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Anatomical Basis of Cranial Neurosurgery

Wolfgang Seeger  •  Josef Zentner

Anatomical Basis of Cranial


Neurosurgery

ERRNVPHGLFRVRUJ
Wolfgang Seeger Josef Zentner
Linden Department of Neurosurgery
Germany University Medical Center Freiburg
Freiburg
Germany

ISBN 978-3-319-63596-5    ISBN 978-3-319-63597-2 (eBook)


https://doi.org/10.1007/978-3-319-63597-2

Library of Congress Control Number: 2018933375

© Springer International Publishing AG 2018


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Dedicated to
Gazi M. Yaşargil
Preface

The main intention for writing this book is to help training neurosurgeons and their colleagues
of related disciplines to combine the modern conventional anatomy with the special anatomi-
cal aspects of brain surgery. Imaging methods, especially neuronavigation, make better and
more spatial presentations in vivo possible than by using conventional anatomical dissections.
Nevertheless, many anatomical details, which are essential for neurosurgery, are not suffi-
ciently presentable by imaging methods and need supporting by modern anatomical presenta-
tions. This may be perceptible by all five parts of this book:

–– Angiographic presentations prefer exact imagings of vessels, omitting adjacent structures.


For training neurosurgeons, topographical landmarks and common variants of vessels
should be added, combined with presentations of surrounding cerebral structures. After
this, vessels and cranial nerves should be presented together with cisternal walls. At an
early stage of the anatomo-surgical training, young neurosurgeons would more easily
understand the topography, especially during its assisting at operations, performed by expe-
rienced neurosurgeons.
–– Further aspects are topographical errors at the interpretation of imaging findings. Using
topographical landmarks, some errors could be avoided.
–– A third aspect are anatomical details which are important during surgery, but not exact to
define by imagings. These details can be presented by illustrations of anatomical
dissections.

It seems to be useful at the beginning of anatomo-surgical descriptions to present an intra-


cranial region, which is often approached by multiple surgical routes. These preconditions are
given by presenting the frontal region. After this will follow further parts about the temporal,
parietal, occipital, and suboccipital region.
Special aspects of the frontal part are as follows:

–– The motor cortex and the pyramidal tract


–– The frontal limbic cortex
–– Cornu anterius of the lateral ventricle and third ventricle and surrounding structures

Special aspects of the temporal part are as follows:

–– Limbic and neocortical structures according to amygdalohippocampectomy and other


methods of the temporal epilepsy surgery
–– Temporobasal approaches for cisternal approaches (and amygdalohippocampectomy)

Special aspects of the parietal part are as follows:

–– The Sylvian region of the parietal lobe


–– The midline region according to the region of sinus sagittalis superior and to surgical
approaches transpassing interfornical to the third ventricle

vii
viii Preface

Special aspects of the occipital part are as follows:

–– Confluens sinuum and adjacent structures


–– Galenic area
–– The optic system

Special aspects of the infratentorial part are as follows:

–– Extradural structures for avoiding bleeding, air embolism, and problems of wound healing
after surgery
–– The central cerebellar region
–– The intrasurgical landmarks at the surface of the middle and caudal brainstem
–– The microanatomy of the middle and caudal brainstem with presentations of the relation-
ships between nuclei, fibers, and intrarhombencephalic arteries

This book is a summary of life-long surgical experiences of Wolfgang Seeger and of his
experiences by giving anatomical training lectures on surgery at numerous neurosurgical
departments. It was supported by anatomical brain dissections and by the drawings of Wolfgang
Seeger. The drawings in this book are mainly developed in the last 10 years and in the publica-
tions of Wolfgang Seeger since 1978. All drawings are now presented schematized in order to
facilitate understanding by younger neurosurgeons.
After that, this book has been improved considerably by Josef Zentner. He and his co-­
workers demonstrated and discussed surgical approaches in the operating room, especially
before and after surgery. In this book, some surgical approaches were presented by both
authors, especially surgery at the limbic areas and frontal, temporal, and parietal
craniotomies.
Both authors are thankful for many motivations by many colleagues and their co-workers,
especially of the Neurosurgical Clinic, Freiburg, and further H.R. Eggert and his successor
W. Deinsberger, J.M. Gilsbach, A.G. Harders, R. Oeckler, and J.P. Warnke. Karen Seeger
always has been a helpful corrector of imperfections in the English language of this book.

Freiburg, Germany Wolfgang Seeger


Freiburg, Germany Josef Zentner
October 2016
Contents

Part I  Frontal Region

1 Diagnostic Base���������������������������������������������������������������������������������������������������������    3


1.1 Landmarks�����������������������������������������������������������������������������������������������������������   3
1.2 Radiology�������������������������������������������������������������������������������������������������������������   5
1.3 Further Imaging���������������������������������������������������������������������������������������������������   9
2 Anatomical Base of Surgery�������������������������������������������������������������������������������������   19
2.1 Extradural Topography and Dural Veins�������������������������������������������������������������  19
2.2 Intradural Topography�����������������������������������������������������������������������������������������  26
2.2.1 Survey �����������������������������������������������������������������������������������������������������  26
2.2.2 Superficial Structures and Structures in the Depth ���������������������������������  34
2.2.3 Midline Structures�����������������������������������������������������������������������������������  41
2.2.4 Third Ventricle�����������������������������������������������������������������������������������������  51
2.2.5 Frontobasal and Frontotemporobasal Structures�������������������������������������  54
3 Special Surgical Aspects�������������������������������������������������������������������������������������������   75
3.1 Extradural Topography ���������������������������������������������������������������������������������������  75
3.1.1 Surgical Routes ���������������������������������������������������������������������������������������  75
3.1.2 Extracranial Surgical Aspects �����������������������������������������������������������������  76
3.1.3 Craniotomies �������������������������������������������������������������������������������������������  78
3.2 Intradural Topography�����������������������������������������������������������������������������������������  83
3.2.1 Topographical Aspects of Superficial and Deep Approaches�����������������  83
3.2.2 Topographical Aspects of Midline Approaches���������������������������������������  90
3.2.3 Topographical Aspects of Approaches to the Third Ventricle����������������� 100
3.2.4 Topographical Aspects of Frontotemporal (Pterional)
and Frontobasal Approaches������������������������������������������������������������������� 109
4 Completion for Chapters 1 to 3: Topographical Areas
of Rhinoliquorrhea���������������������������������������������������������������������������������������������������  125

Part II  Temporal Region

5 Diagnostic Base���������������������������������������������������������������������������������������������������������  139


5.1 Landmarks����������������������������������������������������������������������������������������������������������� 139
5.2 Radiology������������������������������������������������������������������������������������������������������������� 141
5.3 Further Imaging��������������������������������������������������������������������������������������������������� 145
6 Anatomical Base of Surgery�������������������������������������������������������������������������������������  151
6.1 Extradural Topography ��������������������������������������������������������������������������������������� 151
6.2 Intradural Topography����������������������������������������������������������������������������������������� 154
6.2.1 Survey ����������������������������������������������������������������������������������������������������� 154
6.2.2 Lateral Structures������������������������������������������������������������������������������������� 163
6.2.3 Sylvian Structures ����������������������������������������������������������������������������������� 165
6.2.4 Temporal Allocortex ������������������������������������������������������������������������������� 169
ix

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x Contents

7 Special Surgical Aspects�������������������������������������������������������������������������������������������  177


7.1 Extradural Surgery����������������������������������������������������������������������������������������������� 177
7.2 Intradural Surgery ����������������������������������������������������������������������������������������������� 179
7.2.1 Standard Resections of Lobus Temporalis����������������������������������������������� 179
7.2.2 Amygdalohippocampectomy������������������������������������������������������������������� 182
7.2.3 Subtemporal Surgical Approaches to Basal Cisterns������������������������������� 194

Part III  Parietal Region

8 Diagnostic Base���������������������������������������������������������������������������������������������������������  199


8.1 Landmarks����������������������������������������������������������������������������������������������������������� 199
8.2 Radiology������������������������������������������������������������������������������������������������������������� 201
8.3 Further Imaging��������������������������������������������������������������������������������������������������� 205
9 Anatomical Base of Surgery�������������������������������������������������������������������������������������  211
9.1 Extradural Topography ��������������������������������������������������������������������������������������� 211
9.1.1 Extracranial Layers ��������������������������������������������������������������������������������� 211
9.1.2 Skull��������������������������������������������������������������������������������������������������������� 212
9.1.3 Sinus Sagittalis Superior������������������������������������������������������������������������� 214
9.1.4 Dural Sinuses and Its Intradural Connections����������������������������������������� 217
9.2 Intradural Topography����������������������������������������������������������������������������������������� 220
9.2.1 Survey ����������������������������������������������������������������������������������������������������� 220
9.2.2 Lateral Structures������������������������������������������������������������������������������������� 227
9.2.3 Midline Structures����������������������������������������������������������������������������������� 233
10 Special Surgical Aspects�������������������������������������������������������������������������������������������  237
10.1 Extradural Surgery��������������������������������������������������������������������������������������������� 237
10.2 Intradural Surgery ��������������������������������������������������������������������������������������������� 239
10.2.1 Surgical Aspects of Lateral Approaches��������������������������������������������� 239
10.2.2 Surgical Aspects of Midline Approaches ������������������������������������������� 241

Part IV  Occipital Region

11 Diagnostic Base���������������������������������������������������������������������������������������������������������  249


11.1 Landmarks��������������������������������������������������������������������������������������������������������� 249
11.2 Radiology����������������������������������������������������������������������������������������������������������� 251
11.3 Further Imaging������������������������������������������������������������������������������������������������� 254
12 Anatomical Base of Surgery�������������������������������������������������������������������������������������  259
12.1 Extradural Topography ������������������������������������������������������������������������������������� 259
12.2 Intradural Topography��������������������������������������������������������������������������������������� 268
12.2.1 Survey ������������������������������������������������������������������������������������������������� 268
12.2.2 Superficial and Profound Structures ��������������������������������������������������� 272
13 Special Surgical Aspects�������������������������������������������������������������������������������������������  283
13.1 Extradural Topography ������������������������������������������������������������������������������������� 283
13.1.1 Skin-Galea-Incision����������������������������������������������������������������������������� 283
13.1.2 Craniotomy ����������������������������������������������������������������������������������������� 284
13.2 Intradural����������������������������������������������������������������������������������������������������������� 285
13.2.1 Intraventricular Bleeding��������������������������������������������������������������������� 285
13.2.2 Surgical Topography ��������������������������������������������������������������������������� 286
13.2.3 Puncture of Cornu Post ����������������������������������������������������������������������� 287

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Contents xi

Part V  Infratentorial Region

14 Diagnostic Base���������������������������������������������������������������������������������������������������������  293


14.1 Landmarks��������������������������������������������������������������������������������������������������������� 293
14.2 Radiology����������������������������������������������������������������������������������������������������������� 295
14.3 Further Imaging������������������������������������������������������������������������������������������������� 298
15 Anatomical Base for Surgery�����������������������������������������������������������������������������������  307
15.1 Extradural Topography ������������������������������������������������������������������������������������� 307
15.1.1 Extracranial Layers ����������������������������������������������������������������������������� 307
15.1.2 Skull and Atlantoaxial Region������������������������������������������������������������� 310
15.1.3 Dura and  Sinuses��������������������������������������������������������������������������������� 314
15.2 Intradural Topography��������������������������������������������������������������������������������������� 317
15.2.1 Survey ������������������������������������������������������������������������������������������������� 317
15.2.2 Posterior Structures Superior to the Brain Stem ��������������������������������� 328
15.2.3 Basal Cisterns, Variants, and Adjacent Structures������������������������������� 340
15.2.4 Cisterna Tecti and Fissura Horizontalis Cerebelli������������������������������� 359
15.2.5 Intracerebellar Structures��������������������������������������������������������������������� 366
15.2.6 Middle and Inferior Brain Stem. Fibers and Nuclei (Microanatomy
According to Nieuwenhuys, Voogd, van Huiyzen 1990, Modified
for Neurosurgery)��������������������������������������������������������������������������������� 373
15.2.7 Vessels of the Middle and Inferior Brain Stem����������������������������������� 416
16 Special Surgical Aspects�������������������������������������������������������������������������������������������  421
16.1 Extra- and Intracranial Topography������������������������������������������������������������������� 421
16.1.1 Craniotomies for Routes and Target Areas ����������������������������������������� 421
16.1.2 Surgical Aspects of Posterior Midline Approaches����������������������������� 422
16.1.3 Surgical Approaches to Cisterna Medullaris Lat. and Cisterna
Pontocerebellaris��������������������������������������������������������������������������������� 431
16.1.4 Surgical Aspects for Approaches to Cisterna Medullaris Medialis
and Lateralis����������������������������������������������������������������������������������������� 445
16.1.5 Supracerebellar Surgical Approaches to Cisterna
Tecti and Adjacent CSF Spaces����������������������������������������������������������� 449
References �������������������������������������������������������������������������������������������������������������������������  453
Index�����������������������������������������������������������������������������������������������������������������������������������  457

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Part I
Frontal Region

1.1 Introduction

This introduction to Part I contains a short summary of each chapter and of the completion to
Chapters 1–3.

1.2 Chapter 1 Diagnostic Base

It presents an introduction for diagnostic principles:

–– For planning surgical approaches are presented extra- and intracranial landmarks. It may
help to define craniocerebral structures and of the motor cortex.
–– Vessels are simplified presented for understanding its variability later on.
–– MRTs and neuronavigation are combined with landmarks. Fine structures are added which
are essential for surgery but often not sufficient defined at imaging.

1.3 Chapter 2 Anatomical Base of Surgery

It contents extracranial layers, dural structures, intracerebral structures, and cisterns according
to surgery:

–– Galea aponeurotica and its adjacent extracranial layers are presented according to the pres-
ervation of its nerves and vessels at surgical approaches, especially N. VII and supraorbital
vessels and nerves.
–– The numerous variants of bridging veins are essential anatomical components between
dura and cortex. Interruptions of veins and its variants could be dangerous even for cerebral
areas, which may be located far distant to the surgical approach. Another aspect is the
avoiding damage of N. olfactorius by considering its subdural and subarachnoidal course
and endangering bulbus olfactorius by overlying bones during surgery.
–– Defining of the motor cortex using landmarks: The topography of the motor cortex is better
to define, if landmarks and imaging are presented first. After this, exact neurophysiological
methods can be performed easier.
–– Preservation of allocortical (limbic) structures surrounding corpus callosum. Lesions could
be followed by psychological deficits.
–– An essential surgical problem is the consequent preservation of cisternal arachnoid mem-
branes and of fine perforating feeding vessels of basal ganglia, pyramidal tract, and hypo-
thalamus. This principle must be taken in consideration at surgical approaches to all basal
cisterns, not only at the frontobasal region.

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2   Frontal Region

1.4 Chapter 3 Special Surgical Aspects

–– Operations at the frontal lobe are often the first large surgical operations which are performed by training
neurosurgeons. Structures in the depth must be well known. Here is presented the example of a surgical
approach between insula and cornu anterius, close to basal ganglia and other essential adjacent structures
in the depth.
–– Midline approaches to cisterna corporis callosi and the third ventricle are presented. Favorable and less
favorable aspects of midline approaches and transcortical endoscopic approaches to the third ventricle
are discussed according to the preservation of allocortex (stria longitudinalis cinguli and fornix).
–– Callosotomy is a palliative treatment modality for severe epilepsies which prevents propagation of epi-
leptic activity from one to the other hemisphere.
–– The principles of frontotemporal (pterional) basal approaches are presented. Difficult to understand are
the sylvian arachnoid walls, Liliequist’s membrane, the topography of the carotid cistern, and adjacent
structures. For surgery, the high variability of arteries has to be considered, especially Heubner’s artery
and A. corporis callosi mediana, according to its perforating branches. Heubner’s artery may be mixed
with other arteries. For a better understanding of these aspects, the structures are presented by schematic
drawings on the base of Yaşargil’s findings at surgery and of Rhoton’s photographs of anatomical
dissections.

1.5  hapter 4 Completion for Chapters 1 to 3: Topographical Areas


C
of Rhinoliquorrhea

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Diagnostic Base
1

1.1 Landmarks (Figs. 1.1 and 1.2)

na

br

fz
st

pt

zy

Fig. 1.1  Lateral and dorsal bony landmarks for planning frontal and temporalis during innervation and palpation of sutura frontalis, which is
frontotemporal surgical approaches. Defining by palpation: fz frontozy- usually thickened at this point), zy angle of os zygomaticum. Defining
gomatic point, na nasion, st stephanion (palpation of the margin of M. by imaging: br bregma, pt pterion

© Springer International Publishing AG 2018 3


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_1

ERRNVPHGLFRVRUJ
4 1  Diagnostic Base

cg

pt

fo

pc

ds
fv

anterior basal
segment of Insula

Impressio
Gyrus front. 3 of Pars
Pars orbitalis orbitalis

<
5
m
m

Fig. 1.2  Fossa cranii anterior and frontal cerebral base are not congruent. Gyrus frontalis 3 (pars orbitalis) is overlying ala minor and the temporal
pole. cg crista galli, ds dorsum sellae, fo foramen opticum, fv foramen ovale, pc processus clinoideus anterior, pt pterion

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1.2 Radiology 5

1.2 Radiology (Figs. 1.3, 1.4, 1.5, and 1.6)

3
5
6 2
7

5
2
6
7 1

Fig. 1.3  Arteriography. (a) 1 A. carotis interna, 2 A1 (proximal seg- A. carotis interna; 2 A2; 3 A. callosomarginalis; 4 A. pericallosa; 5 A.
ment of A. cerebri anterior), 3 A. communicans anterior, 4 A2 (distal cerebri media, distal trunk; 6 A. operculofrontalis; 7 A. cerebri media,
segment of A. cerebri anterior), 5 A. cerebri media, distal branch, 6 A. proximal trunk
operculofrontalis, 7 A. cerebri media, proximal trunk; (b) 1 siphon of

ERRNVPHGLFRVRUJ
6 1  Diagnostic Base

6
5

b 7

2
8

1
9

10

11

12

13
14

Fig. 1.4  Phlebography. Interruption of larger veins could be danger- (Browder and Kaplan 1976) (variant, dangerous for surgery), 2 angulus
ous, not only interruptions of well-known veins, e.g., the rolandic vein, venosus, 3 V. cerebri interna, 4 V. thalamostriata, 5 vein(s) of the pre-
vein of Labbé, and inner cerebral veins. (a) 1 Bulbus superior of V. central region, 6 central and postcentral veins, 7 sinus sagittalis inferior,
jugularis interna, 2 sinus sigmoideus, 3 knee of sinus transversus, 4 8 galenic point, 9 sinus rectus, 10 confluens sinuum, 11 galenic vein, 12
vein of Labbé, 5 sinus transversus, 6 confluens sinuum, 7 V. basalis of sinus sigmoideus, 13 V. basalis (Rosenthal), 14 temporal choroid point
Rosenthal, 8 V. cerebri interna; (b) 1 frontal bundle of bridging veins

ERRNVPHGLFRVRUJ
1.2 Radiology 7

4
6 3

1
9

Fig. 1.5  MRT, coronal level of Commissura ant. Details added, which tus, 6 foramen interventriculare (Monroi), 7 commissura anterior, 8
are not always sufficient defined by imaging methods. 1 Amygdala, 2 substantia perforata anterior, 9 limen insulae
globus pallidus, 3 putamen, 4 knee of capsula interna, 5 nucleus cauda-

ERRNVPHGLFRVRUJ
8 1  Diagnostic Base

A
B

A
B

a b

2
3

2
3 4 5

Fig. 1.6  MRT. Sagittal slices of the region of insula. (a) 1 Gyrus frontalis 3, pars orbitalis, 2 insula, 3 sulcus inferior insulae. (b) 1 Insula, anterior
region, 2 sulcus (fissura) lateralis (sylvii), 3 putamen, 4 amygdala, 5 cornu inferius

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1.3 Further Imaging 9

1.3 Further Imaging (Figs. 1.7, 1.8, 1.9, 1.10, 1.11, 1.12, 1.13, 1.14, and 1.15)

C
D

D C

a 1
b

3
4
5

Fig. 1.7  Continuation of Fig. 1.6. Region of cornu anterius and midline structures. (a) 1 Thalamus, 2 capsula interna, 3 A. cerebri posterior, 4 N.
oculomotorius, 5 N. opticus; (b) dotted: intercommissural line

ERRNVPHGLFRVRUJ
10 1  Diagnostic Base

br
1
a
2

sc
4

la

na

po
om

b 3 2

sc

ic

Fig. 1.8  Lobus frontalis is far extended to the parietal area of the skull. triangularis; 4 as 2, pars orbitalis. (b) ic intercommissural line, sc sulcus
This can be presented by neuronavigation and marked by landmarks. centralis. 1 Gyrus cinguli, 2 gyrus frontalis 1, 3 lobulus paracentra-
(a) br bregma, la lambda, na nasion, om orbitomeatal line, po porion, sc lis. + The medial limit between lobus frontalis and parietalis is exact to
sulcus centralis, lateral limit between lobus frontalis and parietalis. 1 define at the dorsal point of sulcus centralis – sc
Gyrus praecentralis; 2 gyrus frontalis 3, pars opercularis; 3 as 2, pars

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1.3 Further Imaging 11

10
a
9
8
A 7
B 6
5

11 4
3

6
5
b 4
3

Fig. 1.9  Ventriculus lateralis neuronavigation modified and details 10 gyrus cinguli, 11 V. thalamostriata; (b) 1 knee of capsula interna, 2
added. (a) 1 V. ventriculi lateralis directa, common variant (Huang and sulcus lat. (Sylvii), 3 claustrum, 4 putamen, 5 crus anterius of capsula
Wolf 1974b), 2 taenia chorioidea ventriculi III, 3 thalamus, 4 For. inter- interna, 6 caput nuclei caudati, 7 columna fornicis, 8 For. interventricu-
ventriculare (Monroi), 5 stria terminalis, 6 cavum septi pellucidi, 7 lare (Monroi)
caput nuclei caudati, 8 Vv. longitudinales, 9 stria longitudinalis cinguli,

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12 1  Diagnostic Base

11
a

10
9
8
7
6
5

4
3
2
1

b
9

7
6

3
2
1

Fig. 1.10  Continuation of Fig. 1.9. (a) 1 Globus pallidus, 2 cortex of cis. (b). 1 Corpus mamillare, 2 tractus opticus, 3 recessus infundibuli, 4
insula, 3 putamen, 4 sulcus inferior insulae, 5 adhesio interthalamica, 6 carotid bifurcation, 5 recessus opticus, 6 A. communicans anterior, 7
sulcus superior insulae, 7 knee of capsula interna, 8 claustrum, 9 crus A2, 8 margin of falx, 9 gyrus rectus
anterius of capsula interna, 10 commissura anterior, 11 columna forni-

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1.3 Further Imaging 13

Fig. 1.11  Anatomical dissection similar to neuronavigation

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14 1  Diagnostic Base

Fig. 1.12  Addendum for Fig. 1.11. 1 A2, 2 A. pericallosa, 3 A. callosomarginalis, 4 A. frontopolaris, 5 medial frontobasal artery

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1.3 Further Imaging 15

A B C D E

Bregma
E

D E
B C
A

Cornu Foramen Commiss. Corpora Commiss.


ant. opt. ant mamillaria post

Fig. 1.13  Drawings of the skull and brain according to neuronavigation. Topograms for Figs. 1.14 and 1.15

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16 1  Diagnostic Base

topogram
a

B C D E
A

b c

d e

Fig. 1.14  Continuation of Fig. 1.13. Coronal, axial, and sagittal planes combined. (a) Tip of cornu anterius, (b) level between bregma and foram-
ina optica, (c) commissura anterior, (d) corpora mammillaria, (e) commissura posterior

ERRNVPHGLFRVRUJ
1.3 Further Imaging 17

6 5
7 4
3
2
8
1

10

11

12

13

19

14
18
15 16 17

Fig. 1.15  As Fig. 1.14c. Sectional enlargement. 1 capsula extrema, 2 callosomarginalis, 13 A2, 14 A. frontopolaris, 15 medial frontobasal
claustrum, 3 capsula externa, 4 putamen, 5 knee of capsula interna, 6 artery, 16 third ventricle, 17 carotid bifurcation, 18 amygdala/uncus, 19
nucleus caudatus, 7 gyrus cinguli, 8 stria longitudinalis cinguli, 9 edge sulcus lateralis (Sylvii)
of falx, 10 septum et cavum septi pellucidi, 11 A. pericallosa, 12 A.

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Anatomical Base of Surgery
2

2.1 Extradural Topography and Dural Veins (Figs. 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, and 2.7)

12 11 10
9

8
7

4
3

Fig. 2.1  Galea aponeurotica and adjacent structures. 1 M. orbicularis at linea temporalis superior; 7 periosteum; 8 galea flap; 9 supraorbital
oculi; 2 N. facialis, frontal ramification; 3 M. temporalis; 4 as 3, inser- vessels and nerves; 10 frontal vessels and nerves; 11 periosteum; 12 M.
tion at linea temporalis inferior; 5 fascia temporalis; 6 as 5, its insertion epicranius, frontal portion

© Springer International Publishing AG 2018 19


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_2

ERRNVPHGLFRVRUJ
20 2  Anatomical Base of Surgery

epi Pe
gal rios
eal teu
m

2
m
3 steu
rio
Pe
4

surgical b
loosening
Periosteum

6
7
8 9

Fig. 2.2  Continuation of Fig. 2.16. Cutis, galea, periosteum, and superficialis and a branch of A. cerebri media) (a) and according to
tabula externa and interna according to surgical loosenings for presen- usual frontal approaches (b) or (b’). 1 Epidermis, 2 cutis, 3 subcutis, 4
tations of arteries (e.g., for surgical anastomosis between A. temporalis galea, 5 periosteum, 6 tabula externa, 7 diploe, 8 tabula interna, 9 dura

ERRNVPHGLFRVRUJ
2.1  Extradural Topography and Dural Veins 21

8 7 6 5 4

10

11

12 13 14

Fig. 2.3  Ramifications of N. facialis and adjacent structures which as 4, ramus frontalis; 6 N. auriculotemporalis; 7 A. temporalis superfi-
could be endangered at frontotemporal skin incision. 1 Meatus acusti- cialis; 8 N. facialis, R. (Rr.) frontalis; 9 as 8, Rr. zygomatici; 10 V. ret-
cus externus, projection dotted; 1’as 1, pars cartilaginea; 2 lymphono- romandibularis; 11 glandula parotis, residual; 12 A. carotis externa; 13
dus; 3 glandula parotis; 4 V. temporalis superficialis, ramus parietalis; 5 A. occipitalis; 14 N. auricularis magnus; 15 For. stylomastoideum, pro-
jection; 16 M. temporoparietalis, portion of M. epicranius

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22 2  Anatomical Base of Surgery

6
5
4

br
na
3

2
fz
1
st

pt
7
zy

ma

8
po

Fig. 2.4  Relief of the skull. Landmarks added for planning frontal and inferior, 2 linea temporalis superior, 3 sutura coronalis, 4 For. supraor-
frontotemporobasal (pterional) surgical approaches. br bregma, fz fron- bitale, 5 arcus superciliaris, 6 glabella, 7 processus zygomaticus, 8 ala
tozygomatic point, ma fossa mandibularis, na nasion, pt pterion, po major
porion, st stephanion, zy angle of os zygomaticum. 1 Linea temporalis

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2.1  Extradural Topography and Dural Veins 23

11
12
10

9
8
7
5
6

13

14 3

2
15 1

Fig. 2.5  Bony sulci of meningeal arteries widened at hypervascular- ies originating from falx); 8 sulci of further dural vessels; 9 sulcus sag-
ized lesions (e.g., frontobasal meningiomas). Feeding arteries are A. ittalis; 10 foveolae arachnoidales of Pacchioni (containing granulationes
carotis externa, A. meningea media, A. carotis interna, A. ophthalmica, arachnoidales); 11 as 10 and sulci of dural veins (sinus sphenoparieta-
and A. ethmoidalis anterior et posterior. These should be considered at lis); 12 as 10, close to sinus sagittalis superior; 13 part of impressiones
interventional embolizations. 1 Sinus maxillaris; 2 ala major; 3 orbita; gyrorum; 14 sulcus of R. anterior of A. meningea media; 15 Juga
4 lamina cribrosa; 5 crista galli; 6 For. caecum; 7 sulci of arteries (arter- cerebralia

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24 2  Anatomical Base of Surgery

Fo
r.
et
hm
oid
ale
po
st.

9–11 mm

Fig. 2.6  Short distance measurement between canalis opticus and canalis ethmoidalis posterior. 1 A. nasociliaris, 2 A. ethmoidalis poste-
canalis ethmoidalis posterior. Common finding (Lang). N. opticus rior, 3 canalis opticus
could be endangered at surgery of hypervascularized lesions close to

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2.1  Extradural Topography and Dural Veins 25

Fig. 2.7  Variants of frontal bridging veins and sinus sagittalis superior author). c Veins crossing to the contralateral side. After interruption,
(drawing according to casts of Browder and Kaplan 1976, schema- contralateral cortical encephalomalacia is possible. d At this bilateral
tized). a Usual finding. b This variant could be a draining vein of type of frontal bridging veins, usually the rostral segment of sinus sagit-
occipital to frontal regions. After its interruption at surgery, multiple talis superior is absent. Hatched: fine dural venous network. It is usu-
located cortical encephalomalacia is possible (experiences of the ally to be found adjacent to all dural sinuses

ERRNVPHGLFRVRUJ
26 2  Anatomical Base of Surgery

2.2 Intradural Topography

2.2.1 Survey (Figs. 2.8, 2.9, 2.10, 2.11, 2.12, 2.13, 2.14, and 2.15)

br

pt
fz

po

6
2

Fig. 2.8  Skull. Landmarks added. Projection of the sylvian region 3 as 2, pars triangularis; 4 as 2, pars opercularis; 5 sutura squamosa; 6
drawn in br bregma, fz frontozygomatic point, po porion, pt pterion, fovea mandibularis
and st stephanion. 1 Temporal pole; 2 third frontal gyrus, pars orbitalis;

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2.2  Intradural Topography 27

br 2
3 1
a sc

st

pt

na

4 5 7
6

br
b sc

4
3

fm
ca 2

na

Fig. 2.9  Typical lateral a and medial b cortical relief, schematized. tralis, upper point; st stephanion. 1 Gyrus precentralis; 2 sulcus precen-
Frontal lobe renders prominent. Landmarks added. Typical reliefs pres- tralis; 3 first frontal gyrus; 4 third frontal gyrus, pars orbitalis; 5 as 4,
ent the so-called opercular part of the third frontal gyrus: pars orbitalis, pars triangularis; 6 as 4, pars opercularis. b br bregma, ca commissura
pars triangularis, pars opercularis, and the base of gyrus precentralis anterior, fm foramen interventriculare, sc sulcus centralis. 1 Gyrus rec-
(the region between the posterior segment of pars opercularis and sul- tus, 2 area subcallosa, 3 sulcus corporis callosi, 4 gyrus cinguli, 5 sulcus
cus centralis is usually motor cortex. It will be exactly defined using cinguli, 6 first frontal gyrus, 7 lobulus paracentralis (anterior region:
evoked potentials or magnetoencephalogram (MEG; e.g., see Kristewa part of the motor area)
et al. 1991)); see A. a br bregma; na nasion; pt pterion; sc sulcus cen-

ERRNVPHGLFRVRUJ
28 2  Anatomical Base of Surgery

br 3

2
1a
1

3
2

cg

fo
b

Fig. 2.10 Dorsal c and basal cortical relief d. Projections of basal Its posterior and medial limits (close to gyrus precentralis) are well to
dural duplications and landmarks added. The supplementary motor area define at surgery, but not rostral and lateral), 2 sulcus precentralis, 3
(SMA) of one side participates in all bilateral motor functions. Surgical first frontal gyrus. d cg crista galli, projection; fo foramen opticum pro-
resections would not entail motor deficits. This is an important aspect at jection. 1 Plica petroclinoidea anterior, projection; 2 gyri orbitales; 3
resections of the frontal lobe, especially at eliminations of epilepsy foci bulbus olfactorius; 4 gyrus rectus; 5 trigonum olfactorium; 6 substantia
of SMA. c br bregma, sc sulcus centralis. 1 Gyrus precentralis, 1a sup- perforata anterior; 7 tentorial fold, projection
plementary motor area (SMA) ( Rauber-Kopsch (1987) Thieme, p. 436.

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 29

6
5
a

7
b

Fig. 2.11  Cranial base a and dural penetration points of cranial nerves in consideration at surgical elevation of lobus frontalis (see Figs. 2.42
b. a 1 Processus clinoideus anterior; 2 ala minor; 3 fossa cranii media and 3.35). b 1 Infundibulum and diaphragma sellae; 2 plica petroclinoi-
overlaid by ala minor; 4 siphon of A. carotis interna added; note bony dea posterior; 3 dural gap for N. trochlearis; 4 dural gap for N. oculo-
incisure; 5 foramen opticum; 6 overlaying of lamina cribrosa (and bul- motorius; 5 frontal lobe, projection; 6 plica petroclinoidea anterior; 7
bus olfactorius) by the medial part of os ethmoidale; this has to be taken lamina cribrosa, adjacent bony structures omitted

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30 2  Anatomical Base of Surgery

Gyrus rectus

8
5

3
9

2
10
1

11
12

13

14

15

16

17

18
19

Fig. 2.12  Contents of suprasellar cisterns according to surgery, e.g., of rium; 3 A. communicans anterior; 4 A. recurrens (Heubner) must be
aneurysms of A. cerebri anterior and A. communicans anterior. Gyri preserved at surgery; 5 A2; 6 tractus olfactorius; 7 interhemispheric
recti and Aa. cerebri anterior shifted aside after splitting the basal basal arachnoidea often not transparent; 8 A. corporis callosi mediana,
arachnoidea. Sulcus medianus sometimes cannot be defined during sur- cave perforating branches feeding the hypothalamus; 9 chiasma; 10
gery, because it is masked by a thickened arachnoidea. Gyrus rectus infundibulum; 11 tuber cinereum; 12 corpus mammillare; 13 tractus
could be endangered uni- or bilaterally, with following psychological opticus; 14 crus cerebri; 15 N. oculomotorius; 16 A. cerebri posterior;
deficits ( Hütter 1999, 2000). 1 Carotid bifurcation; 2 trigonum olfacto- 17 A. cerebelli superior; 18 A. basilaris; 19 pons

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 31

10

1
2 3

Fig. 2.13  Continuation of Fig. 2.12. Arachnoid membranes (walls) of interpeduncularis; 5 N. oculomotorius; 6 cisterna cruralis; 7 carotid cis-
cisterns. 1 Liliequist’s membrane, diencephalic portion ( Rhoton 2000); tern; 8 cisterna chiasmatis; 9 cisterna laminae terminalis; 10 cisterna
2 as 1, mesencephalic portion; 3 cisterna pontis medialis; 4 cisterna olfactoria

ERRNVPHGLFRVRUJ
32 2  Anatomical Base of Surgery

b
8 7

9
6

10 4
3

11

12

13
2

Fig. 2.14  Third ventricle. Surrounding structures a and lumen b. 1 interventriculare (Monroi); 7 adhesio interthalamica; 8 plexus choroi-
Recessus infundibuli; 2 recessus opticus; 3 recessus praemamillaris; 4 deus; 9 recessus suprapinealis; 10 recessus pinealis; 11 bulging of com-
recessus postmamillaris; 5 bulging of commissura anterior; 6 foramen missura posterior; 12 tectum, projection; 13 aquaeductus (sylvii)

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 33

18 17
16
19 15

14
13
12
20

11

10

21
9
22
23 8

24
7

25
26
27 6
8
4
3
2
1

Fig. 2.15  Third ventricle. Details of surrounding structures. 1 Corpus interventriculare and fissura transversa, 16 velum interpositum, 17 fis-
mammillare, 2 recessus praemamillaris, 3 recessus infundibuli, 4 reces- sura transversa, 18 adhesio interthalamica, 19 V. magna (Galeni), 20
sus opticus, 5 chiasma, 6 lamina terminalis, 7 commissura anterior, 8 splenium corporis callosi, 21 recessus suprapinealis, 22 corpus pineale,
columna fornicis, 9 rostrum corporis callosi, 10 septum pellucidum, 11 23 commissura posterior, 24 aquaeductus (sylvii), 25 tegmentum mes-
genu corporis callosi, 12 For. interventriculare (Monroi), 13 plexus encephali, 26 crus cerebri, 27 pons, x V. septi pellucidi
choroideus, 14 angulus venosus, 15 fibrous wall between foramen

ERRNVPHGLFRVRUJ
34 2  Anatomical Base of Surgery

2.2.2 Superficial Structures and Structures in the Depth (Figs. 2.16, 2.17, 2.18, 2.19, 2.20, 2.21, and 2.22)

sc
br

2
4

po
pt

fz
na zy

Fig. 2.16  Superficial structures of the skull and brain. br bregma, fz rior, projection; 3 gyrus precentralis; 4 pars orbitalis of gyrus frontalis
frontozygomatic point, na nasion, po porion, pt pterion, sc sulcus cen- 3; 5 ala major et minor; 6 crista frontalis
tralis, zy angle of os zygomaticum. 1 Ala major; 2 linea temporalis infe-

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 35

5
4
6 br

1
a pt

Sulcus centralis
2
Bregma

3
1
4 approx. 5cm
5
6

Fig. 2.17  Gyrus precentralis and landmarks. a Gyrus precentralis and centralis; 5 gyrus precentralis; 6 sutura coronalis, projection. b 1
the skull, b gyrus precentralis and surrounding cortex. a br bregma, pt Angularis region; 2 sulcus centralis; 3 gyrus precentralis; 4 third frontal
pterion, st stephanion. 1 Intercommissural level; 2 pars ascendens of gyrus, pars opercularis; 5 as 4, pars triangularis; 6 as 4, pars orbitalis; 7
sulcus lateralis (sylvii); 3 linea temporalis inferior, projection; 4 sulcus intercommissural level

ERRNVPHGLFRVRUJ
36 2  Anatomical Base of Surgery

7 6

br

pt

na

4
1 2 3

Fig. 2.18  Arteries and surrounding structures. Landmarks added for 3 pars triangularis; 4 pars opercularis; 5 sulcus centralis; 6 as 5, typical
assisting neuronavigation, if necessary. br bregma, na nasion, pt bending; 7 A. sulci centralis; 8 branches of A. operculofrontalis; 9 rami-
pterion. 1 Frontobasal lateral artery; 2 pars orbitalis of gyrus frontalis 3; fication of A. callosomarginalis and of A. pericallosa

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 37

sc

br
2

3
st

po

fz

zy
na

Fig. 2.19  Continuation of Fig. 2.18. Veins. br bregma, fz frontozygomatic point, na nasion, po porion, pt pterion, sc sulcus centralis, st stephanion,
zy angle of os zygomaticum. 1 V. rolandica, 2 further bridging veins, 3 bundles of frontal bridging veins

ERRNVPHGLFRVRUJ
38 2  Anatomical Base of Surgery

ant.
Co rnu
tip of

tip of In
sula

2
ti p
of
Co
rn

6
tip

7
u an
of

8 5
t.
Ins

4
ula

.
u inf
Corn
10 of
tip

Co
mm
ro

iss
on

.a
M

nt.
of

11
en
m

12
ra
fo

Fig. 2.20  Structures in the depth. 1 Sulcus superior insulae, 2 sulcus inferior insulae, 3 putamen, 4 corona radiata, 5 caput nuclei caudati, 6 indu-
sium griseum, 7 genu corporis callosi, 8 gyrus cinguli, 9 Heschl’s gyri, 10 insula, 11 medial septal veins, 12 cavum septi pellucidi

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 39

1
3
2 a
4

6
5

3
2

4 1 b
5

A
7

8
9

10

Fig. 2.21  Tractus pyramidalis (segment of corona radiata). a Historical radiata, 6 tractus parietotemporopontinus of corona radiata. b 1 Capsula
illustration of a fiber brain dissection (according to Ludwig and interna, crus anterior; 2 fiber bundles of corpus callosum, forceps ante-
Klingler 1956). Tractus pyramidalis here renders prominent. b rior; 3 insula, anterior tip; 4 insula and capsula extrema; 5 claustrum; 6
Topogram added. Limit of resection renders prominent. a 1 Sulcus cen- capsula externa; 7 putamen; 8 globus pallidus; 9 capsula interna, knee;
tralis, 2 gyrus precentralis, 3 tractus corticospinalis of corona radiata, 4 10 capsula interna, crus posterior
fasciculus longitudinalis superior, 5 tractus frontopontinus of corona

ERRNVPHGLFRVRUJ
40 2  Anatomical Base of Surgery

5 a

b
2
8
3
4
A
5

Fig. 2.22  Continuation of Fig. 2.21 (Ludwig and Klingler 1956). a callosum fibers penetrating corona radiata; 7 corona radiata, frontal
Pyramidal tract close to capsula interna. b Topogram added. Resection segment. b 1 Capsula interna, crus anterior; 2 capsula externa; 3 claus-
renders prominent. a 1 Putamen; 2 capsula externa; 3 claustrum, cap- trum; 4 putamen; 5 globus pallidus; 6 capsula interna, knee (motor
sula extrema and cortex of insula omitted; 4 corona radiata; 5 transi- fibers); 7 capsula interna, crus posterior (sensoric fibers)
tional region between corona radiata and capsula interna; 6 corpus

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 41

2.2.3 Midline Structures (Figs. 2.23, 2.24, 2.25, 2.26, 2.27, 2.28, 2.29, 2.30, 2.31, and 2.32)

Fig. 2.23  Suprachiasmal interhemispheric structures. 1 Roof of the carotid cistern (substantia perforata anterior), 2 lamina terminalis, 3 commis-
sura anterior, 4 stria longitudinalis cinguli. Light arrows: sulcus longitudinalis dilated. Black arrows: chiasma retracted

ERRNVPHGLFRVRUJ
42 2  Anatomical Base of Surgery

br 50 mm

sc

m
0m
12

cp

fi
70 mm ic
ca

fo
na

Fig. 2.24  Medial landmarks could be helpful, if neuronavigation is 13 cm). Upper point of sulcus centralis added. Cave. br bregma, ca
not available. Topographical relationships of the intercommissural line commissura anterior, cp commissura posterior, fi foramen interventric-
to the coronal plane between foramina optica (projection) and bregma ulare (Monroi), fo foramina optica (projection), ic intercommissural
and to the nasion-bregma distance measurement (distance measure- line, na nasion, sc sulcus centralis
ment between nasion at the bony surface 12 cm and at the skin surface

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 43

5
6

7
8
9

sc

15
14
13
12
10 11
1

Fig. 2.25  Medial arteries and adjacent structures. Anatomical dissec- frontales internae; 7 A. pericallosa; 8 A. callosomarginalis; 9 A2; 10
tion (A1 shifted and extended for presenting subcallosal structures A1; 11 A. communicans anterior; 12 as 1, common trunk; 13 subcallo-
(arrow)). 1 A. corporis callosi mediana, right-sided branch; 2 gyrus cin- sal areas; 14 commissura anterior; 15 foramen interventriculare
guli; 3 A. praecunealis; 4 lobulus paracentralis; 5 A. paracentralis; 6 Aa. (Monroi)

ERRNVPHGLFRVRUJ
44 2  Anatomical Base of Surgery

6
7

Fig. 2.26  Medial bridging veins at the sinuses. Note distance mea- segment of sinus sagittalis superior; 5 hypo- or aplastic segment of
surements between veins for planning surgical midline approaches. 1 sinus sagittalis superior; 6 beginning of sinus sagittalis superior at For.
Sinus sagittalis inferior; 2 bridging vein(s), variable; 3 stria longitudi- caecum; 7 cavum nasi; + bridging veins, rare variants (Experience of
nalis cinguli, projection; 4 bridging veins at the beginning of the main the author)

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 45

A. callosomarginalis
H Heubner’s artery
located close
to Heubner’s artery

A.frontopolaris

a
A.frontobasalis medialis

Lang 1995

A. callosomarginalis

A.frontopolaris
A.frontobasalis medialis

Nieuwenhuys et al 1991

b
H

variants

c
A. callosomarginalis
Stauesand et Ferner 1973

A.frontopolaris

A.frontobasalis medialis

Fig. 2.27  Variable frontomedial arteries could be mixed with Heubner’s artery. This has to be considered at surgery of aneurysms of A. commu-
nicans anterior (Yaşargil)

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46 2  Anatomical Base of Surgery

Palaeocortex

Archicortex

Mesocortex

Isocortex

Fig. 2.28  Frontomedial allocortex (according to Stephan 1975, sche- bilateral lesions of stria longitudinalis cinguli, of fornix, of subcallosal
matized). 1 Indusium griseum at the dorsal surface of corpus callosum; gyri, or of the posterior segment of gyrus rectus (e.g., cave at surgical
2 stria longitudinalis cinguli, enclosed by gyrus cinguli at the lateral rim eliminations of aneurysms of A. communicans anterior) could be fol-
of cisterna corporis callosi; 3 gyrus cinguli; 4 columna fornicis. Uni- or lowed by psychological deficits

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 47

tion
g direc
viewin

retraction

3
2

Fig. 2.29 Allocortex. Cadaver fiber dissection (Seeger 2000. Details 4 stria longitudinalis cinguli (allocortical part of the mesocortical gyrus
are only to present by anatomical dissections. For fiber tracking, see cinguli); 6 neocortical fiber bundles, part of corpus callosum; 7 gyrus
Karaus et al. 2009). 1 Indusium griseum, striae mediales; 2 corpus cal- cinguli
losum; 3 indusium griseum, striae laterales; 5 allocortical fiber bundles;

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48 2  Anatomical Base of Surgery

8
a b

9 Lamina terminalis

Recessus opt.
10 5
4

11

3
12
2
13
1
14
15
16
11

10
b
9
8
12
7
13
14 for of Monro
15 6
16
17 3rd ventricle
5

18 2

19 1
20

Fig. 2.30  Basal midline regions similar to neuronavigation. Some nosus, 15 carotid siphon, 16 hypophysis. b 1 A. basilaris, 2 tractus opti-
details are not sufficiently presented at imagings. a 1 N. ophthalmicus, cus, 3 corpus mammillare, 4 carotid bifurcation, 5 perforating arteries,
2 N. trochlearis, 3 N. oculomotorius, 4 chiasma, 5 carotid bifurcation, 6 6 commissura anterior, 7 V. thalamostriata, 8 stria terminalis, 9 lamina
nucleus caudatus (enclosing nucleus accumbens), 7 capsula interna, 8 affixa thalami, 10 nucleus caudatus, 11 plexus choroideus, 12 corpus
putamen, 9 striate arteries, 10 Subst. perforata anterior, 11 amygdala, callosum, 13 corpus fornicis, 14 septum pellucidum, 15 columna forni-
12 A. carotis interna, 13 processus clinoideus posterior, 14 sinus caver- cis, 16 tip of fissura transversa, 17 A. recurrens (Heubner), 18 N. oculo-
motorius, 19 A. cerebri posterior, 20 A. cerebelli superior

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 49

12 11 10 9 8
7
6

5
4

13

14
27
15 2
26
1
16

17

18

19
20 21 22 23

24 25

Fig. 2.31  Continuation of Fig. 2.30. Stria longitudinalis cinguli must interna, 13 sulcus superior insulae, 14 capsula extrema, 15 claustrum,
be preserved at midline approaches. 1 Indusium griseum, 2 fiber con- 16 capsula externa, 17 Aa. striatae, 18 putamen, 19 globus pallidus, 20
nections between indusium griseum and stria longitudinalis cinguli, 3 amygdala, 21 as 17, 22 tractus opticus, 23 commissura anterior, 24
stria longitudinalis cinguli, 4 transversal veins, 5 cisterna corporis cal- lamina terminalis, 25 area subcallosa. Arrow: foramen interventriculare
losi, 6 gyrus cinguli, 7 sulcus cinguli, 8 as 3, 9 fibers of corpus callo- (Monroi)
sum, 10 Vv. longitudinales, 11 caput nuclei caudati, 12 knee of capsula

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50 2  Anatomical Base of Surgery

3
2 1

6
7
8 17

10

16

14 15
11 12 13

Fig. 2.32  Anatomical dissection similar to a surgical approach to the cut at cadaver brain dissection; 7 caput nuclei caudati; 8 beginning of
floor of the contralateral ventricle. 1 Atypical midline artery feeding sinus sagittalis inferior; 9 stria terminalis; 10 V. thalamostriata; 11 thal-
stria longitudinalis cinguli; 2 A. pericallosa; 3 A. callosomarginalis; 4 amus, pars affixa; 12 plexus choroideus; 13 crus fornicis; 14 V. septi
falx; 5 base of gyrus cinguli (overlying stria longitudinalis); 6 midline pellucidi; 15 medial septal veins; 16 as 6; 17 transversal dorsal ven-
crossing branch of A. pericallosa (common findings ( Marino 1976)), tricular veins. Arrow: foramen interventriculare (Monroi). 1, 6, and 16
noted at surgery

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2.2  Intradural Topography 51

2.2.4 Third Ventricle (Figs. 2.33, 2.34, and 2.35)

4
7

8
9

3
10
2

11 1

Fig. 2.33  Transforaminal endoscopic route to the third ventricle and sula interna; 8 columna fornicis, pars libera; 9 pars tecta fornicis; 10
basal cisterns. MRT level for neuronavigation. a Topogram, b anatomi- tractus mamillothalamicus, projection; 11 crus cerebri, tractus
cal drawing. 1 Corpus mammillare; 2 tractus opticus; 3 hypothalamus; pyramidalis
4 thalamus; 5 nucleus caudatus; 6 cavum septi pellucidi; 7 knee of cap-

ERRNVPHGLFRVRUJ
52 2  Anatomical Base of Surgery

9
a 8

7
b
6

Fig. 2.34  For. interventriculare (Monroi). Anatomical dissection. Fine 6 For. interventriculare, 7 columna fornicis, 8 cavum septi pellucidi, 9
surgical details are not exact to define by imagings. a Dorsal viewing Vv. septi pellucidi. b 1 Lamina terminalis, 2 commissura anterior, 3
direction. b Basal viewing direction. a 1 Medial septal veins, 2 plexus columna fornicis, 4 V. septi pellucidi, 5 plexus choroideus, 6 columna
choroideus, 3 V. cerebri interna, 4 angulus venosus, 5 V. thalamostriata, fornicis, 7 columna fornicis, gray-colored segment

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 53

on
ecti
dir
ng
wi
vie

11

10

8
7

Fig. 2.35  Anterior basal relief of the third ventricle. Anatomical pre- recessus infundibuli; 5 recessus opticus; 6 lamina terminalis; 7 pars
sentation similar to endoscopy. 1 Corpus mammillare; 2 vascular net- tecta columnae fornicis, projection; 8 pars libera columna fornicis; 9
work subependymal cave at surgery; 3 floor of hypothalamus; 4 commissura anterior; 10 plexus choroideus; 11 foramen interventricu-
lare. Plexus choroideus of the third ventricle eliminated. Fornices cut

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54 2  Anatomical Base of Surgery

2.2.5 F
 rontobasal and Frontotemporobasal Structures (Figs. 2.36, 2.37, 2.38, 2.39, 2.40, 2.41, 2.42,
2.43, 2.44, 2.45, 2.46, 2.47, 2.48, 2.49, 2.50, 2.51, 2.52, 2.53, 2.54, 2.55, and 2.56)

1
a

IV

III
2

II

3 V

4
b IV 6
5

III

7
II

8
3
9
10
11

2
1

12 13
14

Fig. 2.36  Craniobasal structures. a Inner relief of dura and adjacent ophthalmicus; 7 N. oculomotorius and its dural penetration point, pro-
structures. b Bony relief and adjacent structures. 1 N. abducens; 2 ham- jection; 8 N. maxillaris at foramen rotundum; 9 A. carotis interna; 10 A.
ulus petrosus, variable; 3 canalis caroticus, projection; 4 foramen lace- ophthalmica; 11 processus clinoideus posterior overlying the carotid
rum, projection; 5 N. mandibularis and foramen ovale; 6 N. siphon

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 55

a
Processus
Plica petroclinoidea
clin. post.
Diaphragma ant.
sellae
post.

III

IV
10
11

b
9

II
8
7

III

VI
4

1 3
2

Fig. 2.37  Dural layers and its contents. a Inner layers of dura. b tentorial layer incised and resected; 9 hamulus petrosus enclosing N.
Middle and profound layers of dura. a 1 A. carotis interna; 2 tentorial abducens, projection; 10 middle tentorial layers; 11 A. carotis interna
edge; 3 tentorial fold, superficial layer incised and resected; 4 middle transpassing apertura interna of canalis caroticus; 12 canalis caroticus
dural layers; 5 A. carotis interna, projection. b 1 N. maxillaris; 2 N. of os petrosum, projection; 13 sinus cavernosus; 14 N. mandibularis
ophthalmicus; 3 processus clinoideus anterior, transectional plane; 4 transpassing foramen ovale; 15 middle segment of sinus cavernosus
processus clinoideus posterior; 5 curvatura posterior of the carotid surrounding the variable carotid siphon II to VI cranial nerves
siphon; 6 plica petroclinoidea posterior; 7 tentorial edge; 8 superficial

ERRNVPHGLFRVRUJ
56 2  Anatomical Base of Surgery

Fig. 2.38  Dural penetration points. N. oculomotorius: anterior from infundibulum (arrows). N. trochlearis: anterior from plica petroclinoidea
posterior

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 57

14 13 12

11
15
16
10
17

18 9

8
19 7

1 2 3 4 5
II

III

IV

Fig. 2.39  Comparison of the bony and dural relief and its contents. 1 lum sellae; 13 sulcus chiasmatis presented especially at childhood; 14
Sulcus petrosus inferior; 2 impressio trigemini; 3 foramen lacerum, interoptic line; 15 sulcus caroticus; 16 anterior margin of For. lacerum;
wide variant hatched; 4 canalis caroticus, projection; 5 sulcus petrosus 17 lingula sphenoidalis surrounding A. carotis interna; 18 For. lacerum
superior; 6 For. spinosum et ovale; 7 region of sinus cavernosus and A. occluded by synchondrosis, hatched; 19 floor of canalis caroticus, bony
carotis interna, projection; 8 bony sulcus at N. maxillaris; 9 processus defect of its roof (common finding) II to IV cranial nerves
clinoideus posterior; 10 canalis rotundus; 11 For. opticum; 12 tubercu-

ERRNVPHGLFRVRUJ
58 2  Anatomical Base of Surgery

a
1

2
3

8
7

6
5

4
3
2
1

Fig. 2.40 Landmarks a and contents b of basal cisterns. a 1 N. opticus; 5 dural penetration point of N. trochlearis, 6 dural penetration point of
2 A. carotis interna; 3 processus clinoideus anterior; 4 infundibulum, N. oculomotorius, 7 A. chorioidea anterior, 8 A. communicans
projection; 5 processus clinoideus posterior. b 1 A. cerebri posterior, 2 posterior
N. oculomotorius, 3 A. communicans posterior, 4 A. cerebelli superior,

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 59

3 2
1

4
3

2
5
1
6

Fig. 2.41  Addendum for Fig. 2.40, lateral presentation. a 1 A. carotis rior of the carotid siphon. b 1 A. cerebelli superior, mouth; 2 A. cerebri
interna; 2 as 1, curvatura posterior; 3 processus clinoideus posterior; 4 posterior, mouth; 3 N. oculomotorius; 4 bifurcation of A. carotis
foramen opticum; 5 processus clinoideus anterior and curvatura ante- interna; 5 A. chorioidea anterior; 6 A. communicans posterior

ERRNVPHGLFRVRUJ
60 2  Anatomical Base of Surgery

12
11
10

7
6

15

14
13

16

Fig. 2.42  Cistern of tractus olfactorius and trigonum olfactorium with men opticum, projection; 4 N. opticus; 5 gyrus rectus; 6 basal arach-
arteries. N. olfactorius is the only cranial nerve which presents a long noid membrane of cisterna laminae terminalis; 7 tractus olfactorius,
subdural route. This is favorable for the surgical elevation of lobus intracisternal segment, and arachnoidea transparent; 8 as 7, arachnoid
frontalis. Variants of the arachnoid penetration point and its bilateral penetration; 9 subdural segment of tractus olfactorius; 10 sulcus media-
asymmetries have to be considered. At surgical preservation of olfac- nus masked by thickened arachnoidea and vessels; 11 falx; 12 bulbus
tory arteries, the posterior segment of gyrus rectus should be preserved olfactorius; 13 A. recurrens (Heubneri); 14 trigonum olfactorium, striae
(damaging of its allocortical part may be followed by psychological mediales; 15 perforating arteries of trigonum olfactorium; 16 arteries at
deficits (Hütter 1999, 2000)). 1 Olfactory branch(es) of Heubner’s sulcus rectus feeding tractus olfactorius should be preserved (Applied
artery (Rhoton, schematized); 2 arachnoid wall of N. opticus; 3 fora- by Prof. Samii, personal communication to the author)

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 61

10

6
5
4
3
11 2

12

13

1
14

Fig. 2.43  Liliequist’s membrane (for Liliequist’s membrane and find- olfactoria; 9 tractus olfactorius penetrating arachnoidea; 10 carotid
ings of Rhoton (2000), see Figs. 2.43, 2.46, and 3.32) and adjacent bifurcation; 11 arachnoid trabeculas thickened, enclosing N. oculomo-
structures. 1 Cisterna pontis medialis; 2 gap of pars mesencephalica of torius; 12 bifurcation of A. basilaris; 13 N. oculomotorius; 14 A. cere-
Liliequist’s membrane; 3 wall of pars mesencephalica of Liliequist’s belli superior enclosed by pars mesencephalica of Liliequist’s
membrane; 4 cisterna interpeduncularis; 5 wall of pars diencephalica of membrane
Liliequist’s membrane; 6 cisterna optica; 7 cisterna carotica; 8 cisterna

ERRNVPHGLFRVRUJ
62 2  Anatomical Base of Surgery

8
9

10
6

11
12

13
4

3
2
1

Fig. 2.44  Cisterna carotica and adjacent cisterns, details. Trabecular superficialis; 6 cisterna laminae terminalis; 7 cisterna olfactoria; 8 cis-
tunnels of A. cerebri media, adhesions of N. oculomotorius, and the gap terna chiasmatis; 9 cisterna carotica; 10 N. oculomotorius; 11 dience-
of pars mesencephalica of Liliequist’s membrane at bifurcation of A. phalic portion of Liliequist’s membrane; 12 mesencephalic portion of
basilaris. 1 Cisterna pontis medialis; 2 cisterna pontis lateralis; 3 cis- Liliequist’s membrane; 13 N. trochlearis
terna cruralis; 4 cisterna ambiens; 5 cisterna interpeduncularis, pars

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2.2  Intradural Topography 63

13
14
15
16

12

17 11

18 10

8
19
7
20
6
21 5

22

23

24

1 2 3 4

Fig. 2.45  Central position of A. carotis interna and its cistern between pontomesencencephalic rim; 9 arachnoid gap (Key and Retzius) con-
sulcus lateralis (sylvian cistern) and cisterna ambiens. A. cerebri media taining bifurcation of A. basilaris; 10 V. interpeduncularis; 11 V. basalis
is the main structure of the sylvian cistern. A. cerebri posterior and (Rosenthal); 12 tractus opticus; 13 temporal choroid point; 14 A. cere-
tractus opticus are the main structures of cisterna ambiens. Between bri media, distal trunk; 15 A. operculofrontalis; 16 arachnoid tunnel of
both cisterns is interposed cisterna carotica. All structures are surround- A. cerebri media; 17 inferior tip vein ( Huang and Wolf 1974b); 18
ing the base of uncus (hatched: transectional plane). 1 Chiasma; 2 dien- cisterna ambiens, tractus opticus, and one of its veins; 19 further arach-
cephalic segment of Liliequist’s membrane; 3 as 2, common segment; 4 noid tunnel; 20 lateral striate arteries (Aa. lenticulostriatae); 21 sub-
dorsum sellae, insertion of 3; 5 mesencephalic segment of Liliequist’s stantia perforata anterior penetrated by 20; 22 cisterna carotica; 23 A.
membrane; 6 A. cerebelli superior, enclosed by 5; 7 A. basilaris; 8 carotis interna; 24 N. opticus
insertion of the mesencephalic segment of Liliequist’s membrane at the

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64 2  Anatomical Base of Surgery

a 4

3
b

Fig. 2.46  Liliequist’s membrane (drawing at the base of photographs arachnoid adhesions, 4 pars diencephalica, insertion. b 1 Gap of pars
of cadaver brain dissections of Rhoton 2000). Synopsis. a 1 Gap of mesencephalica, 2 pars mesencephalica, 3 pars diencephalica, 4 com-
pars mesencephalica, 2 pars mesencephalica, 3 N. oculomotorius and mon part of Liliequist’s membrane and its insertion at dorsum sellae

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 65

tip of insula
tip of cornu ant.

ri
gy
r
e

ula
la
su

ins
in
en
m
7 Li
9 8 6 5
4 3
2

15
14
10
Subst. perforata 11 12
ant.

Fig. 2.47  Ground of basal cisterns and surrounding cerebrobasal torium, 8 bifurcation of A. carotis interna, 9 A1, 10 tractus opticus, 11
structures. Conclusion. 1 Uncus, 2 lateral striate arteries (Aa. lenticulo- A. communicans posterior, 12 A. chorioidea anterior, 13 temporal cho-
striatae), 3 A. cerebri media, 4 striae laterales of trigonum olfactorium roid point, 14 plexus choroideus, 15 inferior tip vein, thick calibrated
at limen insulae, 5 Heubner’s artery, 6 sulcus rectus, 7 trigonum olfac- variant. Dotted: projection of surrounding structures

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66 2  Anatomical Base of Surgery

a 5
6 4
3
7
8

9
1

4
3
2

Fig. 2.48  A. carotis interna and its ramification. a A. cerebri media Frontobasal medial artery, 2 A. frontopolaris, 3 A. corporis callosi
and its branches. b A. cerebri anterior and its branches. a 1 Carotid mediana, 4 A1, 5 A. callosomarginalis, 6 A. pericallosa. For A. com-
bifurcation, 2 A1, 3 frontobasal lateral artery, 4 A. operculofrontalis, 5 municans posterior and A. chorioidea anterior, see Fig. 2.50f Aa.
A. sulci centralis, 6 temporal branch(es) of A. cerebri media, 7 A. angu- hypophysealis inferior and superior omitted
laris, 8 A. temporooccipitalis, 9 A. cerebri media, distal branch. b 1

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 67

6 5

7
4

1
2

Fig. 2.49  Aa. striatae (these fine branches of cerebral arteries are less uncus, 3 limen insulae (arrow), 4 lateral striate arteries (Aa. lenticulo-
variable than large branches of circulus arteriosus (Willisi)). Branches striatae), 5 lateral main branch of A. recurrens (Heubner), 6 medial
of the carotid bifurcation and A. cerebri media. 1 Tractus opticus, 2 main branch of A. recurrens (Heubner), 7 A. recurrens (Heubner)

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68 2  Anatomical Base of Surgery

nt.
a eaa
rioid
ho
A.c

II
N.
c
b
A.co
mmu
n
a post icans
.

Fig. 2.50  Main proximal branches of A. carotis interna and perforat- common findings. Interruption of perforating branches is dangerous
ing arteries. a A. communicans posterior and A. chorioidea anterior, (Yaşargil). b Variants. a a and b: location of typical aneurysms. c and d:
perforating arteries. b Examples of variants

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2.2  Intradural Topography 69

Striate arteries

t.
an
a
de
A.

i
rio
co

o
ch
mm

A.
un
ica
spn
os
t.

Fig. 2.51  Addendum for Fig. 2.50. Perforating branches penetrating tractus opticus and feeding basal ganglia. These branches are feeding not
only tractus opticus. Most of them are feeding basal ganglia and the pyramidal tract after penetrating tractus opticus (Yaşargil)

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70 2  Anatomical Base of Surgery

a H
b H
H
H H
H

c d
Frontobas.
artery Frontobas. artery

H
H
H

H
H

Fig. 2.52  Heubner’s artery, variants of proximal branches (according (Yaşargil). a Bilateral and right-sided variants. b Right sided, normal;
to Kribs and Kleihues 1971, schematized). Perforating branches of left sided, dislocation and duplication. c and d Mixed with other arteries
Heubner’s artery are feeding basal ganglia and pyramidal tract. At sur- is possible. e Left sided: originating from A1, combined with a further
gery, Heubner’s artery could be mixed with other frontomedial arteries variant (see Fig. 2.55f). H A. recurrens (Heubner)

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 71

a b

c d

H
H

A. Frontobasalis med.
A. Frontopolaris
e

Fig. 2.53  Variability of A. cerebri anterior and of A. communicans pyramidal tract, and adjacent structures. a–c v. Mitterwallner (1955). d
anterior. Perforating branches of A. cerebri anterior and Heubner’s Perlmutter and Rhoton (1976). e Yaşargil (1984b). H A. recurrens
artery present perforating branches which are feeding the basal ganglia, (Heubner)

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72 2  Anatomical Base of Surgery

H Heubner’s artery
common trunk
located close
to Heubner’s artery
common trunk
a

A. frontopolaris
A. frontopolaris medialis

Chiasma

b
A. frontopolaris A. frontopolaris medialis
A. frontopolaris medialis originating from A1
(not from A2, as usual)

Common trunk

branch for Trigonum


/Tractus olfactorius
originating from A 2
(not from H, as usual) H H

Chiasma

Fig. 2.54  Casts of variants, examples. Schematized

ERRNVPHGLFRVRUJ
2.2  Intradural Topography 73

A2

hypothalamic
branches

Fig. 2.55  A. corporis callosi mediana -+-. Perforating branches are feeding the hypothalamus (Yaşargil). Arrows: arteries shifted for presentation
of perforating branches

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74 2  Anatomical Base of Surgery

Fig. 2.56  Variants of A. corporis callosi mediana: so-called third A2

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Special Surgical Aspects
3

3.1 Extradural Topography

3.1.1 Surgical Routes (Fig. 3.1)

a b

c d

Fig. 3.1 Survey. (a) Frontolateral routes. (b) Midline routes. (c) Dorsolateral transforaminal routes to the third ventricle. (d) Pterional routes

© Springer International Publishing AG 2018 75


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_3

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76 3  Special Surgical Aspects

3.1.2 Extracranial Surgical Aspects (Figs. 3.2 and 3.3)

st

fz

pt

po

Fig. 3.2  Skin-galea incision -+-.Frontal branch of N. facialis and adjacent structures could be endangered. fz frontozygomatic point, po porion,
pt pterion, st stephanion; 1 frontal ramification of N. facialis, 2 A. temporalis superficialis and N. auriculotemporalis

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3.1  Extradural Topography 77

a
3

4
2

b
1

c
6 5 4
7
3

Fig. 3.3  Subperiosteal loosening (see Fig. 2.2b′) of skin-galea flap tion, 4 M. orbicularis oculi. (b) 1 At incisura supraorbitalis (common
before performing craniotomy nerves and vessels of the supraorbital variant), vessels and nerves are easy to lose at surgical approach. 2
and frontomedial region should be preserved. Damage may be followed Foramen supraorbitale enclosing nerves and vessels. The inferior bony
by anesthesia dolorosa. (a) Layers, (b) foramen supraorbitale right, bridge of the foramen should be resected before loosening of nerves
incisura supraorbitalis left (common findings), (c) connections of facial and vessels. (c) 1 V. facialis, 2 V. supraorbitalis, 3 as 2, 4 R. frontalis
veins to dural sinuses could be routes for intracranial phlebothrombo- medialis, 5 V. angularis, 6 as 4, 7 as 3
sis. a 1 Periosteum, 2 nerves and vessels, 3 M. epicranius, frontal por-

ERRNVPHGLFRVRUJ
78 3  Special Surgical Aspects

3.1.3 Craniotomies (Figs. 3.4, 3.5, 3.6, 3.7, and 3.8)

Fig. 3.4  Bifrontal craniotomy. Variability of crista frontalis should be sagittalis superior and cerebral cortex. a Small burr hole, if other cos-
noticed at preoperative axial CT. If it is configurated like a sharp crest, metic techniques are not available. Dotted: skin incision. b Resection of
a burr hole may be placed at the midline for avoiding damage of sinus the inner wall of the sinus frontalis and of crista frontalis

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3.1  Extradural Topography 79

Fig. 3.5  Addendum for Fig. 3.4. Crista frontalis is flattened: favorable drilling: bleeding of dural venous connections with Vv. Emissariae may
for craniotomy. a Nevertheless craniotomy may be hindered by dural occur. Spare electrocoagulation close to sinus sagittalis superior
adhesions (arrows). A Medial burr hole may be recommended. b After

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80 3  Special Surgical Aspects

Fig. 3.6  Craniotomy for large lesions in the depth (This and the following craniotomies are applied by Prof. Zentner, Freiburg, 2013)

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3.1  Extradural Topography 81

Figs. 3.7  Craniotomy for large lesions at the midline

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82 3  Special Surgical Aspects

sc

m
2c
m
5c

6cm

Fig. 3.8  Craniotomy for large superficial lesions close to the motor cortex; hatched: gyrus precentralis, sc sulcus centralis (upper point)

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3.2  Intradural Topography 83

3.2 Intradural Topography

3.2.1 T
 opographical Aspects of Superficial and Deep Approaches (Figs. 3.9, 3.10, 3.11, 3.12, 3.13,
3.14, and 3.15)

ic

a
b

Fig. 3.9  Defining of sulcus centralis and gyrus precentralis by conventional axial MRT planes. ic intercommissural level; hatched: gyrus
precentralis

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84 3  Special Surgical Aspects

ic

ca

Fig. 3.10  Addendum for Fig. 3.9. Coronal MRT planes present only small segments of the motor cortex

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3.2  Intradural Topography 85

a br sc

b
la

ic

b
br

sc

la

ca

Fig. 3.11  Favorable defining of the motor area by using the Bregma-­ defining will be performed. a Topogram; b level br-la; c level c; br
Lambda plane for CT. If conventional MRTs are unclear, then Bregma-­ bregma, ic intercommissural line, la lambda, sc sulcus centralis (upper
Lambda method may be used before an exact neurophysiological point); hatched: gyrus precentralis

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86 3  Special Surgical Aspects

sc
br

la

intercommissural level

br

sc

la

Fig. 3.12  Addendum for Fig. 3.11. br – la Bregma-Lambda plane, sc sulcus centralis (upper point)

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3.2  Intradural Topography 87

sc

br

6
1

Fig. 3.13  Areas in the depth. Anatomical details similar to neuro- gyrus precentralis; 5 tractus corticospinalis, part of corona radiata; 6
navigation. Landmarks added. Survey. br bregma, sc sulcus centralis temporal pole
(upper point). 1 Insula; 2 tip of the ventricle; 3 first frontal gyrus; 4

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88 3  Special Surgical Aspects

+
b+c

c 5 - 15 mm

Fig. 3.14 Surgical target region between insula and cornu anterius -+-, example MRT a and b Topogram for c , c small lesion
(e.g., cavernoma -+-) between the anterior sylvian area and tip of cornu, anterius

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3.2  Intradural Topography 89

3
4
5

Fig. 3.15  Continuation of Fig. 3.14. Surgical topography: 1 sylvian vessels. Danger for intraventricular bleeding. 2 Insula, 3 cerebral defect after
removal of a lesion, 4 white matter, 5 cortex, 6 caput nuclei caudati

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90 3  Special Surgical Aspects

3.2.2 T
 opographical Aspects of Midline Approaches (Figs. 3.16, 3.17, 3.18, 3.19, 3.20, 3.21, 3.22, 3.23,
3.24, and 3.25)

30
˚- 4

surgical approach
br

ic

yer
id la
hno
arac
3

Fig. 3.16  Midline surgery. Principles. br bregma, ic intercommissural (arrow). Unexpected opening of the contralateral ventricle should be
line; 1 Vv. longitudinales, 2 stria longitudinalis cinguli, 3 gyrus cinguli, taken in consideration
4 opening of cisterna corporis callosi, 5 brain shifting by instruments

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3.2  Intradural Topography 91

spatula
ria
St

Fig. 3.17  Sectional enlargement of Fig. 3.16. Stria longitudinalis cin- Before splitting, shifting of stria could be diminished by loosening of
guli and its arteries –x- could be shifted to the midline area. Now stria arachnoid trabeculas at cisterna corporis callosi
and its arteries are endangered during splitting of the corpus callosum.

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92 3  Special Surgical Aspects

Fig. 3.18  Variants of Fornix (Lang and Ederer 1980) must be taken in consideration especially at callosotomy. a 4%, b 71%, c 19%

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3.2  Intradural Topography 93

Fig. 3.19  Callosotomy (Zentner 1997, modified). Principles of surgery. a Anterior 2/3 callosotomy. b Posterior 1/3 callosotomy. c Complete
callosotomy

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94 3  Special Surgical Aspects

ed
end
mm
co
re
dang
er

1 2 3

Fig. 3.20  Addendum for anterior callosotomy. Columnae fornicis are with genu corporis callosi (common variant). Fornices and rostrum cor-
endangered, if rostrum corporis callosi is thickened. It could be mixed poris callosi can be defined using neuronavigation: 1 perifornical gray
matter, part of fornix; 2 commissura anterior; 3 columna fornicis

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3.2  Intradural Topography 95

approx.
4mm
9

10

11
4
3
12 13 1 2

Fig. 3.21  Surgical topography of midline approach using a frontal, begin of sinus sagittalis inferior; 10 bridging veins; 11 corpus callosum;
parietal, or occipital route. 1 A. pericallosa; 2 homolateral branch of 1; 12 perforating arteries (After interruptions, large defects of corpus cal-
3 midline crossing branch, spare; 4 gyrus cinguli; 5 stria longitudinalis losum could follow. Defect of stria longitudinalis is possible.) (After
cinguli, projection, spare; 6 spatula; 7 sinus sagittalis inferior; 8 falx; 9 interruptions, large defects of corpus callosum could follow. Defect of
stria longitudinalis is possible.) spare, if possible; 13 midline

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96 3  Special Surgical Aspects

 ompletion for Midline Approaches (Figs. 3.22, 3.23, 3.24, and 3.25)


C
Falx variants and bilateral arteries

Falx wide

b
Falx small

Fig. 3.22  Falx variants. a Favorable for subdural routes. b Less favorable

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3.2  Intradural Topography 97

Dura

gap of Falx adhesions

Arachnoidea
subdural space
subarachnoid space

Fig. 3.23  Continuation of Fig. 3.22. Gaps of the frontal segment of falx. a Not problematic for subdural routes along falx. b Less favorable

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98 3  Special Surgical Aspects

ea
oid
hn
rac
dA
an
lx
Fa
of
ps
ga

outer arachnoid
layer

Fig. 3.24  Continuation of Fig. 3.23. Danger for bleeding of homo- or contralateral branches of A2

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3.2  Intradural Topography 99

Fig. 3.25  Midline crossing arteries (according to anatomical brain dissections of Marino 1975) could hinder the surgical approach (for surgical
topography, see Fig. 3.21). Danger for rupture or bleeding of crossing arteries at surgery

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100 3  Special Surgical Aspects

3.2.3 T
 opographical Aspects of Approaches to the Third Ventricle (Figs. 3.26, 3.27, 3.28, 3.29, 3.30,
3.31, 3.32, 3.33, and 3.34)

app
rox
6c.
m
approx. 7 cm

Fig. 3.26  Defining foramen interventriculare. Foramen interventriculare could be masked by plexus choroideus, e.g., now neuronavigation may
be insufficient. It could be assisted by distance measurements and by phlebography (see Fig. 3.27)

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3.2  Intradural Topography 101

a R L

Fig. 3.27  Defining of foramen interventriculare using phlebography. a venous variant (V. ventriculi lateralis directa) must be taken in consid-
Right: usual location of angulus venosus -+-. Left: V. ventriculi lateralis eration, using an axial projection (see a). Angulus venosus is located in
directa (common variant). Dotted: foramina interventricularia. b the posterior wall of foramen interventriculare (arrow), surrounded by
Lateral projection for defining of the foramen. Here the common plexus choroideus

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102 3  Special Surgical Aspects

2
3

4
5

Fig. 3.28  Routes for ventriculocisternostomy. Principles: 1 transcere- laria; 4 incision of the floor of the third ventricle; 5 incision of
bral and midline approach, schematized; 2 presentation of plexus cho- Liliequist’s membrane and identification of A. basilaris or A. cerebri
roideus and of foramen interventriculare (Monroi); 3 presentation of posterior
the third ventricle, recessus infundibuli, and bulging of corpora mamil-

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3.2  Intradural Topography 103

na ia
di tr
lis
itu r S
ng la
lo ngu
ci
≈ 2 cm

Fig. 3.29  Avoiding lesions of stria longitudinalis cinguli and columna surement between midline and stria longitudinalis cinguli is approx.
fornicis at ventriculocisternostomy using neuronavigation. Lesions of 4 mm. Stria longitudinalis could be endangered by midline approaches
the frontal segment of stria longitudinalis cinguli or lesions of columna but less endangered by neuronavigation-guided endoscopic approaches
fornicis could be followed by psychological deficits. The distance mea-

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104 3  Special Surgical Aspects

a 3

5 4
6
7
8

9
10
11

12

1
6
5
4
a’ 3

Fig. 3.30  Avoiding lesions of columna fornicis at transforaminal ven- and veins shifted aside (cave bleeding), 9 columna fornicis, 10 margin
triculocisternostomy. Plexus shifting, if necessary (a and a’). Cave: of For. interventriculare, 11 septum pellucidum, 12 rostrum corporis
bleeding. Shifting of fornix dangerous (b). a 1 Commissura anterior, 2 callosi. a’ 1 Plexus choroideus shifted aside; 2 lamina affixa thalami; 3
plexus choroideus, 3 velum interpositum, 4 fissura transversa, 5 V. cere- V. cerebri interna; 4 V. thalamostriata; 5 columna fornicis, margin; 6 V.
bri interna, 6 posterior wall of For. interventriculare (plexus choroi- septi pellucidi; 7 columna-corpus fornicis; 8 medial septal veins. b
deus), 7 V. thalamostriata/V. cerebri interna (angulus venosus), 8 plexus Shifting of fornix cave

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3.2  Intradural Topography 105

2 3
1 * penetration

Fig. 3.31  Avoiding lesions of corpora mamillaria and infundibulum at anatomical conditions, see Fig. 3.32). 1 Recessus infundibuli, 2 fine
ventriculocisternostomy. At hydrocephalus these regions are less subependymal vessels, 3 corpus mammillare. Arrow: route + incision
endangered by surgery (for ventriculocisternostomy at nearly normal of the ventricular ground (area of the flattened tuber cinereum)

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106 3  Special Surgical Aspects

a 4 3
2
5

1
6

b 8 7
6

5
4
3

10
11

12

13

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3.2  Intradural Topography 107

Fig. 3.33  Endoscopic penetration of Liliequist’s membrane. Superior strated to the author 2009). 1 diencephalic part of Liliequist’s mem-
arrow: usual route. Inferior arrow: rare route (finding at endoscopic brane, 2 common part, 3 mesencephalic part
surgery, performed by Dr. Preuss and PD Dr. Nestler, Gießen, demon-

Fig. 3.32 Ventriculocisternostomy at minimal hydrocephalus, for (incised); 5 pons; 6 common part of Liliequist’s membrane, insertion at
example (Endoscopic surgery performed by PD Dr. Nestler, Neurochir. dorsum sellae; 7 dorsum sellae; 8 floor of the third ventricle (incised);
Universitätsklinik Gießen. No deficits after surgery. Surgical and post- 9 common part of Liliequist’s membrane (incised); 10 A. cerebelli
surgical demonstration to the author 2009), endoscopic topography. a superior; 11 A. cerebri posterior; 12 diencephalic part of Liliequist’s
Ground of the third ventricle, b basal cisterns. a 1 Recessus infundibuli, membrane (incised); 13 corpus mammillare, bulging the ground of the
2 recessus opticus, 3 commissura anterior, 4 columna fornicis, 5 hypo- third ventricle insertion of the diencephalic part of Liliequist’s mem-
thalamus, 6 thalamus, 7 corpus mammillare; b 1 fine subependymal brane at corpus mammillare. Black arrow: surgical route. Light arrow:
vessels; 2 perforating arteries; 3 diencephalic part of Liliequist’s mem- cisterna pontis medialis
brane (incised); 4 mesencephalic part of Liliequist’s membrane

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108 3  Special Surgical Aspects

a a
b c
d
e

4
3

2
1

Fig. 3.34  Retroforaminal route and interfornical splitting (Appuzo crossing fissura transversa and splitting velum interpositum between
et al. 1982; Appuzo 1987), principle. a Surgical route, sagittal presenta- Vv. cerebri internae and lateral to it, d shifting veins and shifting fine
tion, topography. Black arrow, retroforaminal interfornical route; light chorioid arteries aside, e shifting plexus choroideus of the third ventri-
arrow, transforaminal route. b Coronal presentation. a a Incision of the cle aside. b 1 Substantia nigra, 2 crus cerebri, 3 nucleus ruber, 4 V.
homolateral wall of septum pellucidum, b interfornical splitting, c cerebri interna, 5 velum interpositum, 6 fissura transversa

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3.2  Intradural Topography 109

3.2.4 T
 opographical Aspects of Frontotemporal (Pterional) and Frontobasal Approaches
(Figs. 3.35, 3.36, 3.37, 3.38, 3.39, 3.40, 3.41, 3.42, 3.43, 3.44, 3.45, 3.46,3.47, 3.48, and 3.49)

a 7

Fig. 3.35  Basal surgical target areas. a Ground of basal cisterns. N. oculomotorius, 5 plica petroclinoidea anterior, 6 lamina cribrosa (for
Projections of uncus and N. olfactorius drawn in (dotted). b Dorsal roof preservation of bulbus olfactorius at surgery, see Figs. 2.11 and 2.42), 7
of basal cisterns. Projection of tentorial fold and lamina cribrosa/crista crista galli. b 1 Bulbus olfactorius overlying lamina cribrosa; 2 plica
galli drawn in (dotted). a 1 Tentorial edge, 2 plica petroclinoidea poste- petroclinoidea anterior, projection; 3 uncus, cisternal segment; 4 gyrus
rior, 3 dural penetration gap for N. trochlearis, 4 dural penetration for of parahippocampalis, cisternal segment

ERRNVPHGLFRVRUJ
110 3  Special Surgical Aspects

≈ 35
mm m
≈ 20 m

fz

fo
fs

Fig. 3.36  Defining N. opticus at the foramen opticum during surgery, if foramen opticum cannot be identified, e.g., at basal tumors. fo For. opti-
cum, fs lateral point of fissura orbitalis superior, fz frontozygomatic point

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3.2  Intradural Topography 111

pt
a
fz b

fz

fs
pt

Fig. 3.37  Landmarks for craniotomy. Basal bony resection hatched; fz frontozygomatic point, pt pterion, fs lateral point of fissura orbitalis
superior

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112 3  Special Surgical Aspects

Fig. 3.38  Pterional craniotomy and surrounding surgical topography. Sketch dotted: sylvian region

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3.2  Intradural Topography 113

Fig. 3.39  Prefixed chiasma could hinder the interoptic suprasellar approach. Usual finding at childhood (combined with a marked sulcus chias-
matis at tuberculum sellae at childhood), variant at adults. a Usual findings at adults, b prefixed chiasma (Rhoton)

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114 3  Special Surgical Aspects

Fig. 3.40  Pterional routes and target areas according to Yaşargil (1984a, b) (personal demonstrations to the author since 1969 by Prof. Yaşargil).
a Basal route and target area. b Dorsal route and target area

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3.2  Intradural Topography 115

Pterion

Pt

Fig. 3.41  Pterional surgical approach (arrow). Survey. Skin-galea incision (dotted). Sylvian area added. pt Pterion

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116 3  Special Surgical Aspects

fz
st
pt

po

1
2
3

5
6
7
8

Fig. 3.42  Pterional extracranial surgical topography. a Skin incision lis; 2 craniotomy, projection; 3 linea temporalis inferior, insertion of M.
(dotted). b Skin-galea-muscle-flap, burr hole at the beginning of crani- temporalis; 4 fascia temporalis and M. temporalis cut and shifted; 5
otomy (projection). a fz frontozygomatic point, po porion, pt pterion, st periosteum; 6 M. temporalis; 7 aponeurosis temporalis and M. tempo-
stephanion. b 1 Linea temporalis superior, insertion of fascia tempora- ralis cut and shifted; 8 as 4

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3.2  Intradural Topography 117

br
c
fz
st

pt

po +

lat
of eral
p
orb Fissu oint
ita ra
lis
su
p.

Fig. 3.43  Pterional craniotomy. a Lateral segment of craniotomy renders prominent (1st step); basal segment segment -+- hatched (second step).
Dotted: skin incision. b Basal segment -+- as a br bregma, fz frontozygomatic point, po porion, pt pterion, st stephanion

ERRNVPHGLFRVRUJ
118 3  Special Surgical Aspects

st

pt

po

a 3

b
4 3
2
1
5

Fig. 3.44  After performing a dura flap. Incisions of arachnoidea. a 1 veins crossing the sylvian fissure. Small veins interrupted; 2 pars
Incision for CSF-decompression. b Incision of the arachnoid wall supe- orbitalis of gyrus frontalis 3; 3 arachnoidea incised; 4 veins crossing the
rior to V. temporalis superficialis for opening of parietal and sylvian sylvian fissure. Large veins preserved; 5 V. temporalis superficialis; 6
CSF spaces. a 1 Outer temporal arachnoid layer, 2 frontotemporal polus temporalis; 7 dural flap
thickening of the outer arachnoid layer, 3 frontal arachnoidea incised; b

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3.2  Intradural Topography 119

10
11 9

6
12

13 5

4
14
3

2
15

16
17 1

18

20

19

Fig. 3.45  After opening of the sylvian cistern. Main target area of the artery, 10 A. corporis callosi mediana, 11 mediobasal frontal artery at
pterional microsurgical approach: 1 dural branch of A. carotis gyrus rectus, 12 perforating arteries of substantia perforata anterior, 13
interna(Yaşargil), 2 branch for N. opticus, 3 tuberculum sellae, 4 dia- carotid bifurcation, 14 N. trochlearis, 15 N. oculomotorius, 16 perforat-
phragma sellae enclosing sinus intercavernosus anterior, 5 infundibu- ing arteries, 17 A. chorioidea anterior, 18 A. communicans posterior, 19
lum, 6 A. carotis interna, 7 perforating arteries, 8 A1, 9 Heubner’s A. hypophysealis superior, 20 anterior temporal bridging veins

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120 3  Special Surgical Aspects

Fig. 3.46  Wound closure. Suturing of fascia and M. temporalis (applied by Prof. Zentner, Freiburg) avoiding hyperextension and rupture of these
layers. Arrow: incision of fascia temporalis

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3.2  Intradural Topography 121

Fig. 3.47  Lateral frontobasal surgical routes and target areas. Opening of the sylvian cistern according to Dandy (1938) (modified by Samii for
microsurgery, see Ramina R et al. 2008, pp. 92 ff), modified by Samii. a Basal route and target area. b Dorsal route and target area

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122 3  Special Surgical Aspects

Fig. 3.48  Craniotomy according to Samii; skin incision mapped

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3.2  Intradural Topography 123

Fo
ss
a
la
cr
im
al
is

burr hole
trepanation

topogram for B

Fo res
ss ec
al tio
ac n
rim
ali
s

Fig. 3.49  As Fig. 3.48, details. Danger for opening of fossa lacrimalis and periorbita (According to Pia HW, 1957, chief of the author
1957–1975)

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Completion for Chapters 1 to 3:
Topographical Areas 4
of Rhinoliquorrhea

Fig. 4.1  Rhinoliquorrhea by craniobasal defects (arrows). a Defect of cal repair of CSF fistulas. b Defect of lamina cribrosa and adjacent
the wall of sinus frontalis and adjacent layers. Note: ductus nasofronta- layers. c After traumatic defects, e.g., and after transnasal surgery at the
lis could be duplicated at both sides. This should be considered at surgi- region of sella

© Springer International Publishing AG 2018 125


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_4

ERRNVPHGLFRVRUJ
126 4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea

e
ur
ct
f ra

Fig. 4.2  Defect of the orbital wall of sinus frontalis after trauma.


Arrows: rhinoliquorrhea. * common widening of sinus frontalis

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4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea 127

a b

c
c

Fig. 4.3  Widenings of paranasal sinuses may suggest rhinoliquorrhea routes of rhinoliquorrhea had to be taken in consideration: a widenings
after trauma. An example of rare widenings of paranasal sinuses was and protruding of anterior ethmoid cells into the orbital roof, b widen-
found at the computer tomogram of a normal child after a cranial ing and protruding of sinus sphenoidalis into processus clinoideus ante-
trauma. CSF fistula had to be excluded. Typical and atypical hypothetic rior, c as a

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128 4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea

talis
us fron
of Sin
tum alis
Sep en oid le
sph ida
us eno
Sin sph
rpus
Co

B C

a
bit
f Or
fo
roo

Sin
us
sp
he
no
ida
lis

Co
rpu
ss
ph
en
oid
ale

Fig. 4.4  Further example of atypical paranasal sinuses. Sinus frontalis Common finding. c The posterior region of corpus sphenoidale is not
widened, sinus sphenoidalis narrow. CT of a cadaver skull dissection. a pneumatized. Usual finding at childhood (pneumatization of sinus
Sinus frontalis protruded into the roof of orbita. Common variant b. sphenoidalis begins usually at the 4th year), rare at adults

ERRNVPHGLFRVRUJ
4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea 129

Sinus sphenoidalis Sinus forntalis

A B C

Corpus sphenoidale

Fig. 4.5  Continuation of Fig. 4.4

ERRNVPHGLFRVRUJ
130 4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea

II
N.

int.
A.carot.

Processus clin.ant.

II
aneury

N.
sm

Anu
lus
fibro
sus

Sinus sphenoidalis

Fig. 4.6  Danger for rhinoliquorrhea after resection of processus cli-


noideus anterior. Aneurysm at curvatura anterior of the carotid siphon.
Findings before surgery

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4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea 131

alis
enoid
n. sph
of Si
wall

root of Processus clin.ant.


CSF

t.
.an
c lin
s d
ssu te
o ce esec
Pr r

Anulus fi
brosus

Sinus sphenoidalis

Fig. 4.7  After resection of processus clinoideus anterior: aneurysm closed at surgery (For an ethmoidal route of rhinoliquorrhea at pneuma-
eliminated (upper illustration). Liquorrhoea transpassing sinus sphe- tization of processus clinoideus ant, see Fig. 4.9)
noidalis may happen (arrow), if the bony defect is not sufficiently

ERRNVPHGLFRVRUJ
132 4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea

Processus clin.ant.
pneumatized

b Processus clin.ant. resected

Sinus sphenoidalis

Fig. 4.8  a Pneumatization of processus clinoideus anterior. All para- Cadaver skull dissection. b Hypothetical routes of rhinoliquorrhea
nasal sinuses are extremely widened. Canalis opticus surrounded by superior and inferior from canalis n. optici after trauma or surgery, e.g.,
sinus sphenoidalis and a pneumatized processus clinoideus anterior. (arrows)

ERRNVPHGLFRVRUJ
4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea 133

Cav
um
nasi

Cel
lula
e rt
hmm
oida
les
pos
tt.

N.optic
us

int.
ro tis
A.ca

Fig. 4.9  Pneumatization of Processus clinoideus anterior. Processus Hypothetical defect after surgery -+-. Rhinoliquorrhea (arrow) could
clinoideus anterior pneumatized by cellulae ethmoidales posteriores. transpass cellulae ethmoidales posteriores or sinus sphenoidalis or both
Anatomical dissection of a rare variant (Lang 1981). See Fig. 4.3.

ERRNVPHGLFRVRUJ
134 4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea

Sin
Fo

us
N.m
ssa

sp
axi

he
cra

no
ll
ari
nii

ida
s
m

lis
edi
a

Fig. 4.10  Rhinoliquorrhea (arrow) by a posttraumatic defect of the


wall of sinus sphenoidalis and of canalis rotundus. Widening of the
paranasal sinuses with rhinoliquorrhea (three experiences of the
author) + defect of the wall of sinus sphenoidalis

ERRNVPHGLFRVRUJ
4  Completion for Chapters 1 to 3: Topographical Areas of Rhinoliquorrhea 135

3a 2
3b
6 4
5

7
9
8

10

Fig. 4.11  Rhinoliquorrhea. Conclusion. Arrows: routes of rhinoli- of N. maxillaris; 8 cellulae ethmoidales posteriores with inconstant
quorrhea. 1 Ductus nasofrontalis; 2 lamina cribrosa; 3a processus cli- connections to bulla ethmoidalis; 9 cellulae ethmoidales anteriores and
noideus anterior and cellulae ethmoidales posteriores; 3b processus infundibulum ethmoidale; 10 cellulae mastoideae, cavum tympanicum,
clinoideus anterior and sinus sphenoidalis; 4 apertura sphenoidalis; 5 and tuba
cellulae ethmoidales posteriores; 6 sella; 7 canalis rotundus, CSF space

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Part II
Temporal Region

1.1 Introduction

This introduction to Part II contains a short summary of each chapter.

1.2 Chapter 5 Diagnostic Base

The main aspect of imagings is avoiding of distortions at MRTs of the temporal region. This
will be arrived using conventional presentations. Exact presentations without distortions are
possible using hippocampaxial MRTs as illustrated here. After this, hippocampaxial projec-
tions of lobus temporalis are compared with conventional temporal MRTs of the skull and
brain. This may be helpful for understanding errors at using conventional MRTs.

1.3 Chapter 6 Anatomical Base of Surgery

The extracranial fronto-temporo-basal (pterional) region was presented at the frontal region.
Now are additional presented temporal layers and landmarks for defining of the upper limit of
lobus temporalis (sulcus lateralis Sylvii). Intradural presented in this chapter are allocortex and
neocortex of the temporal lobe. Temporal allocortex (limbic cortex) is a combination of amyg-
dala with hippocampus and gyrus dentatus (area dentata) and with gyrus parahippocampalis
and fimbria fornicis. These structures could be eliminated by amygdalohippocampectomy
without damaging neocortex. Neocortical temporal areas are Wernicke’s angularis area and
other neocortical areas of the dominant and nondominant hemisphere. Unilateral elimination
of the acustic areas (e.g., Heschl’s gyrus) would not be followed by functional deficits accord-
ing to the bilateral connections of the acustic system at pons and mesencephalon.

1.4 Chapter 7 Special Surgical Aspects

Presented are the anatomical base of resections of the temporal lobe, keyhole resections,
amygdalohippocampectomy, and other temporal surgical approaches. Preconditions for amyg-
dalohippocampectomy are surgical routes to cornu inferius of the lateral ventricle before per-
forming amygdalohippocampectomy. There are three surgical types of routes: the transylvian
route, the infratemporal route, and transcortical routes. In this book are presented Yaşargil’s
transylvian route and the infratentorial route. The infratemporal approach can be used for
amygdalohippocampectomy and for other basal target areas. Precondition for an infratemporal
route is the exact defining of the basal limit of craniotomy as basal as possible. Labyrinth,
antrum mastoideum, knee of sinus transversus, and articulatio mandibularis must be preserved.
The ground of fovea mandibularis is located close to fossa cranii media.

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Diagnostic Base
5

5.1 Landmarks (Figs. 5.1 and 5.2)

br

pt

fz

po
ma

Fig. 5.1  Temporal and surrounding landmarks of the skull for


­planning surgery. br bregma, fz frontozygomatic point, ma fossa
mandibularis, po porion, pt pterion, st stephanion; dotted: orbitome-
atal line

© Springer International Publishing AG 2018 139


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ERRNVPHGLFRVRUJ
140 5  Diagnostic Base

st

pt

zy

Fig. 5.2  Defining of pterion for craniotomy pterion is an anthropologi- often not recognizable). Approximate defining, if anatomical defining
cal frontotemporal landmark (Yaşargil’s landmark for fronotemporal at the outside of the skull is unclear. Distance measurement a similar to
craniotomy) at the upper point of sutura sphenoparietalis (at adults b. pt pterion, st stephanion, zy angle of os zygomaticum

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5.2 Radiology 141

5.2 Radiology (Figs. 5.3, 5.4, 5.5, and 5.6)

4 3
2
5
1

11
7 8 9 10

Fig. 5.3  Arteries of lobus temporalis, schematized transparent drawing cipitalis; 6 temporobasal branches of A. cerebri posterior, projections; 7
of structures similar to imagings. Landmarks added for defining of A. chorioidea anterior close to the temporal chorioid point, marking the
arteries assisting imagings, if necessary: 1 temporal branches of A. anterior, segment of cornu inferius, projection; 8 A. basilaris, projec-
cerebri media (and A. carotis interna); 2 A. temporalis posterior; 3 pro- tion; 9 A. carotis interna; 10 A. communicans posterior, projection; 11
jection of V. temporalis superficialis; 4 A. angularis; 5 A. temporooc- temporal branches of A. carotis interna (and A. cerebri media)

ERRNVPHGLFRVRUJ
142 5  Diagnostic Base

9 8 7
6
5 4

as 3
10
ks 2
11
po

ma
12
13

Fig. 5.4  Continuation of Fig. 5.3. Veins: as asterion; ea eminentia tions to 7, projections; 7 V.(Vv.) temporalis profunda projection; 8 V.
arcuata, projection; ks knee of sinus transversus; ma fossa mandibu- temporalis superficialis; 9 A. temporalis posterior undercrossing 8; 10
laris; po porion. 1 Sinus paracavernosus, projection; 2 temporopolar venous variant; 11 as 10, bridging connection to tentorium, projection;
bridging veins, projection; 3 sinus alae minoris; 4 frontoparietal veins; 12 typical small vein close to V. Labbé (Scheremet 1V. Labbé (must be
5 one of Rr. temporales of A. cerebri media; 6 sylvian venous connec- preserved at surgery (Cambria 1980)), Arrows: directions of blood flow

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5.2 Radiology 143

8 7
a
6

3
2

1
b 5
6 4
3

Fig. 5.5  Vessels at the temporal surface of sulcus lat. (Sylvii), schema- main trunk; b 1 temporal chorioid point, 2 V.(Vv.) temporalis profunda,
tized. a Arteries, b veins. a 1 Temporal chorioid point; 2 A. temporooc- 3 connections of 2 and 4, 4 V. temporalis superficialis, 5 sinus alae
cipitalis; 3 A. angularis; 4. A. cerebri media, distal trunk; 5 A. temporalis minoris – sinus sphenoparietalis, 6 temporopolar bridging veins (at
posterior; 6 Rr. temporales; 7 A. operculofrontalis; 8 A. cerebri media, pterional surgical approaches not involved)

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144 5  Diagnostic Base

18 17 16
19 15 14 13
22 21 20

12

23

11

10

7
1 6
2 5
3 4

Fig. 5.6  Branches of A. carotis int., schematized. 1 A. hypophysealis of tuberculum sellae; 12 A1; 13 medial striate arteries; 14 lateral striate
inferior; 2 A. tentorii (Bernasconi); 3 meningeal branch; 4 truncus arteries (Aa. lenticulostriate); 15 one of numerous parietal arteries; 16
meningohypophysealis; 5 A. hypophysealis superior; 6 A. chorioidea A. sulci centralis; 17 A. operculofrontalis; 18 as 15; 19 as 15; 20 A.
anterior; 7 A. communicans posterior; 8 A. carotis interna, dural pene- cerebri media, distal trunk; 21 A. angularis; 22 A. temporooccipitalis;
tration; 9 carotid siphon, curvatura anterior; 10 dural branch; 11 region 23 A. temporalis posterior

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5.3  Further Imaging 145

5.3 Further Imaging (Figs. 5.7, 5.8, 5.9, 5.10, 5.11, and 5.12)

a
4 3
5

6
7
2
8

A B C D E

b c
7

3 6

5
4
4

3
5
2

1
6
7 8

d e 4
7 6 5
4
3
3
2
2
1

Fig. 5.7  Conventional MRTs. Coronal slices (a–e) are performed ver- tuba auditiva, 8 capitulum mandibulae; c 1 pons, 2 meatus acusticus
tical to the intercommissural line and not performed right-angled to the externus, 3 gyrus parahippocampalis, 4 hippocampus, 5 plexus choroi-
axis of the temporal lobe. Now temporal presentations are distorted. a 1 deus, 6 tractus opticus, 7 sulcus lateralis (sylvian fissure); d 1 porus
Amygdala, 2 arcus zygomaticus, 3 carotid cistern, 4 gangliae basales, 5 acusticus externus (projection), 2 os petrosum, 3 tentorium, 4 cornu
carotid bifurcation, 6 carotid siphon (curvatura posterior), 7 N. ophthal- inferius, 5 gyrus parahippocampalis, 6 area dentata, 7 isthmus gyri cin-
micus, 8 N. abducens; b 1 tip of cornu inferius, 2 gangliae basales, 3 guli; e 1 hippocampus, 2 gyrus parahippocampalis, 3 area dentata, 4
amygdala, 4 tractus opticus, 5 N. oculomotorius, 6 A. carotis interna, 7 atrium
ERRNVPHGLFRVRUJ
146 5  Diagnostic Base

a 3
2
1

4
transectional
plane

6
7

11
b 10
9
8
7

12

5
13

4
14

15 3
16
17 2

1
18 19

Fig. 5.8  Cadaver brain dissections. Plane a is not performed temporo- 7 region of the chorioid point, 8 pes hippocampi, 9 tip of cornu inferius,
axial. a Topogram, b Axial transection. a 1 Velum medullare anterius, 2 10 amygdala, 11 uncus, 12 trigonum olfactorium, 13 substantia perfo-
atrium, 3 plexus choroideus, 4 crus cerebri, 5 uncus, 6 tip of cornu rata anterior, 14 crus cerebri, 15 pons, 16 atrium (projection), 17 sulcus
inferius, 7 N. trigeminus, projection. b 1 Gyrus occipitotemporalis medianus, 18 pedunculus cerebellaris superior, 19 velum medullare
medius, 2 gyrus occipitotemporalis lateralis, 3 cornu posterius (projec- anterius
tion), 4 sulcus collateralis, 5 gyrus parahippocampalis, 6 N. trigeminus,

ERRNVPHGLFRVRUJ
5.3  Further Imaging 147

A B

b
axis of
Hippocampus

Fig. 5.9  Hippocampaxial MRT. No distortion of the temporal region


(used by Prof. Zentner, Freiburg i b). Topogram for Fig. 1.10.
a Hippocampaxial presentation, b ventriculoaxial presentation, if a is
not available

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148 5  Diagnostic Base

A
B
C
D

a b

1 4
3
2
2
3
1
4

c d

4
3
3

2 2
1

Fig. 5.10  Continuation of Fig. 5.9. a 1 Uncus, 2 chorioid point, 3 etooccipitalis, typical fusion rostral, 2 pons, 3 tip of cornu inferius, 4
gyrus parahippocampalis, 4 hippocampus, 5 atrium, 6 cornu posterius; uncus; d 1 sulcus calcarinus, 2 calcar avis, 3 margin of gyrus
b 1 tentorial fold, 2 pes hippocampi, 3 N. oculomotorius and bifurca- parahippocampalis
tion of A. basilaris, 4 amygdala; c 1 sulcus calcarinus and sulcus pari-

ERRNVPHGLFRVRUJ
5.3  Further Imaging 149

F f (focus)
E
C D
A B

b c

f
f

d e

f f

Fig. 5.11 Example of the exact location of an epilepsy focus a Chiasma, b corpora mammillaria, c and d region of focus –f –, e
(Experience of Prof. Zentner, Freiburg) – f – by hippocampaxial presen- tectum
tation. Frontal planes of MRT vertical to the axis of hippocampus (a–e).

ERRNVPHGLFRVRUJ
150 5  Diagnostic Base


eA
se

nic
15 gale
n t
poi
a’ 14

13
12
11
10

8
7
6
5
4
3
2
1

Tegmentum mesencephali

Fig. 5.12  Area between hippocampus/gyrus dentatus and striae longi- (Rosenthal); 9 allocortex, beginning of striae mediales of indusium gri-
tudinales cinguli/indusium griseum (Figs. 2.19 and 2.37). MRT sche- seum; 10 as 9, beginning of stria longitudinalis cinguli and of striae
matized. Bilateral lesions must be avoided. 1 Aquaeductus; 2 laterales of indusium griseum; 11 as 10; 12 indusium griseum, striae
commissura posterior; 3 recessus pinealis; 4 corpus pineale; 6 plexus mediales; 13 as 12, striae laterales and stria longitudinalis cinguli; 14 V.
choroideus; 5 recessus suprapinealis; 7 V. magna (Galeni); 8 V. basalis magna (Galeni); 15 sinus rectus

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Anatomical Base of Surgery
6

6.1 Extradural Topography (Figs. 6.1, 6.2, and 6.3)

6
5
8 7

Fig. 6.1  Extracranial temporal and adjacent layers. Superficial and temporalis; 4 M. temporalis; 5 sutura coronalis recognizable, if perios-
profound layers of the skin, galea, and periosteum (for further details, teum and fascia are transparent; 6 stephanion (transcutaneous palpable
see volume 1, frontal region, Fig. 2.3). 1 Porion; 2 periosteum; 3 fascia during innervation of M. temporalis), 7 galea with pars frontalis of M.
epicranius; 8 skin and subcutis

© Springer International Publishing AG 2018 151


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_6

ERRNVPHGLFRVRUJ
152 6  Anatomical Base of Surgery

br
3

st

2
pt

fz 1

ma as
8 po

Fig. 6.2  Outside landmarks of the cranial convexity frontotemporal. niotomies for avoiding errors. as asterion, br bregma, fz frontozygo-
Cadaver skull dissection. The outline of sulcus temporalis (Sylvii) (dot- matic point, ma fossa mandibularis, po porion, pt pterion, st stephanion.
ted) is located close to sutura squamosa. The basal region of the lobus 1 Sutura squamosa, variable; 2 sulcus lateralis (Sylvii), projection; 3
temporalis is located close to fossa mandibularis, porion, and asterion sutura coronalis; 4 linea temporalis superior; 5 linea temporalis infe-
(see Fig. 2.25). These relationships must be considered at temporal cra- rior; 6 processus zygomaticus; 7 ala major; 8 orbitomeatal line

ERRNVPHGLFRVRUJ
6.1 Extradural Topography 153

1 cg

(fs)
fo
pt
ts
2 pc ro
(ds)
3
fv

5 ea
pi
ba
6
ks

Fig. 6.3  Inside landmarks craniobasal. Cadaver skull dissection: fora- veins medial from V. Labbé is located. Cave during surgical elevation
men spinosum (enclosing A. meningea media) is located close to fora- of lobus temporalis. ba basion; cg crista galli et For. caecum; ds dorsum
men ovale (enclosing N. mandibularis). This should be considered at sellae (defect); ea eminentia arcuata; fo foramen opticus; fs fissura
surgical evacuations of temporal epidural hematomas and at punctures orbitalis superior, lateral point, projection; fv foramen ovale; ks knee of
of foramen ovale. Apertura interna of canalis caroticus is located at the sulcus transversus; pc processus clinoideus anterior overlying the
posterior margin of foramen lacerum. Eminentia arcuata (enclosing medial segment of fissura orbitalis superior projection; pi porus acusti-
canalis semicircularis labyrinthi) is a landmark for sinus petrosus supe- cus internus; pt pterion; ro canalis rotundus; ts tuberculum sellae. 1
rior (overlying sulcus petrosus sup.) and the palpable superior margin Sulcus chiasmatis, 2 sulcus of A. meningea media, 3 For. spinosum, 4
of os petrosum. At this area, an important bundle of basal bridging For. lacerum, 5 apex ossis petrosi, 6 sulcus petrosus superior, 7 sulcus
transversus

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154 6  Anatomical Base of Surgery

6.2 Intradural Topography

7
6
5

8
3

4
6

3
b 7 2

8
9

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6.2  Intradural Topography 155

Subarachnoid course
Subdural course

a
c

Fig. 6.5  Posterior temporobasal medial bridging veins (Scheremet density of its dural exit points; a low density of dural penetration points,
1984). Interruption could be followed by encephalomalacia similar to b high density, c density of its cerebral exit points; a low density, b high
interruption of V. Labbé. a Leptomeningeal relationships of veins, b density

Fig. 6.4  Anterior basal veins and sinuses. a At pterional surgical poralis superficialis, 7 dural fold of ala minor, 8 uncus; b 1 dural venous
approaches, an interruption of temporopolar bridging veins for eleva- plexus of clivus; 2 dura of dorsum sellae, hypovascularized; 3 sinus
tion of lobus frontalis is not necessary. b Connections of temporobasal intercavernosus posterior; 4 sinus intercavernosus anterior; 5 sinus alae
bridging veins with basal sinuses. The dural envelopments of sinus cav- minoris; 6 sinus sphenopetrosus, enclosed by a thickened dural fold; 7
ernosus and sinus paracavernosus are thickened and intransparent. a 1 as 6, often transparent; 8 sinus paracavernosus (Lang); 9 sinus caverno-
tentorial fold, 2 plica petroclinoidea posterior, 3 plica petroclinoidea sus, often transparent
anterior, 4 diaphragma sellae, 5 temporopolar bridging veins, 6 V. tem-

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156 6  Anatomical Base of Surgery

6
3

1
7

Fig. 6.6  Temporal basal surgical target areas and adjacent medial noidea anterior (projection), 6 uncus, 7 basal bridging vein (subdural
structures. Eminentia arcuata (projection) is a landmark for medial course), 8 eminentia arcuata (projection), 9 basal bridging veins, sub-
basal bridging veins. 1 Temporobasal branches of A. cerebri posterior, dural course
2 A. basilaris, 3 N. oculomotorius, 4 A. carotis interna, 5 plica petrocli-

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6.2  Intradural Topography 157

Fig. 6.7  Tentorial notch, variants. Surgical aspects (Experiences of the of lobus temporalis. c Wide variant. Arachnoid adhesions between cer-
author). a Tentorial notch, usual finding. b Narrow variant. Low toler- ebellum (hatched) and gyrus parahippocampalis could hinder surgical
ance for brain shifting at space occupying lesions or surgical elevation elevation of lobus temporalis

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158 6  Anatomical Base of Surgery

Fig. 6.8  Suprasellar dura penetrating structures (Lang 1975). a Usual plica petroclinoidea posterior. b Rare variant. A. carotis interna is retro-
findings: a transversal level of A. carotis interna, b dural exit points of positioned. This may be favorable for pterional surgical approaches to
N. oculomotorius are located at the transversal level of infundibulum or medial target areas. * Plica petroclinoidea posterior
anterior to it, c dural exit point of N. trochlearis is located anterior from

ERRNVPHGLFRVRUJ
6.2  Intradural Topography 159

5
4
a

pt

as
ea

po

1
2
3

ca

ea
1
2
3
4

Fig. 6.9  Lateral temporal region. Temporal cortex renders prominent. gyrus, 3 third temporal gyrus, 4 gyrus angularis, 5 pars ascendens of
Bony landmarks added for assisting neuronavigation, if necessary. sulcus lateralis (Sylvii), 6 sulcus centralis. b ca commissura anterior, ea
Small distance measurement between porion and lobus temporalis. eminentia arcuata, projection. 1 Gyrus occipitotemporalis lateralis, 2
Small distance measurement between asterion (sinus transversus) and gyrus occipitotemporalis medialis, 3 isthmus gyri cinguli, 4 gyrus para-
lobus temporalis. a as asterion; ea eminentia arcuata, projection; po hippocampalis, 5 sulcus collateralis, * axis of hippocampus
orion; pt pterion, projection. 1 First temporal gyrus, 2 second temporal

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160 6  Anatomical Base of Surgery

5
4

ea

Fig. 6.10  Basal temporal region. ea eminentia arcuata, projection. 1 Cisterna ambiens, 2 sulcus collateralis, 3 gyrus parahippocampalis, 4 uncus,
5 impression of uncus (by plica petroclinoidea anterior), 6 plica petroclinoidea anterior, projection

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6.2  Intradural Topography 161

Fig. 6.11  Addendum for Fig. 6.10. a Anatomical skull dissection com- Dural folds. 1 Plica petroclinoidea anterior, 2 processus clinoideus
bined with a cast of lobus temporalis. Polus temporalis is overlaid by anterior overlaid by 1
ala minor. Uncus is located dorsal from plica petroclinoidea anterior. b

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162 6  Anatomical Base of Surgery

10 9
11 8
12

3
2
1

Fig. 6.12  Dorsal temporal (sylvian) region with adjacent structures. 1 cialis; 7 Heschl’s gyri (compartment of the acoustic cortex); 8 ala
V. basalis (Rosenthal); 2 A. cerebri posterior; 3 gyrus parahippocam- minor, projection; 9 temporopolar bridging veins, projection; 10 uncus,
palis; 4 A. cerebri media; 5 A. temporalis posterior; 6 V. temp. superfi- transectional plane; 11 tip of cornu inferius; 12 temporal chorioid point

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6.2  Intradural Topography 163

6.2.1 Survey (Figs. 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 6.10, 6.11, and 6.12)

pt

as
om po

5 4 3
2
b 1

11

10

Fig. 6.13 Superficial temporal arteries, schematized. Landmarks centralis, 5 temporal branches of A. cerebri media, 6 temporal branches
added for assisting imagings, if necessary. a Bony landmarks, b arter- of A. carotis interna, 7 temporobasal branches of A. cerebri posterior, 8
ies. a as asterion, om orbitomeatal line, po porion, pt pterion. b 1 A. as 7, 9 third temporal gyrus, 10 second temporal gyrus, 11 pars angula-
temporooccipitalis, 2 A. angularis, 3 A. temporalis posterior, 4 sulcus ris of the first temporal gyrus (Wernicke). Light circles: landmarks as a

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164 6  Anatomical Base of Surgery

4
a
3
2

4 3 2
b

Fig. 6.14  V. temporalis superficialis and further temporal veins. a V. rium, variant (Lang), 2 veins of Labbé, 3 variable parietal veins, 4 V.
temporalis superficialis and other cortical veins. b Opening of the syl- temporalis superficialis, 5 temporopolar bridging veins are connected
vian cistern. Arachnoid incision is performed superior from V. tempo- with sinus paracavernosus, projection. Light circles: landmarks as Fig.
ralis superficialis. Now brain damage close to temporal arachnoid 1.2. b 1 Temporal arteries underlying V. temporalis superficialis, 2 V.
adhesions can be avoided. a 1 Temporooccipital bridging vein to tento- temporalis superficialis, 3 superficial arachnoid layer of the parietal
cortex, 4 parietal CSF space, 5 arachnoid adhesions

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6.2  Intradural Topography 165

6.2.2 Lateral Structures (Figs. 6.13 and 6.14)

9
8

Fig. 6.15  Sylvian arteries and arachnoidea, schematized. Temporal main trunk; 4 one of numerous temporopolar branches of A. cerebri
arteries are undercrossing the temporodorsal arachnoid layer which is media; 5 a small frontotemporal vein crossing sulcus lateralis (sylvian
retracted by spatula. Parietal arteries remain in the so-called sylvian cistern) should be interrupted. At surgical opening of the sylvian cis-
cistern. Surgical aspects: incision of sulcus inferior insulae (dotted) for tern; 6 as 4; 7 connection(s) of superficial with profound sylvian veins;
opening of cornu inferius, e.g., for amygdalohippocampectomy. 1 A. 8 V. temporalis superficialis; 9 A. temporalis posterior, *: Heschl’s gyri.
cerebri media, distal trunk; 2 A. operculofrontalis; 3 A. cerebri media, Dotted: incision of sulcus inferior insulae

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166 6  Anatomical Base of Surgery

11 10 9 8

12

13 6

14
4

15

16
2

Fig. 6.16  Temporodorsal sylvian region, cornu inferius, and vessels. 1 with Vv. temporales profundi; 12 one of the parietal branches of A. cere-
A. hippocampi; 2 temporal chorioid point; 3 A. chorioidea anterior; 4 bri media; 13 temporal branches of A. cerebri media; 14 A. temporalis
V.(Vv.) temporalis profunda (ae); 5 A. cerebri media, main trunk; 6 dis- posterior; 15 A. angularis et A. temporooccipitalis; 16 sulcus inferior
tal trunk of A. cerebri media; 7 A. operculofrontalis; 8 arachnoid wall insulae, + adhesion of hippocampus with the roof of cornu inf., (com-
between sylvian cistern and temporodorsal subarachnoid space. Note mon finding). It may be transected at surgery, e.g., amygdalohippocam-
positions of temporal and parietal vessels to it; 9 temporopolar branch of pectomy, if necessary
A. carotis interna; 10 V. temporalis superficialis; 11 connection of 10

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6.2  Intradural Topography 167

9 8 7 6 5
a
4

6 5
4 3
2
b

8
9

10
11

12 1

13

14
15

Fig. 6.17  Cornu inferius, cisterna ambiens, and its vessels. Dorsal a and A. cerebri posterior, 3 V. temporalis profunda, 4 A. communicans
and basal wall b of sulcus lateralis (Sylvii). a 1 Taenia chorioidea, 2 posterior, 5 A. carotis interna, 6 A. chorioidea anterior, 7 uncus, 8 pes
tractus opticus, 3 plexus vein, 4 V. ventricularis inferior, 5 inferior tip hippocampi, 9 temporal chorioid point, 10 A. hippocampi, 11 temporo-
vein, 6 tip of cornu inferius, 7 uncus transected, 8 tractus opticus, 9 A. basal branches of A. cerebri posterior, 12 gyrus parahippocampalis, 13
chorioidea anterior; b 1 V. basalis (Rosenthal), 2 V. interpeduncularis gyrus dentatus, 14 taenia fornicis, 15 fimbria fornicis

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168 6  Anatomical Base of Surgery

7 6
9 8 5
4
3
2

10 1
11

12

13

14

15 23 24
16 17 18 19 20 21 22

Fig. 6.18  Conclusion. Minimized survey of Fig. 6.12 added. 1 V. 12 anastomosis between superficial and profound sylvian veins, 13 A.
interpeduncularis, 2 A. communicans posterior, 3 perforating arteries, 4 temporalis posterior, 14 sulcus inferior insulae, 15 lateral atrial veins,
Vv. temporales profundi, 5 A. chorioidea anterior, 6 perforating arter- 16 atrium, 17 hippocampus, 18 fimbria fornicis, 19 gyrus dentatus, 20
ies, 7 A. cerebri media, 8 temporal chorioid point, 9 bridging veins, 10 gyrus parahippocampalis, 21 A. hippocampi, 22 temporobasal branches
V. temporalis superficialis, 11 temporal branches of A. cerebri media, of A. cerebri posterior, 23 A. cerebri posterior, 24 V. basalis (Rosenthal)

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6.2  Intradural Topography 169

6.2.3 Sylvian Structures (Figs. 6.15, 6.16, 6.17, and 6.18)

Fornix

cingular stria
Commissura ant. Isthmus
gyri cinguli

precommiss.
Palaeocortex

Gyrus uncinatus
Gyr.fasc.

rhinal sulcus intralimbic gyrus uncal sulcus

Palaeocortex (syn.Rhinencephalon)
Allocortex (syn.limbic cortex)
Archicortex
rtical components
Mesocortex =mixtum of allocortical and neoco

Neocortex (syn.Osocor tex)

Fig. 6.19 Allocortex («limbic» system) (schematized). Survey. structures are frontal and parietooccipital striae longitudinales and
Unilateral surgical eliminations of the temporal component of allocor- indusium griseum of corpus callosum, area subcallosa, posterior seg-
tex are performed, e.g., for therapy of epilepsy. Bilateral lesions are ment of gyrus rectus, further tractus et striae olfactoriae and bulbus
followed by severe psychological deficits. Extratemporal allocortical olfactorius et fila olfactoria

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170 6  Anatomical Base of Surgery

4
a
5 3

6
2

7
1
b5

Fig. 6.20  Addendum for Fig. 6.19 (Feneis in Kahle (2001)). a 1 Pes Demonstration during a lecture for anatomy of fornix and temporal
hippocampi, 2 sulcus fimbriodentatus, 3 fimbria fornicis, 4 crus forni- allocortex (Prof. Feneis, Anatomisches Institut der Universität
cis, 5 corpus fornicis, 6 columna fornicis, 7 corpus mammillare. b Tübingen (Germany), teaching 1950. Recollection of the author)

6.2.4 Temporal Allocortex (Figs. 6.19, 6.20, 6.21, 6.22, 6.23, 6.24, 6.25, and 6.26)

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6.2  Intradural Topography 171

4 3 2

3
4
1 2

a
5+6

6
)
is
s on
tu mm
e ta toa
d
io nta
br e
if m us d
2b us lc
2a lc Su
Su yn, 1
(s

3
c

Sulcus
hippoc
ampi

Fissura collateralis Subiculum (Ludwig E, Klinggler J , 1956)


6

Fig. 6.21  Temporal allocortex. a and b Development (According to campus, 6 gyrus parahippocampalis. c 1 Gyrus dentatus, 2a fimbria
Duvernoy 1988, pp 35 and 93, schematized). c Allocortex of adults. a fornicis, 2b taenia fornicis, 3 alveus, 4 cornu inferius, 5 hippocampus,
and b: 1 gyrus dentatus, 2 fornix, 3 alveus, 4 cornu inferius, 5 hippo- 6 gyrus parahippocampalis

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172 6  Anatomical Base of Surgery

5 4
a

2
6

12
lis
era

11
llat

9 10
Sul 7
co

cus 8
coll
tia

ate
ralis
ine

tus
Em

denta
s
fimbrio
Sulcu
pi
c am
b 2 po
ip
3 ush
Sulc

b 6
5
a

Fig. 6.22  Allocortex and surrounding structures. a Survey. b Details gyrus occipitotemporalis lateralis, 10 tail of hippocampus located at the
after digital loosening of area dentata from gyrus parahippocampalis. outer temporal cortex, 11 isthmus gyri cinguli, 12 gyrus occipitotempo-
Numerous fine fiber connections were interrupted. Area dentata: hip- ralis medialis; b 1 gyrus dentatus, 2 fimbria fornicis, 3 taenia fornicis, 4
pocampus plus gyrus dentatus. a 1 Sulcus calcarinus, 2 cuneus, 3 sulcus alveus, 5 digital loosening of area dentata from gyrus parahippocam-
parietooccipitalis, 4 sulcus cinguli, 5 gyrus cinguli, 6 stria longitudina- palis, 6 gyrus parahippocampalis; a ground of sulcus collateralis, b
lis cinguli, 7 gyrus parahippocampalis, 8 gyrus dentatus-fasciolaris, 9 ground of cornu inferius

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6.2  Intradural Topography 173

A. chorioidea ant.

6
A. hippocampi 4 5

Fig. 6.23  Feeding arteries of the temporal allocortex. A. chorioidea bri posterior, 2 A. communicans posterior, 3 A. carotis interna, 4 V.
ant., branches feeding amygdala and temporal chorioid point A. hip- basalis (Rosenthal), 5 temporobasal branches of A. cerebri posterior, 6
pocampi feeding area dentata and gyrus parahippocampalis. 1 A. cere- A. chorioidea posterior lateralis

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174 6  Anatomical Base of Surgery

lis
mpa
oca
h ipp
para
rus
Gy
a
ntat
a de
Are
atter
white m b

Hippocampus

A. cerebri post.

Gyrus parahippocampalis
-Area dentata-Hippocampus-complex

Fig. 6.24  Feeding arteries of area dentata (hippocampus-­gyrus-­dentatus complex). a Transectional plane of the hippocampus, b ramification of
A. hippocampi (According to Stephan 1975, pp 115 and 119)

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6.2  Intradural Topography 175

V.bas.of Rosenthal

transversa hippocampal
subependymal veins

Ingitudinal hippocampal
vein

transverse pial veins

temporobasal bridging veins


Sin.sphenobasalis

Fig. 6.25  Draining veins of the temporal allocortex

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176 6  Anatomical Base of Surgery

striate arteries

Corpus amygdaloideum
Tractus pyramidalis

Fig. 6.26 Corpus amygdaloideum (amygdala) and surrounding structures. Essential adjacent structures must be preserved at
amygdalohippocampectomy

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Special Surgical Aspects
7

7.1 Extradural Surgery (Figs. 7.1 and 7.2)

Fig. 7.1  Pterional craniotomy widened for amygdalohippocampec- pars triangularis; 3 as 1, pars opercularis; 4 gyrus precentralis; 5 first
tomy (Used by Prof. Zentner, Freiburg 2014). Skin-galea incision dot- temporal gyrus
ted. Cerebral relief drawn in 1 third frontal gyrus, pars orbitalis; 2 as 1,

© Springer International Publishing AG 2018 177


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178 7  Special Surgical Aspects

bu
rrh
ole

po

orbito-meatal-line ma

mm

thick- thin
cranial base walled walled

Fig. 7.2 Craniotomy for temporobasal approaches. Craniotomy formed craniotomy. Pneumatic cells must be considered. Note the small
should be performed as basally as possible for avoiding cerebral or cra- distance measurement between fossa mandibularis and fossa cranii
niobasal damage. Endangered are lobus temporalis after too far dorsally media. ma fossa mandibularis, po porion; 1 asterion, 2 knee of sinus
performed craniotomy. Endangered are antrum mastoideum of cavum transversus, 3 lateral insertion of os petrosum at squama temporalis,
tympanicum, labyrinth, and sinus transversus after a too far basally per- close to antrum tympanicum hatched: area of widened mastoid cells

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7.2  Intradural Surgery 179

7.2 Intradural Surgery

7.2.1 Standard Resections of Lobus Temporalis (Figs. 7.3, 7.4, and 7.5)

4-5 cm not dominan


t
4, 5
cm d
omin
ant

5,5 c
m no
t dom
inant

5
cm
do
m
in
an
t
on
ati
rm
l fo
m pa
ca
po
hip

Fig. 7.3  Resection of the temporal lobe at the dominant and nondominant hemisphere with and without amygdalohippocampectomy (According
to drawings of Zentner 1997, modified presentation)

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180 7  Special Surgical Aspects

ion
les
exti ion wid
of le
rpat
s
ion ened
les
ion

tion dened
rpa i
exti sion w
of le

y
ectom
camp
hippo

Fig. 7.4  Keyhole extirpation of a temporopolar lesion combined with amygdalohippocampectomy (According to Zentner 1997, modified
presentation)

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7.2  Intradural Surgery 181

lesion

extirpation of lesion widened

hippocampectomy

Fig. 7.5  Keyhole extirpation of a central temporal lesion combined with amygdalohippocampectomy (According to Zentner 1997, modified
presentation)

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182 7  Special Surgical Aspects

7.2.2 Amygdalohippocampectomy (Figs. 7.6, 7.7, 7.8, 7.9, 7.10, 7.11, 7.12, 7.13, 7.14, 7.15, 7.16, and 7.17)

transylvian

(Yasarg
il)

al
transcortic
li v ie r)
(O

transc
ortical
(Niem
eyer)

subtempora
l

transylvian

subtemporal

Fig. 7.6  Routes and target regions. Survey. Routes (arrow) and target areas (hatched) could be widened to a complete amygdalohippocampec-
tomy (Prof. Zentner, personal communication to the author 2014)

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7.2  Intradural Surgery 183

arachnoid
layer

loosening of Aa. tempp.


if necessary

Fig. 7.7  Transsylvian route to cornu inferius for amygdalohippocam- rior insulae must be identified, before it will be incised for opening
pectomy (black arrows) according to Yaşargil et al. (1985). If Sulcus cornu inferius. Basal ganglia, pyramidal tract, and perforating vessels
inferior insulae is overlaid by A. cerebri media, now this artery should could be endangered. If cornu inferius is presented, amygdalohippo-
be shifted to a superior direction (light arrow). One or two small perfo- campectomy can be performed
rating arteries could be interrupted, if necessary (Yaşargil). Sulcus infe-

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184 7  Special Surgical Aspects

b
is
pal
am

lis
poc

tera
p

a
ahi

coll
par

us
Gyr
s
lcu
Su

Fig. 7.8  Subtemporal route to cornu inferius for amygdalohippocampectomy (light arrows) (Applied by Prof. Zentner, Freiburg i B 2013) tran-
scrossing sulcus collateralis and cornu inferius (a and b)

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7.2  Intradural Surgery 185

a
a

Tra
ctu
so
pt

la
da
yg
us

Am
at
cin
un
us
yr
G

Fig. 7.9  Preservation of tractus opticus. Area of amygdalohippocampectomy hatched

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186 7  Special Surgical Aspects

B
B

Co
rpu
sg
en
icu
l.m
ed B
.

st.
iss.po
Comm
s
li

Su
pa

lcu
am

sc
oc

oll
at
s

ipp
u

.
pa rus
mp

rah
Gy
a
oc
pp
Hi

Fig. 7.10  Continuation of Fig. 7.9. Posterior region

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7.2  Intradural Surgery 187

a b

8
7

c 6

Fig. 7.11  Continuation of Fig. 7.10. Anterior superior limit area of hippocampi, 4 tip of plexus choriodeus (landmark for surgery) 5 amyg-
amygdalohippocampectomy. a and b Topogram. c Drawing similar to dala, 6 gyrus uncinatus, 7 tractus opticus, 8 processus clinoideus
neuronavigation. 1 gyrus parahippocampalis, 2 gyrus dentatus, 3 pes anterior

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188 7  Special Surgical Aspects

5
4
3
2
1

ker

mm
suc

3-4

stop

Fig. 7.12  Preservation of tractus opticus and striate arteries during amygdalohippocampectomy (Applied by Prof. Zentner, Freiburg 2013).
Technical aspects. 1 cornu inferius; 2 tip of plexus choriodeus; 3 uncus, transected; 4 tractus opticus; 5 striate arteries

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7.2  Intradural Surgery 189

stri
ate
arte
ries
.
pt
so
tu
ac
Tr

Fig. 7.13  Preservation of striate arteries, gangliae basales et tractus pyramidalis at surgery (According to anatomical dissections and casts of
Hussein et al. 1987). Hatched: area of resection at surgery

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190 7  Special Surgical Aspects

6 1

15

14

13

9 11 12
10

Fig. 7.14  Posterior area of amygdalohippocampectomy. Cave columna et 7 fimbria fornicis, 8 uncus, 9 gyrus dentatus, 10 Retzius’ gyri, 11 gyrus
crus fornicis. Anatomical aspects. 1 splenium corporis callosi, 2 commis- parahippocampalis, 12 tail of hippocampus, 13 gyrus fasciolaris, 14 gyrus
sura fornicis, 3 sulcus hippocampi, 4 taenia fornicis, 5 crus fornicis, 6 as 4, occipitotemporalis medialis, 15 isthmus gyri cinguli

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7.2  Intradural Surgery 191

ial
o ax
mp
ca
po
hip

4
3
5 2
b
1

13
10 11 12

Fig. 7.15 Middle region of amygdalohippocampectomy. Cadaver rioidea; 7 tractus opticus; 8 gyrus parahippocampalis after shifting of
brain dissection. Microsurgical aspects. 1 fimbria and taenia fornicis, plexus choriodeus, taenia chorioidea transparent; 9 uncus residual,
taenia split, plexus choriodeus shifted; 2 gyrus dentatus after loosening transectional plane; 10 plexus choriodeus shifted, taenia chorioidea
and shifting of plexus choriodeus; 3 gyrus parahippocampalis after transparent; 11 tip of cornu inferius; 12 lobus temporalis; 13
loosening and shifting of plexus choriodeus; 4 lobus parietalis; 5 lobus hippocampus
frontalis; 6 A. cerebri posterior overlying by the transparent taenia cho-

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192 7  Special Surgical Aspects

Pulv.thalami
Rr.perforantes/Subst.perfor.ant.
Caps.int Taenia chor. vessels of Tectum

tip of Cornu inf.

Fig. 7.16  Continuation of Fig. 7.15. Anterior and middle target region of amygdalohippocampectomy

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7.2  Intradural Surgery 193

8 7 6 5

A1

3
9

10 2

Fig. 7.17  As Fig. 7.16. Vessels: 1 temporal chorioid point, 2 A. hip- anterior, 8 V. basalis (Rosenthal), 9 branches of A. chorioidea anterior
pocampi, 3 V. mesencephalica lateralis, 4 A. thalamogeniculata, 5 tem- at the temporal chorioid point, 10 inferior tip vein; A1 A. cerebri ante-
porobasal branches of A. cerebri posterior, 6 knee of A. choriodeus rior, P A. cerebri posterior
posterior lateralis marking corpus geniculatum laterale, 7 A. chorioidea

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194 7  Special Surgical Aspects

7.2.3 Subtemporal Surgical Approaches to Basal Cisterns (Figs. 7.18, 7.19, and 7.20)

13 12 10 9
11
14
15

16

17

5
4
3 6
2
1

Fig. 7.18  Subtemporal route according to Dandy, modified by Drake mandibularis, projection; 9 ala minor, 10 polus temporalis, projection;
Black arrow: retraction of tentorium. Light arrow: surgical route. 1 A. 11 A. carotis interna, 12 N. oculomotorius, projection; 13 N. opticus; 14
cerebelli superior; 2 gyrus parahippocampalis, projection; 3 uncus, pro- N. oculomotorius; 15 processus clinoideus posterior; 16 pons; 17 plica
jection; 4 N. trochlearis; 5 temporobasal bridging veins; 6 knee of sinus petroclinoidea posterior
transversus; 7 sinus petrosus superior, dura sometimes transparent; 8 N.

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7.2  Intradural Surgery 195

incision

te
ve mp
in oro
s ba
sa
l

Fig. 7.19  Addendum for Fig. 7.18. Incision of tentorium according to margo superior ossis petrosi, 5 sinus petrosus superior, 6 incisura tri-
Dandy, if Drake’s tentorial retraction is not applicable. 1 knee of sinus geminalis. Dotted: projections
transversus, 2 eminentia arcuata, 3 temporobasal bridging vein (s), 4

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196 7  Special Surgical Aspects

16
15

17 14

13

18

12

11

10

19 5

2
1

Fig. 7.20  Surgical topography 1 retraction of lobulus quadrangularis rating arteries; 8 plica petroclinoidea posterior; 9 N. oculomotorius; 10
cerebelli; 2 Drake’s retraction of tentorium without tentorial incision; 3 dura; 11 processus clinoideus posterior; 12 dorsum sellae; 13 A. basi-
tentorium; 4 pontomesencephalic rim; 5 A. cerebelli superior; 6 laris; 14 perforating arteries; 15 A. cerebri posterior; 16 crus cerebri; 17
Liliequist’s membrane, pars mesencephalica, margin of its gap; 7 perfo- third temporal gyrus; 18 N. trochlearis; 19 temporobasal bridging veins

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Part III
Parietal Region

1.1 Introduction

This introduction to Part III contains a short summary of each chapter.

1.2 Chapter 8 Diagnostic Base

Landmarks may assist neuronavigation for exact defining of small target areas, if necessary.

1.3 Chapter 9 Anatomical Base of Surgery

Asymmetries of midline structures, incongruence of os parietale and lobus parietalis, and


defining of sinus sagittalis superior should be regarded for avoiding errors at surgery:

–– Asymmetries of sutura sagittalis, bregma and sinus sagittalis superior are often not exact to
define by imagings.
–– Especially the parietal segment of sinus sagittalis superior is variable, its lateral limit is
often not to define by imagings or during surgery. It may be mixed up with lacunae.
–– The anterior limit of lobus parietalis is identic with sulcus centralis. This region is located
far distant from os frontale, overlaid by the middle area of os parietale.
–– The fine cerebral midline structures in the depth, especially fissura transversa and adjacent
structures, are often not exact to define by imagings.

1.4 Chapter 10 Special Surgical Aspects

–– Interhemispheric surgical approaches may be hindered by bridging veins and by unclear


defined lateral limits of the sinus.
–– At approaches to the third ventricle, the middle segment of fornix could be splitted by open-
ing of cavum septi pellucidi. Its posterior segment can be splitted by opening of commis-
sura fornicis between crura fornicis. These areas are variable and well to define using
imagings.
–– At transylvian approaches, it should be considered the short distance measurement between
the middle segment of sulcus superior insulae and tractus pyramidalis.

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Diagnostic Base
8

8.1 Landmarks (Figs. 8.1 and 8.2)

approx.
br 50mm

sc

st

ob

25
mm
pt
spo la

as
om

sc

ob
fr

la

Fig. 8.1  Parietal landmarks. Sulcus centralis added, schematized: as pterion, sc sulcus centralis (for details see Fig. 3.10 ff), spo sulcus pari-
asterion, br bregma, fr foramina parietalia for defining of obelion (more etooccipitalis, upper point, st stephanion
precise than lambda), la lambda, ob obelion, om orbitomeatal line, pt

© Springer International Publishing AG 2018 199


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ERRNVPHGLFRVRUJ
200 8  Diagnostic Base

50mm
approx.

br

sc
ob

25
m
m

la
o
sp
ic

na

in
ba

Fig. 8.2  Continuation of Fig. 8.1. Parietal medial sulci added: ba basion, br bregma (anterior limit of os parietale), ic intercommissural line, in
inion, la lambda, na nasion, ob obelion, sc sulcus centralis (anterior limit of lobus parietalis) , spo sulcus parietooccipitalis

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8.2 Radiology 201

8.2 Radiology (Figs. 8.3, 8.4, 8.5, and 8.6)

6
a
7
5
4
3
2
1

4
5

3
b

Fig. 8.3  Medial (a) and lateral arteries (b). Survey, schematized. (a) 1 2 A. angularis, 3 A. parietalis posterior (posteriores), 4 A. parietalis
A. calcarina, 2 lambda, 3 A. parietooccipitalis, 4 obelion, 5 A. praecu- anterior (anteriores), 5 A. sulci centralis
nealis, 6 sulcus centralis, 7 A. paracentralis; (b) 1 A. temporooccipitalis,

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202 8  Diagnostic Base

arteries crossing to
* the contralateral side

*
*

Fig. 8.4  Midline crossing branches of A. cerebri ant. (According to of A1 could be followed by bihemispheric encephalomalacia. Left, falx,
Marino 1976) Note contralateral branches of A2 (during contralateral and dura right, cortex
digital compression of A. carotis communis). Homolateral interruption

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8.2 Radiology 203

a b

6 3

7
2 main branches
distal branches

Fig. 8.5 A. cerebri media, trifurcation, schematized. (a) and (b) lateral basal branch, 3 A. operculofrontalis, 4 and 5 branches, 6 A. sulci
Angiogram. Arrows: main division of A. cerebri media. (c) Variability centralis, 7 A. cerebri media, distal trunk
(sketches on the base of Ring 1969). 1 A. cerebri media, main trunk, 2

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204 8  Diagnostic Base

5 4
6 3

Fig. 8.6  Lateral veins (sketches). Landmarks added for assisting neuronavigation, if necessary. 1 Lambda, 2 parietooccipital bridging veins, 3
sulcus centralis, 4 V. centralis (Rolandi), 5 vein of Trolard (upper anastomotic vein, variable), 6 bregma, 7 V. temporalis superficialis

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8.3  Further Imaging 205

8.3 Further Imaging (Figs. 8.7, 8.8, 8.9, 8.10, and 8.11)

br
a

ca
1

2
a

sc

b sc

cp

3
b

Fig. 8.7  MRT, coronal planes. Parietal cortex hatched and rendered postcentralis; (b) cp commissura posterior, sc sulcus centralis, 1 lobu-
prominent. Landmarks added for assisting imagings, if necessary: (a) lus paracentralis, 2 gyrus angularis, 3 gyrus temp.1
br bregma, ca commissura anterior, 1 gyrus praecentralis, 2 gyrus

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206 8  Diagnostic Base

la

1
la
2

Fig. 8.8  Continuation of Fig. 8.7. la lambda 1 dorsal parietal cortex, 2 cortex of the angularis area

ERRNVPHGLFRVRUJ
8.3  Further Imaging 207

a
la

fm
3

fm

2 3

Fig. 8.9  Continuation of Fig. 8.8. (a) la lambda 1 angularis area. (b) fm foramen interventriculare (Monroi), 2 gyrus praecentralis, 3 gyrus
postcentralis

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208 8  Diagnostic Base

ic

1
ca
2

Fig. 8.10  Continution of Fig. 8.9. ca commisura anterior, 1 area of sulcus praecentralis, 2 insula

ERRNVPHGLFRVRUJ
8.3  Further Imaging 209

sc

sp
o
3

sp
o
1

Fig. 8.11  Continuation of Fig. 8.10. (a) The complete medial cortex to calcar avis of the ventricle: (a) sc sulcus centralis, spo sulcus parieto-
can be presented at one sagittal slice in contrast to lateral presentations occipitalis, 1 lobulus paracentralis, postcentral segment, 2 lobulus prae-
of the cortex. The medial relief of the cortex is less variable than the cunealis, 3 cuneus, 4 gyrus cinguli; (b) spo sulcus parietooccipitalis, l
lateral relief. (b) The ground of sulcus parietooccipitalis is located close dorsal wall of atrium

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Anatomical Base of Surgery
9

9.1 Extradural Topography

9.1.1 Extracranial Layers (Fig. 9.1)

Galea

7
6
5

8
9

Fig. 9.1  Vessels and nerves of galea aponeurotica (galea) resected. Its frontal branch. Anastomotic branches are supraorbital arteries: 7 V. tem-
contents are preserved: 1 N. occipitalis major, 2 A. occipitalis and its poralis superficialis, 8 linea temporalis superior, insertion of fascia tem-
main anastomotic branches, 3 N. occipitalis minor, 4 anastomotic poralis, 9 linea temporalis inferior, insertion of M. temporalis
vein(s), 5 N. facialis, frontal ramification, 6 A. temporalis superficialis,

© Springer International Publishing AG 2018 211


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212 9  Anatomical Base of Surgery

9.1.2 Skull (Figs. 9.2 and 9.3)

br

ob

la

Fig. 9.2  Incongruity of sutura sagittalis and midline. Cadaver skull dissection, common finding. This must be considered at surgical midline
approaches: br bregma, la lambda, ob obelion

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9.1  Extradural Topography 213

ob
7

Fig. 9.3  Continuation of Fig. 9.2. Inside asymmetry of sulcus sagitta- Pacchioni’s granulations and some lacunae, 3 sutures at the inside not
lis (bed of sinus sagittalis superior) according to sutura sagittalis. ob congruent to sutures at the outside (bregma, recognizable at axial CTs),
obelion, 1 foramina parietalia, 2 foveolae granulares, enclosing 4 sulcus sagittalis, 5 juga cerebralia, 6 impressiones gyrorum, 7 as 2

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214 9  Anatomical Base of Surgery

9.1.3 Sinus Sagittalis Superior (Figs. 9.4, 9.5, and 9.6)

A B
C

a
a

Fig. 9.4  Sinus sagittalis sup and sulcus sagittalis. Common findings. could be unclear at imagings and during surgery. Sinus could be mixed
Sketch for topogram added: a frontal segment, b parietooccipital seg- up with lacunae
ment, c occipital segment. The lateral limits of sinus sagittalis superior

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9.1  Extradural Topography 215

10 9 8 7

11
12
13
14

15

16

17
18 19 20

Fig. 9.5  Sinus sagittalis superior, dural veins, and lacunae, schema- inferior sulcus of the deep channel of the sinus (Lang 1979, 1991). 1
tized. Fine venous network penetrates all dural structures close to the Lacuna; 2 meningeal arteries and veins; 3 granulationes arachnoidales
sinuses. Venous network and adjacent bridging veins could be dilated (Pacchioni); 4 sinus wall; 5 lacuna and mouth at the sinus wall; 6 as 5,
close to extracerebral tumors, e.g., meningiomas. The widened veins bulging to tabula int. containing granulationes arachnoidales; 7
could substitute the compressed sinus and bridging veins. This must be vessel(s) of granulationes arachnoidales; 8 granulationes arachnoidales
considered at surgery. A transversal incomplete or complete horizontal at the inside of lacunae; 9 meningeal veins; 10 fine venous network
septum is dividing the sinus in a superficial and a usually smaller deep penetrating all dural structures;11 bridging vein; 12 superficial part of
channel. Lacunae are connected by surgery without endangering cere- the sinus, often larger than the inner part; 13 deep part of the sinus, 14
bral circulation. Bridging veins are not connected with lacunae falx; 15 cortex; 16 subarachnoid space; 17 outer arachnoid layer; 18
(Browder and Kaplan 1976), but it could be located at the deep wall of subdural space; 19 dural veins; 20 dural arteries
lacunae. The mouth of bridging veins is usually connected with the

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216 9  Anatomical Base of Surgery

bridging vein dural venous network


a

*
Sinus meningeus
connections
to the sinus
meningeal vein

bridging vein

Sin. sagitt.sup. Lacuna meningeal vein

meningeal vein(s)

Lacuna parietalis
and dural venous netwoek

Fig. 9.6  Lacunae, dural veins, and venous network adjacent to the dissection. Hatched: area of numerous foveolae arachnoidales and bony
sinuses. (a) Cast (According to Browder and Kaplan 1976, p 20, Indian sulci for vessels
ink copy). (b) Schematized vascular bony sulci at a cadaver skull

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9.1  Extradural Topography 217

9.1.4 Dural Sinuses and Its Intradural Connections (Figs. 9.7, 9.8, and 9.9)

5
4

3
6

7
2

8
1

9
10

Fig. 9.7  Sinuses and fine venous network. Historical cast (Browder occipitalis, 2 confluens sinuum, 3 sinus rectus, 4 galenic point, 5 sinus
and Kaplan (1976), p 96, Indian ink copy). Similar to modern MRT sagittalis inferior, 6 bridging veins of 5, 7 v. cerebri interna, 8 v. septi
shapes of sinuses rendered prominent. Simplified copy added. 1 Sinus pellucidi, 9 v. thalamostriata, 10 thalamic vein (inconstant)

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218 9  Anatomical Base of Surgery

a
10 9

8
11

7
12
6
13

14

3
2

1
15

outer
chan
nel
axia
l
of th septum
e si
inne nus
r ch
ann
el

lx
Fa

terminal segment of bridging vein

Fig. 9.8  Sinus sagittalis superior. (a) Inside of the sinus (Lang 1979, granulationes arachnoidales at the inside of lacunae; 9 lacuna, anterior
p 49, schematized). (b) Architecture of septa. Arrows: blood stream. limit; 10 usual location of the mouth of bridging veins at the ground of
Note mouth of bridging veins at sinus ground. 1 Lacuna, posterior the sinus; 11 fine vascular network; 12 precentral region; 13 sinus sphe-
region; 2 obelion, projection; 3 mouth of lacuna; 4 right-sided lateral noparietalis; 14 fine meningeal arteries and fine venous network; 15 Vv.
wall of the sinus; 5 lacuna, parietalis (common finding), long type; 6 V. emissariae of the foramen parietale Fig 9.9
centralis (Rolandi); 7 sinus wall medial from lacuna; 8 typical groups of

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9.1  Extradural Topography 219

Fig. 9.9  Sinus rectus. (a) Usual finding. (b) and (c) Rare variants. Vein(s) of falx are compensating the deficit of sinus rectus

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220 9  Anatomical Base of Surgery

9.2 Intradural Topography

9.2.1 Survey (Figs. 9.10, 9.11, 9.12, 9.13, 9.14, 9.15, and 9.16)

4
5
3

sc
br

ob

o
la

sp
2

Fig. 9.10  Cortex of lobus parietalis. Numerous cortical functions of definings of small lesions. The problem is brain shifting after dura
lobus parietalis may be endangered by surgical manipulations at the opening with flow up CSF. Recommended is using a superficial vein for
parietal cortex (Fig. 3.14), more endangered than at surgery of lobus landmark, e.g., a ramification or loop of a vein. Distance measurements
frontalis, temporalis, or occipitalis. The ground of cortical sulci is as short as possible between the venous configuration, a sulcus, and the
extended into the depth of centrum semiovale (Figs. 3.20 and 3.22). lesion in the depth make possible an exact defining of the lesion during
Surgical routes are possible along sulci without opening its pial walls in surgery. This is possible with or without using a sector scan (experience
the depth (Yaşargil). An exact topographical location of lesions during of the author).Arteries are not recommended for landmarks at transul-
surgery is necessary and could be defined and carefully approached cal surgical routes, because arteries are pulsing in the CSF space and
using neuronavigation and supported by bony landmarks, if necessary. are not fixed at the brain by pia mater like superficial cortical veins. br
This is illustrated here. But small lesions in the depth could be problem- bregma, la lambda, ob obelion, sc sulcus centralis, spo sulcus parieto-
atic, if stereotactic methods are contraindicated (e.g., for some caverno- occipitalis. 1 Gyrus frontalis, 3 pars opercularis; 2 gyrus angularis; 3
mas). Solely neuronavigation may not be sufficient for topographical lobulus parietalis superior and inferior, high variability; 4 gyrus post-
centralis; 5 gyrus praecentralis

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9.2  Intradural Topography 221

6 5

br
sc

3
ob

la

o
sp
1
ic

10
7 8 9

Fig. 9.11  Continuation of Fig. 9.10. Well to define is the medial pari- lus paracentralis, parietal segment, 5 as 4, frontal segment, 6 gyrus
etal cortex, in contrast to the lateral cortex. br bregma, ic intercommis- front. 1, 7 sulcus cinguli, 8 gyrus cinguli, 9 sulcus corporis callosi, 10
sural line, la lambda, ob obelion, sc sulcus centralis, spo sulcus isthmus gyri cinguli
parietooccipitalis. 1 Sulcus calcarinus, 2 cuneus, 3 praecuneus, 4 lobu-

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222 9  Anatomical Base of Surgery

br 2

sc

ob

la

Fig. 9.12  Continuation of Fig. 9.11. Usual asymmetry of the anterior neuromagnetic fields (Kristewa et al. 1991). br bregma, la lambda, ob
limit of lobus parietalis (sulcus centralis). At right-handed individuals, obelion, sc sulcus centralis; 1 upper parietal gyri, 2 gyrus postcentralis,
the left-sided sulcus centralis is reversed to a posterior direction, as it 3 gyrus praecentralis
was presented by Bischoff 1868 and is presented today by imagings and

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9.2  Intradural Topography 223

approx
br . 50mm

sc

st
Os
pa
rie ob
tal
e

25m
pt

m
la

om as

br

st

Lo ob
bu
s
pa
rie
pt ta
lis
la

Fig. 9.13  Comparison of lobus parietalis with os parietale. For avoiding topographical errors at craniotomy. as asterion, br bregma, la lambda, ob
obelion, om orbitomeatal line, pt pterion, sc sulcus centralis, st stephanion

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224 9  Anatomical Base of Surgery

Os
pa
rie
ta
le

lis
ta
rie
pa
s
bu
Lo

Fig. 9.14  Continuation of Fig. 9.13

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9.2  Intradural Topography 225

Sulc
us su
p. ins
ulae

Sulc
us in
f. ins
ulae

Fig. 9.15  Lateral parietal region and insula. (a) Insula, projection. (b) Relief of insula similar to neuronavigation

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226 9  Anatomical Base of Surgery

10 9

11 7

Fig. 9.16  Medial parietofrontal region. Coronal transectional plane tical fibers between stria longitudinalis cinguli and indusium griseum, 7
similar to MRT. Details added. 1 Hypothalamus, 2 V. cerebri interna, 3 stria longitudinalis cinguli, 8 gyrus cinguli, 9 septum of sinus longitu-
velum interpositum, 4 crus fornicis, 5 fissura transversa, 6 fine allocor- dinalis superior, 10 mouth of a lacuna, 11 mouth of a bridging vein

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9.2  Intradural Topography 227

9.2.2 Lateral Structures (Figs. 9.17, 9.18, 9.19, 9.20,9.21, and 9.22)

5
ob
sc

la

aa

1
st

as

pt

Fig. 9.17  Superficial cortical arteries, schematized. Similar to neuro- asterion, la lambda, ob obelion, pt pterion, sc sulcus centralis, st stepha-
navigation, assisted by landmarks, if necessary. aa angularis area as nion. 1 A. temporalis posterior, 2 A. temporooccipitalis, 3 A. angularis,
4 Rr. parietales of A. cerebri media, 5 gyrus postcentralis

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228 9  Anatomical Base of Surgery

ob
sup
. pa
riet
.are la
a

sc

s
trali
tcen
m flexu
cu s
cir
pos

aa

us
Gyr
s
Gyru

st

pt
as

Fig. 9.18  Lateral cortex, schematized. Essential regions hatched. High landmarks, if necessary. aa angularis area, as asterion, la lambda, ob
variability of anatomical areas and its functions. It may be defined obelion, pt pterion, sc sulcus centralis, st stephanion
using neurophysiological methods and neuronavigation, supported by

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9.2  Intradural Topography 229

6 5
a

9 4
10

2
Sul
cus
sup
. in
sul
ae

4 res
ect
are ion
ao
f Li
me
n in
sul
5 ae

6 8
Sulcu
s inf. in 7
sulae

Fig. 9.19  Sylvian segments of A. cerebri media. These branches are as 1, pars opercularis; 3 as 1, pars triangularis; 4 sulcus praecentralis; 5
running close to sulcus superior insulae. The sulcus is located close to bregma; 6 sulcus centralis; 7 as 6; 8 gyrus praecentralis; 9 pars ascen-
corona radiata, especially its tractus pyramidalis. (a) Survey with pro- dens of sulcus lat. (sylvii); 10 gyrus angularis. (b) 1 A. angularis, 2 A.
jection of sulcus superior insulae (dotted), (b) fronto-parietooccipital temporooccipitalis, 3 parietal branches of A. cerebri media, 4 A. sulci
branches of A. cerebri media. (a) 1 Third frontal gyrus, pars orbitalis; 2 centralis, 5 A. operculofrontalis, 6 A. cerebri media, distal trunk

ERRNVPHGLFRVRUJ
230 9  Anatomical Base of Surgery

4 5

3
2
b 1

6 Insula
7

Fig. 9.20  Addendum for Fig. 9.19. a Sectional magnification. (b) frontal gyrus, pars orbitalis; 2 as 1, pars triangularis; 3 as, pars opercu-
Relief of Cortex. (a) 1 A. cerebri media, distal trunk, 2 A. sulci centralis, laris; 4 sulcus superior insulae, projection; 5 sulcus inferior insulae, pro-
3 A. cerebri media, common trunk, 4 A. operculofrontalis, 5 lateral fron- jection; 6 tip of cornu inferius; 7 uncus, transected; 8 trigonum
tobasal artery. Uncus hatched, its residual shifted (arrow). (b) 1 Third olfactorium

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9.2  Intradural Topography 231

8 7

2
3

Fig. 9.21  Veins of insula. Sketch. Note the connections between V. variability of diameter, number, and course; 3 A. cerebri media overlap-
temporalis profunda et superficialis 1. Superficial cortical veins are ping 2; 4 third frontal gyrus, pars orbitalis; 5 frontopolar vein(s); 6
feeding V. temporalis superficialis. Rare are anastomotic branches with anastomotic vein; 7 thick calibrated parietotemporal vein, cave; 8 small
bridging veins to sinus sagittalis sup. 6. 1 anastomoses between super- parietal vein draining to superficial or profound sylvian veins; 9 V. tem-
ficial and profound sylvian veins, cut; 2 V. temporalis profunda; high poralis superficialis

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232 9  Anatomical Base of Surgery

Fig. 9.22  Insula. MRT, intercommissural level. Projection of the basal region of insula added. 1 Angularis region, 2 frontoparietal gyri, 3 anterior
tip of insula

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9.2  Intradural Topography 233

9.2.3 Midline Structures (Figs. 9.23, 9.24, 9.25, and 9.26)

4
3

approx.
50mm

br sc

ob

25
mm
m
5m
-5
45

la
2

ic

Fig. 9.23  Medial cortex. MRT. Parietal cortex and suturae rendered, tralis. 1 Praecuneus, 2 gyrus cinguli, 3 lobulus paracentralis, parietal
os parietale hatched. Landmarks and distance measurements added. br segment, 4 as 3, frontal segment
bregma, ic intercommissural line, la lambda, ob obelion, sc sulcus cen-

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234 9  Anatomical Base of Surgery

13 12 11
10

8
14
7

6
15
5

4
16

17 1

18

19

Fig. 9.24  Anterior medial parietal region. MRT, plane of corpora cinguli; 10 granulationes arachnoidales (Pacchioni); 11 sinus sagittalis
mamillaria, details added. 1 V. cerebri interna; 2 fissura transversa; 3 superior, deep located compartment (channel); 12 as 11, outer compart-
crus fornicis; 4 A. corporis callosi mediana; 5 stria longitudinalis cin- ment; 13 mouth of lacuna; 14 first frontal gyrusm; 15 A. pericallosa; 16
guli; 6 edge of falx; 7 sinus sagittalis inferior; 8 gyrus cinguli; 9 sulcus sulcus superior insulae; 17 taenia chorioidea; 18 taenia fornicis; 19
velum interpositum

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9.2  Intradural Topography 235

13 12 11 10 9 8

14 4

15 3

2
16
1

17

Fig. 9.25  Posterior medial parietal region. MRT, level of commissura by dural layers; 10 sinus sagittalis superior, inferior compartment; 11 as
posterior, details added. 1 Aquaeductus; 2 commissura posterior; 3 sul- 10, superior compartment; 12 lacuna; 13 dural network of fine arteries
cus inferior insulae; 4 sulcus superior insulae; 5 V. magna (Galeni); 6 and veins; 14 as 4; 15 velum interpositum; 16 thalamus; 17 velum inter-
crus fornicis; 7 commissura fornicis; 8 bridging vein; 9 as 8, enclosed positum and plexus chorioideus of the third ventricle

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236 9  Anatomical Base of Surgery

11

10

5
4

12
13 14

Fig. 9.26  Floor of ventriculus lateralis. Similar to neuronavigation, lamina affixa thalami; 7 stria terminalis; 8 columna fornicis; 9 Vv.
details added. 1 Lateral atrial veins; 2 V. ventriculi lat. directa, common nuclei caudati; 10 longitudinal veins along the lateral rim of the ven-
variant; 3 taenia fornicis; 4 taenia chorioidea; 5 medial septal veins; 6 tricle; 11 stria longitudinalis cinguli; 12 medial atrial veins; 13 stria
longitudinalis cinguli; 14 V.magna (Galeni)

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Special Surgical Aspects
10

10.1 Extradural Surgery (Figs. 10.1 and 10.2)

a
sc ob

la

as

Fig. 10.1  Large parietal surgical approach, principles. Superficial extracerebral target area landmarks, pars ascendens of sulcus lat. (sylvii), and
sulcus centralis. (a) Skin-galea-flap. (b) Craniotomy. (a) as asterion, la lambda, ob obelion, sc sulcus, centralis. (b) Landmarks as (a)

© Springer International Publishing AG 2018 237


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_10

ERRNVPHGLFRVRUJ
238 10  Special Surgical Aspects

c a

cave

Fig. 10.2  Lacunae, surgical aspects. Lacunae are located superficial (Browder and Kaplan 1976). (a) Occlusion of the mouth of a lacuna,
from bridging veins. It could present one or several mouth at the lateral anatomical principle, (b–d) problematic occlusions of a lacuna with
rim of the sinus. Further presentations are numerous connections to fine more than one mouth
dural networks but no connection of lacuna with bridging veins

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10.2  Intradural Surgery 239

10.2 Intradural Surgery

10.2.1 Surgical Aspects of Lateral Approaches (Figs. 10.3 and 10.4)

4
6 5
3
a 2

re
fissu
ian
7 sylv

2 1
4 3

b
s ulae
sup.in
Su lcus
lae
su
in
nf.
si
lcu
Su

Fig. 10.3 Parietal branches of A. cerebri media, schematized. culofrontalis, 7 pars orbitalis of the third frontal gyrus; (b) 1 A. tempo-
Superficial cortical arteries (a) and insular arteries (b). (a) 1 Gyrus rooccipitalis, 2 A. angularis, 3 posterior parietal branch of A. cerebri
angularis, 2 A. temporooccipitalis, 3 A. angularis, 4 posterior parietal media, 4 A. sulci centralis, 5 A. operculofrontalis, 6 lateral striate arter-
branch of A. cerebri media, 5 A. sulci centralis, 6 branches of A. oper- ies close to limen insulae

ERRNVPHGLFRVRUJ
240 10  Special Surgical Aspects

is
a ital
A. o
perc A. s
ulci o c cip
o
ulof
ront cen por 4
trali em cm
2 alis 3 s A. t c of a
lat.
fron is t a l trun
toba d 5
sal
1 ar te
ry

c
3 3
b 2
5
2

5
1 1

d 3
2 4

Fig. 10.4  Region of the so-called trifurcation, common findings should be considered especially at microsurgical and interventional
(Yaşargil 1985, personal communication with W. Seeger). (a) eliminations of aneurysms, AVMs, and meningiomas
Bifurcation of A. cerebri media. (b)–(d) Different types. These findings

Fig. 10.5  Interfornical approach to the third ventricle (Apuzzo et al. callosum. Transversal incision of corpus callosum would endanger stria
1982). Steps of surgery, steps A to E are the principles of approaches longitudinalis cinguli. (D) Method of Apuzzo: longitudinal splitting of
which are presented at Figs. 3.30, 3.31, 3.32, 3.33, and 3.34. (A) septum pellucidum (cave septal veins) and interfornical splitting. (E)
Subdural route. (B) Arachnoid incision for opening of cisterna corporis Splitting velum interpositum along Vv. cerebri internae and between
callosi. (C) Incision of corpus callosum for opening of the lateral ven- the numerous fine medial branches of Aa. choroideae posteriores before
tricle. Cave opening of the contralateral ventricle. Cave transversal opening the third ventricle
veins of the ventricular roof at the usual longitudinal incision of corpus

ERRNVPHGLFRVRUJ
10.2  Intradural Surgery 241

10.2.2 Surgical Aspects of Midline Approaches (Figs. 10.5, 10.6, 10.7, 10.8, 10.9, and 10.10)

subdural space
dilated

arachnoid layer cut

Cisterna corporis callosi

Cavum septi pellucidi

Fornix

Fissura transversa E

V.cerebri int.

Velum interpositum cut

3rd ventricle

ERRNVPHGLFRVRUJ
242 10  Special Surgical Aspects

D
E

Fig. 10.6  Falx meningioma, example surgical approach according to step A of Fig. 10.5

ERRNVPHGLFRVRUJ
10.2  Intradural Surgery 243

Fig. 10.7  AVM of falx, gyrus cinguli, and cisterna corporis callosi, example approach according to steps A and B of Fig. 3.29

ERRNVPHGLFRVRUJ
244 10  Special Surgical Aspects

ia
str
C
u lar inalis
g
cin gitud
lon

ve
ca

Fo
rni
x

Fig. 10.8  Tumor of plexus choroideus of the lateral ventricle, if a transcortical neuronavigatory-guided approach is not indicated. Approach
according to steps A to C of Fig. 3.29

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10.2  Intradural Surgery 245

D’

Fig. 10.9  AVM of corpus callosum and its cistern, of Fissura trans- the galenic vein. After a complete elimination of the AVM, the light-
versa, and of velum interpositum according to Yaşargil et al. 1992. colored galenic vein changes to its normal venous color (D’)
Surgical approach according to steps A to D. This AVM is draining to

ERRNVPHGLFRVRUJ
246 10  Special Surgical Aspects

Fis
sur
a tr
ans
D For ver
n ix s a

V. c
e rebr
i int
.

Ve
lu m
int
er
po
s itu
m

Cr
us
ce
reb
ri

Fig. 10.10  Cavernoma between hypothalamus and mesencephalon (after surgical elimination, no neurological or psychological deficits.
Microsurgery performed by H.R. Eggert, coworker of the author 1988. See Seeger 1990). Example according to steps A to E of Fig. 10.5

ERRNVPHGLFRVRUJ
Part IV
Occipital Region

1.1 Introduction

This introduction to Part IV contains a short summary of each chapter.

1.2 Chapter 11 Diagnostic Base

The anatomical and functional limits of lobus occipitalis are unclear. The cortical area optica
begins at dorsal precuneus, between sutura parietooccipitalis and sulcus calcarinus. Ventrobasal
complex begins at the posterior area of gyrus parahippocampalis, anterior from isthmus gyri
cinguli. The area angularis is located between lobus temporalis, parietalis, and occipitalis.
Anatomical configuration and location of its functions are variable.

1.3 Chapter 12 Anatomical Base for Surgery

–– The lumen of confluens sinuum presents less lacunae than other sinus segments. Trabeculae
are rare or were missing, but septa and its topographical relationships with other sinuses are
variable.
–– Radiatio optica is better to present by fiber tracking than by all other methods but not the
surrounding fibers which presents much fiber crossings. Fiber crossing are hindering fiber
tracking.
–– Cave bilateral lesions of the preoccipital segments of striae longitudinalis cinguli and its
interruption would be followed by irreversible psychological deficits.
–– Cave occipitobasal anterior veins of lobus occipitalis, if no resection of lobus is planned.
Danger for encephalomalacia. The vein is a part of the inner cerebral veins close to the
midline. Cave.

1.4 Chapter 13 Special Surgical Aspects

–– At skin-galea incision, cave anastomotic branches of A. occipitalis


–– Cave the numerous V. emissaria close to confluens sinuum
–– Danger for intraventricular bleeding of A. calcarina or A. parietooccipitalis and its branches,
which are presented in the depth of Sulci, close to cornu posterius.
–– At puncture of cornu posterius and fornices and structures at cisterna tecti and ambiens
could be endangered.

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Diagnostic Base
11

11.1 Landmarks (Figs. 11.1 and 11.2)

spo
la

aa

as
ea
in

la

6
o
sp

gl

ic

in

1
2 3 4 5

Fig. 11.1  Extra- and intracranial landmarks for assisting of imagings. occipitalis. 1 Isthmus gyri cinguli, 2 area of gyrus occipitotemporalis
(a) aa angularis area, as asterion, ea eminentia arcuata, projection, in medialis, 3 sulcus calcarinus, 4 knee of sinus transversus, 5 sinus rectus,
inion, la lambda, spo sulcus parietooccipitalis, projection; (b) gl galenic 6 cuneus
point, ic intercommissural line, in inion, la lambda, spo sulcus parieto-

© Springer International Publishing AG 2018 249


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_11

ERRNVPHGLFRVRUJ
250 11  Diagnostic Base

ob
p

la

cos

as

in

Fig. 11.2  Continuation of Fig. 11.7. as asterion, cos confluens sinuum, projection, in inion, la lambda, ob obelion, p for parietale

ERRNVPHGLFRVRUJ
11.2 Radiology 251

11.2 Radiology (Figs. 11.3, 11.4, and 11.5)

la 4
3
2

o
sp
1

ic

in

la
aa

as
in
om

Fig. 11.3  Arteries, skull, and brain, schematized. Landmarks added parietooccipitalis. (b). aa angularis area, as asterion, in inion, la
for assisting imagings, if necessary. (a) Medial arteries. (b) Lateral lambda, om orbitomeatal line. 1 Sulcus calcarinus, 2 temporobasal
arteries. (a) ic intercommissural line, in inion, la lambda, spo sulcus branch(es) of A. cerebri posterior, projection, 3 A. temporalis posterior,
parietooccipitalis. 1 A. calcarina, 2 cuneus, 3 sulcus calcarinus, 4 A. 4 A. temporooccipitalis, 5 A. angularis

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252 11  Diagnostic Base

la

gl

4
ic
3

2
5
1
6 7
in
b

la

as

in

1
2
3

Fig. 11.4  Continuation of Fig. 11.3. Veins medial (a) and lateral (a) gl occipitomedial bilateral vein(s), 6 V. supraculminalis, 7 V. cerebellaris
galenic point, ic intercommissural level, in inion, la lambda. 1 sinus precentralis. (b) as asterion, in inion, la lambda. 1 Vein of labbé, 2 knee
occipitalis, 2 confluens sinuum, 3 sinus rectus, 4 sinus sagittalis sup., 5 of sinus transversus, 3 sinus transversus

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11.2 Radiology 253

3 ea

3
ea

Fig. 11.5  Basal arteries (a) and veins (b). Eminentia arcuata of os during surgery. (a) ea eminentia arcuata, projection. 1 A. cerebri poste-
petrosum is located close to sinus petrosus superior et margo superior rior, 2 branches of A. choroideae posterior, 3 mesencephalic vessels, 4
ossis petrosi. It is a landmark for defining temporo-occipital basal posterior basal branches of A. cerebri posterior. (b) 1 Margo superior
bridging veins during surgery. Interruption of temporobasal arteries and ossis petrosi, projection; 2 temporobasal vein, subdural segment, vari-
of bridging veins at this area (V. labbé included) could be followed by able; 3 as 2, subarachnoid segment, variable; 4 as 2, subpial segment,
neurological deficits. Differentiation of the subarachnoid and subdural variable; 5 as 2 to 4; 6 occipitomedial basal veins, draining to the
segment of basal medial veins could be necessary for its preservation galenic system

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254 11  Diagnostic Base

11.3 Further Imaging (Figs. 11.6, 11.7, 11.8, 11.9, and 11.10)

9 8
7

o
sp la 6

gl
3
ic

1
in

Fig. 11.6  Neuronavigation, modified. Landmarks added for assisting line, in inion, spo sulcus parietooccipitalis. 1 confluens sinuum, 2 sinus
neuronavigation, if necessary. gl galenic region, ic intercommissural rectus, 3 cuneus, 4 A. calcarina, 5 sulcus calcarinus, 6 praecuneus, 7 A.
parietooccipitalis, 8 gyrus cinguli, 9 lobulus paracentralis

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11.3  Further Imaging 255

8 7
a 6
5

la

in

6 la
4

2
7
1
in

Fig. 11.7  Continuation of Fig. 11.6. Intra- and extradural occipitopari- 5 A. parietooccipitalis, 6 praecuneus, 7 A. praecunealis, 8 A. pericallosa.
etal structures. (a) Landmarks, arteries, and cerebral relief. (b) Falx, ten- B. in inion, la lambda. 1 sinus occipitalis, 2 confluens sinuum, 3 sinus
torium, and galenic area. (a) in inion, la lambda. 1 A. cerebri posterior, rectus, 4 mediobasal anterior veins of lobus occipitalis, 5 ampulla of V.
2 posterior basal branch of A. cerebri posterior, 3 A. calcarina, 4 cuneus, magna (Galeni), 6 V. basalis (Rosenthal), 7 V. mesencephalic lat

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256 11  Diagnostic Base

8 7
a 6
5

B A
C 4
3
2
1

b
4
3
5
6
2 c
1

1
7 2
8 3
4
9

Fig. 11.8  Occipitoparietal MRT. (a) Plane at corpus pineale. (b) Area Cornu inferius; 2 as 1, narrow segment; 3 atrium; 4 V. magna (Galeni),
of splenium. (c) Tip of cornu posterius (length of cornu post. is vari- 5 crus fornicis; 6 pulvinar thalami; 7 tail of hippocampus; 8 area den-
able). (a) 1 Tectum, 2 thalamus, 3 corpus pineale, 4 V. magna (Galeni), tata; 9 gyrus parahippocampalis. (c) 1 Tip of cornu posterius, 2 calcar
5 atrium, 6 plexus choroideus, 7 crus fornicis, 8 gyrus cinguli. (b) 1 avis, 3 precuneus, 4 sulcus calcarinus

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11.3  Further Imaging 257

A
B
C

2
1

b c

8
7

6
1

5 2

3 5
4 4

1 3
2

Fig. 11.9  Continuation of Fig. 11.8. (a) Transsectional plane at the dor- (Galeni), 4 thalamus, 5 plexus choroideus. (c) 1 Thalamus, 2 tip of cornu
sal ventricular area. (b) Middle region of splenium. (c) Transsectional posterius, 3 area dentata, 4 V. magna (Galeni), 5 crus fornicis, 6 atrium,
plane of for. interventriculare (Monroi). (a) 1 Sulcus parietooccipitalis, 7 corpus pineale, 8 third ventricle
2 thalamus. (b) 1. Sulcus parietooccipitalis, 2 sinus rectus, 3 V. magna

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258 11  Diagnostic Base

Fig. 11.10  Continuation of Fig. 11.9. 1 Sulcus calcarinus, 2 calcar avis, 3 narrow ventricular segment between the atrium and cornu inferius

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Anatomical Base of Surgery
12

12.1 Extradural Topography (Figs. 12.1, 12.2, 12.3, 12.4, 12.5, 12.6, 12.7, 12.8, and 12.9)

a
12
11

10

4
3
1 2

1
2
3

5
6

7
8

10
Carotis int
Carotis 11
Commun.

Fig. 12.1  Skin, galea aponeurotica, and periosteum. Wound healing cleidomastoideus; 9 N. occipitalis major; 10 gap of fascia nuchae, con-
could be endangered after interruptions of anastomotic connections of taining N. occipitalis minor and A. et V. occipitalis; 11 V. occipitalis,
A. occipitalis with A. temporalis superficialis. Galea nerves spare. a 12 M. occipitofrontalis, pars occipitalis. b 1 A. temporalis superficialis;
Vessels and nerves. b Historical addendum and copy of it (Heitzmann 2 and 3 anastomotic branches; 4 A. occipitalis; 5 A. retroauricularis
1875, VI, p 182 (anatomical Atlas with woodcuts according to drawings close to For. stylomastoideum and N. facialis, cave at surgery; 6 N.
of Prof. Heitzmann, Wien)). Arteries rendered. a 1 M. trapezius; 2 M. facialis; 7 M. trapezius; 8 M. sternocleidomastoideus; 9 A. occipitalis;
longissimus capitis; 3 M. levator scapulae; 4 M. splenius capitis; 5 N. 10 A. carotis interna; 11 A. carotis externa
occipitalis minor; 6 processus mastoideus; 7 A. occipitalis; 8 M. sterno-

© Springer International Publishing AG 2018 259


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_12

ERRNVPHGLFRVRUJ
260 12  Anatomical Base of Surgery

≈ 7 cm

as

in

Co
nf
lue
ns
sin
uu
m

Fig. 12.2  Planum occipitale et planum nuchale. Projection of sinuses. Landmarks and measurement for planning craniotomies and punctures of
cornu posterius. Projection of sinus sagittalis superior. Confluens sinuum et sinus transversus added. as asterion, in inion, la lambda

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12.1  Extradural Topography 261

5
6 4

a
2

3
b

c 1

Fig. 12.3  Confluens sinuum (According to Browning 1953 and to ens sinuum, 7 incomplete septum. b 1 Sinus occipitalis wide, 2 sinus
Browder and Kaplan 1976, p73). a Common findings b and c variants. transversus hypoplastic, 3 duplication of sinus sagittalis superior. c 1
a 1 Sinus occipitalis, unilateral mouth at confluens, 2 sinus rectus, con- Sinus occipitalis wide and deviated, 2 sinus occipitalis wide and con-
tralateral mouth at confluens, 3 galenic region of falx and tentorium, 4 nected with sinus transversi, 3 sinus transversus medial wide, lateral
venous network, 5 sinus sagittalis inferior, 6 sagittal septum of conflu- connected with sinus occipitalis

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262 12  Anatomical Base of Surgery

Fig. 12.4  Confluens sinuum and venous network (Cast of Browder ration of confluens (e.g., by tumors), the network of veins may be
and Kaplan 1976, p 70. Indian ink copy). Venous network is surround- widened, compensating the occluded confluence. Now the surgical
ing all intracranial sinuses, especially the region of confluens. At obtu- interruption of venous network of dilated veins could be dangerous

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12.1  Extradural Topography 263

5
6

3
7

b
2
8
1

9 10

Fig. 12.5  Confluens sinuum and variants of sinus rectus. a Duplicated taken in consideration at surgery, e.g., at meningiomas 1 sinus rectus
mouth of sinus rectus and incomplete septum of sinus sagittalis supe- duplicated, projection; 2 margin of tentorium; 3 V. magna (Galeni); 4
rior. b Duplicated mouth unilateral and complete septum of sinus sagit- splenium corporis callosi; 5 galenic point; 6 sinus sagittalis superior; 7
talis superior/confluens sinuum. c Duplicated mouth of sinus rectus and septum, fenestrated at confluens; 8 duplicated mouth of sinus rectus; 9
complete septum of sinus sagittalis superior. These variants should be sinus occipitalis; 10 sinus transversus

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264 12  Anatomical Base of Surgery

Fig. 12.6  Addendum for Fig. 12.4. Rare variants (According to Browning 1953, modified)

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12.1  Extradural Topography 265

br
a

approx.

m
4c

m
la

5c
6c
gl m

in

4 3 2
5
6
1
7

10

11

12

13
14
15 16 17 18

Fig. 12.7  Falx and tentorium landmarks and measurements for plan- 7 bridging veins, 8 sinus transversus, 9 confluens sinuum, 10 protuber-
ning occipital surgical approaches. a Sinuses of falx. b Sinuses of falx antia occipitalis interna, 11 protuberantia occipitalis externa (inion), 12
and tentorium. a br Bregma, gl galenic point, in inion, la lambda. b 1 venous network, 13 sinus rectus, 14 tentorium, 15 knee of sinus trans-
Bridging veins, 2 sinus sagittalis inferior, 3 V. magna (Galeni), 4 net- versus, 16 A. tentorii (Bernasconi), 17 bridging veins, 18 sinus petrosus
work of veins close to the galenic point, 5 numerous veins close and superior
distant to the galenic point, 6 granulationes arachnoidales (Pacchioni),

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266 12  Anatomical Base of Surgery

a
9

10

6
11
5
12

3
2
1

b c

Fig. 12.8  Sinus rectus according to Browning 1953, schematized. a fluens sinuum; 5 sinus sagittalis superior; 6 veins of falx, high density;
Usual presentations. b Platform-like septum. c Sagittal septum. d 7 falx; 8 sinus rectus; 9 galenic point; 10 splenium corporis callosi;
Multiple septa. At bleeding during surgery spare electrocoagulation, if 11 V. magna (Galeni); 12 V. basalis (Rosenthal). b The platform-like
possible. Suturing should be preferred. Danger for sinus thrombosis. a septum could be multiple fenestrated. c The sagittal septum could be
1 Tentorial veins, high density; 2 inion; 3 mouth of sinus rectus; 4 con- multiple fenestrated. d Common finding

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12.1  Extradural Topography 267

8 7
9 6
a 5

10
3

5
b

10

Fig. 12.9  Galenic system conclusion. a 1 Sinus occipitalis; 2 conflu- lis (Rosenthal). b 1 Occipitobasal veins of lobus occipitalis, projection;
ens sinuum; 3 sinus rectus; 4 sinus sagittalis superior; 5 occipitobasal 2 V. basalis (Rosenthal); 3 V. mesencephalica lateralis; 4 galenic point;
medial veins of lobus occipitalis, projection; 6 galenic point; 7 sinus 5 junction of Vv. cerebri internae; 6 V. cerebri interna; 7 sinus rectus; 8
sagittalis inferior; 8 V. magna (Galeni); 9 V. cerebri interna; 10 V. basa- sinus occipitalis, projection; 9 sinus transversus; 10 confluens sinuum

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268 12  Anatomical Base of Surgery

12.2 Intradural Topography

12.2.1 Survey (Figs. 12.10, 12.11, 12.12, and 12.13)

la

aa

øa

as
in
po

b
la
o
sp

gl 3

ic 2

in

Fig. 12.10  Occipital lobe lateral a and medial cortex b. Landmarks porion. b gl galenic region, ic intercommissural line, in inion, la
added for assisting imagings, if necessary. a aa angularis region, as lambda, spo sulcus parietooccipitalis. 1 Gyrus occipitotemporalis
asterion, ea eminentia arcuata, projection, in inion, la lambda, po medialis, 2 sulcus calcarinus, 3 cuneus

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12.2  Intradural Topography 269

ea

Fig. 12.11  Addendum for Fig. 12.10. ea eminentia arcuata, projection. 1 Gyrus occipitotemporalis lateralis, 2 gyrus occipitotemporalis medialis,
3 gyrus parahippocampalis

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270 12  Anatomical Base of Surgery

Fig. 12.12  Radiatio optica schematized. 1 Sulcus calcarinus; 2 corpus geniculatum laterale; 3 genu temporale of radiatio optica, projection; 4
tractus opticus

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12.2  Intradural Topography 271

sc

la

it
lim
2

aa

anterior

in

ea as

po

Fig. 12.13  Topography for planning lateral surgical approaches. aa angularis region, as asterion, ea eminentia arcuata, projection, in inion, la
lambda, po porion, sc sulcus centralis. 1 region of sulcus calcarinus, projection; 2 region of sulcus parietooccipitalis, projection

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272 12  Anatomical Base of Surgery

12.2.2 Superficial and Profound Structures (Figs. 12.14, 12.15, 12.16, 12.17, 12.18, 12.19, 12.20, 12.21,
12.22, and 12.23)

sc

la
4

gl

ca cp

in
ea

Fig. 12.14 Topography for planning medial surgical approaches. nentia arcuata, projection, gl galenic point, in inion, la lambda, sc sul-
Well-defined relief of gyri in contrast to the varable lateral relief (see cus centralis, projection. 1 sulcus calcarinus, 2 sulcus parietooccipitalis,
Fig. 12.13). ca commissura anterior, cp commissura posterio,r ea emi- 3 cuneus, 4 precuneus

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12.2  Intradural Topography 273

7
6

1
2

7
6 2b
5 2a
4
3 1

10

17 18 19

16
11 12 13 14 15

Fig. 12.15  Profound medial occipital and adjacent structures survey a lobus occipitalis; 10 V. basalis (Rosenthal); 11 splenium corporis cal-
and details b. a 1 Crus fornicis, 2 V. magna (Galeni), 3 A. cerebri pos- losi; 12 area dentata; 13 begin of indusium griseum and stria longitudi-
terior, 4 cuneus, 5 precuneus, 6 A. parietooccipitalis, 7 gyrus cinguli. b nalis cinguli; 14 gyrus occipitotemporalis medialis and the beginning of
1 Lambda, projection; 2a A. parietooccipitalis; 2b A. calcarina; 3 stria gyrus parahippocampalis; 15 isthmus gyri cinguli and the beginning of
longitudinalis cinguli, projection; 4 stria medialis et lateralis of indu- gyrus parahippocampalis; 16 V. magna (Galeni); 17 sulcus parietooc-
sium griseum, projection; 5 gyrus cinguli, covering 3 and 4; 6 sulcus cipitalis; 18 sulcus calcarinus; 19 cuneus
corporis callosi; 7 sulcus cinguli; 8 V. cerebri interna; 9 medial vein of

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274 12  Anatomical Base of Surgery

1
6

14
7

8 13

10

11
12

Fig. 12.16  Continuation of Fig. 12.15. Galenic area 1 splenium corpo- 8 recessus pinealis, 9 commissura posterior, 10 aquaeductus, 11 V.
ris callosi, 2 cisterna tecti, 3 galenic cistern, 4 fissura transversa cerebri, supraculminalis, 12 V. cerebellaris precentralis, 13 tentorium, cut, 14
5 velum interpositum, 6 Vv. cerebri internae, 7 recessus suprapinealis, anterior mediobasal veins of lobus occipitalis

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12.2  Intradural Topography 275

hb

10

11 lo

12

13

Fig. 12.17  Continuation of Fig. 12.16. Dorsal viewing direction. aris; 4 colliculus inferior; 5 colliculus superior; 6 corpus pineale; 7 V.
Habenulae are landmarks at imagings and during surgery for defining cerebri interna; 8 plexus choroideus, margin; 9 branches of A. chorioi-
of divisions of Aa. choroideae posteriores laterales and mediales. dea posterior, division (Plets 1969); 10 pulvinar thalami; 11 V. basalis
Baumgartner’s loop is a landmark during surgery for defining of pulvi- (Rosenthal); 12 V. cerebellaris precentralis; 13 V. supraculminalis. hb
nar thalami. 1 V. magna (Galeni); 2 splenium, projection; 3 N. trochle- habenula, lo Baumgartner’s loop

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276 12  Anatomical Base of Surgery

7 6
5
a

8 3
2
1

b 5

3
9

10

medial
basal o
ccipita
l veins

11 2
12 1

Fig. 12.18  Adjacent structures of splenium corporis callosi. Lateral a marking the midline region, 6 striae laterales of indusium griseum, 7
and posterior b viewing directions. Splenium is surrounded by essential stria longitudinalis cinguli, 8 area dentata. b 1 Falx; 2 high density of
vessels and cortex (optic and allocortical segments) at the narrow space veins; 3 area dentata; 4 sinus sagittalis inferior; 5 falx; 6 sulcus cinguli;
between falx and tentorium. During surgery, a surgical shifting of the 7 gyrus cinguli, penetrated by fiber bundles of stria longitudinalis cin-
brain is hindered by the connection of V. magna (Galeni) with falx- guli and fiber bundles of corpus callosum; 8 striae mediales of indusium
tentorium. a 1 Branches of A. cerebri posterior feeding area dentata. griseum; 9 striae laterales of indusium griseum; 10 posterior begin of
Cave at surgery 2 A. calcarina, 3 mediobasal vein(s) of lobus occipita- stria longitudinalis cinguli; 11 V. magna (Galeni); 12 isthmus gyri
lis, 4 A. parietooccipitalis, 5 striae mediales of indusium griseum, cinguli

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12.2  Intradural Topography 277

2 1

17

14 16
15
13

7 12
8
9 10 11

Fig. 12.19 Arteries of cisterna ambiens and adjacent structures. tion, 3 corpus geniculatum mediale, 4 corpus geniculatum laterale, 5
Numerous fine branches are feeding the midbrain, tractus opticus, the pulvinar thalami, 6 A. calcarina, 7 A. parietooccipitalis, 8 V. basalis
upper pons, and basal ganglia. It is originating from A. communicans (Rosenthal), 9 A. tecti, 10 N. trochlearis, 11 A. chorioidea posterior
posterior, A. chorioidea anterior, A. cerebri posterior, and its branches. medialis, 12 temporo-occipital basal branch of A. cerebri posterior, 13
These could hinder surgical approaches. Further hindering is the deep pedunculus cerebellaris superior, 14 trigonum lemnisci hypervascular-
location of cisterna ambiens. Surgical routes along these natural CSF ized, inconstant finding, 15 V. mesencephalic lateralis connected with
spaces present only small sections of cisterna ambiens. More favorable V. petrosa and sinus petrosus superior, 16 V. basalis (Rosenthal), 17
routes could present transcerebral endoscopic approaches. 1 A. thal- crus cerebri
amogeniculata, 2 loop of A. chorioidea posterior or its main ramifica-

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278 12  Anatomical Base of Surgery

9 8 7
6
a
5
4

10
2
11

1
b

6
7
5

1 2 3

Fig. 12.20  Cisterna ambiens and cisterna tecti. Synopsis. a Vessels. b chorioidea post. lateralis, 10 A. parietooccipitalis, 11 A. calcarina. b 1
Mesencephalon. a 1 Anterior branch of temporobasal arteries, 2 A. Pedunculus cerebellaris superior, 2 trigonum lemnisci, 3 crus cerebri, 4
cerebri posterior, 3 V. basalis (Rosenthal), 4 A. thalamogeniculata, 5 tractus opticus, 5 corpus geniculatum laterale, 6 corpus geniculatum
loop of A. chorioidea posterior lateralis, 6 habenula, projection, 7 mediale, 7 corpus pineale, 8 tectum (colliculi superiores et inferiores),
Baumgartner’s loop, 8 pulvinar thalami, 9 division of branches of A. 9 N. trochlearis

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12.2  Intradural Topography 279

3 2

Fig. 12.21  Radiatio optica, schematized. 1 Sulcus calcarinus, 2 tip of cornu inf. et genu temporale of radiatio optica, 3 corpus geniculatum
laterale

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280 12  Anatomical Base of Surgery

a 1

4 9 10

5 6 7 8
2
b 1

12
11
3 5 7 8 9 10
4 6

1
2
3 4 5 6 7

Fig. 12.22  Radiatio optica and adjacent structures. Anatomical fiber of radiatio optica, 3 chiasma, 4 tractus opticus, 5 crus cerebri, 6 corpus
dissections according to Ludwig and Klingler 1956. a Lateral viewing geniculatum laterale, 7 corpus geniculatum mediale, 8 pulvinar thal-
direction. b Basal viewing direction. c Lateral posterior viewing direc- ami, 9 splenium corporis callosi, 10 atrium, 11 U-fibers close to sulcus
tion. a 1 Fasciculus longitudinalis superior, 2 corona radiata, 3 capsula parietooccipitalis, 12 sulcus calcarinus. c 1 Radiatio optica, 2 fasciculus
interna, 4 putamen, 5 N. opticus, 6 tractus opticus, 7 crus cerebri, 8 longitudinalis superior, 3 corona radiata, 4 genu temporale of radiatio
corpus geniculatum laterale, 9 radiatio optica, 10 genu occipitale of optica, 5 tractus opticus, 6 capsula interna, 7 N. opticus
radiatio optica. b 1 Genu occipitale of radiatio optica, 2 genu temporale

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12.2  Intradural Topography 281

10
3

11

12
1 2

Fig. 12.23  Occipital lobe. Cadaver brain dissection. Conclusion. 1 V. ual, 7 gyrus cinguli, residual, 8 striae laterales of indusium griseum, 9
magna (Galeni), 2 sulcus calcarinus, 3 medial atrial veins, 4 lateral striae mediales of indusium griseum, 10 plexus choroideus, 11 calcar
atrial veins, 5 pulvinar thalami, 6 area striata of the optic cortex resid- avis, 12 splenium corporis callosi

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Special Surgical Aspects
13

13.1 Extradural Topography

13.1.1 Skin-Galea-Incision (Fig. 13.1)

Fig. 13.1  Preservation of anastomotic arteries at skin-galea-incision. a Sufficient unilateral preservation of the right-sided A. occipitalis. b
Danger for necrosis of the skin after surgery. Circles: landmarks

© Springer International Publishing AG 2018 283


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_13

ERRNVPHGLFRVRUJ
284 13  Special Surgical Aspects

13.1.2 Craniotomy (Fig. 13.2)

as
in

Pr
o
oc tube
cip ra
.e ntia
xt.

Fig. 13.2  Widening of craniotomy. This may be recommended, if the thickened bone and emissariae of the region of inion and confluens sinuum
are hindering craniotomy. as asterion, in inion

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13.2 Intradural 285

13.2 Intradural

13.2.1 Intraventricular Bleeding (Fig. 13.3)

a
5

c b

Fig. 13.3  Danger for intraventricular bleeding at surgery by vessels of at surgery. 1 Cornu posterius, 2 calcar avis, 3 A. calcarina, 4 plexus
sulci. Note the small distance measurements between the ground of choroideus, 5 tail of hippocampus
sulci and the wall of the ventricle. a Usual anatomy. b and c Bleeding

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286 13  Special Surgical Aspects

13.2.2 Surgical Topography (Fig. 13.4)

9 8
10

11

12

13 7

14 6

15

3
16

17

18

19

20

2
1

Fig. 13.4  Topography of tectum according to supratentorial surgical oidea posterior lateralis, 11 corpus pineale, 12 colliculus superior, 13 V.
approaches cadaver brain dissection. 1 Splenium corporis callosi, 2 ten- basalis (Rosenthal), 14 Baumgartner’s loop, 15 Vv. tecti, 16 colliculus
torium, 3 sinus rectus, 4 ampulla of V. magna (Galeni), 5 falx, 6 sinus inferior, 17 Aa. tecti, 18 V. cerebellaris precentralis, 19 N. trochlearis,
sagittalis inferior, 7 corpus callosum, 8 medial ramification of A. chori- 20 V. supraculminalis
oidea posterior lateralis, 9 habenula, 10 lateral ramification of A. chori-

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13.2 Intradural 287

13.2.3 Puncture of Cornu Post (Figs. 13.5, 13.6, and 13.7)

B
e
a

se
<3 cm b
6 cm

4 cm
re
ctu
pun

pu
nc
tur
e
2, 5 cm

4 cm

Fig. 13.5  Puncture of cornu posterius for assisting neuronavigation, if necessary. a and b Torkildsen method, modified. c Approximate
measurements

ERRNVPHGLFRVRUJ
288 13  Special Surgical Aspects

20

a b
55
mm

58
mm

40

c
65
mm

Fig. 13.6  Avoiding of aberration at puncture of cornu posterius example. a Correct route. b Aberration minimal. c Crus fornicis and pulvinar
thalami endangered

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13.2 Intradural 289

e
59
mm

62
mm

f
67 mm

Fig. 13.7  Continuation of Fig. 13.6. d–f V. magna (Galeni), allocortical striae, vessels of cisterns, tectum, area optica, and corpora geniculata
could be endangered

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Part V
Infratentorial Region

1.1 Introduction

This introduction to Part V contains a short summary of each chapter.

1.2 Chapter 14 Diagnostic Base

–– Extra- and intracranial landmarks can support planning surgery, because it could be help-
ful for the topographic orientation, if imagings are unclear. The schematized illustrations of
vessels could be used as introduction for a better understanding of the high variability of
vessels which is presented later on.
–– A typical example of introduction for surgery is the intracerebellar surgical approach. Wide
areas of cerebellum can be resected without following neurological deficits. It motivates
neurosurgeons to start infratentorial surgery by performing intracerebellar approaches. But
problematic is the deep located area. The high density of fibers of all three cerebellar pedun-
culi close to nucleus dentatus and the fourth ventricle presents a region which must be
preserved at surgery. It can be preserved regarding the topographical relationships of the
cerebellar sulci to the essential cerebellar structures in the depth. Anatomical dissections
and a series of MRTs may help to define the problematic area by neuronavigation before
and during surgery, as presented in this book.

1.3 Chapter 15 Anatomical Base of Surgery

–– Extracranial and cranial structures: Muscles, nerves, and vessels of the neck are detailed
presented for preservation at surgery, if possible. These aspects have to be considered for
avoiding problems of wound healing, development of neuromas after transection of nerves,
liquorrhea, and infections.
–– Dural structures, which have to be considered, are sinuses, its connecting veins, and its
variants. Illustrations may be helpful for avoiding bleeding, air embolism, and encephalo-
malacia by surgery.
–– Cisterna cerebellomedullaris and its contents are presented according to the surgical
approach to the fourth ventricle. The cistern is filled out by the bilateral vermis-tonsillar-
complex. The ground of cistern is built by velum medullare posterius. This is the posterior
wall of the fourth ventricle. The velum presents a hypo/avascular thin-walled compartment
(«nidus avis») and a plexus-choroideus compartment. PICA and branches of it are inter-
posed between vermis-tonsillae and velum medullare posterius. PICA presents a variable
loop close to the midline. The surgical route to the fourth ventricle is located between ton-
silla and nodulus vermis. The fourth ventricle is opened after incision of velum medullare
posterius.

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292   Infratentorial Region

–– At surgical dilation of this opening, tractus flocculonodularis must be preserved for avoiding deficits of
the optokinetic nystagmus, as presented.
–– Cisterna pontocerebellaris and surrounding cisterns are presented as introduction for training neurosur-
geons according to Yaşargil’s creation of cisternal microsurgery. Further illustrated is the high variability
of vessels, especially arteries, e.g., according to elimination of aneurysms and AVMs.
–– Intrarhombencephalic target areas for surgery, especially circumscript lesions (e.g., cavernomas) are
sometimes approached by microsurgical methods. It must be considered the microanatomy of nuclei and
fibers of the brain stem. Favorable for surgery is the minimal variability of nuclei and fibers. Even less
variable are the fine intracerebral branches of perforating arteries. An example for using a favorable
surgical approach is the microsurgical elimination of lesions at the voluminous pedunculus cerebellaris
inferior. But nucleus and tractus solitarius and other components of N. vagus are underlying the peduncle
and must be preserved. This example demonstrates that it is helpful to present a specific introduction for
microanatomy of nuclei and fibers of the brain stem, as given here. After this is added an illustration of
the neuronal control of respiration at the dorsal pontomedullary area, according to surgical approaches
to the fourth ventricle. Further illustrated is the chemosensory control of respiration at the ventral surface
of the medullopontine area according to the transcondylar premedullary surgical approach. Perforating
arteries of the brain stem are added, combined with essential nuclei and fiber systems.
–– Presented are landmarks at the superficial relief of the brain stem and cerebellum for orientation during
surgical approaches. These landmarks are polus inferior and superior olivae, ligamentum denticulatum,
pontomedullary rim, obex, fastigium, frenulum tecti, cranial nerves, colliculi tecti, fossa interpeduncu-
laris (corpora mamillaria), lobulus centralis cerebelli, ala lobuli centralis, lingula cerebelli, fissura hori-
zontalis cerebelli, flocculus, uvula vermis, and nodulus vermis.

1.4 Chapter 16 Special Surgical Aspects

Anatomical base of special surgical approaches:

–– Tonsillo-nodular surgical approach to the fourth ventricle. Preservation of paleocerebellar functions


(optokinetic nystagmus) in contrast to splitting vermis.
–– Cerebellopontine surgical approach according to Yaşargil. Principles of basal cisternal approaches with
preservation of arachnoid walls of cisternae basales and its contents according to Yaşargil1.
–– Transcondylar approaches to the premedullary cisterns. Basal approach for craniospinal lesions ventral
from medulla and pons (Seeger 1978).
–– Supracerebellar approaches to cisterna tecti. F. Krause’s approach, Yaşargil’s modification for micro-
surgery with widening of the approach to adjacent CSF spaces.

These principles are applicable for all basal cisterns (with modifications).
1 

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Diagnostic Base
14

14.1 Landmarks (Figs. 14.1 and 14.2)

la

in

as

ba

Fig. 14.1  Planum occipitale et planum nuchale. Landmarks added for planning surgery. as asterion, ba basion, in inion, la lambda

© Springer International Publishing AG 2018 293


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ERRNVPHGLFRVRUJ
294 14  Diagnostic Base

la

gl

ic

ds

fs

ox

in

ba

pt

ks
ds
as øa

in
po

ba

Fig. 14.2  Extra- and intracranial landmarks. as asterion, ba basion, ds projection, la lambda, ox obex, po porion, pt pterion dotted: sinus trans-
dorsum sellae, ea eminentia arcuata, projection, fs fastigium, gl galenic versus and further structures, projections
point, ic intercommissural line, in inion, ks knee of sinus transversus,

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14.2 Radiology 295

14.2 Radiology (Figs. 14.3, 14.4, and 14.5)

12 11 10 9 8

13

14

15
16
17 18 19

Fig. 14.3  Arteriogram schematized drawing. For variants see Figs. A. chorioidea posterior lateralis, loop at corpora geniculata; 12 A. cho-
15.22 ff and 15.39 ff. 1 ramification of PICA; 2 A. vermis; 3 AICA, rioidea posterior medialis and A. tecti at the pontomesencephalic rim;
inferior branch; 4 plexus choroideus; 5 PICA, choroid point; 6 AICA, 13 Rr. ad pontem; 14 as 13, short types; 15 intrapontine arteries in the
meatal loop; 7 AICA, trigeminal loop; 8 ramification of A. cerebelli depth; 16 as 13; 17 AICA; 18 Aa. vertebrales, junction; 19 A. spinalis
superior, lateral group; 9 as 8, medial group; 10 A. cerebri posterior; 11 anterior

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296 14  Diagnostic Base

16

15
17
14

13

12

11

10

Fig. 14.4  Continuation of Fig. 14.3. 1 A. spinalis anterior; 2 usual ste- point. inconstant; 10 AICA, meatal loop; 11 A. labyrinthi; 12 AICA,
nosis of A. vertebralis at its dural penetration point; 3 PICA; 4 Aa. ver- trigeminal loop; 13 Rr. ad pontem; 14 A. basilaris; 15 A. cerebelli supe-
tebrales, junction; 5 AICA; 6 as 5, inferior branch; 7 as 5, choroid rior; 16 A. cerebri posterior; 17 A. labyrinthi, inconstant finding
segment of the inferior branch; 8 as 5, superior branch; 9 PICA. choroid

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14.2 Radiology 297

11 10 9 8

12

13 6

2
1

Fig. 14.5  Phlebogram. Schematized drawing of anatomical casts by anterolateral pontine veins; 5 V. petrosa superior; 6 V. mesencephalica
Duvernoy 1975 and others (especially Stephens and Stilwell 1969, lateralis; 7 V. basalis (Rosenthal); 8 Vv. tecti; 9 V. magna (Galeni); 10 V.
p 157). Cerebral structures added. 1 dorsal medullary vein; 2 paraolivar cerebellaris praecentralis; 11 V. vermis superior; 12 tributary veins of
vein; 3 V. cerebellaris horizontalis, inconstant connection with 4; 4 11; 13 V. vermis inferior

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298 14  Diagnostic Base

14.3 Further Imaging (Figs. 14.6, 14.7, 14.8, 14.9, 14.10, 14.11, 14.12, and 14.13)

8 7

10

11

12

Fig. 14.6  Anatomical brain dissection similar to neuronavigation. 9 fastigium, 10 velum medullare posterius, insertion, 11 plexus com-
Details added. 1 N. statoacusticus, 2 pedunculus flocculi, 3 flocculus, 4 partment of velum medullare posterius, 12 velum medullare posterius,
lobulus biventer cerebelli, 5 fissura horizontalis cerebelli, 6 lobulus hypo/avascular compartment («nidus avis») 11 and 12 see Fig. 1.13
semilunaris superior, 7 lobulus semilunaris inferior, 8 tonsilla,

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14.3  Further Imaging 299

2 1
3

Fig. 14.7  Central area of cerebellum. MRT, details added. 1 Fissura horizontalis cerebelli, anterior segment, 2 lobulus centralis cerebelli, 3 velum
medullare anterius, 4 pedunculus cerebellaris superior et nucleus dentatus, 5 pedunculus cerebellaris inferior, 6 pedunculus cerebellaris medius

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300 14  Diagnostic Base

6
7
8

Fig. 14.8  Continuation of Fig. 14.7. 1 Uvula vermis, 2 nucleus dentatus, 3 pedunculus cerebellaris medius, 4 pedunculus cerebellaris inferior,
5 plexus choroideus, 6 fossa rhomboidea, 7 sulcus medianus, 8 decussatio olivarum

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14.3  Further Imaging 301

4
5 6 7 8

Fig. 14.9  Continuation of Fig. 14.8. 1 Uvula vermis, 2 recessus dorsolateralis, 3 nucleus dentatus, 4 tonsilla, 5 plexus choroideus, 6 pedunculus
cerebellaris inferior, 7 oliva, 8 fourth ventricle

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302 14  Diagnostic Base

Fig. 14.10  Continuation of Fig. 14.9. 1 Afferent fiber bundles of bellaris medius, 3 pedunculus cerebellaris superior (efferent fiber bun-
nucleus dentatus and bundles of pedunculus cerebellaris medius which dle of nucleus dentatus), 4 decussatio of 3 5 nucleus ruber
are surrounding nucleus dentatus, 2 fiber bundles of pedunculus cere-

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14.3  Further Imaging 303

Fig. 14.11  Continuation of Fig. 14.10. 1 Oliva, 2 pedunculus cerebellaris inferior, 3 pedunculus cerebellaris medius, 4 pedunculus cerebellaris
superior, 5 as 4, 6 decussatio of 4, 7 nucleus ruber

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304 14  Diagnostic Base

B
A

Fig. 14.12  Anatomical dissection for assisting imagings. It presents ralis of the fourth ventricle. Here are defined these layers by shifting it,
more details than imagings, especially the presentations of the narrow similar to the surgical approach to the fourth ventricle. a Anatomical
space of cisterna cerebellomedullaris between tonsilla and velum dissection for assisting MRT. b Anatomical dissection for assisting
medullare post and the underlying narrow space of recessus dorsolate- neuronavigation

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14.3  Further Imaging 305

10 9

11
a

12 8
7

13
5
14
4

2
1

b 12
11

10

8
7
6
5
13 4

Fig. 14.13  As Fig. 14.12, sectional enlargement. A 1 N. facialis, 2 N. plexus choroideus, 4 pedunculus flocculi, 5 velum medullare posterius,
statoacusticus, 3 flocculus, 4 recessus lateralis, 5 plexus choroideus hypo/avascular compartment («nidus avis,» bed of tonsilla), 6 cisterna
(compartment of velum medullare posterius), 6 nucleus dentatus, cerebellomedullaris, lateral wall, 7 as 5, 8 recessus dorsolateralis, 9
7 velum medullare posterius, 8 tractus flocculonodularis, 9 as 8, 10 nucleus dentatus, 10 tonsilla, 11 uvula, 12 velum medullare posterius,
uvula vermis, 11 recessus dorsolateralis of the fourth ventricle (Lang), 13 velum medullare posterius, plexus compartment thin walled
12 as 7, 13 PICA, 14 tonsilla. B 1 N. glossopharyngeus, 2 flocculus, 3

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Anatomical Base for Surgery
15

15.1 Extradural Topography

15.1.1 Extracranial Layers (Figs. 15.1, 15.2, and 15.3)

a
7

6
5

4
3
2

b
1

4
5

Fig. 15.1  Superficial nerves, vessels, and muscles of the neck. Nerves minor, 5 N. occipitalis tertius, 6 N. occipitalis major and vessels, 7 inion. (b) 1
should be preserved at surgery and – if possible – large vessels. (a) 1 N. acces- processus mastoideus, 2 N. occipitalis minor, 3 N. auricularis magnus, 4 N.
sorius, 2 Nn. supraclaviculares, 3 N. auricularis magnus, 4 N. occipitalis accessorius, 5 Nn. supraclaviculares, 6 N. cutaneus colli fasciae omitted

© Springer International Publishing AG 2018 307


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308 15  Anatomical Base for Surgery

a
3

4 3
b

Fig. 15.2  Superficial muscles of the neck. (a) Superficial layer. (b) Middle layer. (a) 1 M. trapezius, 2 M. splenius capitis, 3 M. sternocleidomas-
toideus, 4 M. semispinalis capitis. (b) 1 M. levator scapulae, 2 M. splenius capitis, 3 M. semispinalis capitis, 4 inion

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15.1  Extradural Topography 309

9 8
a
10
11 7

12
1

13

14

3
2
1

Fig. 15.3  Muscles in the depth. (a) Dorsal. (b) Ventral. (a) 1 Mm. inter- 11 M. obliquus capitis superior, insertion at a bony crest (aspects of cra-
spinales; 2 M. obliquus capitis inferior; 3 arcus atlantis posterior; 4 M. niotomy see Fig. 6.1); 12 tuberculum atlantis posterius; 13 processus spi-
rectus capitis laterali; 5 gap for A. vertebralis; 6 M. rectus capitis poste- nosus axis; 14 M. multifidus. (b) 1 M. longus capitis, 2 M. rectus capitis
rior major; 7 M. rectus capitis posterior minor; 8 inion; 9 as 7; 10 as 6; anterior, 3 processus transversus atlantis, 4 M. rectus capitis lateralis

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310 15  Anatomical Base for Surgery

15.1.2 Skull and Atlantoaxial Region (Figs. 15.4, 15.5, 15.6, and 15.7)

11
10

2
1

Fig. 15.4  Outer relief of Os occipitale. 1 condylus occipitalis, 2 fossa mastoideum, 7 sutura squamosa, 8 sutura lambdoidea, 9 planum
paracondyloidea, 3 emissarium condylare, 4 fossa biventerica et sulcus nuchae, 10 crista occipitalis externa, 11 planum occipitale
a. occipitalis, 5 sutura occipitomastoidea, 6 foramen (Emissarium)

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15.1  Extradural Topography 311

as

ea 4

ba

8 3
ds

Fig. 15.5  Inner relief. Bony impressions of the sinuses are landmarks ea eminentia arcuata, 1 tuberculum jugulare, 2 canalis n. hypoglossi, 3
for planning dural incisions and during surgery, especially sinus trans- emissarium condylare (between sulcus sigmoideus and fossa jugularis),
versus/sigmoideus (cerebellopontine surgical approach, Fig. 6.3) and 4 sulcus petrosus superior, 5 sutura occipitomastoidea, 6 sulcus trans-
its variants (Figs. 2.6 and 5.2). as asterion, ba basion, ds dorsum sellae, versus, 7 protuberantia occipitalis interna, 8 sulcus sigmoideus

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312 15  Anatomical Base for Surgery

5
pi

fh
4

3
ks

2
1

Fig. 15.6  Basal inner relief. Fossa cranii posterior. fh foramen n. superior v. jugularis.internae), 5 boni sulci of tuberculum jugulare, cov-
hypoglossi, ks knee of sulcus transversus, pi porus acusticus internus, 1 ered by Nn. IX to XI, 6 tuberculum jugulare, 7 foramen jugulare, ante-
sulcus transversus, 2 sulcus sigmoideus, 3 sulcus petrosus superior, 4 rior segment (containing Nn. IX to XI and Sinus petrosus inferior), 8 as
fossa jugularis, posterior roof of foramen jugulare (enclosing bulbus 3, 9 incisura trigeminalis

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15.1  Extradural Topography 313

Fig. 15.7  Dorsal atlantoocipital bony structures (anatomical base for and dura added. 1 processus transversus atlantis, 2 A. vertebralis, 3 pro-
para- and transcondylar surgical approaches, Fig. 16.25 ff). Anatomical cessus articularis atlantis superior, 4 condylus occipitalis, 5 fossa para-
base of transcondylar surgical approaches (Fig. 6.9 ff). A. vertebralis condylaris, 6 emissarium condylare

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314 15  Anatomical Base for Surgery

15.1.3 Dura and Sinuses (Figs. 15.8, 15.9, and 15.10)

L R

Fig. 15.8  Occipital bony impressions by the dural sinuses. Examples. Bony sulci should be taken in consideration using imagings. Unexpected
openings of a sinus could be avoided. m midline

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15.1  Extradural Topography 315

5
4

6
1

7 8
12
9 10 11
6
b 5

Fig. 15.9  Rare variants of occipital and suboccipital sinuses and its the widened sinus marginalis; 9 emissarium condylare; 10 as 9, its con-
bony impressions. (a) Example of a cadaver skull dissection (transpar- nection to fossa jugularis; 11 mouth of emissarium condylare at fossa
ent presented). (b) Example of a cadaver head dissection (Lang 1979, jugularis; 12 V. jugularis interna added. (b) According to Lang, sche-
p 239). (a) 1 for. jugulare; 2 bony sulcus between foramen mastoideum matized. 1 sinus transversus, 2 atypical sinus, 3 knee of sinus transver-
and foramen jugulare; 3 foramen mastoideum; 4 sulcus transversus; 5 sus, 4 vein of Labbé, 5 sinus petrosus superior, 6 bulbus superior of V.
protuberantia occipitalis interna marking confluens sinuum; 6 sulcus jugularis interna, 7 sinus sigmoideus, 8 sinus sagittalis superior
sigmoideus; 7 crista occipitalis widened to a sulcus; 8 sulcus marking

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316 15  Anatomical Base for Surgery

9
7

2
1

Fig. 15.10  Infratentorial sinuses. Synopsis. 1 Sinus petrosus inferior; 2 V. jugularis interna; 3 bulbus superior of V. jugularis interna; 4 sinus
sigmoideus; 5 sinus petrosus superior; 6 sinus transversus; 7 sinus occipitalis, wide variant; 8 confluens sinuum; 9 sinus marginalis

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15.2  Intradural Topography 317

15.2 Intradural Topography

15.2.1 Survey (Figs. 15.11, 15.12, 15.13, 15.14, 15.15, 15.16, 15.17, 15.18, 15.19, 15.20, and 15.21)

2
1

Fig. 15.11  Dorsal relief of the cerebellum. Its main part is lobulus ning V. cerebellaris horizontalis. Close to the ground of fissura horizen-
biventer. Between lobulus biventer and lobulus semilunaris inferior is talis is located nucleus dentatus (Fig. 3.8). 1 vermis, inferior segment
located fissura horizontalis cerbelli. This is the deepest fissure of the (nodulus vermis), 2 tonsilla, 3 lobulus biventer, 4 fissura horizontalis, 5
cerebellar hemisphere. Along the ground of fissura horizontalis is run- lobulus semilunaris inferior, 6 lobulus semilunaris superior, 7 culmen

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318 15  Anatomical Base for Surgery

Fig. 15.12  Basal relief of the cerebellum and brain stem. Drawing for region of decussatio pyramidum (Fig. 3.9 ff) and for the inferior region
assisting neuronavigation with defining of fine structures (e.g., rhomb- of decussatio lemniscorum (Fig. 3.18 ff). The lateral margin of floccu-
encephalic exit points of cranial nerves). The relief of oliva is variable lus is located close to porus acusticus internus. 1 lobulus semilunaris
configurated and could be masked by periolivar veins. The inferior pole superior, 2 lobulus semilunaris inferior, 3 fissura horizontalis, 4 lobulus
of oliva is a landmark during surgery for the location of the superior biventer, 5 lobulus quadrangularis, 6 flocculus 7 tonsilla, 8 nodulus
vermis

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15.2  Intradural Topography 319

11 10
12 9 8
13 7
14

15
6

16

3
17
1 2

Fig. 15.13  Anterior dorsal and basal cerebellar relief. Characteristic flocculi, 4 fissura horizontalis, 5 flocculus, 6 pedunculus cerebellaris
configurated are the reliefs of lingula cerebelli, velum medullare ante- medius, 7 as 4, 8 pedunculus cerebellaris superior, 9 ala lobuli centralis,
rius, lobulus centralis et paracentralis cerebelli, flocculus, uvula, and 10 lobulus centralis, 11 lingula cerebelli, 12 velum medullare anterius,
nodulus. It may be used for landmarks during intracisternal surgical 13 fourth ventricle, 14 velum medullare posterius, 15 uvula vermis,
approaches. 1 recessus lateralis, 2 plexus chorioideus, 3 pedunculus 16 N. statoacusticus, 17 tonsilla

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320 15  Anatomical Base for Surgery

3 10
4 9
7 8
5 6

Fig. 15.14  Dorsal relief of the cerebellum. This region presents the lis, 3 culmen vermis, 4 declive, 5 fissura prima, 6 as 3, 7 lobulus quad-
subdural supracerebellar part of the surgical route to cisterna tecti and rangularis, 8 lobulus semilunaris inferior, 9 lobulus simplex, 10 lobulus
adjacent CSF spaces (Fig. 6.14). 1 ala lobuli centralis, 2 lobulus centra- semilunaris superior

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15.2  Intradural Topography 321

14

13
12

11

10

15 9

7
17
16

6
18
5

19

Fig. 15.15  Basal relief of the brain stem and cranial nerves. Projections satio pyramidum; 4 radix spinalis n. accessorii; 5 N. hypoglossus; 6
of dural exit points of cranial nerves added. The brain stem exit areas of dural penetration point of 5, projection; 7 Nn. glossopharyngeus, vagus
N. statoacusticus and N. glossopharyngeus are usually covered by et accessorius; 8 For. jugulare, anterior segment, projection; 9 N. stato-
plexus chorioideus (plexus chorioideus here omitted for presenting exit acusticus; 10 N. facialis (and N. intermedius); 11 porus acusticus inter-
regions of N. statoacusticus and glossopharyngeus) and sometimes nus, projection; 12 N. trigeminus; 13 tentorial gap, projection; 14 N.
adherent with it. This area and its fine vessels are not exact to define by abducens; 15 posterior point of porus acusticus internus, projection; 16
neuronavigation, but essential for pontomedullary surgical approaches. anterior point of For. n. hypoglossi, projection; 17 interforaminal line
Connected with the plexus are arachnoid walls (Fig. 15.35). This is (porus acust.int.-For. jug.-For. n. hypoglossi) dotted; 18 Lig. denticula-
essential for surgery (Figs. 15.36 and 16.14) and is presented by ana- tum; 19 insertion of 18 at the medulla oblongata, variable at this region
tomical dissections. 1 funiculus anterior; 2 funiculus lateralis; 3 decus-

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322 15  Anatomical Base for Surgery

2 3
1

Fig. 15.16  Oblique viewing direction of the brain stem. Introduction the recessus lateralis. For details see Klose 2000 and Klose and
for cerebral exit areas of cranial nerves. N. trochlearis is mapping the Sollmann 1998, 1999. The exit region of N. facialis is located at the
inferior margin of colliculi inferiores. The exit region of N. trigeminus fossa paraolivaris («supraolivaris»). Here N. facialis is flattened con-
presents numerous variable fascicles beween the pons and pedunculus figurated. The cerebral exit areas of N. facialis and N. gossopharyngeus
cerebellaris medius («brachium pontis»). Portio minor n. trigemini may are separated by two arachnoid membranes (walls of cisterna medul-
present a variable mixtum of motoric and sensoric fibers at the superior laris lateralis and of cisterna pontocerebellaris). The roots of Nn.vagus
margin of portio major. Sometimes it is surrounding portio major et accessorius are located close to N. glossopharyngeus and 1–2 mm
(Rhoton). This region could present numerous pial veins. The terminal dorsal from sulcus postolivaris. Lig. denticulatum is located ventral
branch of AICA (trigeminal loop) and the loop of A. cerebelli superior from radix spinalis n. accessorii and dorsal from N. hypoglossus. N.
could be located close to the exit region of N. trigeminus, as it is well hypoglossus is overlying A. carotis interna. 1 fossa rhomboidea 2 velum
known by Janetta’s operation.The exit area of N. statoacusticus is medullare posterius, insertion; 3 recessus lateralis; 4 N. glossopharyn-
located at the floor of the recessus lateralis (Figs. 2.19 and 2.30). This geus; 5 N. statoacusticus; 6 N. facialis (and N. intermedius); 7 N. tri-
exit region and the exit region of N. glossopharyngeus could be covered geminus; 8 N. trochlearis
by the inferior main branch of AICA. Veins are located at the floor of

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15.2  Intradural Topography 323

a
a
1

8
9
b
b
1’

2’

3’

4’

5’

6’

7’

8’
9’

Fig. 15.17  Cranial bony and dural exit areas of cranial nerves and of talis interna; a hamulus petrosus and the transdural course of N.
basal vessels for assisting neuronavigation, if necessary. (a) craniobasal abducens. (b) 1′ N. facialis et N. acusticus; 2′ sinus petrosus superior;
bony exit areas, (b) dural penetration areas. (a) 1 porus acusticus inter- 3′ N. glossopharyngeus, N. vagus et N. accessorius; 4′ bulbus superior
nus; 2 sulcus petrosus superior; 3 For. jugulare, anterior segment; 4 as v. jugularis internae; 5′ knee of sinus transversus; 6′ V. condylaris; 7′ N.
3, posterior segment; 5 knee of sulcus transversus; 6 emissarium condy- hypoglossus; 8′ sinus marginalis; 9′ sinus occipitalis; b dural penetra-
lare; 7 canalis n. hyoglossi; 8 margin of For. occipitale; 9 crista occipi- tion point of N. abducens

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324 15  Anatomical Base for Surgery

1 2

Velum medullare post./Plexus chor.

Fig. 15.18  Ground of cisterna cerebellomedullaris: velum medullare implantation of the cochlear nucleus at the floor of recessus lateralis
posterius and apertura mediana (Magendi). For microanatomy see Fig. (Klose and Sollmann 1998). Apertura mediana may be narrowed by
2.26. Two examples. The dorsal arachnoid wall of cisterna cerebellom- arachnoid layers (see b). Plexus chorioideus is variable. (a) (Key and
edullaris is resected for presenting its ground. Velum medullare poste- Retzius 1875) 1 arachnoidea, 2 apertura mediana tonsillae shifted aside
rius is essential for surgical routes to the fourth ventricle and for (arrows). (b) (Lang 1979, p 425) 1 arachnoidea, 2 arachnoid adhesions

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15.2  Intradural Topography 325

a
5

Fig. 15.19  Velum medullare posterius and vermis-tonsillar-complex. and its variable plexus compartment, 4 uvula vermis, 5 fourth ventricle.
(a) Interposion of velum medullare posterius between the uvula- (b) 1 velum medullare posterius, plexus compartment bulging into
tonsillar-­complex and the 4th ventricle. (b) Loosening and shifting of basal cisterns, 2 recessus lateralis, 3 velum medullare posterius, 4 cis-
nodulus vermis and tonsillae from velum medullare posterius (arrows) terna cerebellomedullaris, 5 insertion of velum medullare posterius at
for defining cisterna cerebellomedullaris, uvula-tonsillar-complex, and uvula preserved
fourth ventricle. (a) 1 flocculus, 2 tonsilla, 3 velum medullare posterius

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1 2 3

Fig. 15.20  Recessus lateralis. Velum medullare posterius eliminated velum medullare posterius at the medulla oblongata; 3 plexus chorioi-
except its extraventricular (cisternal) plexus compartment. Presentation deus, cisternal segment preserved; 4 apertura lateralis (Key-Retzii,
of fossa rhomboidea. Its lateral segment (recessus lateralis) contains Luschkae), inconstant opening; 5 striae cochleares and nucleus cochle-
nucleus cochlearis dorsalis. This is the region of cochlear implanta- aris dorsalis; 6 pedunculus cerebellaris inferior, transectional plane;
tions. For details see Klose 2000 and Figs. 3.27f. 1 obex; 2 insertion of 7 N. statoacusticus, projection; 8 pedunculus flocculi, transectional
plane; 9 striae medullares

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15.2  Intradural Topography 327

4
3

5
2

Fig. 15.21  Velum medullare posterius., bed of tonsilla («nidus avis» cus and N. facialis; 3 pedunculus flocculi; 4 tractus flocculonodularis,
in the past). This is the posterior wall of recessus dorsolateralis (Lang) insertion area of velum medullare posterius; 5 fenestration of velum
of the 4th ventricle. Vermis, contralateral tonsilla, and wall of recessus medullare posterius and view into recessus dorsolateralis; 6 nodulus
lateralis and dorsolateralis are preserved. Cisternal part of plexus chori- vermis; 7 tonsilla
oideus is cut and eliminated. 1 plexus chorioideus cut; 2 N. statoacusti-

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15.2.2 Posterior Structures Superior to the Brain Stem (Figs. 15.22, 15.23, 15.24, 15.25, 15.26, 15.27,
15.28, 15.29, 15.30, 15.31, 15.32, and 15.33)

5
a
4

3
1 2

b galenic vein

p.
su
6

s
su
8 7 5

tro
pe
s
nu
Si

m
riu
nto
4 Te
9
3

2
10
1

Fig. 15.22  Vessels at the posterior cerebellar relief. (a) Arteries, (b) bridging veins, variable; 4 V. petrosa superior; 5 superior medial tribu-
veins. (a) 1 A. vermis, 2 PICA (A. cerebelli inferior posterior), 3 as 2, tary veins of 6; 6 V. vermis superior; 7 V. cerebellaris praecentralis; 8 V.
lateral ramification, 4 ramification of A. cerebelli superior, 5 as 1. (b) supraculminalis; 9 as 3; 10 superficial arachnoid wall of cisterna
1 V. vermis inferior; 2 V.cerebellaris horizontalis; 3 superior lateral cerebellomedullaris

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Fig. 15.23  Variable overcrossing and undercrossing of medial arteries overcrossing artery (dark arrow), 3 artery overcrossing vein (light
and veins. Arachnoidea omitted. (a) arteries, usual finding, (b) variants. arrow), 2 and 3: typical overcrossing of veins by arteries at the superfi-
(a) 1 PICA (A. cerebelli inferior posterior), 2 chorioid point of 1 (not cial cerebellar cortex
constant), 3 plexus chorioideus, 4 vermis. (b) 1 A. vertebralis, 2 vein

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330 15  Anatomical Base for Surgery

3
a
2

1b

1a

4
3
2b

b 2a

Fig. 15.24  PICA, velum medullare posterius, and recessus dorsolate- tricle; 3 tonsilla, residual; 4 uvula vermis. (b) 1 PICA; 2a velum medul-
ralis of the 4th ventricle. (a) Superficial segments of tonsillae and ver- lare posterius, plexus compartment; 2b velum medullare posterius,
mis resected. (b) PICA after elimination of tonsillae, located lateral hypo/avascular compartment («nidus avis»); 3 choroid points of PICA,
from nodulus (or anterior from it close to the midline). (a) 1a flocculus, high variability
1b tractus flocculonodularis; 2 recessus dorsolateralis of the 4th ven-

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15.2  Intradural Topography 331

a 2
1

a
rn is
s te llar
ci du
of me
d
n l l o
ou e
gr reb
c e

8
7

5
3 4
2
10 11 1
12

Fig. 15.25  PICA, ramifications. (a) Survey, (b) ramifications of PICA. tional plane between tonsilla and pons, 6 nodulus vermis, 7 lobulus
(a) 1 velum medullare posterius, 2 bulging of velum medullare poste- biventer, 8 lateral branches of PICA, 9 addendum: small cortical ves-
rius (plexus compartment) against the 4th ventricle, bed of uvula ver- sels, 10 lateral main branch of PICA, 11 plexus chorioideus, 12 A.
mis. (b) 1 PICA, 2 uvula vermis, 3 flocculus, 4 velum medullare vermis
posterius (hypo/avascularized bed of tonsilla, «nidus avis»), 5 transec-

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332 15  Anatomical Base for Surgery

10

11

5
12

13 3

14 1

Fig. 15.26  PICA and its main branches. 1 PICA; 2 lobulus biventer, recessus lat.; 8 Tractus flocculonodularis; 9 A. vermis; 10 nodulus ver-
projection; 3 tonsilla; 4 lateral main branch of PICA; 5 loop located mis; 11 velum medullare posterius, plexus compartment; 12 some of
anterior or lateral from uvula, high variability; 6 velum medullare pos- the numerous perforating arteries; 13 uvula vermis; 14 apertura medi-
terius, ventricle fenestrated; 7 recessus dorsolateralis (Lang), part of ana (Magendi)

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15.2  Intradural Topography 333

A. vermis
a
bed of tonsil

PICA

Fig. 15.27  Variants of A. vermis. Examples (a) A. vermis right-sided duplicated, (b) common variant of chorioid loop

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334 15  Anatomical Base for Surgery

b 4

1
6

Fig. 15.28  Velum medullare post and apertura mediana (Magendi). apertura mediana (Magendi) ruptured, often masked by plexus chorioi-
The fine velum medullare posterius could rupture at apertura mediana. deus; 5 pia mater; 6 hypo-/avascular compartment of velum medullare
Bilateral connections of vessels should be considered during surgery. posterius; 7 fourth ventricle, recessus lateralis; 8 ependyma of the wall
(a) Example (Lang 1979, p 424). (b) as (a), microanatomy schema- of the fourth ventricle at pedunculus cerebellaris inferior and peduncu-
tized. 1 plexus compartment of velum medullare posterius variable; lus flocculi (area of apertura mediana)
2 velum medullare posterius; 3 branch of PICA or other fine vessels; 4

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15.2  Intradural Topography 335

5
6 7

Fig. 15.29 Velum medullare posterius and the fourth ventricle. pharyngeus; 6 velum medullare posterius, hypo/avascular compartment
Multiple fenestrations of velum medullare posterius for inspection of («nidus avis»); 7 choroidal compartment of velum medullare posterius.
the fourth ventricle. Tonsilla eliminated, vermis resected. 1 and 2 trac- Arrows: fossa rhomboidea
tus flocculonodularis; 3 flocculus; 4 pedunculus flocculi; 5 N. glosso-

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336 15  Anatomical Base for Surgery

14

13

12

11

10

15 9

16

17 7

5
4
1 2 3

Fig. 15.30  Fourth ventricle (Cadaver brain dissection, Seeger 1987, 9 residual of lobulus quadrangularis; 10 residual of ala lobuli centralis;
schematized) and surrounding structures. 1 uvula vermis; 2 nodulus 11 pedunculus cerebellaris superior; 12 velum medullare anterius; 13
vermis; 3 PICA; 4 tonsilla, residual; 5 cisterna cerebellomedullaris; colliculus inferior; 14 frenulum tecti; 15 nucleus dentatus; 16 A. and V.
6 velum medullare posterius; 7 recessus lateralis; 8 fissura horizontalis; vermis; 17 pedunculus cerebellaris inferior

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15.2  Intradural Topography 337

5
4
6
3
7 2
1

8 9 10 11 12

Fig. 15.31  The fourth ventricle, medial area velum medullare ante- its hypo- or avascular component; 4 ependyma; 5 fastigium; 6 lingula
rius, fastigium, velum medullare posterius, and obex. High variability cerebelli; 7 velum medullare anterius; 8 fourth ventricle; 9 ependyma;
of the plexus-chorioideus-compartment of velum medullare posterius. 10 velum medullare posterius, hypo/avascular compartment; 11 pia
1 Uvula vermis; 2 plexus compartment of velum medullare posterius; 3 mater; 12 cisterna cerebellomedullaris

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338 15  Anatomical Base for Surgery

7 6

*
*
10

11

12
* Plexus chor.

Fig. 15.32  The fourth ventricle, recessus lateralis, and adjacent areas. nus, 9 striae medullares, 10 insertion (taenia) of velum medullare pos-
1 N. hypoglossus, 2 N. vagus et accessorius, 3 N. glossopharyngeus, terius, 11 obex, 12 pedunculus flocculi et tractus flocculonodularis,
4 N. facialis at fossa paraolivaris, 5 pons, 6 N. statoacusticus, 7 striae transectional plane* area of Apertura lat. After elimination of plexus
cochleares and region of nucleus n. cochlearis dorsalis, 8 sulcus media- chorioideus

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15.2  Intradural Topography 339

4 2
3
a 1 b

d 1

7
8
9

10

2
3

1 3

Fig. 15.33  Apertura lateralis of the fourth ventricle (Key-Retzius, cal dissection. (a) 1 pyramis medullae; 2 N. abducens; 3 oliva; 4 N.
Luschka (Cit. Rauber-Kopsch 1987; Lang 1979)). Examples (a) usual facialis (and N. intermedius); 5 N. statoacusticus; 6 flocculus; 7 cister-
findings, (b) apertura lateralis narrow or obturated by adhesions, (c) nal wall; 8 plexus chorioideus, cisternal bulging; 9 N. glossopharyn-
apertura lateralis narrow or obturated by an avascular compartment of geus; 10 Lig. denticulatum. B (c) 1 arachnoid adhesions, 2 arachnoid
velum medullare posterius, (b) and (c) common variants, (d) usual find- membrane, 3 pyramis medullae. (d) 1 ependymal margin of apertura
ings of cranial nerves after resection of plexus and flocculus at anatomi- lateralis, 2 region of nucleus cochlearis dorsalis, 3 N. statoacusticus

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340 15  Anatomical Base for Surgery

15.2.3 Basal Cisterns, Variants, and Adjacent Structures

Basal Cisterns (Figs. 15.34, 15.35, 15.36, 15.37, and 15.38)

b 1

2
8

7
3

Fig. 15.34  Penetration points of perforating arteries at the brain stem, lemnisci; 2 taenia chorioidea (insertion of velum medullare posterius);
schematized. Intracerebral anastomoses of arteries to each others are 3 fossa paraolivaris; 4 pontomedullary rim; 5 fissura mediana anterior;
rare. At surgery the perforating arteries should be preserved (Yaşargil 6 region of N. abducens, vertebrobasilar junction, AICA, pyramis
1978). (a) 1 trigonum lemnisci, 2 pedunculus cerebellaris medius, 3 medullae, adherent by adhesions; 7 Rr. ad pontem, short and long
pedunculus cerebellaris superior, 4 colliculus inferior. (b) 1 trigonum branches; 8 and 9 as 7

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15.2  Intradural Topography 341

12
11
14 13
15

16

10

17
9
8

18
5

19
4
3

2
1

Fig. 15.35  Duplicated cisternal walls and its contents (Key and approaches. 1 cisterna medullaris medialis; 2 cisterna medullaris latera-
Retzius 1876, modified for surgery by Yaşargil, schematized presenta- lis; 3 N. glossopharyngeus, vagus et accessorius; 4 plexus chorioideus;
tion), schematized. Arachnoid duplications are nearly constant findings 5 flocculus, 6 cisterna pontocerebellaris; 7 N. trigeminus; 8 its penetra-
at basal cisterns. At surgery, the duplicated walls can be stepwise dis- tion of arachnoid walls; 9 N. trigeminus, cisterna cruralis; 10 arachnoid
sected from each other, combined with stepwise hollowing of tumors. fold enclosing the tentorial edge; 11 cisterna pontis lateralis; 12 cisterna
Walls of cisterna medullaris medialis et lateralis and of cisterna ponto- pontis medialis; 13 N. statoacusticus; 14 N. facialis; 15 cisterna
cerebellaris lat. are adherent at the lateral segment of plexus chorioi- ambiens; 16 lobulus quadrangularis; 17 fissura horizontalis; 18 lobulus
deus. These aspects should be considered at cisternal surgical biventer; 19 as 4

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342 15  Anatomical Base for Surgery

pb
as

it

ss
4
V
3

2
1

VII
5 VIII po
pb

pl
VI
IX
ss

X ja

XI

jp
ks

XII

Fig. 15.36  Pontomedullary cisterns. as asterion; it incisura trigemina- sinus petrosus superior. 1 flocculus; 2 AICA, meatal loop (for variants
lis; ja foramen jugulare, anterior segment, projection; jp foramen jugu- see Naidich and Kricheff 1976); 3 V. petrosa superior; 4 AICA, trigemi-
lare, posterior segment; ks knee of sinus transversus; pb superior margin nal loop; 5 AICA, superior lateral main branch; 6 inferior medial branch
of Os petrosum; pl plexus chorioideus; po porus acusticus internus; ss V to XII cranial nerves

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15.2  Intradural Topography 343

9
8
10
7

11
6
5

3
N. vagus

12

13

14

15
1

16

17

18 19

Fig. 15.37  Addendum for Fig. 15.36. Arachnoid walls omitted. 1 Lig. ullary rim, 12 A. spinalis anterior, 13 PICA, 14 N. hypoglossus, 15
denticulatum, 2 N. accessorius, 3 N. glossopharyngeus, 4 plexus chori- periolivar veins, 16 funiculus anterior, 17 decussatio pyramidum, 18
oideus, 5 N. statoacusticus, 6 N. facialis, 7 AICA, 8 N. abducens, 9 Rr. funiculus lateralis, 19 stenosis of A. vertebralis at its dural penetration,
ad pontem, 10 junction of Aa. vertebrales, 11 vessels of the pontomed- usual finding

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344 15  Anatomical Base for Surgery

a 4

5
6

11
b
10

9
12

6
13
5
4

Fig. 15.38  Cisterns of the pontomedullary rim. (a) principles of its the perforating branches of PICA; 4 periolivar vein(s); 5 lateral med-
architecture (schematized), (b) masking of arachnoid walls by its ullary vein; 6 branch of PICA or A. vertebralis; 7 veins of the ponto-
contents and arachnoid adhesions. (a) 1 wall of cisterna medullaris medullary rim; 8 one of the perforating branches of AICA; 9
medialis, 2 wall of cisterna pontocerebellaris, 3 wall of cisterna pon- anterolateral main branch of AICA; 10 as 8, variant; 11 Rr. ad pon-
tis medialis, 4 N. abducens, 5 pyramis medullae, 6 oliva, 7 peduncu- tem of A. basilari; 12 vertebrobasilar junction; 13 A. spinalis
lus cerebellaris inferior. (b) 1 A. spinalis anterior; 2 PICA; 3 one of anterior

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15.2  Intradural Topography 345

Variants of Cisternal Arteries (Figs. 15.39, 15.40, 15.41, 15.42, 15.43, 15.44, and 15.45)

CA
PI 5
CA

AI
II
.X lis
a n.n ipita
l C cc
na s o
d itio dylu
ad Con
of

2
6
1

Canalis n.XII

fenestr
ation o
f A.vert
7 ebr.

9
PICA

10

Fig. 15.39  Multiple variants (Lang 1979, schematized) of contents of sus (common variant). 1 Nn. glossopharyngeus, vagus et accessorius, 2
pontomedullary cisterns. Example. Left PICA is feeding both sides plexus chorioideus, 3 N. statoacusticus et N. facialis, 4 A. basilaris,
(rare), fenestration of A. vertebralis (rare). Duplication of N. hypoglos- 5 N. abducens, 6 roots of N. hypoglossus, 7 A. spinalis anterior 8 A.
vertebralis, 9 Lig. denticulatum, 10 N. cervicalis 1

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346 15  Anatomical Base for Surgery

a b

c d

Fig. 15.40  Variants of A. vertebralis, A. basilaris, and A. cerebelli superior. Examples (a) left-sided A. vertebralis, (b) left-sided A. cerebelli
superior, (c) and (d) A. basilaris. (a) and (b) Common findings, (c) and (d) (cadaver brain dissections, experiences of the author) rare variants

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15.2  Intradural Topography 347

Fig. 15.41  Variants of the junction of Aa. vertebrales and of the termi- p 35) a level of vertebrobasilar junction as (a), b level of bifurcation
nal segment of A. basilaris. (a) Usual finding, (b) and (c) rare, (d) approx. 50%, c and d common findings
(Krayenbühl and Yaşargil 1957; Saecki and Rhoton 1977; Lang 1991,

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348 15  Anatomical Base for Surgery

10
9
8
11
7

6
a

12
5

Fig. 15.42  Variants of PICA. Examples (Lang 1991, modified presen- accessorius; 7 N. glossopharyngeus; 8 pedunculus cerebellaris inferior;
tation). Further variants: (a) Approx. 50%, (b) Approx. 30%. 1 N. 9 oliva; 10 N. abducens; 11 N. facialis; 12 dolichoectasy of A. vertebra-
accessorius, radix spinalis; 2 Lig. denticulatum; 3 retinaculum of A. lis (elderly individual)
vertebralis, usual finding; 4 PICA; 5 N. hypoglossus; 6 N. vagus et

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15.2  Intradural Topography 349

g
A tin
PIC etra
pen
ral
du

Fig. 15.43  Continuation of Fig. 15.42. The extradural origin of PICA the neck. For surgical aspects see Fig. 16.26 B 3. Further variants are
(inferior presentation) is a rare variant (Lang 1985, anatomical dissec- hypoplasia or aplasia of PICA. It could be substituted by hyperplasia of
tion). At surgery, it could be confound with a muscle feeding artery of AICA. Hypoplasia of AICA could be substituted by hyperplasia of
PICA

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350 15  Anatomical Base for Surgery

a b

VI

AICA

c d

Fig. 15.44  AICA (A. cerebelli inferior anterior (Scialfa et al. 1976). origin of AICA rare. See right side VI N. abducens. All segments of
Variants (a) N. abducens overcrosses AICA. Undercrossing is possible, AICA could present perforating branches. Cave
(b) rare variants, (c) common variants of the main branches, (d) distal

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15.2  Intradural Topography 351

VI
a
VI

lab
AIC
A

lab

AIC
A

Fig. 15.45  Variants of A. labyrinthi (lab), AICA, and N. abducens (VI). (a) Usual findings (Lang 1979) and contralateral variants, (b) variants of
A. labyrinthi (Wende and Nakayama 1975)

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352 15  Anatomical Base for Surgery

 djacent Basal Structures (Figs 15.46, 15.47, 15.48, 15.49, 15.50, 15.51, and 15.52)
A
Extradural structures which are presented according to the intra-extradural way of some neurosurgical approaches

8 7
9 6

tion
direc
view

2
1

Fig. 15.46  Fundus of meatus acusticus internus (Rauber-Kopsch omitted. 1 tractus spiralis foraminosus, 2 mastoid cells, 3 crista vertica-
1987, p 641 modified, and skull dissections of the author). Meatus acus- lis inferior, 4 area vestibularis inferior, 5 diploe, 6 area vestibularis
ticus internus resected similar to surgery. Dura and leptomeninges superior, 7 crista transversa, 8 crista verticalis superior (Rhoton, 2000,
not constant), 9 area n. facialis

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15.2  Intradural Topography 353

ks
ss

pb
pi it

hp

ja
jp si
dp

fh

Fig. 15.47  Petrooccipital landmarks. Bony landmarks may be helpful, glossi, hp hamulus petrosus enclosing N. abducens, it incisura trigemi-
if details of foramen jugulare or canalis n. hypoglossi are not exact to nalis, ja foramen jugulare, anterior segment, enclosing Nn. IX to XI, jp
define by imaging. For variants of canalis n. hypoglossi and a bony foramen jugulare, posterior segment, enclosing bulbus superior v.jugul.
channel for N. glossopharyngeus, see Figs. 15.50, 15.51, and 15.52. Internae, ks knee of sulcus transversus, pb superior margin of Os petro-
Canalis n. hypoglossi and adjacent bony structures present numerous sum, pi porus acusticus internus, ss sulcus petrosus superior, pi-ja-fh
veins, which must be considered at transcondylar surgical approaches. interforaminal line
dp dural penetration of N. abducens, projection, fh foramen n. hypo-

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354 15  Anatomical Base for Surgery

b 8
a
10

7
11

3
2
b
1

9 7

b
10 5

11 4

12

13 3

14
2

15

16

17

Fig. 15.48 Addendum for Fig. 15.47. Interforaminal line/plane. sus superior; 11 incisura trigeminalis. (b) 1 condylus occipitalis tuber-
Anatomical skull dissections. (a) interforaminal line, (b) interforaminal culum jugulare-complex; 2 excavation of the arachnoid wrap could be
plane. Nerves and vessels drawn in. This plane could be used for defin- widened by tumors (e.g., meningiomas); 3 A. carotis interna; 4 pneu-
ing of landmarks by imagings. For variants see Fig. 2.48 ff. (a) 1 fora- matic cells; 5 fundus of meatus acusticus internus; 6 CSF space; 7 sinus
men occipitale; 2 condylus occipitalis; 3 foramen n. hypoglossi; 4 petrosus superior; 8 tentorium; 9 N. facialis et intermedius; 10 Nn. glos-
tuberculum jugulare; 5 foramen jugulare, anterior segment; 6 as 5, pos- sopharyngeus, vagus et accessorius; 11 arachnoidea; 12 tuberculum
terior segment; 7 processus intrajugularis; 8 apertura externa canalis jugulare; 13 Dura; 14 as 11; 15 CSF space; 16 N. hypoglossus; 17 exca-
carotici; 9 porus acusticus internus, posterior margin; 10 sulcus petro- vation of arachnoid wrap as 2

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15.2  Intradural Topography 355

4 3

a 5

10

7
b
6

11

3
2

Fig. 15.49  Foramen jugulare and adjacent structures. View direction to Nn. IX to XI; 3 foramen jugulare, anterior segment; 4 apertura externa
into a large variant of foramen jugulare. (a) Survey, (b) details. (a) 1 fora- of canalis caroticus; 5 foramen jugulare, posterior segment; 6 processus
men jugulare, 2 sulcus sigmoideus, 3 sulcus petrosus superior, 4 porus styloideus; 7 processus vaginalis; 8 processus intrajugularis; 9 bulging of
acusticus internus, 5 as 3, 6 sulcus petrosus inferior, 7 foramen occipitale, os petrosum, enclosing ductus et saccus endolymphaticus; 10 bony fis-
8 foramen n. hypoglossi. (b) 1 tuberculum jugulare; 2 sulci at 1 according sure, enclosing 9; 11 canalis caroticus. Projection

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356 15  Anatomical Base for Surgery

var
ian
t of
Ca
nal
is n
. gl
oss
oph
ary
nge
i

i h
ogloss
n. hyp
Canalis
ant of
vari

Fig. 15.50  Variants of N. glossopharyngeus and Canalis n. hypoglossi. (a) Canalis glossopharyngeus is a rare bony variant (Lang 1979, p 391).
(b) Duplication of canalis n. hypoglossi is a common variant. Example h canalis n. hypoglossi, i interforaminal line (dotted), j foramen jugulare

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15.2  Intradural Topography 357

Fig. 15.51  Intra- and extracranial presentation of canalis n. hypo- between canalis n. hypoglossi and foramen jugulare. This region pres-
glossi Common finding, schematized. (a) Probes introduced into cana- ents numerous veins, draining to sinus petrosus inferior and bulbus
lis n. hypoglossi and – superior to it – into the accessorial canalis n. superior of V. jugularis interna
hypoglossi − + −, (b) note the extracranial short distance measurement

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Fig. 15.52  Intra- and extradural presentation of a duplicated canalis n. carotis interna; 4 N. hypoglossus; 5 tuberculum jugulare; 6 accesory
hypoglossi. Common finding. Vessels and Nn. IX to XI added. 1 V. foramen n. hypoglossi distant to the interforaminal line; 7 foramen n.
jugularis interna; 2 Nn. glossopharyngeus, vagus et accessorius; 3 A. hypoglossi located at the interforaminal line; 8 condylus occipitalis

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15.2.4 Cisterna Tecti and Fissura Horizontalis Cerebelli (Figs. 15.53, 15.54, 15.55, 15.56, 15.57, 15.58,
and 15.59)

10
9 8
7
6
5
4
11

12

1 2

Fig. 15.53  Cisterna tecti and surrounding regions. Survey. 1 V. cere- basalis (Rosenthal), 9 Vv. tecti, 10 fissura transversa, 11 velum inter-
bellaris praecentralis, 2 lobulus centralis, 3 V. supraculminalis, 4 medial positum, 12 plexus chorioideus
sagittal veins, 5 tentorium, 6 arachnoid layer, 7 V. magna (Galeni), 8 V.

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23 22

21

20

24 19

18
25
17

16

26 15

27 14

28 13

29 12
11
30

31 10

32 9

33
8
34
7

35 6

36
5

2
37 38 1

Fig. 15.54  Ground of cisterna tecti and adjacent CSF spaces. 1 lingula feeding plexus chorioideus; 18 tela chorioidea of the third ventricle
cerebelli; 2 velum medullare anterius; 3 V. mesencephalica lateralis; 4 (medial segment of velum interpositum); 19 V. dorsalis thalami, incon-
Frenulum tecti; 5 N. trochlearis; 6 colliculus inferior; 7 V. basalis stant; 20 velum interpositum (lateral region); 21 plexus chorioideus of
(Rosenthal), small variant; 8 A. cerebelli superior; 9 vessels of trigonum the lateral ventricle; 22 fissura transversa cerebri; 23 corpus fornicis;
lemnisci; 10 A. cerebri posterior; 11 A. tecti; 12 A. chorioidea posterior 24 V. cerebri interna; 25 taenia chorioidea ventriculi III; 26 thalamus; 27
medialis; 13 ramification of A. chorioidea posterior lateralis; 14 hypothalamus; 28 brachium colliculi superioris; 29 pulvinar thalami; 30
Baumgartner’s loop for localization of pulvinar thalami during surgery; corpus geniculatum mediale; 31 brachium colliculi inferiori; 32 crus
15 Vv. tecti, drainage to the galenic vein; 16 Habenula, landmark for cerebri; 33 Vv. tecti; 34 trigonum lemnisci; 35 pedunculus cerebellaris
MRT and landmark during surgery for 17; 17 division of branches of A. superior; 36 pedunculus cerebellaris medius; 37 V. supraculminalis;
chorioidea posterior lateralis to a medial and lateral bundle of arteries 38 V. cerebellaris praecentralis. Underlines: landmarks

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15.2  Intradural Topography 361

9
8
7

10

1 4
2 3

Fig. 15.55  Anterior cerebello-mesencephalic region. 1 A. basilaris, 2 at trigonum lemnisci, 8 Vv. tecti, 9 Aa. tecti, 10 A. cerebelli superior,
A. cerebri posterior, 3 N. oculomotorius, 4 A. cerebelli superior, 5 per- division
forating branches of 4, 6 Aa. thalamoperforantes, 7 perforating branches

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b d

Fig. 15.56  Variants of A. cerebelli superior. (a) Loop close to N. tri- cerebri posterior (more than 10%), b proximal division; (c) c duplica-
geminus (+): Anatomical base of Janetta’s operation (Janetta 1967, tion, d distal division, usual finding
Janetta and Rand 1966); (b) a A. cerebelli superior originates from A.

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15.2  Intradural Topography 363

8
9 7
6
10 5
4

11

12

Fig. 15.57  Fissura horizontalis cerebelli. This CSF space is connected ment of fissura horizontalis is located close to the anterior segment of
with cisterna tecti, cisterna ambiens, and adjacent cisterns. It contains nucleus dentatus (2). 1 transectional plane, lateral limit; 2 pedunculus
venous anastomoses between supra- and infratentorial CSF spaces (Fig. cerebellaris superior et nucleus dentatus; 3 pedunculus cerebellaris
2.56 f). The anterior segment of fissura horizontalis cerebelli is over- medius, ground of fissura horizontalis cerebelli; 4 lingula cerebelli;
layed by lobulus quadrangularis (which is resected at the right side). 5 N. trigeminus; 6 N. trochlearis; 7 frenulum tecti; 8 culmen; 9 declive;
The ground of cisterna horizontalis presents the dorsal surface of 10 lobulus quadrangularis; 11 fissura prima; 12 lobulus semilunaris
pedunculus cerebellaris medius and superior. The anterior medial seg- superior and inferior

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Sinus petrosus sup.


6

5
7
4
8

3
9

Fissura horizontalis cerebelli

10

Fig. 15.58 Anastomotic veins of fissura horizontalis cerebelli. tomotic veins could be insufficient (Seeger 1984, pp. 348 to 351,
Essential is a widened variant of V. mesencephalica lateralis. It should example of a widening of V. petrosa sup.), 4 V. mesencephalica lateralis
not be interrupted at surgery. 1 V. cerebellaris horizontalis, vein of the connecting supra- and infratentorial veins (5 with 1 to 3); 5 V. basalis
posterior segment of fissura horizontalis cerebelli; 2 lateral pontine (Rosenthal); 6 veins connecting medial with lateral veins of fissura
veins; 3 V. petrosa superior, thick-calibrated variant (rare) (after surgi- horizontalis (7 with 4); 7 V. cerebellaris praecentralis; 8 V. supraculmi-
cal interruption of V. petrosa sup., the compensatory function of anas- nalis; 9 tributary veins of 8; 10 bridging veins to tentorium (Fig. 16.30)
hatched: sinus petrosus superior

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15.2  Intradural Topography 365

6
5

a 4

8 1

2
3 1

4 5

2 1

3
c

Fig. 15.59  Further variants of venous connections. (a) 1 V. cerebel- lateralis, 2 sinus petrosus superior, 3 V. petrosa superior, 4 V. cerebel-
laris horizontalis, 2 N. statoacusticus, 3 V. petrosa superior, 4 sinus laris horizontalis, 5 veins of recessus lateralis. (c) 1 lateral pontine
petrosus superior, 5 N. trigeminus, 6 V. basalis (Rosenthal), 7 V. mes- veins, 2 sinus petrosus superior, 3 V. petrosa superior, 4 V. cerebellaris
encephalica lateralis, 8 lateral pontine veins. (b) 1 V. mesencephalica horizontalis, 5 veins of recessus lateralis

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15.2.5 Intracerebellar Structures (Figs. 15.60, 15.61, 15.62, 15.63, 15.64, 15.65, and 15.66)

2 1

3 4

Fig. 15.60  Central cerebellar fiber systems (according to Neuwenhuys contains tractus spinocerebellaris anterior et posterior and tractus olivo-
et al., modified). Survey. The area of nucleus dentatus should be pre- cerebellaris. These are connected with the cerebellar cortex; afferent
served at surgery. It contains four main fiber systems, which are con- fiber plates of nucleus dentatus, these are the main intracerebellar fiber
nected with nucleus dentatus or are surrounding it: pedunculus plates which are connecting the cerebellar cortex (Purkinje cells) with
cerebellaris superior, this fiber bundle connects efferent fibers of nucleus dentatus. In this drawing the fiber plates are not drawn in. 1
nucleus dentatus with nucleus ruber; pedunculus cerebellaris medius, pedunculus cerebellaris superior, 2 nucleus dentatus, 3 pedunculus cer-
numerous fiber plates are connecting nuclei pontis with the cerebellar ebellaris medius, 4 pedunculus cerebellaris inferior. *Central cerebellar
cortex (Fig. 3.9f); pedunculus cerebellaris inferior, these fiber plates region

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5
4
3

1 2

Fig. 15.61  Central cerebellar fiber systems. MRT. 1 pedunculus cerebellaris inferior, 2 pedunculus cerebellaris medius, 3 nucleus dentatus, 4
pedunculus cerebellaris superior, 5 velum medullare anterior

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6
2

Fig. 15.62  Central cerebellar fiber systems. Anatomical dissection. pedunculus cerebellaris inferior connected with vermis, 5 pedunculus
1 nucleus dentatus, dentationes, 2 fibers of Purkinje cells connected cerebellaris medius, 6 as 2
with nucleus dentatus, 3 pedunculus cerebellaris superior, 4 fibers of

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15.2  Intradural Topography 369

1
4 a

Fig. 15.63  Continuation of Fig. 15.62. Fiber bundles dorsal from superior, 4 dentationes of nucleus dentatus, a distance measurement to
Nucleus dentatus are eliminated. 1 fiber plates bulging by nucleus den- the ground of fissura horizontalis cerebelli, b distance measurement
tatus, 2 pedunculus cerebellaris medius, 3 pedunculus cerebellaris between the ground of fissura horizontalis cerebelli and nucleus
dentatus

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1 2

Fig. 15.64  Central cerebellar fiber systems. Fiber plates. Numerous thin-walled fiber plates are crossing each other with changing fiber directions.
Crossings are hindering fibertracking

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15.2  Intradural Topography 371

Fig. 15.65  Conclusion. Nucleus dentatus and adjacent fiber layers (Seeger 1987, p 100 f, 106 f). 1 fibers of pedunculus cerebellaris superior;
2 nucleus dentatus; 3 as 2, projection; 4 afferent fibers of nucleus dentatus; 5 fibers of pedunculus cerebellaris medius or inferior

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372 15  Anatomical Base for Surgery

1 2

Fig. 15.66  Anatomical principles of intracerebellar surgical approaches must be considered. Neuronavigation may be helpful. (a) Splitting and
(motivated by Prof. Lang, Direktor des Anatmischen Instituts der dilation of sulci (arrows). (b) The area of nucleus dentatus is endangered
Universität Würzburg, 1986). Avoiding damage of nucleus dentatus and by brain splitting at a deep sulcus. 1 surrounding fibers of nucleus den-
adjacent structures. The small distance measurements between the tatus, 2 afferent fibers of nucleus dentatus
ground of sulci and nucleus dentatus, especially at fissura horizontalis,

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15.2  Intradural Topography 373

15.2.6 Middle and Inferior Brain Stem. Fibers and Nuclei (Microanatomy According


to Nieuwenhuys, Voogd, van Huiyzen 1990, Modified for Neurosurgery)

Motor and Sensory Long Systems (Figs. 15.67, 15.68, 15.69, 15.70, 15.71, 15.72, 15.73, 15.74, 15.75, 15.76, and 15.77)

13
12

11

10

9
8
7

14

Fig. 15.67  Motor system. Survey. Tractus corticospinalis (pyramida- rior; 2 tractus pyramidalis lateralis; 3 decussatio pyramidum; 4 oliva,
lis). Tractus corticopontinus frontalis et parietotemporalis. Tractus pon- inferior pole, region of the upper begin of decussatio pyramidum; 5 trac-
tocerebellaris (content of pedunculus cerebellaris medius). Tractus tus pyramidalis; 6 oliva, intrapontine segment; 7 tractus parietotemporo-
corticopontinus is crossing the midline before its neurons are connected pontinus; 8 nuclei pontis; 9 tractus pontocerebellaris; 10 tractus
with the neurons of tractus pontocerebellaris (see 8 and 9), analogous to frontopontinus; 11 tractus pyramidalis; 12 tractus parietotemporoponti-
the connections of decussatio pyramidum (3), tractus pyramidalis latera- nus; 13 tractus frontopontinus; 14 decussationes of tractus corticopon-
lis (2), and neurons of cornu spinalis anterius. 1 tractus pyramidalis ante- tini. Underline: landmark

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374 15  Anatomical Base for Surgery

a
1

4 b

Fig. 15.68  Transectional planes of mesencephalon (a) and pons (b). (a) 1 tractus frontopontinus, 2 tractus pyramidalis, 3 tractus parietotemporo-
pontinus. (b) 1–3 as A, 4 nuclei pontis, 5 tractus pontocerebellaris

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15.2  Intradural Topography 375

Fig. 15.69  Transectional planes of pons (a) and medulla oblongata (b). 1 tractus pyramidalis

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376 15  Anatomical Base for Surgery

Fig. 15.70  Transectional planes at the cranial (a) and caudal level (b) pyramidalis; 2 oliva, inferior pole; 3 decussatio pyramidum, upper
of decussatio pyramidum. Note: The cranial region of decussatio pyra- region. (b) 1 tractus pyramidalis, funiculus dorsolateralis, 2 Lig. den-
midum is located at the level of the inferior pole of oliva. (a) 1 tractus ticulatum, 3 fibers of C1. Underlines: landmarks

Fig. 15.71  Sensory system. Survey. a Fasciculus gracilis et cuneatus and from the medullary insertion line of ligamentum denticulatum. Dorsal
nuclei (4,5). b Trigeminal tracts and nuclei (9, 13, 14, 15). c Tractus spi- from tractus spinothalamicus and Lig. denticulatum is located tractus
nothalamicus, tracts, and nuclei (6). a Neurons of cornu posterius of corticospinalis (endangered at surgical transections of tractus spino-
medulla spinalis are located homolateral to nuclei fasciculi gracilis et thalamicus). The fibers of tractus spinothalamicus represents a multisyn-
cuneati and nucleus tractus spinalis n. trigemini. Crossing of its fibers are aptic system, connected with formatio reticularis spinalis, nucleus ruber,
compartments of decussatio lemniscorum. The inferior region of decus- and thalamus. According to the multisynaptic connections, the therapeu-
satio lemniscorum begins at the region of polus inferior olivae. It is tic effects after a surgical interruption of tractus spinothalamius (chor-
nearly the same region as the region of the superior beginning of decus- dotomy) are inefficient after a short time. 1 ganglion spinale; 2 cornu
satio pyramidum. The postcommissural segment of decussatio lemnisco- posterius; 3 decussatio of tractus spinothalamicus; 4 fasciculus gracilis; 5
rum is lemniscus medialis of the medulla oblongata, pons, and fasciculus cuneatus; 6 tractus spinothalamicus; 7 nucleus fasciculi cune-
mesencephalon. b Fibers of nucleus tractus spinalis n. trigemini accom- ati; 8 nucleus fasciculi gracilis; 9 nucleus et tractus spinalis n. trigemini,
pany the contralateral nucleus tractus spinalis after crossing midline. The 10 decussatio lemniscorum (The inferior region of decussatio lemnisco-
midline crossing of trigeminal fibers is a compartment of decussatio lem- rum is located close to the inferior pole of oliva. The superior region is
niscorum. For details, see Fig. 3.23 f. c Some neurons of cornu posterius located at the upper region of pons); 11 as 10, superior segment; 12 lem-
of medulla spinalis (2) are crossing at the same spinal segment (3) or niscus medialis; 13 decussatio of tractus trigeminothalamicus
some segments superior to it. Its continuation is called tractus spino- (Nieuwenhuys et al. 1990); 14 region of nucleus sensorius principalis n.
thalamicus (6), which is a part of columna ventrolateralis, located ventral trigemini; 15 ganglion semilunare (Gasseri). Underlines: landmarks

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15.2  Intradural Topography 377

12
13

14 11

15

10

2 3
4 5

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378 15  Anatomical Base for Surgery

8 7
6
5
a 4
3

10
9
8

7
6

5
4
3
2
b 1

9
8

7
6

c 4

2
1

Fig. 15.72  Fasciculi and nuclei cuneati et gracilis. Transectional lev- lis n. trigemini; 7 its nucleus; 8 fasciculus cuneatus; 9 its nucleus;
els. (a) 1 decussatio pyramidum, 2 radix ant. C1 (fascicle), 3 Lig. den- 10 nucleus fasciculi gracilis. (c) 1 lemniscus medialis et decussatio,
ticulatum, 4 radix spinalis n. accessorii, 5 tractus spinalis n. trigemini, 2 N. hypoglossus (fascicle), 3 oliva, 4 Lig. denticulatum, 5 radix spina-
6 its nucleus, 7 fasciculus cuneatus, 8 fasciculus gracilis. (b) 1 Radices lis n. accessorii, 6 tractus spinalis n. trigemini, 7 its nucleus 8 fasciculus
n. hypoglossi; 2 oliva, inferior pole; 3 lemniscus medialis et decussa- cuneatus, 9 velum medullare post., insertion. Underlines: landmarks
tion; 4 Lig. denticulatum; 5 radix spinalis n. accessorii; 6 tractus spina-

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15.2  Intradural Topography 379

2
1

b
4

Fig. 15.73  Transectional level of recessus lat. (a) and inferior region pyramidalis, 2 lemniscus medialis et decussatio, 3 N. statoacusticus, 4
of pons (b). (a) 1 pyramis medullae, 2 lemniscus medialis et decussatio, genu int. n.facialis. Underlines: landmarks
3 oliva, 4 N. glossopharyngeus, 5 recessus lateralis. (b) 1 tractus

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380 15  Anatomical Base for Surgery

a
4
3
2

5
4

3
b

Fig. 15.74  Middle area of pons (a) and (b). (a) 1 tractus spinalis n. 1990), 3 radix sensoria n. trigemini, 4 nucleus principalis n. trigemini
trigemini, 2 its nucleus, 3 nucleus n. facialis, 4 nucleus n. aducentis, 5 (lateral) et nucleus motorius n. trigemini (medial), 5 genu internum. n.
tractus pyramidalis, 6 lemniscus medialis. (b) 1 lemniscus medialis, 2 facialis
decussatio tractus trigeminothalamici ventralis (Nieuwenhuys et al.

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15.2  Intradural Topography 381

5
4
3

2
1

4
3

2
1

Fig. 15.75  Superior region of pons (a) and (b), dorsal inferior region 1 decussatio of pedunculi cerebellares superiores, 2 pedunculus cere-
of mesencephalon (b). H 1 lemniscus medialis, 2 lemniscus lateralis, 3 bellaris superior et nucleus ruber, 3 lemniscus medialis, 4 lemniscus
pedunculus cerebellaris superior, 4 fasciculus longitudinalis medialis, lateralis, 5 fibers of N. trochlearis
5 velum medullare anterius and decussatio of Nn. trochleares. (b)

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a 6
5

2
1

Fig. 15.76  Intercollicular level (a) and level of colliculi superiores colliculi inferioris. (b) 1 N. oculomotorius, 2 tractus pyramidalis, 3 sub-
(b). (a) 1 decussatio of pedunculi cerebellares superiores, 2 pedunculus stantia nigra, 4 lemniscus medialis, 5 brachium colliculi inferioris.
cerebellaris superior, 3 substantia nigra, 4 lemniscus medialis, 5 fas- Underline: landmark
ciculus longitudinalis medialis, 6 fibers of N. trochlearis, 7 brachium

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15.2  Intradural Topography 383

a
3

Fig. 15.77  Superior region of mesencephalon (a) and (b) and of exit (medially) and pedunculus cerebellaris superior, 3 tractus pyramidalis,
region of N. oculomotorius. (a) 1 tractus pyramidalis, 2 lemniscus 4 lemniscus medialis, 5 tractus spinothalamicus, 6 tractus trigemino-
medialis, 3 brachium colliculi inferioris, 4 brachium colliculi superi- thalamicus dorsalis. Underlines: landmarks
oris, 5 tractus spinothalamicus. (b) 1 corpus mamillare 2 nucleus ruber

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 ranial Nerves, Nuclei, and Roots (Figs. 15.78, 15.79, 15.80, 15.81, 15.82, 15.83, 15.84, 15.85, 15.86, 15.87, 15.88,
C
15.89, 15.90, and 15.91)

9 8
a 7
6
5

10
11

12 13 2 3
1

motorii
Nucleus nervi oculo

7
6
5
b
4

10

11 2
1 3
12

Fig. 15.78  N. oculomotorius. (a) The rostral segment of nucleus n. culus cerebellaris superior (lateral), 11 fibers of N. oculomotorius, 12
oculomotorii is located at the axial level of colliculi superiores. (b) Its midbrain exit of N. oculomotorius, 13 fasciculus longitudinalis media-
caudal segment is located close to nucleus ruber and pecunculus cere- lis. (b) 1–3 as (a); 4 lemniscus medialis; 5 brachium colliculi inferioris;
bellaris superior rostral from its crossing. For variants of N. oculomoto- 6 tractus trigeminothalamicus dorsalis; 7 nucleus mesencephalicus n.
rius which are relevant for surgery see Fig. 15.79. (a) 1 tractus trigemini; 8 colliculus superior; 9 pedunculus cerebellaris superior;
frontopontinus, 2 tractus pyramidalis, 3 tractus parietotemporoponti- 10 nucleus ruber, penetrated by fibers of N. oculomotorius; 11 midbrain
nus, 4 brachium colliculi inferioris, 5 lemniscus medialis, 6 lemniscus exit of N. oculomotorius, 12 fasciculus longitudinalis medialis.
lateralis, 7 tractus tectospinalis, 8 tractus et nucleus mesencephalicus n. Underlines at (a) and (b): landmarks
trigemini, 9 colliculus superior, 10 nucleus ruber (medial) and pedun-

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Fig. 15.79  Roots of N. oculomotorius. Its variants should be considered at basal surgical approaches. (a) Usual finding. (b) Common variant

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386 15  Anatomical Base for Surgery

a
7

8 6

* 5

3
9 10 11 2
Nucleus and fibers
of N. trouchlearis 1

11
10
b
9
8

7
6
5
c 9 4
8 12
7
6
5

4 3

2
1

3
2

Fig. 15.80  N. trochlearis. Surrounding structures. The brain stem exit tangential transected. (b) 1–3 as (a), 4 decussatio of pedunculi cerebel-
points could be used for landmarks during surgery, if the relief of col- lares superiores, 5 pedunculus cerebellaris superior, 6 lemniscus media-
liculi tecti is flattened, e.g., by tumors. (a) 1 tractus corticopontinus lis,7 lemniscus lateralis, 8 tractus mesencephalicus n. trigemini, 9 its
frontalis, 2 tractus pyramidalis, 3 tractus corticopontinus parietotempo- nucleus, 10 colliculus inferior, 11 fasciculus longitudinalis medialis, 12
ralis, 4 lemniscus medialis, 5 nucleus mesencephalicus n. trigemini, 6 pedunculus mamillaris. (c) 1–3 as (a) and (b), 4 lemniscus medialis, 5
its tractus, 7 area intercollicularis, 8 brachium colliculi inferioris, 9 pedunculus cerebellaris superior, 6 lemniscus lateralis, 7 and 8 nucleus
decussatio of pedunculi cerebellares superiores, 10 pedunculus cerebel- et tractus spinalis n. trigemini, 9 N. trochlearis *Frenulum tecti.
laris superior, 11 pontine segment close to isthmus rhombencephali, Underlines: landmarks

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15.2  Intradural Topography 387

12 10
11

13
9

14
5

Fig. 15.81  N. trigeminus. Survey. Intra- and extrarhombencephalic niscus medialis; 3 nucleus fasciculi gracilis et cuneati; 4 nucleus et trac-
structures of N. trigeminus: 1. Intrarhombencephalic structures. tus spinalis n. trigemini; 5 nucleus principalis n. trigemini; 6 nucleus
Nucleus et tractus spinalis n. trigemini (4) and its nucleus principalis motorius n. trigemini; 7 motor fibers of it (it doesn’t exist an exact limit
(5), nucleus et tractus mesencephalicus (12), its participation at decus- beween motor and sensory fibers of N. trigeminus at portio minor and
satio lemniscorum (14) and lemniscus medialis (10), nucleus motorius major (presentation of Prof. Rhoton at Neurochirurgische Klinik of the
(6) and its decussatio (9). 2. Extrarhombencephalic structures. The vari- Kantonspital Zürich 1976)); 8 ganglion trigeminale (Gasseri); 9 decus-
able topographical relationships of portio major and minor (7) to the satio of motor fibers of N. trigeminus, part of tractus pyramidalis; 10
loop of A. cerebelli superior are relevant to Janetta’s operation for the lemniscus medialis; 11 precommissural motor fibers of N. trigeminus;
treatment of Fothergil’s disease. The variability of sensory and motor 12 nucleus et tractus mesencephalicus n. trigemini; 13 decussatio trac-
fibers of portio major (8) and minor (7) should be considered at surgery tus trigeminothalamici; 14 decussatio lemniscorum. Underlines:
(Rhoton). 1 decussatio pyramidum; 2 trigeminal compartment of lem- landmarks

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388 15  Anatomical Base for Surgery

F
E
D

C
B

A
4

a 3 b 3 c
2 3
2

1 1 2

3
4 2

d e
1
3

3
2
f 2 g

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15.2  Intradural Topography 389

2
1

b 5

Fig. 15.83  N. abducens and N. facialis. (a) Survey and topogram for (b). medialis, 2 fibers of N. facialis, 3 nucleus n. facialis, 4 nucleus n. abducen-
(b) Upper region of nucleus n. facialis and abducens. (a) 1 fasciculus lon- tis, 5 genu internum n. facialis, 6 pars prima n. facialis (first motor
gitudinalis medialis, 2 nucleus n. abducentis, 3 nucleus n. facialis, 4 fibers neurons)
of N. facialis, 5 genu interneum n. facialis. (b) 1 fasciculus longitudinalis

Fig. 15.82  N. trigeminus. Surrounding structures. (a) 1 decussatio et tractus spinalis n. trigemini, 4 obex. (e) 1 nucleus et tractus spinalis
pyramidum, middle segment, 2 nucleus et tractus spinalis n. trigemini, n. trigemini, 2 nucleus fasciculi cuneati, 3 nucleus fasciculi gracilis. (f)
3 fasciculus cuneatus and its nucleus, 4 fasciculus gracilis and its 1 nucleus et tractus spinalis n. trigemini, 2 nuclei vestibulares and
nucleus. (b) 1 decussatio lemniscorum, inferior beginning, and decus- nuclei of N. vagus et N. hypoglossus, 3 recessus lateralis, stria cochle-
satio pyramidum, superior beginning (mixed fibers), 2 nucleus et trac- aris, and nucleus dorsalis n. cochlearis. (g) 1 nucleus principalis senso-
tus spinalis n. trigemini, 3 nucleus fasciculi gracilis. (c) 1 decussatio rius n. trigemini, 2 nucleus motorius n. trigemini. Underlines:
lemniscorum, 2 oliva close to its polus inferior, 3 nucleus et tractus landmarks
spinalis n. trigemini. (d) 1 oliva, 2 decussatio lemniscorum, 3 nucleus

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390 15  Anatomical Base for Surgery

13 12
11
10

a 9
8
7
6
5

4
3

1
c

d
Recessus lat.

12 11

10

b 8
7

5
4
3
2
1

Fig. 15.84  Continuation of Fig. 15.83. (a) Inferior region of nucleus niscorum, 2 fasciculus longitudinalis medialis, 3 superior part of
n. facialis et n. abducentis. (b) Area of recessus lateralis. (a) 1 fascicu- nucleus n. hypoglossi and nuclei verstibulares, 4 nucleus ambiguus,
lus longitudinalis medialis; 2 nuclei olivares, superior region; 3 fibers of 5 nucleus et tractus solitarius, 6 nucleus et tractus spinalis n. trigemini,
N. facialis; 4 nucleus et tractus spinalis n. trigemini; 5 nucleus n. facia- 7 fibrae olivocerebellares, 8 N. glossopharyngeus, 9 pedunculus cere-
lis; 6 nucleus n. abducentis; 7 nuclei vestibulares mediales et laterales; bellaris inferior, 10 nucleus cochlearis dorsalis, 11 striae cochleares
8 genu internum n. facialis; 9 nucleus n. hypoglossi (nucleus praeposi- dorsales, 12 striae medullares recessus lat. See (b). Underlines:
torius); 10 pedunculus cerebellaris inferior; 11 pedunculus cerebellaris landmarks
superior; 12 plexus chorioideus; 13 uvula vermis. (b) 1 decussatio lem-

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15.2  Intradural Topography 391

6 5

7
8

10

Fig.99
B

Corpus
trapezoideum

Fig. 15.85  N. cochlearis. Survey. 1 striae medullares; 2 connections of cochleares ventrales (see Fig. 3.30), projection; 8 stria acustica dorsalis;
the vestibular segment of lemniscus medialis with fasciculus longitudi- 9 nucleus cochlearis dorsalis; 10 oliva, lateral nucleus. Little circle: lat-
nalis medialis; 3 fasciculus longitudinalis medialis; 4 lemniscus media- eral segment of corpus trapezoideum. (a) and (b) topogram for Fig. 3.30
lis; 5 radiatio acustica; 6 commissura colliculi inferioris; 7 nuclei

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392 15  Anatomical Base for Surgery

4
a

6 5
4
3

1
b

Fig. 15.86  N. cochlearis. Surrounding structures. (a) 1 decussatio cor- decussatio lemniscorum and begin of lemniscus medialis, 2 corpus
poris trapezoidei; 2 connection of decussation corporis trapezoidei with trapezoideum, 3 recessus lateralis (lateral region of corpus trapezoi-
the begin of Lemniscus lat., nucleus lat. olivae and nuclei cochleares deum), 4 nucleus cochlearis dorsalis, 5 medial limit region of 4, 6 striae
ventrales; 3 nuclei cochleares ventrales; 4 nucleus lateralis olivae. (b) 1 medullares and stria acustica. Underline: landmark

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15.2  Intradural Topography 393

Nucleus and Tractus solitarius

Nucleus ambiguus

Nucleus dorsalis n.vagi

(Nucleus alae cinereae)

Fig. 15.87  N. glossopharyngeus, N. vagus et N. acessorius. Survey. Dark colored: nucleus et tractus solitarius and nucleus ambiguus. Light col-
ored: nucleus dorsalis n. vagi (modern term identic with nucleus alae cinereae in the past)

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394 15  Anatomical Base for Surgery

6 5 4
7
3

D 2

a 1

Nucleus dorsalis n.vagi


5
Nucleus and Tractus solitarius
6 4
3
2

1
7
6
b Nucleus ambiguus 8
5

c
7
6 3

5
2

d 1
4

2
1

Fig. 15.88 N. glossopharyngeus, N. vagus et N. accessorius. vestibulares; 6 nucleus n. hypoglossi, superior region; 7 fasciculus lon-
Surrounding structures. The exit areas of Nn. glossopharyngeus, vagus, gitudinalis medialis. (b) 1 N. vagus, 2 nucleus et tractus spinalis n. tri-
and accessorius at the medulla oblongata are located dorsal from sulcus gemini, 3 fasciculus longitudinalis medialis, 4 nucleus n. hypoglossi,
posterior olivae. The upper limit of nucleus et tractus solitarius is 5 nucleus fasciculi cuneati, 6 pedunculus cerebellaris inferior. (c) 1
located at the horizontal level of recessus lat. Its inferior limit is located lemniscus med. and its decussatio, 2 fasciculus longitudinalis medialis,
at the region between the medulla oblongata and medulla spinalis. In 3 nucleus ambiguus, 4 nucleus et tractus spinalis n. trigemini, 5 nucleus
the depth nucleus et tractus solitarius are located close to peduculus et fasciculus cuneatus, 6 nucleus et tractus solitarius, 7 nucleus et fas-
cerebellaris inferior. Cave at surgical removal, e.g., of cavernomas of ciculus gracilis, 8 nucleus dorsalis n. vagi. (d) 1 decussatio pyramidum,
pedunculus cerebellaris inferior. Radix spinalis n. accessorii is located 2 C1 3 nucleus retroambiguus, 4 N. accessorius, 5 nucleus et tractus
dorsal from Lig. denticulatum. A 1 nucleus ambiguus; 2 N. glossopha- spinalis n. trigemini, 6 fasciculus cuneatus, 7 fasciculus gracilis.
ryngeus; 3 striae medullares; 4 nucleus et tractus solitarius; 5 nuclei Underlines: landmarks

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15.2  Intradural Topography 395

A
Nucleus n. hypoglossi

b A

XII

Fig. 15.89  N. hypoglossus. Survey and topogram for Fig. 3.32. (a) approaches, e.g., for removal of craniospinal meningiomas (The roots
Nucleus n. hypoglossi is extended between the level of recessus latera- of N. hypoglossus are interposed beween ligamentum denticulatum and
lis and caudal from obex. (b) The roots of N. hypoglossus are variable. A. vertebralis, Figs. 6.9 and 6.11). Underlines: landmarks
This should be considered at transconylar premedullary surgical

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396 15  Anatomical Base for Surgery

2 1

4
Nucleu

us
ss
lo
A

g
ot po
s n. hy

ro . hy
3

s
2

N
4
poglos

2
1
si

3
1

1
B
4
C
5

2
3 4 5
1

2
3

Fig. 15.90  Continuation of Fig. 15.89. (a) 1 dorsal shape of the fissura mediana ant., 5 pyramis medullae. (c) 1 dorsal shape of the
medulla oblongata, 2 sulcus medianus, 3 fissura mediana ant., 4 shape begin of medulla spinalis, 2 fissura mediana ant., 3 pyramis medullae.
of pyramis medullae. (b) 1 funnel-like shape of the mouth of canalis Underlines: landmarks
spinalis centralis, 2 dorsal shape of the medulla oblongata, 3 obex, 4

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15.2  Intradural Topography 397

A
B
C
D

E
5 4
5 4
6 3 3

2
2
1

a
1
b

XII

7 6 5
6 5
4 8 4
3 3
2 2
1
1

c d

5
4
3
2
1

Fig. 15.91  N. hypoglossus. Surrounding areas. (a) 1 pedunculus cer- tractus solitarius, 6 nucleus dorsalis n. vagi. (d) 1 fasciculus longitudi-
ebellaris inferior, 2 nucleus et tractus spinalis n. trigemini, 3 nucleus nalis medialis, 2 nucleus et tractus fasciculi cuneati, 3 nucleus et tractus
ambiguus, 4 nucleus et tractus solitarius, 5 nucleus dorsalis n. vagi, 6 solitarius, 4 nucleus dorsalis n. vagi, 5 nucleus fasciculi gracilis, 6 sul-
fasciculus longitudinalis medialis. (b) 1 nucleus ambiguus, 2 nucleus et cus longitudinalis, 7 obex, 8 mouth of canalis spinalis centralis. (e)
tractus spinalis n. trigemini, 3 nucleus et tractus solitarius, 4 nucleus 1 nucleus et tractus spinalis n. trigemini, 2 nucleus n. accessorii,
dorsalis n. vagi, 5 fasciculus longitudinalis medialis. (c) 1 nucleus et 3 nucleus fasciculi cuneati, 4 nucleus et tractus solitarius, 5 nucleus
tractus spinalis n. trigemini, 2 nucleus ambiguus, 3 nucleus fasciculi fasciculi gracilis, 6 canalis spinalis centralis. Underlines: landmarks
cuneati et gracilis, 4 fasciculus longitudinalis medialis, 5 nucleus et

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398 15  Anatomical Base for Surgery

Spinocerebellar and Olivocerebellar System (Fig. 15.92)

9 8

Fig. 15.92  Olivae and its main connections. Survey. This system rior, 2 oliva, 3 lemniscus medialis and its decussatio, 4 decussatio of
should be preserved at surgery for avoiding statomotoric and other bul- tractus olivocerebellaris, 5 tractus olivocerebellaris, 6 cerebellar cortex,
bar and cerebellar deficits. 1 tractus spinocerebellaris anterior et poste- 7 tractus rubroolivaris (tractus tegmentalis centralis), 8 nucleus ruber, 9
decussatio of pedunculi cerebellares superiores

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15.2  Intradural Topography 399

Neuromotor and Chemosensory Control of Respiration (Figs. 15.93 and 15.94)

area for exsp


iration

area for inspiration


Ob
ex

Fig. 15.93  Central neuronal areas for inspiration and exspiration. fied by in- and exspiratory pontine and mesencephalic areas. In- and
Schematized (Wyss 1955; Tarlov and Giancotti 1956; Frowein 1963; exspiratory functions are endangered by lesions of the obex region and
Seeger 1968; Schlaefke and Loeschke 1979). The main neuronal con- caudal to it. Underline: landmark
trol of inspiration and exspiration is located at the region of obex, modi-

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400 15  Anatomical Base for Surgery

ric
so
en
os
e m rs
ch nte
ce at
-
-c

Fig. 15.94  Central chemosensory centers at cats and rabbits according gered at transcondylar premedullary surgical approaches, e.g., for
to Schlaefke and Loeschke (Schlaefke 1981; Schlaefke et al. 1979). In- removal of craniospinal meningionas. Landmarks for neuronavigation:
and exspiratory functions at mammals (and humans?) may be endan- pontomedullary rim and olivae

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15.2  Intradural Topography 401

 ynopsis of Nuclei and Fibers of the Brain Stem (Figs. 15.95, 15.96, 15.97, 15.98, 15.99, 15.100, 15.101, 15.102,
S
15.103, 15.104, 15.105, 15.106, 15.107, 15.108, and 15.109)

10

a 9

5
4
11 3
2

b
10
9
8

11
2

12
1

Fig. 15.95 (a) 1 C1, 2 cornu anterius, 3 decussatio pyramidum, 4 cana- dum, 3 nucleus et tractus solitarius, 4 canalis spinalis centralis, 5 radix
lis spinalis centralis, 5 tractus pyramidalis lateralis, 6 Lig. denticulatum, spinalis n. accessorii, 6 nucleus spinalis n. trigemini, 7 tractus spinalis n.
7 radix spin.n. accessorii, 8 radix posterior of C1 and cornu posterius, 9 trigemini, 8 fasciculus cuneatus, 9 nucleus fasciculi gracilis, 10 fascicu-
fasciculus cuneatus, 10 fasciculus gracilis, 11 tractus spinothalamicus. lus gracilis, 11 tractus spinocerebellaris anterior et posterior, 12 funicu-
(b) 1 tractus pyramidalis (tractus corticospinalis), 2 decussatio pyrami- lus anterolateralis, region of tractus spinothalamicus

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402 15  Anatomical Base for Surgery

a
11 10
9
8
7

12 5
13

14

8
b

9 7 6
5

10 3

11

12

13
1

Fig. 15.96 (a) 1 tractus pyramidalis; 2 cornu anterius; 3 tractus spino- segment; 14 cornu anterius. (b) 1 tractus pyramidalis, 2 oliva, 3 tractus
cerebellaris anterior et posterior; 4 canalis spinalis centralis; 5 nucleus spinalis n. trigemini, 4 nucleus tractus spinalis n. trigemini, 5 nucleus
tractus spinalis n. trigemini; 6 tractus spinalis n. trigemini; 7 nucleus fasciculi cuneati, 6 nucleus fasciculi gracilis, 7 nucleus n. hypoglossi,
dorsalis n. vagi; 8 fasciculus cuneatus; 9 fasciculus gracilis; 10 nucleus 8 nucleus tractus solitarii, 9 tractus solitarius, 10 tractus rubrospinalis,
fasciculi gracilis, main segment; 11 nucleus fasciculi cuneati, inferior 11 tractus spinocerebellaris anterior et posterior, 12 tractus tectospina-
segment, 12 nucleus n. hypoglossi, 13 decussatio lemniscorum, inferior lis, 13 decussatio lemniscorum

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15.2  Intradural Topography 403

a
* Obex 10 9
11
8
12
13 7
14 6

15

16 4

2
1

b
10 9
11

12
8
7

5
4
13

2
15
14 1

Fig. 15.97 (a) 1 tractus pyramidalis, 2 oliva, 3 nucleus ambiguus, 3 nucleus ambiguus, 4 nucleus tractus spinalis n. trigemini, 5 tractus
4 nucleus tractus spinalis n. trigemini, 5 tractus spinalis n. trigemini, spinalis n. trigemini, 6 nucleus tractus solitarii, 7 nucleus fasciculi cune-
6 nucleus fasciculi cuneati, 7 nucleus tractus solitarii, 8 tractus solitarius, ati, 8 tractus solitarius, 9 nucleus fasciculi gracilis, 10 nucleus dorsalis n.
9 nucleus fasciculi gracilis, 10 canalis spinalis centralis, 11 nucleus dor- vagi, 11 nucleus n. hypoglossi, 12 pedunculus cerebellaris inferior, 13
salis n. vagi, 12 nucleus n. hypoglossi, 13 fasciculus longitudinalis fila radicularia n. hypoglossi, 14 decussatio of lemniscus medialis, 15
medialis, 14 pedunculus cerebellaris inferior, 15 fila radicularia n. hypo- fasciculus longitudinalis medialis
glossi, 16 lemniscus medialis. (b) 1 tractus pyramidalis, 2 hilus of oliva,

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404 15  Anatomical Base for Surgery

a
15 14 13
12
16

11
17

10
9

8
7
6
5
4

(18) 3
2
1

b 16 12
17
13
11
18 14 10
15
9
8

6
5

19
4

(21) 3

21 1

Fig. 15.98 (a) 1 tractus pyramidalis; 2 fila radicularia n. hypoglossi; 3 idalis, 2 fila radicularia n. hypoglossi, 3 hilus of oliva, 4 Lig. denticula-
hilus of oliva; 4 accessorial nucleus of 3; 5 nucleus ambiguus; 6 Lig. tum, 5 nucleus ambiguus, 6 fila radicularia n. vagi, 7 nucleus cochlearis
denticulatum; 7 nucleus tractus spinalis n. trigemini; 8 tractus spinalis n. dorsalis, 8 nucleus tractus spinalis n. trigemini, 9 tractus spinalis n. tri-
trigemini; 9 nucleus tractus solitarii; 10 tractus solitarius; 11 nucleus gemini, 10 nucleus tractus solitarii, 11 tractus solitarius, 12 nuclei ves-
fasciculi cuneati; 12 nuclei vestibulares, caudal segments; 13 nucleus tibulares, 13 nucleus dorsalis n. vagi, 14 nucleus n. hypoglossi, 15
dorsalis n. vagi; 14 nucleus n. hypoglossi; 15 fasciculus longitudinalis fasciculus longitudinalis medialis, 16 fila radicularia n. vagi, 17 nuclei
medialis; 16 pedunculus cerebellaris inferior; 17 fila radicularia n. vagi vestibulares, 18 pedunculus cerebellaris inferior, 19 fila radicularia n.
(18) chemosensoric area for respiration (mammals). (b) 1 tractus pyram- hypoglossi, (20) chemosensoric area for respiration, 21 lemniscus med

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15.2  Intradural Topography 405

11 10 9

12
7
13
6
14

15
4

16
3

17

18

Fig. 15.99  1 fasciculi pyramidales, 2 oliva, 3 nucleus ambiguus, recessus lateralis, 12 nucleus cochlearis dorsalis, 13 lateral limit region
4 nucleus tractus spinalis n. trigemini, 5 tractus spinalis n. trigemini, of 12, 14 N. glossopharyngeus, 15 fila radicularia of N. glossopharyn-
6 nucleus tractus solitarii, 7 tractus solitarius, 8 nuclei vestibulares, 9 geus, 16 tractus rubrospinalis et tectospinalis, 17 decussatio lemnisco-
fasciculus longitudinalis medialis, 10 nucleus vestibularis medialis, 11 rum, (18) chemosensoric area for respiration (mammals)

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406 15  Anatomical Base for Surgery

12 11
10
13
9

8
7
6

14

15

4
16

17

Fig. 15.100  1 tractus pyramidalis; 2 fossa paraolivaris; 3 fila radicu- internum n. facialis; 11 fasciculus longitudinalis medialis; 12 nucleus n.
laria n. vestibularis; 4 nucleus ambiguus; 5 tractus spinalis n. trigemini; abducentis, 13 nucleus n. facialis, middle segment; 14 fila radicularia n.
6 nucleus tractus spinalis n. trigemini; 7 fila radicularia n. facialis; facialis; 15 lemniscus medialis; 16 fila radicularia n. abducentis; 17
8 nuclei vestibulares; 9 nucleus n. facialis, caudal segment; 10 genu oliva

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15.2  Intradural Topography 407

11
10
16 12
15
14 13

7
17
6

18

1
19

20

Fig. 15.101  1 nuclei pontis, 2 fibrae pontocerebellares, 3 tractus abducenti, 14 genu internum n. facialis, 15 pars prima (prenuclear seg-
pyramidalis, 4 fila radicularia n. abducentis, 5 corpus trapezoideum, ment) of N. facialis, 16 fasciculus longitudinalis medialis, 17 oliva, 18
6 nucleus ambiguus, 7 tractus spinalis n. trigemini, 8 nucleus tractus decussatio lemnisci medialis, (19) chemosensoric region for respiration
spinalis n. trigemini, 9 pedunculus cerebellaris inferior, 10 nuclei n. (mammals), 20 N. abducens
vestibularis, 11 nucleus n. facialis, 12 fila n. facialis, 13 nucleus n.

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408 15  Anatomical Base for Surgery

11
10

13 12 8
7

5
14
4

15
3

16
2

Fig. 15.102  1 nuclei pontis; 2 fibrae pontocerebellares, pedunculus motorius n. trigemini; 10 radix mesencephalica n. trigemin; 11 genu
cerebellaris medialis; 3 tractus pyramidalis; 4 corpus trapezoides; 5 fila internum n. facialis; 12 nucleus n. abducentis, cranial segment; 13 fas-
radicularia n. facialis, cranial segment; 6 nucleus n. facialis; 7 nucleus ciculus longitudinalis medialis; 14 fila radicularia n. trigemini; 15 fila
tractus spinalis n. trigemini; 8 tractus spinalis n. trigemini; 9 nucleus radicularia n. abducentis; 16 decussatio lemniscorum

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15.2  Intradural Topography 409

9
8

10

6
11
5

12
4

2
1

Fig. 15.103  1 nuclei pontis, 2 tractus pyramidalis, 3 pedunculus cer- ini, 7 nucleus n. vestibularis, 8 nucleus dentatus, 9 pedunculus cerebel-
ebellaris medialis, 4 nucleus et tractus motorius n. trigemini, 5 nucleus laris superior, 10 pedunculus cerebellaris inferior, 11 lemniscus
sensorius principalis n. trigemini, 6 nucleus mesencephalicus n. trigem- medialis, 12 lemniscus lateralis

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410 15  Anatomical Base for Surgery

11
10

12
9
8

5
4

Fig. 15.104  1 tractus corticopontinus frontalis; 2 tractus pyramidalis; lus cerebellaris medius); 8 lemniscus medialis; 9 lemniscus lateralis;
3 tractus corticopontinus parietotemporalis; 4 nucleus tractus spinalis et 10 nucleus motorius n. trigemini; 11 pedunculus cerebellaris superior,
nucleus sensorius principalis n. trigemini; 5 tractus spinalis n. trigem- 12 fasciculus longitudinalis medialis
ini; 6 N. trigeminus, portio major; 7 tractus pontocerebellaris (peduncu-

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15.2  Intradural Topography 411

10
9

8
7

6
5

11
4

Fig. 15.105  1 pedunculus cerebellaris medialis, 2 tractus corticopon- cerebellaris superior, 8 nucleus mesencephalicus n. trigemini, 9 N.
tinus frontalis, 3 tractus pyramidalis, 4 tractus corticopontinus parieto- trochlearis, 10 fasciculus longitudinalis medialis, 11 decussatio of
temporalis, 5 lemniscus medialis, 6 lemniscus lateralis, 7 pedunculus pedunculi cerebellares superiores

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412 15  Anatomical Base for Surgery

8
5

9 3

Fig. 15.106  1 tractus corticopontinus frontalis, 2 tractus pyramidalis, tractus mesencephalicus n. trigemini, 8 decussatio of pedunculi cere-
3 tractus corticopontinus parietotemporalis, 4 lemniscus medialis, 5 bellares superiores, 9 nuclei pontis
lemniscus lateralis, 6 fasciculus longitudinalis medialis, 7 nucleus et

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15.2  Intradural Topography 413

4
7

Fig. 15.107  1 tractus corticopontinus frontalism, 2 tractus pyramida- n. trigemini, 7 decussatio of pedunculi cerebellares superiores, 8 fibrae
lis, 3 tractus corticopontinus parietotemporalis, 4 lemniscus medialis, 5 pontocerebellares
fasciculus longitudinalis medialis, 6 nucleus et tractus mesencephalicus

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414 15  Anatomical Base for Surgery

10 9

11 6

Fig. 15.108  1 tractus corticopontinus frontalis; 2 tractus pyramidalis; tractus mesencephalicus n. trigemini; 9 nucleus n. oculomotorii,
3 tractus corticopontinus parietotemporalis; 4 substantia nigra; 5 lem- somatic portion (Westphal-Edinger); 10 as 9, parasympathic portion
niscus medialis; 6 lemniscus lateralis; 7 brachium colliculi inferioris; 8 (Perlia); 11 fila radicularia n. oculomotorii

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15.2  Intradural Topography 415

11
12
13

10
14
9

15 6

16 5

3
1 2

Fig. 15.109  1 N. oculomotorius; 2 tractus corticopontinus frontalis; 3 brachium colliculi superioris; 11 tractus spinothalamicus; 12 nucleus n.
tractus pyramidalis; 4 tractus corticopontinus parietotemporalis; 5 sub- oculomotorii, parasympathic portion; 13 as 12, somatic portion, 14 fila
stantia nigra; 6 lemniscus medialis; 7 corpus geniculatum mediale; 8 radicularia n. oculomotorii and fasciculus longitudinalis medialis, 15
brachium colliculi inferioris; 9 tractus mesencephalicus n. trigemini; 10 nucleus ruber, 16 pedunculus cerebellaris superior

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15.2.7 Vessels of the Middle and Inferior Brain Stem (Figs. 15.110, 15.111, 15.112, 15.113, and 15.114)

6
3
7

10 2
a

11
1

4
5 b

Fig. 15.110 Intrarhombencepalic perforating arteries (casts of satio et pedunculus cerebellaris superior; 10 tractus pyramidalis; 11
Stephens and Stilwell, 1969, pp. 103–115, schematized). The perforat- upper pontine transection. (b) 1 branches of the bifurcation of A. basi-
ing arteries of the brain stem present more regulary configurations than laris, A. cerebelli superior, cerebri posterior, and Rami ad pontem; 2 as
the large branches of circulus arteriosus (Willisi). (a) 1 Aa. thalamoper- 1; 3 branches of A. cerebelli superior et A. cerebri posterior; 4 fascicu-
forantes; 2 branches of A. basilaris, A. cerebri posterior et A. cerebelli lus longitudinalis medialis; 5 colliculus inferior; 6 lemniscus lateralis;
superior; 3 as 2 and 4; 4 branches of A. cerebri posterior, A. cerebelli 7 lemniscus medialis; 8 decussatio et pedunculi cerebellares superiores;
superior, and A. tecti; 5 fasciculus longitudinalis medialis; 6 trigonum 9 tractus pyramidalis
lemnisci; 7 lemniscus medialis et lateralis; 8 substantia nigra; 9 decus-

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15.2  Intradural Topography 417

a
3

3
2
4
b 1

8 2

Fig. 15.111  Continuation of Fig. 15.110. (a) 1 Rr. ad pontem of A. Rr. ad pontem of A. basilaris and branches of AICA, 2 as 1, 3 fasciculus
basilaris and branches of AICA, 2 as 1, 3 nucleus dentatus, 4 fasciculus longitudinalis medialis, 4 nucleus n. abducentis, 5 nucleus principalis n.
longitudinalis medialis, 5 tractus spinalis n. trigemini, 6 nucleus tractus trigemini, 6 nucleus n. facialis, 7 lemniscus medialis, 8 tractus
spinalis n. trigemini, 7 lemniscus medialis, 8 tractus pyramidalis. (b) 1 pyramidalis

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418 15  Anatomical Base for Surgery

2
3

1
b

Fig. 15.112  Continuation of Fig. 15.111. (a) 1 branches of Aa. vertebrales at the pontomedullary junction, 2 branches of PICA and AICA, 3
oliva, 4 tractus pyramidalis. (b) 1 branches of A. spinalis anterior et A. vertebralis

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15.2  Intradural Topography 419

Vein of the pontomedullary sulcus 11

10

Sin. petros. sup.

l. lat.
sen cepha
V. me

7
Sin. petros.
6 sup.
5

C1

Fig. 15.113  Subarachnoid and pial veins (Duvernoy 1975, p 39, sche- dangerous, if Vv. petrosae superiores and Sinus petrosus superior are
matized). Basal lateral veins are the lateral pontine veins and V. hori- widened and V. mesencephalica lateralis is missing (see angiogram).
zontalis cerebelli of fissura horizontalis. These are connected with sinus Large dorsal cerebellar bridging veins should be spared (Fig. 16.30 ) at
petrosus superior by one or several small Vv. petrosae superiores surgery. 1 posterior medullary pial vein, 2 anterior medullary vein, 3
(Fig. 15.59 ). Usually Vv. petrosae superiores could be interrupted by lateral medullary vein, 4 postolivary vein, 5 V. cerebellaris horizontalis,
surgery without following deficits, because the other lateral basal veins 6 lateral pontine vein(s), 7 V. mesencephalica lateralis, 8 lateral pontine
are connected with V. basalis Rosenthal by V. mesencephalica lateralis vein(s), 9 pontine veins surrounding N. trigeminus, 10 medial pontine
and with other veins. Interruption of Vv. petrosae superiores could be veins, 11 V. interpeduncularis

ERRNVPHGLFRVRUJ
420 15  Anatomical Base for Surgery

at.
susL
Reces
(s) of
vein

Sin
us m
arg
inal
is

Fig. 15.114  Addendum for Fig. 15.113. Variable dorsal medullary veins. 1 dorsolateral vein(s), 2 obex, 3 dorsomedial vein(s)

ERRNVPHGLFRVRUJ
Special Surgical Aspects
16

16.1 Extra- and Intracranial Topography

16.1.1 Craniotomies for Routes and Target Areas (Fig. 16.1)

B
B’
A C

Fig. 16.1  Craniotomies and surgical target areas survey. A Suboccipital as B, contralateral route, if the usual route is hindered by large dorsolat-
craniotomy for medial approaches to cerebellum and fourth ventricle. B eral bridging veins (Yaşargil). C Laterobasal craniotomy for approaches
Laterodorsal craniotomy for supracerebellar approaches and for to cerebellum, pontocerebellar, and other cisternal approaches. D
approaches to cisterna tecti, fisssura transversa cerebri, cisterna ambiens Trans- and paracondylar craniotomy for approaches to premedullary
and the anterior segment of fissura horizontalis cerebelli, B′ target areas and prepontine cisterns

© Springer International Publishing AG 2018 421


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2_16

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422 16  Special Surgical Aspects

16.1.2 Surgical Aspects of Posterior Midline Approaches (Figs. 16.2, 16.3, 16.4, 16.5, 16.6, 16.7, 16.8,
16.9, and 16.10)

Fig. 16.2  Suboccipital craniotomy for medial approaches to cerebellum and fourth ventricle splitting skin and fascia nuchae drawn in - * -

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16.1  Extra- and Intracranial Topography 423

4 3

2
7

8 1

10
11
12

13
14

Fig. 16.3  Craniospinal dorsal anatomical aspects of surgery vessels 10; 10 V.condylaris, cave air embolism at surgery; 11 condylus occipi-
added. 1 Emissarium condylare; 2 fossa paracondyloidea; 3 sinus mar- talis; 12 processus articularis superior (atlantis); 13 common muscular
ginalis; 4 sinus occipitalis; 5 sinus sigmoideus; 6 fossa biventerica; 7 branch, connected to A. vertebralis; 14 A. vertebralis
sulcus a.occipitalis; 8 A. occipitalis; 9 sinus sigmoideus connected to

ERRNVPHGLFRVRUJ
424 16  Special Surgical Aspects

2
a
3

1
1
2
3
b
4

10
11

12

Fig. 16.4  Extradural surgical topography. a Sketch during surgery. b sulcus a. occipitalis; 6 M. sternocleidomastoideus; 7 processus mastoi-
Anatomical dissection. a 1 Vein of M. multifidus, e.g., danger for air deus, projection; 8 condylus occipitalis, projection; 9 processus articu-
embolism after spreading of retractor. 2 Sinus marginalis, 3 branch of laris superior, projection; 10 A. vertebralis; 11 bony crest of sulcus A.
A. vertebralis, 4 A. vertebralis masked by intransparent fibrous tissue. b vertebralis of Atlas; 12 M. multifidus
1 Dura; 2 V. condylaris; 3 fossa paracondyloidea; 4 A. occipitalis; 5

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16.1  Extra- and Intracranial Topography 425

Fig. 16.5  Further aspects. a Bony defect of arcus atlantis posterior. geons). c Loosening of A. vertebralis and periosteum from sulcus A.
Usual finding at childhood, rare at adults. Cave at surgical splitting of vertebralis of Atlas
Lig. nuchae. b Bleeding close to A. vertebralis (for training neurosur-

ERRNVPHGLFRVRUJ
426 16  Special Surgical Aspects

Fig. 16.6  Air embolism and danger for venous bleeding. a Extracranial veins, sinus condylaris opened (black arrow). Ruptured vein after retrac-
tion of M. multifidus (light arrow). b Dural sinuses. Large variants of sinuses endangered at surgical dura opening (arrows)

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16.1  Extra- and Intracranial Topography 427

Fig. 16.7  Variants of falx cerebelli and sinus occipitalis. For example, falx cerebelli is inconstant presented

ERRNVPHGLFRVRUJ
428 16  Special Surgical Aspects

a
5

b
1

Fig. 16.8  Atypical sinus at the cerebellar convexity. Typical bleeding wall at suturing. b Favorable 1 suturing of both walls of the atypical
at dura incision. Technical aspects. a Unfavorable 1 dura, 2 outer wall sinus. Cave cerebellar vessels
of the sinus, 3 inner wall, 4 lumen, 5 typical rupture of the thin dural

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16.1  Extra- and Intracranial Topography 429

Fig. 16.9  Anatomical base of the tonsillonodular approach to the fourth ventricle. Preservation of tractus flocculonodularis (for avoiding defictis
of the optokinetic nystagm, in contrast to splitting of vermis). 1 Uvula vermis, 2 tonsilla

ERRNVPHGLFRVRUJ
430 16  Special Surgical Aspects

no
du
l o–
to
nsil
a
r–
co
nne
cti
7

on 6

8
5

10

11 4

12 1

Fig. 16.10  Tonsillonodular surgical approach to the fourth ventricle. tion; 5 striae medullares of 6; 6 fossa rhomboidea; 7 nucleus dentatus,
Surgical topography. 1 Pedunculus cerebellaris inferior; 2 apertura projection; 8 residual of velum medullare posterius at nidus avis; 9 nod-
mediana (magendi); 3 velum medullare posterior and its plexus com- ulus vermis; 10 tonsilla; 11 uvula vermis; 12 obex
partment; 4 plexus choroideus, incised and retracted to a caudal direc-

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16.1  Extra- and Intracranial Topography 431

16.1.3 Surgical Approaches to Cisterna Medullaris Lat. and Cisterna Pontocerebellaris

Architecture of cisterns according to pontomedullary sur-


gery according to Yaşargil (Figs. 16.11, 16.12, 16.13, 16.14
and 16.15).

4
9

10

11

12
13
14

15

1 2

Fig. 16.11  Two cisterns for different surgical routes. Opening of cis- geminus; 9 roof of porus acusticus internus, projection; 10 lateral
terna medullaris lateralis for CSF decompression. Opening of cisterna pontine vein(s); 11 N. facialis et N. statoacusticus; 12 arachnoid wall of
pontocerebellaris, e.g., for removal of a tumor. 1 Route to cisterna cisterna pontocerebellaris; 13 plexus choroideus; 14 arachnoid wall of
medullaris lateralis; 2 route to cisterna pontocerebellaris; 3 asterion, cisterna medullaris lateralis; 15 Nn. glossopharyngeus, vagus et
projection; 4 sinus petrosus superior, projection; 5 V. cerebellaris hori- acceessorius
zontalis; 6 V. petrosa superio; 7 V. mesencephalica lateralis; 8 N. tri-

ERRNVPHGLFRVRUJ
432 16  Special Surgical Aspects

3
2
VII
VIII V

IX
1

5
VI
XI
XII

Fig. 16.12  Architecture of cisterna medullary lateralis and pontocere- lis containing N. trigeminus, cisterna medullaris lateralis containing
bellaris. Cisterna pontocerebellaris containing Nn. facialis et statoacus- Nn. glossopharyngeus, vagus et accessorius. 1 Cisterna pontis medialis,
ticsus and the pontine exit region of N. trigeminus, cisterna pontis 2 cisterna pontis lateralis, 3 cisterna pontocerebellaris, 4 plexus choroi-
medialis containing N. abducens, cisterna medullaris medialis contain- deus, 5 cisterna medullaris lateralis, 6 cisterna medullaris medialis V to
ing the pontomedullary exit point of N. abducens, cisterna pontis latera- XII cranial nerves

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16.1  Extra- and Intracranial Topography 433

14

13

12

11

10

15 8

16
6

17 5

18 3

19

Fig. 16.13  Contralateral to Fig. 6.12. Details added. 1 N. glossopha- cisterna pontocerebellaris, 11 trigeminal loop of AICA, 12 N. trigemi-
ryngeus, vagus et accessorius, 2 cisterna medullaris lateralis, 3 wall of nus penetrating arachnoid walls, 13 cisterna pontis lateralis, 14 cisterna
cisterna medullaris lateralis, 4 wall of cisterna pontocerebellaris, 5 pontis medialis, 15 N. abducens, 16 and 17 branches of AICA penetrat-
medial caudal branch of AICA, 6 N. statoacusticus, 7 N. facialis, 8 A. ing arachnoid walls, adherent to plexus choroideus (inconstant), 18 A.
labyrinthi, variable, 9 lateral cranial branch of AICA, meatal loop, 10 spinalis anterior, 19 plexus choroideus

ERRNVPHGLFRVRUJ
434 16  Special Surgical Aspects

4
a

VI

VII 3

VIII

1
4

(5)

IX

5 XI

s
lari
re bel
t oce VI
I
t.pon or
Cis ch
b VI us
II ex
Pl

.
e.g
get,
4 lad
lp
w oo
tton
co

IX

X t.
l.la
5 XI e dul
Cist.m

Fig. 16.14  Duplicated arachnoid walls. Loosening and shifting before IX–XI. 1 Plexus choroideus, 2 wall of cisterna medullaris medialis, 3
and during a pontocerebellar tumor will be removed. a Loosening of the wall of cisterna pontis medialis, 4 wall of cisterna pontocerebellaris, 5
wall of cisterna medullaris lateral from the wall of cisterna pontocere- wall of cisterna medullaris lateralis, loosened and shifted from the wall
bellatris. Shifting of the wall of cisterna medullaris lateralis and Nn. of cisterna pontocerebellaris (arrows) (5) as 5 before shifting, projec-
IX–XI to a basal medial direction (arrows). b Interposition of, e.g., a tion VI–XI cranial nerves
cotton wool pladget between arachnoid walls for preservation of Nn.

ERRNVPHGLFRVRUJ
16.1  Extra- and Intracranial Topography 435

a 5
4
ern
cist
f the
ll o
wa
C 3

6
5
7
4
b
3

12
9 10 11

Fig. 16.15  Meatus acusticus int. (Yaşargil et al. 1974; Salamon and vestibulare inferior, 2 ganglion vestibulare superior, 3 A. labyrinthi, 4
Huang 1976, Scialfa et al. 1976) cisternal and extracisternal part. a margin of Porus acusticus internus, 5 N. intermedius, 6 petrosal
Contents, survey. b Details added. a 1 AICA, 2 N. vestibularis inferior, branches for labyrinth, 7 AICA, 8 as 7, 9 N. facialis, 10 N. cochlearis,
3 N. vestibularis superior, 4 N. facialis (and N. intermedius), 5 adhe- 11 N. vestibularis inferior, 12 N. vestibularis superior
sions, cave N. VII at surgery, 6 N. cochlearis c variable. b 1 Ganglion

ERRNVPHGLFRVRUJ
436 16  Special Surgical Aspects

Microsurgical approach (Figs. 16.16, 16.17, 16.18, 16.19,


16.20, 16.21, 16.22, 16.23, and 16.24).1

4
all
sm
oo
tt
no

Fig. 16.16  Positioning at the operation table and skin incision. 1 Fold of the skin, 2 linea nuchae inferior, bony crest for insertion of muscles,
projection, 3 inion, 4 processus mastoideus (palpable)

According to Yaşargil.
1 

ERRNVPHGLFRVRUJ
16.1  Extra- and Intracranial Topography 437

2
a

7
b 6

4
8

1 3

B’

Fig. 16.17  Extracranial route. Preservation of superficial nerves and 1 N. occipitalis minor, 2 fascia nuchae. b 1 Processus mastoideus; 2 M.
avoiding foramen occipitale. a Preservation of N. occipitalis minor. b biventer and A. occipitalis; 3 bony crest (linea nuchae inferior), see B′t;
Dissection of muscles. Arrow: see B′ B′ mediobasal region of craniot- 4 M. splenius capitis; 5 skin; 6 sinus transversus, projection; 7 sutura
omy. Arrow: mediobasal limit region of craniotomy (According to lambdoidea; 8 asterion; 9 For. mastoideum, B′ stop bony resection
Samii) -3- at insertion of M. obliquus capitis superior, see Fig. 2.1. a (arrow)

ERRNVPHGLFRVRUJ
438 16  Special Surgical Aspects

5
4

3
2
1

b
2

Fig. 16.18  Addendum for Fig. 16.17. a Survey. b M. sternocleidomas- (projection, dotted), 3 M. trapezius, 4 M. splenius capitis, 5 linea
toideus incised. Incision of M. splenius capitis. a 1 M. sternocleidomas- nuchae inferior, projection. b 1 M. semispinalis capitis, 2 M. splenius
toideus, 2 M. splenius capitis, insertion at linea nuchae inferior capitis, 3 M. sternocleidomastoideus

ERRNVPHGLFRVRUJ
16.1  Extra- and Intracranial Topography 439

n
rio
te
As

Fig. 16.19  After loosening of muscles, vessels, and nerves: defining of presentation of M. biventer and A. occipitalis), 3 muscles of the neck, 4
craniotomy. Lateral widening of the bone resection using a drill for first burr hole at asterion for identification of sinus transversus (applied
preservation of emissarial veins and presentation of the medial margin by Prof. Samii, Hannover), 5 widening of craniotomy for presentation
of sinus sigmoideus. 1 M. sterocleidomastoideus, insertion at processus of sinus sigmoideus and Vv. emissariae mastoideae
mastoideus, 2 retraction of skin and M. sternocleidomastoideus (for

ERRNVPHGLFRVRUJ
440 16  Special Surgical Aspects

1 2 3

Fig. 16.20 Craniotomy. 1 Processus mastoideus, 2 fossa biventerica, 3 sulcus a. occipitalis variable, 4 fossa paracondyloidea, 5 emissarium
mastoideum, 6 linea nuchae inferior, 7 linea nuchae superior

ERRNVPHGLFRVRUJ
16.1  Extra- and Intracranial Topography 441

wa ist.
C
ll o me
f du
lla
ris
la
t.
To
ns
illa

1m
Nn

m
.I
F

X
CS

to
XI

Fig. 16.21  After dura opening: transcisternal route. Step a incision of the arachnoid wall of cisterna medullaris lateralis for CSF decompression

ERRNVPHGLFRVRUJ
442 16  Special Surgical Aspects

b
1

Fig. 16.22  Steps b–d. Incisions of the arachnoid wall of cisterna pon- pontocerebellaris.(cistern of Nn. V to VIII), c interposition of cotton
tocerebellaris and of the tumor arachnoidea. a Viewing direction wool pladget, e.g., d incision of the wall of cisterna pontocerebellaris. 1
(arrow). b Steps a see Fig. 16.21, b loosening of the wall of cisterna Arachnoid wall of cisterna pontocerebellaris, 2 Nn. IX–XI enclosed by
medullaris lateralis (cistern of Nn. IX–XI) from the wall of cisterna 3, 3 transparent arachnoid wall of cisterna medullaris lateralis

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16.1  Extra- and Intracranial Topography 443

a
5
6 4
7

8 1

9 15
10 11 12
14
13

b 12

13

11

10

2
3
9
8
7
4
5
6

Fig. 16.23  Steps e–g removal of the tumor. a Principles e tumor arach- 10 flattened gliotic and fibrotic residuals of flocculus; 11 N. cochlearis;
noidea incised, tumor hollowed, f arachnoid wall -2- and N. facialis 12 cotton wool pladget, e.g.; 13 wall of cisterna medullaris lateralis; 14
loosened, repeated during further tumor hollowing, g loosening V. wall of cisterna pontocerebellaris; 15 Nn. IX–XI arrows: cisterna
petrosa superior and N. trigeminus,plexus choroideus, flocculus (resid- medullaris lateralis. b Surgical topography, step e, 1 wall of cisterna
ual), AICA, Vv. pontis, and (if indicated) N. cochlearis. Transmeatal pontocerebellaris; 2 rim between 1 and 3 after loosening and shifting of
cisternal and extracisternal removal of the tumor. 1 Tumor incised and cisternal walls; 3 wall of cisterna medullaris lateralis transparent;
hollowed; 2 arachnoidea of the tumor; 3 roots of N. VII (not to identify 4 N. IX; 5 Nn. X and XI; 6 cotton wool pladget e.g.; 7 flap of the wall
before hollowing of the tumor); 4 adhesions at AICA; 5 AICA or of cisterna pontocerebellaris; 8 root of N. VII; 9 tumor arachnoidea; 10
branches of it; 6 cisterna pontocerebellaris after loosening of its wall tumor; 11 wall of cisterna pontocerebellaris; 12 tumor arachnoidea and
from tumor arachnoidea; 7 roots of N. VII; 8 widened and vulnerable roots of N. VII; 13 cerebellum
lateral pontine subpial vein(s); 9 fibrotic residuals of plexus choroideus;

ERRNVPHGLFRVRUJ
444 16  Special Surgical Aspects

12 11 10

13

2
3

4 5

Fig. 16.24  Surgical topography after removal of the tumor. Sketch flap; 6 resected bony wall of meatus acusticus internus; 7 pneumatic
during surgery. After a short time, these structures will be contracted cells open before occluded by surgery; 8 fundus of meatus acusticus
and could be normal configurated. 1 N. cochlearis; 2 residuals of plexus internus; 9 branches of AICA feeding brainstem; 10 V. petrosa superior;
choroideus and flocculus; 3 N. facialis; 4 Nn. IX and X; 5 arachnoid 11 AICA, trigeminal loop; 12 N. trigeminus; 13 lateral pontine vein

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16.1  Extra- and Intracranial Topography 445

16.1.4 Surgical Aspects for Approaches to Cisterna Medullaris Medialis and Lateralis (Figs. 16.25,


16.26, 16.27, and 16.28)

a 5

2
6 1

b
4

op Lig denticlatum
c era N. VII/VIII
tive Dura v3 No. IX-XI
ap
pro Nn.IX-XI
ac
h m
lu
cu e
b er lar Bulbus venae
N.XII u
Tu jug jugularis su
p

Condylus
occipitalis
cave!
veins of Fossa condylaris Focus
*Plexus venos a. vertebralis v1
(e.g. aneurysm) N. XII Can hypoglossi
v2

Fig. 16.25  Transcondylar approach to cisterna medullaris medialis et Example of surgery of an aneurysm of the vertebrobasilar junction (first
cisterna pontis medialis. Anatomical base. a Craniotomy, the lateral description of a transcondylar surgical approach (Seeger 1978)). a 1
segment of conylus occipitalis and processus articularis atlantis must be Canalis n.hypoglossi; 2 fossa biventerica; 3 tuberculum jugulare; 4
preserved (Prof. Putz, Anatomisches Institut der Universität Freiburg, margin of For. occipitale, resected; 5 sinus sigmoideus; 6 processus
personal communication with the author 1977). b Mobilization of mastoideus; 7 condylus occipitalis, resected. b 1 N. hypoglossus; 2
medulla oblongata and the adjacent segments of medulla spinalis are Radix spin. n. accessorii; 3 lig. denticulatum; 4 as 3, cut; 5 tuberculum
possible after transection of ligamentum denticulatum. Arrows: jugulare resected; 6 bulbus superior v. jugularis internae; 7 canalis n.
Paracondylar routes to a premedullary and a prepontine target area. c hypoglossi, resected; 8 condylus occipitalis, resected; 9 A.vertebralis

ERRNVPHGLFRVRUJ
446 16  Special Surgical Aspects

10
9 8
7

b 6

11

Fig. 16.26 Addendum. Extradural origin of PICA from A. vertebralis along sulcus A. vertebralis of Atlas; 4 PICA, extradural origin; 5 usual
(Lang 1985, modified). This rare variant should be considered at imag- stenosis of A. vertebralis marking the dural penetration of A. vertebra-
ings before performing basal medial surgical approaches. a Normal lis. b 1 Loop of A. vertebralis; 2 segment of A. vertebralis along Sulcus
angiogram. The usual stenosis of A. vertebralis at its transdural penetra- A. vertebralis of arcus atlantis posterior; 3 usual branch of A. vertebra-
tion (5) allows a discrimination of the usual intradural origin of PICA lis feeding muscles; 4 processus articularis superior; 5 condylus occipi-
(right) from its extradural variant (4). b Extradural origin of PICA from talis; 6 PICA, extradural origin; 7 usual stenosis of A. vertebralis; 8
A. vertebralis (6). a 1 A. vertebralis; 2 loop of A.vertebralis at its pen- PICA, intradural segment; 9 tonsilla; 10 medulla oblongta et spinalis;
etrating foramen transversarium of Atlas; 3 segment of A. vertebralis 11 A. vertebralis

ERRNVPHGLFRVRUJ
16.1  Extra- and Intracranial Topography 447

6
7

1
8

10

Fig. 16.27  Removal of a craniospinal meningioma (experience of the Presentation during surgery. 1 A. vertebralis; 2 tumor residual; 3 roots
author) using a transcondylar surgical route. Presentation before loos- of N. XII; 4 Lig. denticulatum, cut; 5 Nn. X and XI; 6 PICA; 7 oliva; 8
ening of the tumor residual from A. vertebralis and N. hypoglossus. pyramis medullae; 9 as 4; 10 dural penetration of A. vertebralis
Surgical topography. a Topogram. Arrow: viewing direction b. b

ERRNVPHGLFRVRUJ
448 16  Special Surgical Aspects

8
7

6
5
4

10
11
3

14
12 13

Fig. 16.28  Paramedullary surgical approach from a dorsolateral direc- 3 N. XII, 4 tuberculum jugulare, 5 pedunculus cerebellaris inferior, 6
tion. Removal a cystic lindau angioma of tonsilla (Seeger 1986). plexus choroideus, 7 inferior segment of pons, 8 flocculus, 9 residual of
Surgical topography. a Topogram. Arrow: viewing direction b. b tonsilla, 10 vermis, 11 PICA, 12 radix spinalis n.XI, 13 radix anterior
Microsurgical topography. 1 A. vertebralis, 2 Lig. denticulatum, C1, 14 as 9

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16.1  Extra- and Intracranial Topography 449

16.1.5 Supracerebellar Surgical Approaches to Cisterna Tecti2 and Adjacent CSF Spaces (Figs. 16.29,
16.30, 16.31, and 16.32)

Fig. 16.29  Craniotomy. Different types of craniotomy for the same surgical route depends on calibre and location of dorsolateral bridging
surgical target areas according to Yaşargil. These target areas are cis- veins. Thick calibrated veins could hinder the supracerebellar part of
terna tecti and adjacent CSF spaces. The choice of a supracerebellar the surgical route and should be preserved at surgery

According to F Krause 1926, modified for microneurosurgery by Yaşargil.


2 

ERRNVPHGLFRVRUJ
450 16  Special Surgical Aspects

2
a 3

1
4
3
b 2

Fig. 16.30  After dura opening: step a. Supracerebellar subdural route. bridging veins, 2 V. cerebellaris praecentralis, 3 V. supraculminalis, 4
Interruption of thick calibrated bridging veins should be avoided. The small bridging veins. b 1 Fissura horizontalis cerebelli, anterior seg-
thin calibrated medial bridging veins (4) could be interrupted for a bet- ment; 2 velum medullare anterius, fusioned with lingula cerebelli, com-
ter reclination of culmen cerebelli, if necessary. Superior a and anterior mon finding; 3 lobulus centralis cerebelli; 4 V. cerebellaris praecentralis
b viewing direction. Arrows: surgical route. a 1 Cerebellotentorial originates ventral or dorsal from lobulus centralis cerebelli

ERRNVPHGLFRVRUJ
16.1  Extra- and Intracranial Topography 451

b 14
13
12
b

a 11
b

10

9
c

d
15
e

16

8
17

18 7

19
6

5
4
1 2 3

Fig. 16.31  Step b. Supracerebellar subarachnoid route. a Surgical inferioris; 9 V. basalis (Rosenthal); 10 pulvinar thalami; 11 colliculus
principles, a subdural (supracerebellar) route, b subarachnoid (transcis- superior; 12 corpus pineale; 13 habenula, landmark for neuronavigation
ternal) route. b Surgical target area, a fissura transversa dorsal from and during surgery; 14 division of chorioid arteries at the horiziontal
velum interpositum and third ventricle, b medial from ventriculus late- level of habenula; 15 Baumgartner’s loop, 16 as 9; 17 Aa. chorioideae
ralis, c pulvinar thalami, (landmark during surgery: Baumgartner’s posteriores laterales; 18 A. tecti, running along the pontomesencephalic
loop), d cisterna ambiens. 1 Lingula cerebelli; 2 pedunculus cerebel- rim, together with a small chorioid branch; 19 Vv. tecti, draining veins
laris superior; 3 velum medullare anterius; 4 frenulum tecti; 5 N. troch- of V.magna (Galeni)
learis; 6 colliculus inferior; 7 trigonum lemnisci; 8 brachium colliculi

ERRNVPHGLFRVRUJ
452 16  Special Surgical Aspects

a 8

4
3

2
9
1

10

9
8

10
3

11
2

12 1

13
14 15

Fig. 16.32  Step c. Presentation of surgical target areas, examples. a b 1 Colliculus superior; 2 A. tecti; 3 habenula; 4 division of chorioid
Microsurgical topography of the third ventricle. b Microsurgical topog- arteries; 5 V. basalis (Rosenthal); 6 Baumgartner’s loop; 7 velum inter-
raphy of fissura transversa cerebri. a 1 N. trochlearis; 2 colliculus supe- positum; 8 fornix, elevated for opening of fissura transversa; 9 commis-
rior et inferior; 3 corpus pineale; 4 habenula; 5 division of chorioid sura fornicis; 10 V. magna (Galeni); 11 V. cerebellaris praecentralis;
arteries; 6 Baumgartner’s loop; 7 V. basalis (Rosenthal); 8 velum inter- 12 V. supraculminalis; 13 Vv. tecti; 14 adhesions,cut; 15 as 14; preser-
positum, elevated after rupture of the thin wall of recessus suprapinea- vation of corpus pineale
lis; 9 V. magna (Galeni); 10 commissura anterior and columna fornicis.

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ERRNVPHGLFRVRUJ
Index

A A. labyrinthi, variants, 351


A. angularis, 66, 141, 143, 144, 163, 166, 201, 227, 229, 239, 251 Ala lobuli centralis, 292, 319, 320, 336
Aa. parietales anteriores and posteriores, 201 Ala major, 22, 23, 34, 152
Aa. tecti, see A. tecti Ala minor, 4, 26, 155, 161, 162, 194
Aa. thalamoperforantes, 361, 416 Allocortex, 2, 46, 47, 150, 169–176
Aa. vertebrales, 295, 296, 343, 347, 418 Alveus, 171, 172
A. basilaris, 30, 48, 61–63, 102, 141, 148, 156, 196, 296, 345–347, Amygdala (corpus amygdaloideum), 7, 8, 48, 49, 145, 146, 148, 173,
361, 416, 417 176, 187
variants, 346, 347 Amygdalohippocampectomy, 165, 166, 176, 177, 179–193
A. calcarina, 201, 251, 254, 255, 273, 276–278, 285 craniotomies, 177
A. callosomarginalis, 5, 14, 17, 36, 43, 50, 66 preservation of perforating vessels, 185, 188
A. carotis externa, 21, 23, 259 routes, 182
A. carotis interna, 5, 23, 29, 48, 54, 55, 57–59, 63, 65, 66, 68, 119, surgical topography, 191
141, 144, 145, 156, 158, 163, 166, 167, 173, 194, 259, 322, A. nasociliaris, 24
354, 358 Angularis area/region, 206, 207, 227, 228, 249, 251
retropositioned, 158 Angulus venosus, 6, 33, 52, 101, 104
A. cerebelli inferior anterior (AICA), 295, 296, 322, 340, 342–344, Antrum mastoideum, 178
349–351, 417, 418, 433, 435, 443, 444 Antrum tympanicum, 178
variants, 350 A. occipitalis, 21, 211, 259, 283, 310, 423, 424, 437, 439, 440
A. cerebelli inferior posterior (PICA), 291, 295, 296, 305, 328–332, A. operculofrontalis, 5, 36, 63, 66, 144, 165, 166, 203, 229, 230, 239
334, 336, 343–345, 348, 418, 447, 448 A. paracentralis, 43, 201
extradural origin (variant), 348, 349, 446 A. parietooccipitalis, 201, 251, 254, 255, 273, 276–278
A. cerebelli superior, 30, 48, 58, 59, 61, 63, 107, 194, 196, 295, 296, A. pericallosa, 5, 14, 17, 36, 43, 50, 66, 95, 234, 255
322, 328, 346, 360, 361, 387, 416 Apertura externa canalis carotici, 354
variants, 362 Apertura lateralis (Key-Retzius, Luschkae), 326
A. cerebri anterior, 5, 30, 66, 71, 193 Apertura mediana (Magendi), 324, 332, 334, 430
variants, 71 Apex ossis petrosi, 153
A. cerebri media, 5, 20, 62, 63, 65–67, 141–144, 162, 163, 165, 166, A. praecunealis, 43, 201, 255
168, 183, 203, 227, 229–231, 239, 240 Aquaeductus, 32, 33, 150, 235, 274
sylvian branches, 229 Archicortex, 169
trifurcation, 203 Arcus atlantis posterior, 309, 425, 446
A. cerebri posterior, 9, 30, 48, 58, 59, 63, 102, 107, 141, 156, 162, Area dentata, 145, 172–174, 256, 257, 273, 276
163, 167, 168, 173, 191, 193, 196, 251, 253, 255, 273, MRT, 256
276–278, 295, 296, 360–362, 416 Area vestibularis superior, 352
A. chorioidea anterior, 58, 59, 65, 66, 68, 119, 141, 144, 166–168, A. recurrens (Heubneri), 30, 48, 60, 67, 70, 71
193, 277 A. retroauricularis, 259
A. chorioidea posterior A. spinalis anterior, 295, 296, 343–345, 418, 433
lateralis, branches, 173, 278, 286, 295, 360 Asterion, 142, 152, 159, 163, 178, 199, 223, 227, 228, 237,
medialis, 277, 295, 360 249–252, 260, 268, 271, 284, 293, 294, 311, 342, 431,
A. communicans anterior, 5, 12, 30, 43, 45, 46, 71 437, 439
A. communicans posterior, 58, 59, 65, 66, 68, 119, 141, 144, 167, 168, A. sulci centralis, 36, 66, 144, 201, 203, 229, 230, 239
173, 277 A. tecti, 277, 295, 360, 361, 416, 451, 452
A. corporis callosi mediana, 2, 30, 43, 66, 73, 74, 119, 234 A. temporalis posterior, 141–144, 162, 163, 165, 166, 168, 227, 251
Adhesio interthalamica, 12, 32, 33 A. temporalis superficialis, 20, 21, 76, 211, 259
Adhesion of hippocampus with the ventricular roof, 166 A. temporooccipitalis, 66, 141, 143, 144, 163, 166, 201, 227, 229,
A. ethmoidalis posterior, 24 239, 251
A. frontobasalis medialis, 45 A. tentorii (Bernasconi), 144, 261
A. frontopolaris, 14, 17, 45, 66, 71 A. thalamogeniculata, 193, 277, 278
A. frontopolaris medialis, 72 A. vermis, 295, 328, 331–333
A. hippocampi, 166–168, 173, 174, 193 A. vertebralis, variants, 346
A. hypophysealis superior and inferior, 66, 119, 144 AVM of corpus callosum, 245

© Springer International Publishing AG 2018 457


W. Seeger, J. Zentner, Anatomical Basis of Cranial Neurosurgery, https://doi.org/10.1007/978-3-319-63597-2

ERRNVPHGLFRVRUJ
458 Index

B Cisterna tecti, 274, 278, 292, 320, 359–365, 421, 449–452


Basal bridging veins, 153, 156, 253 Cisterns pontomedullary, 342, 344, 345
Basal cisterns, see Cisternae basales contents, 345
Basion, 153, 200, 293, 294, 311 variants, 345
Baumgartner’s loop, 275, 278, 286, 360, 451, 452 Claustrum, 11, 12, 17, 40, 49
Brachium colliculi inferioris, 360, 382–384, 386, 414, 415, 451 Cochlear nuclei, 324
Brachium colliculi superioris, 360, 383, 415 Colliculus inferior, 275, 286, 336, 340, 360, 386, 416, 451
Bregma, 3, 10, 16, 22, 26–28, 34–37, 42, 85, 87, 90, 117, 139, 152, Colliculus superior, 275, 286, 384, 451, 452
199, 200, 204, 205, 212, 213, 220–223, 229, 233, 265 Columna(ae) fornicis, 11, 12, 33, 46, 48, 51–53, 94, 103, 104, 107,
Bridging veins 170, 236, 376, 452
dorsocerebellar, 419 Commissura anterior, 7, 12, 16, 27, 32, 33, 41–43, 48, 49, 52, 53, 94,
temporobasal, 155, 194–196, 253 104, 107, 159, 205, 272, 452
temporopolar, 142, 143, 155, 164, 166 Commissura posterior, 16, 32, 33, 42, 150, 205, 235, 272, 274
Bulbus superior venae jugularis internae, 6, 312, 315, 316, 353, Condylus occipitalis, 310, 313, 354, 358, 423, 424, 445, 446
357, 445 Confluens sinuum, 6, 217, 250, 252, 254, 255, 260–263, 265–267,
284, 315, 316
variants, 263
C Cornu anterius, 2, 9, 16, 88, 401, 402
C1 (radix spinalis), 448 Cornu inferius, 8, 141, 145, 146, 148, 162, 165–167, 171, 172, 183,
Calcar avis, 148, 209, 256, 258, 281, 285 184, 188, 191, 230, 256
Callosotomy, 2, 92–94 Cornu posterius of ventriculus lateralis, 376
Canalis caroticus, 54, 55, 57, 153, 355 Cornu spinalis posterius, 376
Canalis centralis spinalis, 396, 397, 401–403 Corona radiata, 38–40, 87, 229, 280
Canalis ethmoidalis posterior, 24 Corpora mamillaria (corpus mamillare), 12, 102, 105, 234, 292, 383
Canalis glossopharyngeus, variants, 356 Corpus amygdaloideum, 176
Canalis n. hypoglossi, 311, 353, 356–358, 445 Corpus callosum, 1, 39, 40, 46–49, 91, 95, 169, 240, 245, 276, 286
variants, 356 Corpus fornicis, 48, 104, 170, 360
Canalis rotundus, 57, 153 Corpus geniculatum laterale, 193, 270, 277–280
rhinoliquorrhoea, 134, 135 Corpus geniculatum mediale, 277, 278, 280, 360, 415
Capsula externa, 17, 39, 40, 49 Corpus mamillare, 12, 383
Capsula interna, 7, 9, 11, 12, 17, 39, 40, 48, 49, 51, 280 Corpus pineale, 33, 150, 256, 257, 275, 278, 286, 451, 452
Caput nuclei caudati, 11, 38, 49, 50, 89, 236 Corpus sphenoidale, 128
Carotid bifurcation, 12, 17, 30, 48, 61, 66, 67, 119 Corpus trapezoideum, 391, 392, 407
Carotid cistern, 2, 31, 41, 145 Cranial nerves V to XII, 342, 432
Carotid siphon, 48, 54, 59, 130, 144, 145 Craniospinal topography, 423
Cavum septi pellucidi, 11, 17, 38, 51, 52, 241 variants of sinuses, 426
Cavum tympanicum, 135, 178 Crista galli, 4, 23, 28, 109, 153
Cellulae ethmoidales and atypical rhinoliquorrhea, 133, 135 Crista occipitalis externa, 310, 315, 323
Cerebellar cortex, survey, 398 Crista transversa, 352
Cerebellar vessels dorsal, survey, 328 Crista verticalis superior (Rhoton), 352
Cerebellopontine surgical approach, anatomy and technical Crista vestibularis inferior, 352
aspects, 311 Crista vestibularis superior, 352
Cerebellotentorial bridging veins, 450 Crus cerebri, 30, 33, 51, 108, 146, 196, 277, 278, 280, 360
Cerebellum, 157, 291, 292, 299, 317, 318, 320, 421, 422, 443 Crus fornicis, 50, 170, 190, 226, 234, 235, 256, 257, 273, 288
Chiasma, 30, 33, 41, 48, 63, 113, 149, 280 Culmen vermis, 320
Chorioid point (loop) of PICA, 295, 296 Cuneus, 172, 209, 221, 249, 251, 254, 255, 268, 272, 273
Chorioid point temporal, 141, 143, 162, 166–168, 173, 193
Cisterna ambiens, 62, 63, 160, 167, 278, 341, 363, 421, 451
arteries, 277 D
Cisterna carotica, see Carotid cistern Declive, 320, 363
Cisterna cerebellomedullaris, 291, 304, 305, 324, 325, 328, 336, 337 Decussatio corporis trapezoidei, 392
Cisterna chiasmatis, 31, 62 Decussatio lemniscorum, 318, 376, 387, 389, 390, 392, 402, 405, 408
Cisterna corporis callosi, 2, 46, 49, 90, 91, 240, 243 Decussationes of tractus corticopontini, 373
Cisterna cruralis, 31, 62, 341 Decussatio of peduculi cerebellares superiores, 381, 382, 386, 398,
Cisternae basales at rhombencephalon, 340–344 411–413, 416
Cisterna interpeduncularis, 31, 61, 62 Decussatio olivarum (decussatio of tractus olivocerebellaris), 300, 398
Cisterna laminae terminalis, 31, 60, 62 Decussatio pyramidum, 318, 321, 343, 373, 376, 378, 387, 389, 394,
Cisternal arteries, variants, 345–351 401
Cisternal walls duplicated, 341 Diaphragma sellae, 29, 119, 155
Cisterna medullaris lateralis, 322, 341, 431–434, 441–443 Diploé, 20, 352
Cisterna medullaris medialis, 341, 344, 432, 434, 445–448 Dorsum sellae, 4, 63, 64, 107, 153, 155, 196, 294, 311
Cisterna olfactoria, 31, 61, 62 Ductus nasofrontalis, 125, 135
Cisterna optica, 61 Duplicated cisternal walls, 341
Cisterna pontis lateralis, 62, 341, 432, 433 Dural sinuses of
Cisterna pontis medialis, 31, 61, 62, 107, 341, 344, 432–434, 445 fossa cranii posterior, variants (and bony impressions), 312, 314, 315
Cisterna pontocerebellaris, 292, 322, 341, 344, 431–444 usual findings, survey, 317

ERRNVPHGLFRVRUJ
Index 459

E Fourth ventricle, 291, 292, 301, 304, 305, 319, 324, 325, 327, 330,
Eminentia arcuata, 142, 153, 156, 159, 160, 195, 249, 253, 268, 269, 331, 334–339, 421, 422, 429, 430
271, 272, 294, 311 Foveolae arachnoidales (Pacchioni), 23, 216
and basal veins and Margo superior ossis petrosi, 253 Frenulum tecti, 292, 336, 360, 363, 386, 451
Emissarium condylare, 310, 311, 313, 315, 323, 423 Frontal allocortex, 46
Emissarium mastoideum, 310, 440 anatomical slices, 47
Epidermis, cutis, subcutis, galea and periosteum, loosening, 20 dissections, 47
fiber tracking, 47
Frontal arteries, 119
F Frontal bridging veins, 25, 37
Falx cerebelli, 427 Frontal structures in the depth, 38, 87
Falx cerebri Frontobasal approaches according to Dandy, 121
surgical arachnoid incision, 240 Frontobasal arteries, variants, 71
tumor, 242 Frontobasal bony and intradural structures, 29, 54, 57
variants, 96 Frontobasal cisterns, 58
Fascia nuchae, 259, 422, 437 Frontobasal dural penetration points, 56
Fascia temporalis, 19, 116, 120, 151, 211 Frontomedial arteries
special surgical aspects, 116, 120 fiber dissections, 39
Fasciculus cuneatus, 376, 378, 389, 394, 401, 402 landmarks, 42
Fasciculus gracilis, 376, 378, 389, 394, 401, 402 Frontoparietal bony and cerebral landmarks, 199
Fasciculus longitudinalis medialis, 381, 382, 384, 386, 389–391, 394, arteries, 144, 165
397, 403–408, 410–413, 415–417 veins, 142, 164
Fasciculus longitudinalis superior, 39, 280 Frontotemporal (pterional) approaches, 3, 109, 115
Fastigium, 292, 294, 298, 337 craniotomies, 111, 112, 117, 122
Fiber tracking, 47 landmarks, 140
Fibrae olivocerebellares, 390 routes, 114, 121
Fimbria fornicis, 167, 168, 170–172, 190 Frontozygomatic point, 3, 22, 26, 34, 37, 76, 110, 111, 116, 117, 139, 152
Fissura collateralis, see Sulcus collateralis Fundus of Meatus acusticus internus, 352, 354, 444
Fissura horizontalis cerebelli, 292, 298, 299, 359–365, 369, Funiculus anterior, 321, 343
421, 450 Funiculus dorsolateralis, 376
Fissura mediana anterior, 340, 396 Funiculus lateralis, 321, 343
Fissura orbitalis superior, 110, 111, 153
Fissura prima cerebelli, 320, 363
Fissura transversa, 33, 48, 104, 108, 226, 234, 246, 274, 359, 360, G
451, 452 Galea aponeurotica, 1, 19, 211, 259
special surgical aspects, 241 Galenic cistern, 274
Flocculus, 292, 298, 305, 318, 319, 325, 330, 331, 335, 339, 341, 342, Galenic point, 6, 8, 249, 252, 263, 265–267, 272, 294
443, 444, 448 Galenic vein, 6, 245, 360
Foramen caecum, 23, 44, 153 adjacent structures, 328
Foramen ethmoidale posterius, 24 Ganglion semilunare (gasseri), 376
Foramen interventriculare (Monroi), 7, 11, 27, 32, 33, 42, 43, 49, 50, Ganglion spinale, 376
52, 53, 100–102, 104, 207, 257 Globus pallidus, 7, 12, 39, 40, 49
Foramen jugulare, 312, 315, 321, 323, 342, 353–357 Granulationes arachnoidales, 23, 215, 218, 234, 265
Foramen lacerum, 54, 57, 153 Gyrus angularis, 159, 205, 229, 239
Foramen mastoideum, 315 Gyrus cinguli, 10, 17, 27, 38, 43, 46, 47, 49, 50, 90, 95, 172, 209, 221,
Foramen nervi hypoglossi, 312, 321, 353–355, 358 226, 233, 234, 243, 254, 256, 273, 276, 281
Foramen (emissarium) occipitale, 323, 354, 355, 437, 445 Gyrus circumflexus, 228
Foramen opticum, 4, 28, 29, 59, 60, 110, 153 Gyrus dentatus, 137, 150, 167, 168, 171, 172, 187, 190, 191
Foramen ovale, 4, 54, 55, 153 Gyrus fasciolaris, 190
Foramen parietale, 218 Gyrus frontalis, 4, 8, 10, 34, 36, 118, 220
Foramen spinosum, 153 Gyrus occipitotemporalis lateralis, 146, 159, 172, 269
Foramen supraorbitale (incisura supraorbitalis), 77 Gyrus occipitotemporalis medialis, 146, 159, 172, 190, 249, 268,
Fornix, 2, 46, 94, 104, 170, 171, 452 269, 273
variants, 92 Gyrus parahippocampalis, 109, 137, 145, 146, 148, 157, 159, 160,
Fossa biventerica, 310, 423, 440, 445 162, 167, 168, 171–173, 190, 191, 194, 247, 256