the P-I artery will be seen at its
junction with the P-2 artery and the posterior
communicating artery (Fig. 8.8). Usuall y the
P- I artery is obscured by the a nterior thalam ic
perforators as the artery curves ca udall y and
medially away from the surgeon a nd lOward
the basilar a rte ry tip. The upper trunk of the
basilar a rtery may come into view (Fig. 8.9).
At times the membrane of Liliequist will be
thickened and imper fo rate from a previous
subarachnoid hemorrhage or me ningitis
(Fig. 8.10), resulting in an obstruction to the
fl ow of CSF a nd subsequent hydrocephalus.
An incision in this thickened me mbrane
(Fig. 8. 11 ) will result in a sudden flow of CSF
a nd relaxation of the brain. Note thal now the
a mel'ior thalamic perforators are seen on their
lateral side whe reas views of the carotid cistern
earlier showed these small arteries on their me-
dial side (sec Figs. 6.7 and 6.8).
In a rare patie nt the posterior clinoid pro-
cess and its dural cover may project up between
the caudal surfaces of the internal carotid ar-
tery and o ptic nerve or ch iasm (Fig. 8.1 2). In
the majority of patients the posterior clinoid
process projects upward in a parasagiual plane
late ral to the in ternal carotid a rtery (Fig. 8.13).
On occasion both posteriorclinoid processes
and the top of the dorsum sel lae ca n be seen
(Fig. 8. 14). This same figure shows the right
posterior com municating artery clipped with
small malleable clips (avoidi ng perforators)
prior to severing this aner y between the cl ips.
The P·2 artery passes laterally between the
temporal lobe an d oculomotor nerve. The P- I
artery takes its typical course away from the sur-
geon ; it loops superiorl y, caudally, a nd me-
dially lOwa rd the rostral tip of the basi lar ar-
tery. In Fi g. 8.14 the midd le half of the P- I ar-
tery is hidden by the P-2 artery.
Figure 8.15 is the sa me case after severin g of
the right posterior communicating artery. Th is
is a n unusual view of both P- I arteries, both 1'-2
arteries, and the left (opposite) posterior com-
municating a rtery.
Figures 8.16 and 8. 17 a re two se parate exam-
ples of prev iolls su ba rachnoid hemorrhages
that have caused adhesions in the arachnoid
sheath enclosing the anterior thalamic per-
forators. T hese adhesions have ca used many of
the perforators to stick together. This situation
requires slow, del icate d issection to prevent
perforator injury.
Figures 8.18 and 8.19 are two se parate exam-
ples of approaches to the interped uncular cis-
tern where the intracranial internal carotid ar-
tery is short. Re traction of the fronta l lobe
brings A- I and M-I perforators into " iew at the
bifurcation of the internal carotid artery. In
Fig. 8. 18 the uncus, which hides the P·2 artery,
is still ad herent to the oculomotor nerve. In
Fig. 8. 19 the internal carotid artery hides the
posterior communicating arte ry.
 Anatomy
Fig. 8.7. Plastic model of brain: viewed as from a
right pterional appro.1ch to the anatomy around the
interpedu ncular cistern (see Figs. 4.6 and 4.i). The
right temporal lobe and right cerebellum have been
removed, btu the view is similar to that afte r wide
opening of sylvian fiss ure. r-fl. Right front.allobe; J,
both olf.lclory tracts; 1-1l, medial side of left (oppo-
she) temporal lobe; p-J, le ft Pol artery; i-sea, left
supe rior cerebellar artery; ), right oculomotor
lIerve; ba, b;:lsilar artery; '·va. left vertebral a rte ry: J~
va . rig ht I'enebral artery; //lcd, medulla oblo ngata ;
Iii
aiea, right anterior inferior cerebellar artery; 7 and
8. origins of facial and acoustic nerves; 6, right abd u-
cent nerve; 5. right trigeminal nerve arising from
POllS: mep. sectioned middle cerebellar peduncle;
ebllll, medial surface of le ft cerebellum (right side cut
away); r-sea, right superior cerebellar artery; p·2,
right 1'-2 ;1I·tel'}'; I'ed. pedu ncle (pyramidal tract) of
midbrain: il'[. interpeduncular fossa of midbrain ;
pea, right poste rior communicating artery; pil, pitu-
itary bod y; 2. right optic nen'e; lIIam, mamillar}'
bod y.
172 8. The Ambient and Imerpeduncular Cisterns

Figures 8.20 th rough 8.23 are examples of pending on the exaCl direction of the optics of
the right latcral zone, middle zone, and left lal~ the microscope, the surgeon now sees both
eral zone of the interpeduncular cistern as superior ce rebellar arteries (origins), both
viewed progressively from the right pterional oculomoto r nerves, both P- I arte ries (origins),
approach. In each res peClive case the micro- and the left mesence phalic peduncle (pyrami-
scope is tilted from a partial cauda-med ial di- daltract), T he anterior (frolltobasa l) surface of
reclio n (ie, direction of the surgeon's view) to a the upper basilar a rtery is viewed by the sur-
caudal , yet morc medial, direction. Atthc same geon.
time the righ t internal carOlid artery and the Figures 8.24 and 8.25 represent another
proximal M- J artery arc displaced gently to the example of the transition from a view of the
left (med iall y) by a llalTOW self-reta ining re- junClion of the a mbient and interped uncular
tractor. Care is take n not to occlude the carotid cisterns (Fig. 8.24) to a view of the center of the
artery (es pecially if vascular hypotension is interpeduncular cistern (Fig. 8,2 5), Note how
used) or fracture atherosclerotic plaques in the the P-1 artery on the right tul"llS caudall y away
a rtery. In some cases it may be necessary to clip fro m th e surgeon whi le the P- I artery on the
(with sma ll malleable cli ps) and sever the post- left ta kes a more lateral course. Large and vital
e rior com mu nicatin g artery (see Figs . 8.14 and ante rior a nd posterior thalamic perforators
8. 15), avoiding occlusion of anterior thalamic are presen l.
pe rforato rs by the clips. Figure 8.26 gives a view of the anatomy of
In Fig. 8.20 a clear view of the oculomotor the lamina termi nalis, chiasmatic, carotid , am-
nerve separating the superior cerebellar artery bient, a nd interpeduncular cistcl"Ils in one pa-
and the P-2/posterior com municating junClion tient. Figme 8.27 demonstrates anatomy about
is present. T his th ird cranial nerve begins, as it the carotid, ambient, and prepontine cistel"lls.
typically does, as a broad neural band fro m the Figures 8.28 through 8.30 represent
midbrain in the interpeduncular fo ssa. This another example of transi tion from viewing
broad band gathers together rostral to the the lateral zone to viewing the central zone of
pons and passed forward under the tentorial the interpeduncular cistern in a case of low-
edge and into the oculomotor trigone (see lying basilar artery bifmcation. Figures 8.31
Fig. 8.3)just lateral to the posterior clinoid pro- through 8.33 il lustrate the ma ny anterior
cess . The midbrain, from whence the thalamic perforators arising from the inte rnal
oculomotor nerve originates, is hidden from carotid a nd posterior communicating arteries.
view owing to the buckli ng of the brainstem They lie e nsheathed wi thin their own filmy
during the e mbryonic stage of development. arachnoid envelope. Th e anter ior choroidal a r-
The forward buckling of the developin g pon s tery takes a prominent course from the inter-
accounts fo r the rostral pons being seen by this nal carotid artery and' disappears behind the
surgical ap proach. uncus.
With retraction of the in temal carotid anery Figure 8.33 additionally gives a panoramic
and a more medial til t of the aim of the micro- view of the anatomy of the lamina terminalis,
scope, the center of the inter ped uncu lar cis- chiasmatic, carotid, ambient, and interpedun-
tern ca n be seen in Fig. 8.21. An even sharper cu lar cisterns. The relationshi p of th e pos-
medial angulation of the microscope aimed terior communicming artery to the P-I and P-2
caudal to the carotid a nery a nd hypothalamus arteries is illustra ted. Figure 8,34 gives a dear
permits the surgeon to see beyond the inter- view from the bifurcation of the internal
ped uncular midline as is revealed in Figs. 8.22 carotid a nd adjacent optic tract to the bifmca-
a nd 8.23. In thi s circumstance the observer is tion of the basilar artery. The last two fi gures
looking through the space between the back of dea rl y demonstrate that the pterional a p-
the dorsum sellae and clivus (see Figs. 4.7 and proach permits access to lesions situatcd any-
8. 1) and the fron t of the brainstem (see where about the circle of Willis, It is ideally
Fig. 8.7). With this right pterional approach , suited for multiple lesions (eg, aneurysms) pre-
the dorsum sellae (Fig. 8. 14) lies in the upper, sen t in diffcrent loci, yet within reach from the
left-ha nd field of the observer's view, and the chiasmatic to the interpeduncular cisterns.
basilar artery and rostral pons lie in the lower, The approach requi res sign ificant removal of
right- hand field of the observer's view. De- the sphenoid wing and , in many cases, a wide
 Anatomy
opening of the sylvian fissure. Add itional de-
tails of the neurosurgical techniques used by
the author for lhis approach are given else-
where [2].
Bibliography
I. Fox J L (1979) f\I icrosurgical exposure of intracra-
nial aneurysms.J Microsllrg I: 2-31
2. Fox J L (1983) Intracranial Ancwysms, vol 2. New
York. Springer·Verlag, PP 877 - 1069
3. Fox JL (1985) Microsurgical exposure of vene-
brobasi lar aneurysms, in Rand RW (ed): Micra'
neurosurgery, cd 3. St Louis, CV ]\'Iosby Co,
PI' 589-599
173
4. "ox J L, AI-Mefty 0 (1980) Suprasellar arachnoid
cysts: an extension of the membrane of Liliequisl.
Neurosurgery 7: 615-618
5. Greilz T, Uifsled S (1954) The relationshi p be-
tween the third ventricle and the basilar anery.
Acta Radiol42: 85 - 100
6. Malkasian DR, Rand RW (1978) Microsurgical
anatomy, in Rand RW (ed): Micronfuroslllgcry,ed 2.
St Louis, CV Mosbr Co, pp 37- 70
7. l avaras J M (1960) The roentgen diagnosis of in·
cisural intracranial space occupring lesions. Am J
Rocntgenol84: 52 - 69
8. Ya~rgil MG, Kasdaglis K, J ain KK el al (1976)
Anatomical observations of the subarachnoid cis-
terns of the brai n during surgery. J Neurosurg
44: 298 - 302
174 8. The Ambient and Interpeduncular Cisterns
Fig. 8.8. Plcrional approach to ambient and inter-
pedu ncular cisterns (see Fig. 8.7 and Fig. 4.7). pr,
Probe retracting the illternal carotid artery (ica); 2,
right o ptic nerve; ac, anterior clinoid process; aI',
arachnoid: pc, posterior clinoid process; Ie , tentorial
edge;), oculomotor ncn"c at lateral oordcr of inter-
pedu ncular cistern and emering cavernous sinus
th rough oculomotor ostium (see FIg. 8.3); sea,
super"jol" cerebellar artery; col, cononoid: rei, tem-
\Xlra! lobe retractor; pons, rostral pan of pons; pea,
posterior communicating anery entering posterior
cerebral artery at the pol (P- / )/P-2(P-2) junction; p,
anterior thalamic perforators; !lIIC, urlCUS: adw, dup-
licated anterior choroidal artery; v, \'cin. Note: P-2 ar-
tery and basal vein of Rosenthal lie ill ambient cis-
tcrn between pontomesencephalic region and tem-
porallobe. From Fox lll.
 Anatomy 175

fi g. 8.9. Same case as in foig. 8.8. Probe (pr) isretrac t-
ing posterio r commu nicating artc!"y (pea) to show
origin of superio r cerebel lar a rtery (.sta) from basilar
an ery (ha) in imcrpc duncula r cistcl"lI . m; Arach noid :
porlS, rostral pa rt of pons; J, base of ocu lomo tor
ne rve naring out at its midbra in origin: /1-/,1'-1 ar-
ter)'; p-2, 1>-2 arter), entcrin g ambien t cistern: Ii-rei,
tempo ral lobe retracto r: ac}w, d u plicated anterio r
choroidal artery ; Ime, uncus; V, vein : fl-rrt, frOlltal
lobe rctractOl'; 2, optic nervc: iea, inte rnal carotid ar-
tcry:pc, posterio r clinoid process.
176 8. The Ambient and Interpeduncular Cisterns
Fig. 8.10. Path of posterior communicating anery
(pea) in anothe r case. The thickened (horn previous
subarachnoid bleed) arachnoid membrane of
Liliequist (mem) separates unseen interpeduncu lar
cistern from carotid cistern. The posterior com-
municating anery (pea) follows posterior extension
of carotid cistern to join (*) the posterior cerebral ar-
tery (p-2) in the ambient cistern. The 1'-2 anery
(P-2) ascends in the wing of the ambient cistern. ica,
Internal carotid artery; at, alllerio r clinoid process;
Ie, tentorial margin: 3, oculomotor nerve; /l·rel, tem-
poral lobe retractor; p, anterior thala mic per-
forators; ar, arachnoid membrane e nsheathing pos-
terior communicating artery and its perforators (p);
rei, relractor displacing M·l artery and carotid ar·
lery bifurcation median),; a'/, ol'igill of A·] ,trtery; 2.
right optic nerve; at, anterior clinoid process. From
Fox [2].
 Anatomy 177

Fig. 8.11. Same case as in Fig. 8. 10. Membrane or sea, right superior cerebellar artery; p-2, P-2 artery;
Liliequist (mem) has been opened, revcaling intcr- pea, posterior communicating artery; INd, medial
peduncular cistern. ), Right oculomotor nen'e; p, side or lert (opposite) peduncle of midbrain. From
lateral medullary perforators: bo, basilar artery; r- Fox [2).
178 8. The Ambiem and Imerpeduncular Cisterns

Fig. 8.12. Another case illustrating an unusual pre- unc, UIl CUS; J, ocu lomotor nerve; an, collapsed
sentation of the posteriordinoid process (PC) project- aneurysm at posterior communicating artery; clp,
ing up between o ptic nerve (2) and internal carolid clip on aneurysm; Ile, anterio r clinoid process.
artery (ica). gr, Gyrus rectus; a-J, A- I artery; v, vein;
 Anatomy li9

Fig. 8.13. Anothe r case with view through ca rotid
cistern into interpeduncular cistern. m-l, t.·I- 1artery;
a- l , A- I artery; ot, optic tract; p, hypothalamic and
anterior thalamic perfor,llors; ch, opLic chiasm; 2,
right optic nerve; ac, amerior clinoid process; ica, in-
ternal carotid arterY;CTossed arrow, origin of posterior
communicating artery (pea); ac/uJ., anterior choroidal
a rtery; pol, P_I arte ry; p-2, P-2 artery; 3, oculomotor
nerve; br, branch from superior cerebellar artery
(sea); PO/IJ, rostral pons; an, aneurysm of basilar ar-
tery (00) at origi n of superior cerebella r artery (sea);
pe, posterior clinoid process;ds, lOp of dorsum sellae.
180 8. The Ambient and Interpeduncular Cisterns
Fig. 8.14. Same case as in Fig. 8.13, looking leftward
across interpeduncular cistern. fl. Frontallobc; ret,
retractor on internal cal"Olid artery (ica) and its bifur-
cation; p, ilnterior thalamic perforators; 2, right
optic nerve; ac, amcrior clinoid process; l-pc, left (op'
posite) posterior clinoid process; tis, LOp of dorsum
sellae; pc. right posterior clinoid process; I-sea, left
superior cerebcll,ll" artery; ped, medial side o f left
I·sea
peduncle of midbr.aiu; 3, left and right oculomotor
nerves; cmssed Ulnm', one of twO malleable clips on
posterior communicating ancry (pea); b-Ul!. base o f
bifurcation aneurysm of basilar anery (00); /1-1, right
pol anery; /1-2, right P-2 artery; UIlC, uncus; If-ret, tern-
porallobe retractor; pons. rostral pons; an, dome o r
aneurysm at hidden origin or I'ight supcl·iorcerebcl.
lar artery (r-sea).
 Anatomy lSI

Fig. 8.15. Same case asin Figs. 8.13 and 8.14. showing
posterior circle of Willis in interpeduncular cistern.
2, Right optic nerve; iea, internal carotid al·tery; ae,
anterior clinoid process; i-pea , left poster ior com-
municating anery: p-2, left and right P-2 arteries;
p-I.leftand right 1'- 1 aneries ;J, left (labeled twice)
and right oculomotor nerves: l-pc, left posterio r
clinoid process; r-pc, right posterior clinoid process;
00, tip o f basilar artery; an, aneurysm at bifu rcation
of hasilar artery; p, posterior thalamic perforators;
ped, medial side of left peduncle of midbrain; sea,
right superior cerebellar artery: pons. rostral pons;
crossed arr~ malleable clip on caudal end of severed
right posterior communicating artery; !Inc, uncus.
182 8. The Ambient and Inter peduncular Cisterns

Fig.8.16. Anothe r case illustrating the posterior choroidal artery; mol, M-I artery; pr, probe retract-
comm unicating artery (pea) and its amerior thalamic ing internal carOlid artery (ica); a-I, A-I artery; 2,
perforators (p) stuck together by adhesions from optic ne rve; pc, posterior clinoid process; mem, thick-
previous hemorrhage. WIC, Uncus; aeM, anterior ened membrane of Liliequist;;, ocu lomotor nene.
 AnalOmy 183

Fig. 8.17. Anothcr case wherc the amerior thalamic
perforalOrs (p) are stuck IOgether by adhesions in
their cnclosing arach noid sheath. pr, Probe retract-
ing intcrnal carotid artcry (ita); acha, duplicated an·
terior choroidal artery and perforators ; crossed arrow,
origi n of antcriorchoroidal aner),jan, aneurysms at
origin antcrior choroidal artcry (bottom) and pos·
terior communicating artery (toP): 2, optic ncn'c;
boo, bifurcation of basilar artcry: 00, trunk of basilar
artcry;), oculomotor ncrve;sca, superior ccrcbellar
artcr),; p-2, P-2 an ery; pol, P_I artcry; pea, posterior
comm unicating artcry; !II", uncus.
184 8. T he Ambient and Interpeduncular Cisterns

col

" I

Fig. 8.18. Following posterior comm u nicating artery
(pea) toward interped uncular cistern hidden behind
membrane of Liliequisl (mem). col, Coltonoicl; rei,
temporal lobe retraCLQr; J, oculomotor nerve; unc,
uncus;p, anterior thalamic perforators and A-I per-
forators; akl, anterior temporal artery; mol, M-l af-
tery; a-I, A-I artery; 2, optic nerve; aeM, atHerior
choroidal artery; ica, internal carotid artery; crossed
arrow, origin of posterior communicating artery
(pea); all, aneurysm at origin of posterior com-
municating artery; It, tentorial margin;pc, posterior
clinoid process.
 Anatomy 185

II-ret

Fig. 8.19. View ofrightlatcraJportion ofintcrpcdun-
cular cistern after opening membrane of LiliequisL
jl-rtl. Frontal lobe retractor; p, perforators from
bi fu rcation of internal carotid artery (iea); 01, optic
tract; a- I, A- I artery; mem, med ial jX>rtion of mem-
brane of Liliequist; pc, posterior clinoid process; 00,
basi lar artery; an, aneurysm of basilar artery at ori-
gin of superior cerebellar artery (sea); p-l, P_I artery;
p-2, P-2 artery; m-J, M-l artery; m-2, M-2 artery; It-nl,
temjX>ral lobe retractor; unc, uncus; 3, ocu lomotor
nerve; fe, tentor ial margin.
186 8. The Ambient and Intt:rpWuncular Cisterns
Fig. 8.20. Another case with view of right lateral por-
tion o f interpeduncu lar cistern after remm'al of
mcmbr.mc of Liliequisl. Notc how oculomotor
nerve (J) gathers together from a broad band exiting
the midbrain. pons. Rostral pons; sea, su perior cere-
bellar artery; 00, basilar artery near its bifu rcation: Ie,
margin of te ntori um; /1, temporal lobe; col, cot-
lOno id ; rei, retractor: p-2, P·2 artery; p, perforators;
111-2. M-2 artery : mol, M- l artery; ot, optic tract; a-I.
A-I artery; 2, optic ne rve; mem, membrane of
Liliequisl (anterior re n ectioll around pituitary
stalk); ial, internal carotid artery; pea, posterior com-
municating artery; aciUl, anterior choroidal artery;
pol, P_I artery. Reproduced by permission from Fox
JL ( 1985) Microsurgical exposure ofvertebrobasilar
aneurysms, in Rand RW (cd): MicrmleUrQS1I1gery, cd 3.
Sf Louis, CV Mosby Co, pp 589-599 [3].
 Anatomy
Fig. 8.21 . Same case as in Fig. 8.20. Internal carotid
artery (ica ), middle cerebral artery (m-I), and pos-
teriorcomm unicating artery (pea) retracted med ially
by na rrow retractor (rtt ) to expose ceme r o r imer-
ped uncu la r cistern contai ning aneurysm (an) at
bi rurcation or basilar artery (ba). Except at its base,
aneurysm is covcred by a carpet or fi brin. p-I. Left
(loP) and rig ht (bottom) P- l arteries;sca, right su perior
cerebellar a rtery: Ie, margin or tentorium : J,
187
oculomOlOr nen'C; pons. rostral pons; p. one o r sev-
eral anterior thalamic perrorators rrom postcrior
com municaling art.ery; 2. optic nerve; /le, anterior
clinoid process:pc, posterior clinoid process. Repro-
d uced by permission rrom Fox J L (1985) Micro-
neurosu rgical exposure or vertebrobasilar an-
e urysms. in Ra nd RW (cd): M icrotll'UfOsmgery,ed 3. 51
Lou is. CV Mosby Co, pp 589 - 599 [3).
188 8. The Ambient and Interpeduncular Cisterns

cot

Fig. 8.22. Example of ventral surface of basilar ar-
lcry (ha) in interpeduncu lar cistern flanked by
oculomotor nerves (3) . The membrane of Liliequist
has been removed. t-sea, Left superior cerebellar af-
tef),; r-sea, right superior cerebellar artery; ], right
and left oculomotor nerves; lie, right posterior
clinoid process; pol, left and right P-l arteries; I),
posterior thalamic perforators from pol; *, base of
basilar tip aneurysm; ica, internal carotid artery; ret,
rClraClOr displacing iea bifurcation medially; aelia,
anterior choroidal artery; fl. frontal lobe; col, cot-
tonoid; /l-ret, right temporal lobe re tractor; crossed
arrow, malleable dip on caudal end of severed right
posterior communicating artery. From Fox [2J.
 Anatomy 189

Fig. 8.23'. Another example of ventral surface of
bifurcafion oflhe basilar artery (bba) in Ililerpedun-
cular cistern between both oculomotor nerves (3).
prd, Left (opposite) peduncle (pyramidal tract) of
mid brain ;sca. lcft superior cerebellar artery ; bo. basi-
iiiI' artery; Ie, margin oftentorium;p-l, right and left
pol arteries; all, base of aneurysm at tip of basilar ar-
tery; fl-rel, frontal lobe retractor; Col, cottonoids; 11-
rtt, temporal lobe retractor. From Fox [2].
190 8. The Ambient and Interpeduncular Cisterns

,.1

'01

Fig. 8.24. Another case illustrating anatomy at j unc-
tion o f carotid , interpeduncular, and ambient cis-
terns after removal of arachnoid membrane of
Lilicquist. rei, Retractor displacing internal carotid
arte l")' medially; CQl, cou onoids; p, perforators; mol,
M- I artery;aw, duplicated anter ior temporal artery;
v, veins; pons, rostral pons;), oculomotor nerve;sco,
superior cerebellar artery; 00, basilar artery; pea,
posterior communicating artery in carotid cistern;
p-2, P-2 artery emering wing of ambient cistern be·
tween pons and lemporallobe;p-J, pol artery going
medially in interpeduncular cistern. From Fox [2J.
 Ana{Qmy 191

".
co.
/
J
r
)

I
Fig. 8.25. Same case as in Fig. 8.24. View of ventral
aspect of bifurcation of basilar artery (boo) and inter·
peduncular cistern between oculomO{Qr nerves (3).
00, Basilar artery: sea. right superior cerebellar ar-
tery; p-l, right (labeled twice) and lef! P_I arteries; p-
2, right P-2 arter y; pons, rostral pons; v, veins; ala, an-
terior temporal artery; mol. M-I artery; col, (ot-
{Qnoid; rel, retra({Qr on ica; p, posterior thalamic per-
forators; i-sea, left superior cerebellar artery; an,
aneurysm of tip of basilar artery;crossed arrow, caudal
end of severed posterior commu nicating artery
(with malleable dips on it). From Fox [2] .
192 8. The Ambient and Interpeduncular Cisterns

Fig. 8.26. Another example of anatomy at conflu-
ence of carotid. lllle rpeduncular, and ambiem cis-
lerns. cau-an, Dura of cavernous si nus containing
giant internal carotid artery aneurysm; ica, internal
carotid artery exiting from C3\'CrnOUS sinus; 00, basi-
lar ancry; $la, superior cerebellar artery: J,
OCU lO ll1 010 l' nerve entering cavernous sinus; pmlJ,
rostral pons; p-2. P-2 artery; crossed arrow points to
posterior communicating artery hidden by internal
carotid artery; unc, uncus; p. anterior thalamic per-
foralOr ; acha, anterior choroidal artery; *, bifurca-
tion of internal carotid artery; col, cOllOnoids; fl,
froma l lobc; QI, right optic tract; II, lamina terminalis;
eli, o ptic chiasm; 2. both optic ne rves. t'rom Fox [2).
 Anatomy 193

1I".t

00'

fig. 8.27. A vicw through carotid a nd interpeduncu-
lar cistel'lls into prepoilline cistern anterior to the
pons (PO"s). ll·rtt , Temporal lobe retractor; col, cot·
tonoid; fl·ret, fro ntal lobe retractor; clp. shank of
aneurysm clip on an 3mcriorcommunicating a rte ry
ancurysm; a· l. A- I artcry; mol . M-l an ery; tmc,
uncus; sea, superior cerebellar anery; an, a neurysm
of basilar arte ry (1M) at takeoff of amerior inferior
cerebellar anery ; J, oculomotor nerve; pc. posterior
cli noid process; ica. internal carotid artery. From Fox
[2].
194 8. The Ambicni and Jnterpeduncular Cisterns

Fig. 8.28. Another case with view of carotid , inter-
peduncula r, and rostral prepontine cisterns. Ie, Ma r-
gin o f te ntorium ; mem, remainde r of membrane o f
Lilicquisl (most removed): rti, temporal lobe retrae-
LOr ; pons, rostral pons; J, oculomotor ncn'c;jK. post-
crior clinoid process; ac, anterior clinoid process; ica,
jlllcrnal carotid artery; 2, o ptic nCl've; QI. optic tract;
a-I, A- I artery; m-l, M-I artery; p-2, P-2 artery;p- J. p.
I artery; crossed arrou, origin of posterior com-
municating artery.
 Anatomy 195

fig. 8.29. Same case as in ~ig. 8.28 with medial re-
traction (1"(/) of the internal carotid artery (ica). 2.
Optic ne rve: ac, anterior clinoid process; pc, pos-
terior clinoid process;p·l, left (obscured with blood)
and right P- J arteries; " bifurcation of basilar artery;
an, aneurysm of b.1silar artery at takeoff of hidden
right su pcrior cerebella r artery; ), oculomotOr nen'e
entering cavernous sinus; POtU, rostral pons; p, per-
forator; p-2, right P-2 artery: pea, posterior com-
municating artel")'; m-l, M·J artel")'; 0-1, A- I artery;
01, optic tract.
196 8. The Ambient and Interpeduncular Cisterns

Fig. 8.30. Same case as in Figs. 8.28 and 8.29. View of superior cerebellar artery (sea); Ie, margin of ten-
bifurcation of basilar artery (boo) in center of imer- LOriu m; pons. rostral pons; *, bifurcation of imernal
peduncular cistern. pol, Left and right po l arteries; carotid artery; ret, retractor displacing imernal
J, ocu lo motor ncn"c; all, aneurysm at o rigi n of carotid artery medially.
 AnatOmy
Fig. 8.3 1. Another case, following arachnoid sheath
of posterior communicating artery (pea) and iL" an·
terior thalamic pe rforators (I) caudally toward inler-
peduncular cistern hidden behind membranc o f
Lilic(IUist (mem). Ie, f\hrgin ofte nlOriull1 : ulle. uncus;
If·rel, temporal lobe retractor: fl, fronta l lobe; PI',
probe rctracting M-I artery (m-I) medially; 01, o ptic
197
tracl;jl-J'et, frontal lobe retractor; a-I, A-I artery; fl,
lamina te n ninalis; cit, optic chiasm; iea, internal
carotid artery: 011, aneurysm at origin o f posterior
communicafing artcry; Gclla, amcrior choroidal ar-
tery passing under uncus toward choroid fissurc of
lClllporallobe.
198 8. The Ambient and Interpeduncular Cisterns

Fig. 8.32. Same case as in Fig. 8.31 at higher magnifi- bands within envelope of arachnoid about per-
catio n to show anterior thalamic perforators (p) forators and posterior communicating artery; un"
from postcfiorcommunicating artery (pea) and thei r uncus of right tern poral lobe; adm , anterior choroi-
ensheathi ng a rachnoid. ar, Thickened arachnoid dal artery; ica, interna l carotid artery; QI , o ptic tract.
 AnalOmy 199

Fig.8.33. Same case as in Figs. 8.3 1 and 8.32.
Arach noid membrane of Liliequ ist has becn dissect-
ed away. Note how pterional approach can gi\·c
panoramic vicw of chiasmatic, lamina terminalis,
carotid, ambielll, and interpeduncular cisterns. 2,
Both optic nerves; eh, optic chiasm; It. lamina ter-
mi nalis; 01, right optic tract; a.-I, A-I artery; p, per-
forators ; m-J, M-l artery; m-2, M-2 artery; ar,
arachnoid sheath; aeM, anterior choroidal artery;
ita, internal carotid artery; an, aneurysm; pea, pos-
terior communicating artery; 00, basilar artery; p- l ,
P-I artery; p-2, P-2 a rte ry:), oculomotor nerve ; sea,
origin of right superior cerebellar artery.
200 8. T he Ambient and Interpeduncular Cisterns

Fig. 8.34. Another case illustrating bifurcation of
basilar artery (boo) in interpeduncular cistern. I-sea,
Left superior cerebellar artery; pc. posterior clinoid
process; ), left (h idden in shadows) and right
oculomotor nerves; v, vein; r-sea, or igin of right
superior cerebellar artery; {1-J, right and le ft pol ar-
teries in interped uncular cistern; pea, posterior com-
municating artery; p-2, origin of right P·2 artery; p,
perforators; Il-ret, temporal lobe retractor ; unc,
uncus; mol, r.1- 1 artery; ot, optic tran; ha, artery of
Heubncr;jl, frontal lobe; a-I, A- I artery; aCM, an-
terior choroidal artery; ica, internal carotid artery.

A posterior cerebral an ery P- I,
Abducens nerve, 171
Acoustic nerve, origi n of, 17 1
Adhesions
arachnoid membra ne, 94
between fro ntal and te mporal
lobes. 56, 71
carotid arlery aneurysm to
ocu lomoto r nerve, 111
fron tal lobe to oplic tract,
10.
Ambient ciste rn, 165-200
anatomy of, 172, 199
body of, 169
j unction with ca rotid and in-
terpeduncular ciste rns.
169, 172, 190, 192
j unction wi th sylvian and
chiasmatic cisterns, 169
Aneurys m
anterior cere bral artery A- I,
92, 16 1
anle rior choroidal artery. 92.
108
at o rigin, 84, 115, 183
anterior communicating ar·
lery, 124 , 132, 137, 139,
140, 143- 144, 193
hypothalamic perfo rators
stuck to, 125, 149
basilar artery_ Stt Basilar af-
tery. aneurys m o f
internal carotid artery. See
Carotid artery, internal,
a neurysm of
middle cerebral arte ry M- I
al bifurcation, 76-77
d ome in temporal lobe, 75
fl anked by tem poral and
fro ntal M-2 arte ries, 78-
79
Index
120
posterior commun icati ng ar·
tery, 11 4. 178
at o rigin. 11 5- 11 6, 183-
184,197
at superio r cerebellar artery
origin , 180. 185, 196
Aqueduct of Sylvius, 166
Arachnoid , 156, 174- 175
anterior re fl ection at pitu-
itary sta lk, 125, 186
between frontal and tem poral
lobes, 72
sc\'e red by microscissors,
56,84
between left optic nerve and
frolltallobe. 140
between optic nerves, 98-99.
102, 116, 132-134, 148,
160
coveri ng inte rnal carotid ar-
tery and o ptic ne rve, 53,
74
d iste nded by cerebrospinal
fl uid , 56. 59
at inte rhemispheric fissu re,
144, 150, 153-155, 160
at pituitary stalk, 138, 169
surgica l opelling of, 57, 87-
88, 177
and sepa ration by fo rceps
blades, 64-65, 67
at sylvia n fissure. 146
Arachnoid bands o r fibers, 57,
87.90-91, 11 7. 153
at anterior cerebral artery
A- I, 84, 127, 16 1- 163
in arachnoid envelope of tha-
lamic perfo rators and
posterio r communicating
artery. 198
between hypothalamic per-
forators and o ptic tract,
81
between midd le cerebral ar-
te ry branches, 56, 70-
73
between middle cerebral M- l
artery and temporal
lobe. 80
between sylvia n vessels and
pia, 63
at illlernal carotid artery, 67.
11 6
at lamina terminalis cistern ,
125.14 1
at o ptic nerve/carotid a rtery
j u nctio n, 67
at posterio r communicating
artery, 83
in subd ura l space, 56, 58,
60-6 1
at sylvian fissure base. 56,
65-66
Arachnoid membrane of Lilie-
quist, 68-69, 93-94, 98-
100, 103- 104. 107, 111 -
112, 116. 11 8. 125, 134,
138, 141 , 146- 148, 15 1,
165- 166, 184
adhesions o f, 94
attachme nts of, 98
coloratio n o f. 97
medial portion of, 185
at pituita ry stalk, 125, 138.
147- 148, 186
reflection of, 98
removal of, 188
surgical opening o f. 177
th ickening after he morrhage.
170, 176, 182
202
Arachno id sheath
of posterior communicating
artery. 176
o f thalam ic perforators, 120
from posterior communi-
cating an ery. 172, 197-
198
B 159, 162- 163, 166, 169,
Basilar ane ry. 39, 44-45, 69,
84, 107, 114 , 152. 171 ,
177, 190,192,199
aneurysm of. 179
at anterior infe rior (erebel·
lar artery takeoff. 193
at bifurcation, 82, 180-
18 1, 187
at superior cerebellar ar-
teryorigin, 185, 195
at tip. 18S-189, 191
bifurcation of, 166. 168, 183,
195--196, 200
between oculomotor
nerves, 19 1
medullary perforators from,
11 5
near bifurcation, 186
origin of superior cerebellar
artery. 165. 175, 179
relation to dorsum sellae, 168
relation to third ventricle.
168
lip of, 165, 18 1
tru nk of. 183
ventral surface of
at bi furcation, 189, 191
nan ked by ocu lomotor
nerves, 188
Basilar vein of Rosenthal, 165,
174
Bone nap
attached to temporalis mus-
cle, 40, 49
frontotemporal, 39-40
sutures for reattachment of,
40, 49
Bone-removal instrume nts, 24
Bonewax, use of, 24
Bridging artery from anterior
communicating artery
to left A-I, 126, 162
to left A-2, 11 2, 126, 153-
154, 157
Bridging veins between tem-
poral lobe and spheno-
parietal sinus, 4 1, 56,
Index
66,74
electrocoagulatio n of, 56, 68
BUTT holes, 40, 48, 50
C relation to posterior clinoid
Carotid artery, internal, 52, 6 1,
65-66, 77, 91, 110- 112,
135, 140, 145, 150-153,
174- 176, 179- 184,IS6-
ISS, 193- 195, 197- 198
aneurysm of, 89-90, 104,
160, 192, 199
ad hesion to ocu lomotor
nerve, II I
adhesion to temporal lobe,
100
adhesion to tentori um ,
101
at anterior cho roidal artery
takeoff, 84
at bifurcation , 57,85. 112-
113, 121 , 156- 157
arachnoid bands on, 67 ,11 6
arachnoid co,"ering of, 53, 74
athe rosclerotic, 63, 80, 10 1-
102, 107, 147- 148
bifurcatwn of, 79, 81, 84,
134 , 153, 156- 158, 192.
196,200
branches of, 57, 79
exit from cavernous sinus,
192
lateral retraction of, 103
left, 106, 114, 117- 11 9, 138,
146-147
bifurcation of, 138
long, 95, 98--99, 102
medial retraction o f, 109
origi n of anterior choroidal
artery, 95, 100, 104, 13'1,
144, 152, 183
origin of posterior communi-
cating artery, 95, 98,
100-101 , 104-105, I I I,
134, 141-142, 144 , 152-
153, 179,184, 194
ostium of, 167
perforatOrs from , 11 3- 114 ,
158
to anterior perforated sub-
stance, 118
at bifurcation, 11 8, 185
hypo physeal, 95, 99, l iS,
120, 125, 138
hypothalamic, 8 1, 95, 102-
103, 106, 11 8, 148, 159,
179
thalamic, anterior, 95,
102- 103, 120,172, 179
relation to carotid cistern, 93
process, 96, 114- 115
unusual, 170, 178
relation to posterior commu-
nicating artery, 192
right, 106, 114 , l iS, 138,
146, 148
bifurcat ion of, 12 1, 139
short, 95, 100-10 I
sympathetic fibers on , 96,
11 6
view 10 optic tract, 103
Carotid cistern , 93- 12 1, 123,
128, 14S, 152
analOmy of, 93-97, 162, 172,
199
exposure of, 52
j unction with ambient and in-
terpeduncular cisterns,
172, 190, 192
structures in, 96
Cavernous sinus, 95, 98
internal carotid artery exit
from , 192
oculomotor nerve in , 170,
174
e ntrance of, 192, 195
unusual veins in , 97, 11 8-- 119
Cerebellar artery. anterior infe-
rior
aneurysm at takeoff from
basilar artery, 193
right, 171
Cerebellar artery, superior,
165, 166.170, 174 , 183,
190, 192- 193
aneurysm at origin o f, ISO,
IS5, I96
branch of, 179
le ft , 114 , 17 1, ISO, 188-- 189,
191,200
origin from basilar artery,
165,175,179
rig ht, S2, li S, 17 1, 177, l SI,
187- ISS, 191
aneu rys m at takeoff from
basilar artery, 195
origin of, 199,200
separated by oculomotor
nerve, 186
Cerebellum, 166
middle peduncle of, 17 1

tentorium of. See Tentorium
cerebelli
vermis of, 169
Cerebral arteries, anterior, 124,
167
A- I artery, 77, 85, 91, 93- 94,
10 1, 11 0, 11 3- 115. 118,
120, 123, 124, 133-135,
178-179, 182, 193-195,
197, 199-200
aneurysm of, 92, 16 1
arachnoid band over, 84,
127, 161- 163
hypoplasia of, 125. 146-
147, 149
left, 11 9, 125, 126, 136-
140,143- 144,149- 157,
159- 160. 162- 163
bridging artery to anter-
IOr communicating
artery, 127, 162
origi n of, 82-83. 100, 108.
11 7,176
perforators from, 57. 79-
80,82,84,92,106.141-
142, 161 - 163, 170, 184,
186, 199
relation to artery o f Heub-
ner, 95
right. 125. 126, 136- 140,
143-144 , 150-163
j unction with right A-2,
11 2
transsylvian view of, 82-83
A-2 artery, 126, 156-157
and common tru nk for ar-
tery of Heubner and
right fro ntopolar artery,
126, 15 1
left. 137. 139- 140, 144,
153- 158, 160
bridging artery from an-
terior communicating
artery. 112, 126, 1 53~
154, 157
origin of, 159. 163
rig ht, 120, 137. 139- 140,
143, 149. 153- 158, 160
j unctio n with anterior
communicating artery,
144
ju nction with rig ht A- I ,
11 2
origin of, 163
accessory. 126, 156- 157
o rigin o f, 127. 160
in chiasmatic cistern, 55
Index
Cerebral arteries, mid d le. 55
branches of, 56, 57,60,66,
70-71,75,86-90,133
M- I arte ry. 84-85, 93, 94,
118, 120, 123, 14 1- 142,
144, 162-163, 179,182,
193-195, 197, 199-200
aneurysm o f
at bifurca tion, 76-77
dome in temporal lobe,
75
nan ked by temporal and
frontal M-2 arteries,
78-79
deep in sylvian fissu re, 89
emering sylvian fissu re, 8 1
frontal artery from, 75, 89
left, 11 9
long, 67, 78
origin of, 82-83, 106, 108,
112- 11 3, 11 5, 117
perforators fro m, 57.79-
8 1,89-92,125,1 46- 147,
170, 181, 184-187, 190-
191,200
short, 57, 79
transsylvian view of, 82-83
variations in, 57 , 75
M-2 artery, 83, 90,157, 185-
186,199
aneu rys ms at bi fu rcation at
M- I.77
dee p branches of, 87
fronta l artery from, 61, 76,
80,88, 146
variations in, 57, 75
Cerebral arteries, posterior.
108-109, 166- 167
1'-1 artery, 175 , 179, 183,
185-186, 194
aneurysm of, 120
ascending. 169
course o f, 170, 172, 190
left, 17 1, 181, 187- 189,
191. 195-196,200
origi n o f. 165
perforators from, 165, 168,
181,188,195
right, 180- 18 1, 187-189,
191, 195-196,200
short, 165
P-2 artery, 109, 114-1 15,
165, 176- 177,179. 183,
185, 192. 194
course of. 170
entering ambient cistern,
175, 190
203
left, 18 1
perfo rators from, 186,
190--19 1
right, 171, 180- 18 1. 19 1,
195
origin of. 200
relatio n o f P- 1 and 1'-2 to
posterior communicating
artery. 170, 172, 174.
186,199
Cerebral peduncle, 166
Cerebrospinal fluid
circulation of, 94
in d istension of arachnoid
membrane, 56, 59
drainage by lu mbar punc-
ture, 40-4 1
fl ow through interpedu ncu-
lar cistern, 165, 166
in midbrai n se<:tions, 169
Chair, surgeon's, 16
Chiasmatic cistern. 93, 123- 164
anatomy o f, 123- 127. 172,
199
structures in. 126
union with sylvian and am-
bient cisterns, 169
Cho roidal artery, anterior. 57.
77,80--82,85,9 1,107,
110, 112- 113, 11 8, 145,
162- 163, 179,182,184,
186, 188, 192. 198-200
aneurysm of, 92, 108
at origin , 84. 115, 183
cou rse of, 172. 197
duplicated, 174, 175, 183
origin of, 95, 100, 104, 134,
144, 152, 183
perforato rs from, 183
relation to uncus of te mporal
lobe, 95, 105
Circle o f Willis
posterior, 18 1
relation to posterior clinoid
process, 167
Clinoid process of sphenoid
bon'
anterior, 37-38, 4 1-44. 5 1,
69,83, 100, 107- 108,
11 0- 11 2. 11 6- 11 7. 123.
128, 134,141-142, 147,
151-152. 156, 167, 169.
174, 176,178-18 1, 187,
194- 195
attach ment to tentorium,
165
rig ht, 140, 157
204
Clino id process (to'I/.)
posterior, 37-38, 42-45, 66-
67 ,69,83,98,100, 106-
108, 110- 111 , lJ 8, [20-
121, 138,152, 162, 167,
169, 174-175, 179, 182,
184-185, 187, 193- 195,
200
at tachment to tCllloriutn,
165
dura on, 99, 102. 118
left, 170, 180-- 18 1
relation to internal carotid
artery. 96, 114- 115
right, 114, 166, 170, 180-
18 1, 188
unusual presentation or.
170, 178
Com municating artery. anter-
ior, 11 3. 120, 150, 159,
163
aneurysm of, 124, 132, 137,
139- 140, 14 3- 144 , 193
hypothalamic perforators
stuck to, 125, 149
bridging artery from left A· I,
127, 162
bridging artery to left A-2.
112. 126, 153- 154, 157
duplicating, 126, 127, 134,
ISS, 158. 164
ju nction with A·I and A-2
arteries, 112, 144
perforators from , 11 2, 157
triplicating complex of, 125,
144
variations in complex of, 126.
127, 153- 157
V-shaped. 126. 152- 154.
156-157
Communicating artery. poster·
ior, 77, 85, 91, 99. 11 2-
11 3, 162- 163. 175,177.
195, 200
adjacent aneurysm, 114
aneurysm of
collapsed, 178
at origin , 115- 11 6, 183-
184, 197
in carotid cistern, 190
caudal end in interpeduncu·
lar cistern, 165
clips on, 170, 178, 180- 18 1,
188, 191
course o f, 176
ensheathed by arachnoid
membrane, [76
Index
hidden by internal carolid ar- exposure o f. 40, 49-50
tery, 192 frontal,49-50
junction with P· I and P·2 ar· margin of, 62
teries, 170, 172, 174 , 186 as o ptic canal margin, 128
lateral direction of, 95, 106- of orbital roof p rojections.
107 129, 13 1
left , 11 8- 119, 138 of posterior cli noid process,
origin of. 95. 98.100-10 1, 99, 102, 118
104- 105.11 1. 134, 14 1- of sphenoid wi ng, 65, 68, 72,
142, 144,152- 153,179, 86
184,194 of sylvian fi ssure, 50
perforalOrs frOm tempordl, 50
hypoph yseal,95, 102 venous sinus in , 114-115
hypothalamic, 95. 102- 103 Dural flap , 4 1
thalamic, anterior, 82-83,
95, 102- 103, 109- 110,
172.174,176, 180, 184, E
187.190, 192, 197- 198 Electrocautery, 24-26, 39. 40-
adhesions in arachnoid 41
sheath of. 170. 182-
183
in arachnoid sheath . 198 F
preaneurysmaltype of infun- Facial nerve
dibulum . 95. 1[0 fro ntalis branches of, 40
relation to P· I and P-2 arter- origin o f. 17 1
ies, 170, 172. 174. 186, "'alciform ligament, 167
199 Fishhook retractors. 22-23, 39,
right, 138, 17 1 48
small, 95, 108 "1aps
Cranimomy, right frontolateral, cranial. 39-40
39 dural,41
Cribriform plate, 124, 130 scalp. 39. 47-48
Crista ga lli, 124 , 130-13 1 Foramen ovale. 38
Cushing, Ha rvey. 2, 3. 4 Forceps
electrocautery, 24-26
jewelers, 27, 29. 56. 62
D to open and separate arach-
Dahlgren. Karl , 3 noid , 64-65, 67
Dandy, Walter, 4, 5-6 "' rontal M-2 arteries, 61, 70,
De Martel, Thierry. 3-4 75-76. 88-89
Diaphragm sellae, 106. 112, microaneurysllIs of. 76
118 frolll middle cerebral M-I ar-
opening for pituitary stalk, tery. 75. 89
167 from middle cerebral M-2 ar-
Dissecting instruments, 29, 30 tery. 6 1, 76, 80, 88, 146
Dorsum sellae, 166 aneurysm flanked by, 78-
front of. 115 79
relation to basi lar artery te r· Frontal dura. 49-50
mination, 168 Frontal lobe. 53, 58-59, 6 1-64,
side of, 114- 115 66,69.72,74-75,77,
to p o f, 114- 11 5, 170, 179- 81-83,85-87,9 1,180.
180 188.192
Doyen, Emile, 3 adhesion 10 optic tracl, 104
Drake, Charles, 16, 18 adhesion to temporal lobe,
Drills and burrs, 24, 41 56,71
Dura base o f, 131
of crista g'dlli . 130 c1evillion o f, 52, 124

le ft, 139- 140, 150
in quadrangular zone of
chiasmatic cistern, 132-
133
righi , 139, 143, 150, 155, 171
Frontolaleral craniotomy, right,
'9
Fronto-orbital arteries, 114 ,
124 , 132-133, 137, 14 2,
14 7, 154
left, 117, 133, 140, 143-- 144.
149- 15 1, 155-159,162-
163
right, 14 3- 144 , 156. 163
fo-rontoparietal sutu re line, I , 37
Frontopolar arte ries
left. 140, 149
low ta keoff o f. 155
low ta keoff o f. 125, 149, 155
rig ht, 149
common trunk with anery
o f Heubner, 126, 15 1
Fron tosphenoidal suture li ne,
1,37
Fro ntotemporal bone nap, 39-
40
G Hydrocephalus. commu nicat-
Gigli saw, 3, 24, 40
Gyrus rectus, 65, 98, 105, 120,
123, 124. 128, 16 1, 178
initial exposu re o f, 124, 132-
13'
le ft, 114, 137, 142, 14 7-149,
155-156, 158. 162- 163
medial surface o f, 133
rig ht, 112, 11 4. 133, 136,
146- 147,151. 155- 156
ve in on, 99, 143
H fro m posterior communicat-
Hayes, George, 5
Head holder, 13-16
Hemorrhage, suba rach noid
and adhesions in arachnoid
sheath of thalamic per-
foralOrs, 170, 182- 183
thicke ned arach noid mem-
bra ne of Liliequ ist fro m,
170. 176
and xanthoch romic pigment
from hemoglobin, 15 1
Heu bner recurrent arte ry, 57,
80-8 1,9 1. 102, 105,108,
113, 134- 135, 142- 143,
Index
14 7, 152- 155, 158. 170-
171,200
adherent to aneurysm al ca-
rotid arte ry bifu rcation,
85
cOlllmo n trunk with right
fromopolar artery. 126.
15 1
course o f, 127, 164
variations in, 125
large size of, 125, 14 6, 149
left, 133, 136- 137, 140, 144,
149, 157,159, 162- 163
perfo rato r fro m, 83
relation to anterior cerebral
a rtery. 95
right, 136- 137. 139, 144,
150, 157, 163
Heuer, George, 4 , 5
History o f pte riona! a pproach,
1-7
cranial saws in, 2-3
hypophyseal nap in , 5-6
osteoplastic method o f Wag-
ner, 1-2
skin incisio ns in , 7
tre phine and melal guide of
de Martel in, 3-4
ing, 94
Hypoph y.seal a pproach of
Heucr a nd Dandy. 4, 5-
6 ap proaches to. 170. 184-185
Hypo physeal a rtery, su perior,
79,84, 95, 99, 102. 106,
120
Hypophyseal cistern , 125. 138,
14 1, 169
Hypophyseal perforators
from imernal carotid artery,
95,99, 11 5, 125, 138
arachno id sheath o f, 120
ing artcry, 95, 102
Hypothala mic perforato rs
from internal carotid artery.
81,95, 102- 103, 106,
11 8, 14 8, 159, 179
from posterio r commun icat-
ing artery, 95, 102-103
stuck to anterior commu ni-
cating artery aneu rysm,
125, 149
Hypothalamus. mammillary
body of, 166, 169,
17 1
Hyrtl's ca nal, 4 1
205
I
Incisions in skin, 7. 39, 46
Instrumentation, 11-30
bone-removal, 24
d issccting, 29, 30
electroca u tery, 24-26, 39,
40-4 1
external, 13-22
fishhook retracto rs, 22-23,
39, 48
intraoperative, 22-30
jewelers' fo rceps, 27, 29, 56,
62
mirrors, 29
opcrating microscope, 16-22
overhead table, 22
retf3clOrs, 26-27. 28. 48. 5 1-
52,56,58
scissors, 27, 29, 68, 74
suction and suctioll-i rrigatio n
devices, 23-24, 4 1
surgeon's chair, 16
television systcms. 22
Inte rhe mispheric fiss ure (cis-
te rn), 123, 124. 133, 142,
147, 158, 169
arach noid covcring of, 144,
150, 153-- 155. 160
Interpedu ncu la r cistern , 69,
9l-94, 14 1, 152, 165-
200
anatomy of, 165- 173, 199
basilar artery bifurcation in.
189
cente r of, 172, 187, 194-
196
fro nlOlateral ro ute 10, 98
j unCtio n with a mbient and
C.t rOlid cisterns. 169.
172,190, 192
right lateral ponion of, 185-
186
Interpeduncu la r fossa o f mid-
brain, 17 1
Irrigating flu id , 23--24
J
J ewelers' forceps. 27, 29, 56, 62
K
Kempe. Ludwig, 6, 39
Kcy and Retzius membra ne. Set
Arachnoid membrane o f
Lilieq uist
206
L le ft , 114. 180- 18 1, 188,200
Lacrimal artery, 5 1
Lamina lerminalis, 85, 112-
11 3, 123. 124, 125, 133-
148, 150- 151 , 155- 160,
162- 163, 192, 197
anatomy 0[, 172, 199
Lamina terminalis cistern, 93,
125, 134- 136, 144 , 149,
169
anatomy of, 160-- 162
arachnoid bands at margin
of, 125, 141
structures in, 126
Liliequist membrane. See Arach-
noid mem brane of Lilie-
quist
M lower portion of, 128
Mammillary body of hypot hala-
mus, 166, 169, 171
Medu lla oblongata, 17 1
Medu llary perforators from
basilar artery. 115, 177
Meningo-orbital artery. 41, 5 1
Microscissors. 27.29.68, 74
Microscope, operating, 16-22
advantages of, 17- 18
disadvantages of, 17
Midbrain
anatomy of, 165, 166
interpeduncular fossa of, 171
peduncle of (pyramidal
tract), 169, 171- 172, 189
left. medial side of, 177 ,
180- 181
Mirrors at tip o f probes, 29
o Optic cistern, 124
Obalinski, Alfred, 3
Ocu lomotor nerves, 65, 69, 94,
98-100, 102. 104, 106-
110, 11 2, 11 5, 12 1, 152,
169, 176, 178- 179.182-
183. 185. 187, 190, 193-
194, 196, 199
adhesion to carotid artery
aneurysm, III
adhesion to uncus of tempo-
ral lobe, 170, 184
angulation of, 83
base of, 175
course of, 172
entering cavernous sinus,
170,174,192,195
Index
origins of, 165
oSlium o f, 167, 174
relation to basilar artery bi-
furcatio n. 19 1
right, 114 , 166. 171, 177,
180- 18 1, 188,200
separating superior cerebellar
artery. 172, 186
Oculomotor trigone, 167, 172
Olfactory bulb, 124, 131
O lfactory cistern , 123, 124,
129
Olfactory nerves, 124
Olfactory stria, medial and lat-
eral, 124
Olfactory trace, 53, 95, 98--99.
102, 105, 124, 132-133,
155, 17 1
left. 158-- 159
middle portion of, 129
rig ht, 156
upper portion of, 130, 13 1
Operating microscope, 16-22
Operating room table. 13
Ophthalmic artery, 95
left, 148
origin of, 104, 148
Optic canal, 38, 167
dural margin of, 128
Optic chiasm, 80-84, 9 1, 106,
112, 11 4, 11 7- 120, 123,
133, 136, 140- 144, 146-
152. 154-156, 158, 160,
162, 166,179,192,197,
199
lateral side of, 157
prefi xed, 124 , 125-126, 134-
135, 150
Optic nerves, 52, 66, 69, 77,
82-83, 100-101, 103-
105, 107- 108, 110, 112,
11 4, 11 8-- 120, 167.175,
182- 184. 186-187, 194-
195
arachnoid band over, 67
arachno id between, 98--99,
102, 11 6, 132- 134,148,
160
arachnoid covering of, 53. 74
lateral portion in carotid cis-
tern, 123
left, 106, 117, 133, 138, 140-
143, 146- 152, 154-156,
158--160,162, 192, 199
in orbit, 124
right, 98-99, 102, 106, 11 6-
117.121, 128,133.138,
141 - 14 3, 146-- 150,152,
154- 160,162,171, 174,
176, 179- 181 . 192,199
unusual relation to posterior
clinoid process, 170, 178
Optic tract, 79-85, 89-9 1, 106,
108- 110, 11 5, 120, 123,
135-136, 145,150- 15 1,
154, 161- 163, 169,179,
185-186, 194-195, 197-
198, 200
adhesion to frontal lobe, 104
right, 112, 114 , 118, 133,
138--1 44 , 146-- 149, 152,
155-159, 192, 199
terminus of, 165
view to inte rnal carotid ar-
tery, 103
Orbit
dura covering roof projec-
tions, 129, 13 1
in surgical position, 42-45
Orbital fissure, superior. 38
O rbital gyrus, medial. 123, 124
p
Parietosphenoidal suture line,
1,37
Parictotemporal suture line, I,
37
Peduncles
cerebellar, middle, 17 1
cerebral, 166
interpedu ncular cistern. Set
Interpeduncular cistern
midbrain. 169, 171-172, 189
Perforated substance, anterior,
9.
front border of, 124
perforators to, 57, 79, 84, 89,
118
Perforating arteries
on aneurysm dome, 78
from anterior cerebral A- I
artery, 57. 79-80, 82, 84,
92,106, 14 1- 142, 16 1-
163,170,184,186, 199
from anterior choroidal ar-
tery, 183
from anterior communicating
artery, 11 2, 157
to anterior perforated sub-
stance, 57, 79, 84, 89, 11 8
 Index 207

arachnoid fibers from, 57, Q Sylvian aqueduct, 166

90
from artery of Heubner, 83
hypo physeal. Su Hypophy-
seal perforators
hypothalamic. Su Hypotha-
lamic perforatOrs
from internal carotid artery.
Su Carotid artery. inter-
nal, perforators from
medu llary, from basilar ar-
tery, 115, 177
from middle cerebral M- I ar-
tery, 57, 79-81, 89-92,
125 , 146-147,170,181,
184-187, 190-191, 200
from posterior cerebral arter-
Quadrangular zone in chias·
matic ciste rn , 124. 133-
163
Quadrigeminal cistern , 169
Quadrigeminal plate, 166
R surgical opening of, 56-91
Raney dips, 47
Recurrent artery o f Heubner.
Set Heubner recurrent
artery
Reil island, 7 1
Retractors, 26-27, 28, 48, 5 1-
52, 56, 58
fishhook, 22-23, 39, 48
Sylvian fissure (cistern), 52, 55-
92.93-94, 123
anatomy of. 56-57
arachnoid over, 146
dura over, 50
lateral, 169
medial, 169
union with chiasmatic and
ambient ciSlern, 169
veins in, 63, 66, 75-76, 78
branches of, 59
Sympathetic fibers on internal
carotid artery, 96, 116

''
P_I, 165, 168, 188, 195
P-2, 186, 190-19 1
from posterior com municat-
ing artery. Su Commu-
nicating artery, posterior,
perforators from
stria thalam ic, 57, 89-92
thalamic. See Thalamic per·
foralO rs
Pericallosal cistern, 123
Periosteal patch elevated from
frontal bone, 39, 47
Petrous pyram id , 42-45
PhoLOgraphy, 33-35
current techniques in, 34-35
Pituitary gland, 97, 118, 140,
171
in fu ndibulum of. 166
Pituitary stalk , 82, 95-96, 102.
104, 106, 11 0, 114 , 119,
12 1,125, 138, 140- 14 1,
146,149
opening for, in diaphragm
sellae, 167
portal veins of, 11 8
surrounded by arach noid,
125, 138, 147-148, 169
Pons
rostral paft of, 115, 170, 172,
174-175,179-1 8 1,186-
187, 190-192, 194- 196
trigeminal nerve arising
from, 171
Positioning of patient, 39
importance of, II , 16
Prepontine cistern, 193, 194
Psychopathic point, 6, 39
Pterion, defin ition of, 1,37
Pterygoid plates, 38
self· retaining. 26-27
Rongeurs, 24, 40
Rosenthal vein , basilar, 165,
T
Table
operating room, 13
174 overhead , 22
Television systems, 22
Temporal arteries
S anterior, 70, 75, 77-79, 83,
Saws, cranial, development of, 88-89,9 1, 100, 134, 147,
2-3, 24, 40 184,19 1
Scalp nap, 39. 47-48 duplicated. 190
Scissors, types of, 27, 29, 68, 74 from middle cerebral arter-
Sella turcica, 37-38 ies, 70
Skin incisions, 7, 39, 46 M·I, 75, 89
Skull fixation, three·poim, 13- M-2. 6 1,76,80,88, 146
16,39 aneurysm nanked by, 78,
Sphenoid wings, 37, 38, 42-43, 79
45 posterior, 76
dura over, 65, 68, 72. 86 superficial . 40
prior to removal, 49-50 Temporal lobe, 53, 56, 58-59,
removal of, 39, 40-41 6 1-62,65-66.69-70,74,
Sphenoidotemporal suture line, 85-87,9 1,186
1,37 ad hesions
Sphenoparietal sinus, bridging with carotid artery, 100
veins to temporal lobe, with frontal lobe, 56, 71
41,56,66.74 aneurysm dome in , 75
electrocoagulation of. 56, 68 bridgi ng veins to sphenopa.
Stria thalamic perforators, 57. rictal si nus, 41,56.66,74
89-92 electrocoagulation of. 56,
Subarachnoid hemorrhage 68
and adhesions in arach noid dura of, 49-50
sheath of thalamic per- elevation of, 52
foralOrs, 170, 182-183 left, medial side of, 11 7, 119,
thickened arachnoid memo 171
brane of Liliequist from , medial , 169
170, 176 right, 120
and xanthochromic pigment uncus of, 69, 102, 108-109,
from hemoglobin. 151 11 2- 113, 115, 121, 152,
Suction and suction.irrigation 174-1 75, 178, 180-183,
devices, 23-24, 4 I 185, 192-193, 197-198,
Sutu re lines of skull, 1,37 200
208
Tcmporal lobe (conI.)
adherence to oculomotor
nerve, 170, 184
left, medial side of, 117
relation to anterior choroi-
dal artery, 95, 105
retractio n of, 83
vein on, 128
Temporalis muscle. incision of,
39,47
T entorium cerebcUi, 166
anterior reflection of, 99, 162
attach ments to clinoid pro-
cesses, 165
carotid artery aneurysm
adhesion to, 101
edge or margin of, 68, 105,
107-108, 11 0, 114 , 116,
121 , 134,174, 176, 184-
187,189.194,196--197
incisura of, 166
medial reflections of, 167
Thalamic perforators
alllerior
from internal carotid ar-
tery, 95, \02- \03, 172,
179
in arachnoid sheath, 120
from posterio r communi-
cating artery. 82-83, 95,
102-103, 109-110,170,
172,174,176,180, 184,
187, 190. 192, 197- 198
adhesions in arachnoid
sheath of, 170, 182-
183
in arach noid sheath . 198
posterior, from posterio r ce-
rebral arteries
P_I. 165, 168, 18 1. 188. 195
P-2. 186, 190- 191
Index
Third ventricle, 145
cerebrospinal fluid in, 169
relation to basilar artery, 168
Toison , J ean, 2-3
Tremor. reduction of, 29
Trephines, d evelopment of, 3-
4 and olfactory cistern ,
Trigeminal ne rve. right, a rising
from pons, 171
Trochlear nerve, 165, 166
ostium of, 167
Tuberculum sellae, 37-38, 43-
44,117,135, 148, ISS,
159
U relation 10 basilar artery, 168
Uncus of temporal lobe, 69,
102, 108--109, 11 2- 113,
115, 121,152,174-175,
178, 180- 183,185,192-
193, 197-198,200
adherence 10 oculomotor
nerve, 170, 184
left, medial side o f, 117
relation to anterior choroidal
artery, 95, 105
retraction of, 83
V Xanthochromic pigment from
Veins
in ambient cistern , 174- 175,
178
basilar, of Rosenthal, 165,
174
in carotid ciste rn, 110
in cavernous si nus, unusual,
97,1 18--119
in chiasmatic ciste rn , 163
on gyrus rectus, 99, 143
in interpeduncular cistern ,
190- 191,200
in lamina te rminalis cistern ,
127, 161
portal, of pituitary stal k, 11 8
in sulcus belween frontal lobe
129
in sylvian fissure, 59, 63, 66,
75-76, 78
o n temporal lobe, 128
Venous d rainage, preservation
of,41
Venous sinus, dural, 114- 115
Ventricle, third, 145
cerebrospinal fluid in , 169
Vertebral arteries, 17 1
Von Bergma nn , Ernst, 2
W
Wagner. Wilhelm, 1-2,3
Willis circle
posterior, 18 1
relation 10 posterior clinoid
process, 167
X
hemoglobin of subarach-
noid hemorrhage, 151
y
Yasargil, Gazi, 6-7, 16
Z
Zygoma. frOll tal process of, 44