Pictorial Essay

Trigeminal Nerve Anatomy: Illustrated Using Examples

of Abnormalities
H. A. M. Kamel 1,2 and J. Toland 3

T he trigeminal nerve has an exten-

sive anatomic course. Comprehen-
sive knowledge of trigeminal
nerve anatomy facilitates understanding of the
propagation and perineural spread of malig-
nant and inflammatory disease.

Peripheral Divisions of the Trigeminal

relationship between the brainstem, skull base,
and facial area. In our article we attempt to so-
lidify this knowledge using examples of ab-
normalities. We will describe the anatomy
from the peripheral branches toward the brain-
stem in keeping with the direction of sensory
Nerve
The trigeminal nerve trifurcates into oph-
thalmic, maxillary, and mandibular nerves
distal to the trigeminal ganglion. The oph-
thalmic nerve passes forward in the lateral
wall of the cavernous sinus. It gains access
into the orbit via the superior orbital fissure
(Fig. 1). The ophthalmic nerve then divides to
supply sensation to the eyeball, lachrymal
glands, conjunctiva, part of the nasal mucosa,
skin of the nose, eyelid, and forehead [1].
The maxillary nerve exits the skull base
through the foramen rotundum ossis sphe-
noidalis inferolateral to the cavernous sinus.
It then enters the pterygopalatine fossa
where it gives off several branches. Its main

Fig. 1.—Diagram shows trigeminal nerve

(TGN), trigeminal ganglion, and peripheral
divisions and their branches. From fora-
men rotundum ossis sphenoidalis, maxil-
lary nerve (thin underline) gains access to
pterygopalatine fossa and continues in
floor of orbit as infraorbital nerve. Inferior
alveolar and lingual nerves (thick underline)
are branches of mandibular nerve.

Received August 17, 1999; accepted after revision March 2, 2000.

1
Department of Neuroradiology, The Royal Victoria Hospital, Grosvenor Rd., Belfast BT12 6BA, United Kingdom.
2
Present address: Radiology Department, Hamad Medical Corporation, P. O. Box 3050, Doha, Qatar. Address correspondence to H. A. M. Kamel.
3
Department of Neuroradiology, Beaumont Hospital, Dublin 9, Ireland.
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AJR:176, January 2001 247

 Kamel and Toland
Fig. 2.—Sagittal diagram shows three peripheral divisions of trigeminal nerve entering convexity and root bundles
leaving concavity of sickle-shaped trigeminal ganglion. Motor root (solid arrowhead ) bypasses ganglion and re-
unites with mandibular nerve in foramen ovale basis cranii. Open arrowhead indicates descending spinal trigeminal
tract. Diagram also shows motor and sensory trigeminal nuclei (underline ) in brainstem and cervical cord. A, B, and
C track nuclear origin of fibers contributing to opthalmic; D and E, the maxillary; and F, H, and I, mandibular divisions
of trigeminal nerve.
Fig. 3.—72-year-old man with nasopharyn-
geal carcinoma. Coronal contrast-enhanced
T1-weighted spin-echo MR image with fat
suppression shows enhancement and thick-
ening of mandibular nerve extending into
trigeminal ganglion (arrow ). Note widening
of foramen ovale basis cranii and enhancing
soft-tissue mass causing destruction of right
side of sphenoid bone.
A B
248
trunk continues anteriorly in the orbital floor
(Fig. 1) and emerges onto the face as the in-
fraorbital nerve to innervate the middle third
of the face and upper teeth [1].
The mandibular nerve runs laterally along
the skull base then exits the cranium by de-
scending through the foramen ovale into the
masticator space. The motor root of the trigemi-
nal nerve bypasses the trigeminal ganglion and
reunites with the mandibular nerve in the fora-
men ovale basis cranii (Fig. 2). As the mandibu-
lar nerve enters the masticator space, it divides
into several sensory branches to supply sensa-
tion to the lower third of the face and the
tongue, floor of the mouth, and the jaw (Fig. 1).
The motor root of the mandibular nerve inner-
vates the four muscles of mastication: the mylo-
hyoid, the anterior belly of digastric, the tensor
muscle of the tympanic membranes, and ten-
sor muscle of valum palatinum [2]. Infection
and neoplasia most commonly involve the pe-
ripheral divisions of the trigeminal nerve. Direct
spread from local tumors (Figs. 3 and 4) or me-
tastases from distant malignancies are the most
common causes of malignant involvement [1].
Trigeminal Ganglion and Preganglionic
Trigeminal Nerve
The trigeminal ganglion is contained
within the Meckel’s cavity posterolateral to
the cavernous sinus on either side of the sphe-
noid bone. The Meckel’s cavity is a cere-
brospinal fluid–containing arachnoidal pouch
protruding from the posterior cranial fossa.
Medial to the ganglion in Meckel’s cavity is
the internal carotid artery in the posterior por-
tion of the cavernous sinus. Inferior is the
motor root of the trigeminal nerve (Fig. 2)
and the apex of the petrous temporal with the
internal carotid artery in its bony canal [1].
The Meckel’s cavity can be involved either
by extrinsic or intrinsic disease. Extrinsic le-
Fig. 4.—55-year-old man with squamous cell carci-
noma of skin.
A, Axial T2-weighted spin-echo MR image shows
thickening of skin and subcutaneous tissue of right
cheek and band of intermediate signal intensity ex-
tending along course of infraorbital nerve (arrow ).
High signal is noted in thickened mucosa of both max-
illary sinuses.
B, Coronal T1-weighted spin-echo MR image after IV
contrast injection shows spread of irregular enhanc-
ing mass (arrow ) along infraorbital nerve. Note nor-
mal mucosal enhancement in both maxillary sinuses.
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 Trigeminal Nerve Anatomy

Fig. 5.—15-year-old girl with known diagnosis of leu-

kemia.
A, Expansion and reduction of normal high signal in-
tensity in Meckel’s cavity (arrows ) on T2-weighted
spin-echo MR image. Note signal void from internal
carotid artery medial to Meckel's cave.
B, Coronal T1-weighted spin-echo MR image after IV
contrast injection shows bilateral Meckel’s cavity en-
hancement (arrows ), particularly of left side, as result
of leukemic deposits.

A B

sions, usually bony metastasis, chordoma, or Fig. 6.—29-year-old woman with

chondrosarcoma, destroy adjacent bone as pituitary adenoma. Spread of
large enhancing pituitary
they extend toward the Meckel’s cavity. Intrin- mass through cavernous sinus to
sic lesions simply expand the Meckel’s cavity involve trigeminal ganglion in
(Fig. 5). When the tumor is large enough, the Meckel’s cavity on T1-
weighted contrast-enhanced
pressure exerted by it leads to erosion of the coronal spin-echo MR image.
surrounding bone. Tumors may also extend Left-sided Meckel’s cavity
away from the Meckel’s cavity with enlarge- (arrow) is normal. Signal void as-
ment of the foramen ovale basis cranii, fora- sociated with flowing blood dif-
ferentiates carotid artery within
men rotundum ossis sphenoidalis, or the enhancing pituitary adenoma.
superior orbital fissure. Intrinsic lesions in-
clude primary tumors of the Meckel’s cavity as
well as secondary neoplasms from perineural
spread of local tumors, leptomeningeal, or he-

Fig. 7.—48-year-old man with pial arteriovenous mal-

formation.
A, Tangle of dilated blood vessels (arrow ) at root entry
zone of right trigeminal nerve on T2-weighted spin-
echo MR image.
B, Late arterial phase of vertebral angiogram shows
arteriovenous malformation supplied by dilated pon-
tine artery (small arrow ). Note also early shunting into
dilated draining vein (large arrow ).
A B

Fig. 8.—56-year-old woman with pet-

rous apex meningioma. Homogenous
enhancing mass involving root entry
zone and Meckel’s cavity. Mass forms
obtuse angle with dura on axial con-
trast-enhanced T1-weighted spin-echo
MR image. Arrow indicates normal
right-sided Meckel’s cavity and dural
tail on posterior surface of clivus.

Fig. 9.—57-year-old man with trigemi-

nal schwannoma. Dumbbell-shaped
high-signal-intensity mass extending
between middle and posterior cranial
fossa, along course of trigeminal nerve,
on axial T2-weighted spin-echo MR im-
age. Trigeminal schwannomas have
smooth margins and appear iso- to hy-
perintense to brain on T2-weighted MR
imaging. Larger tumors may show het-
erogeneous signal intensity.
8 9

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 Kamel and Toland

Fig. 10.—53-year-old man with histologic diagnosis of

epidermoid cyst. (Courtesy of McKinstry CS, Belfast,
United Kingdom)
A, T2-weighted spin-echo MR image shows spread of
slow-growing smooth mass of high signal intensity from
cerebellopontine cistern to prepontine cistern across
root entry zone of trigeminal nerve. Note septa and focal
areas of high signal intensity within mass. Associated
brainstem compression is causing hydrocephalus.
B,T1-weighted spin-echo MR image shows cauli-
flower-shaped contours and nonhomogeneous low to
intermediate signal intensity within mass.

A B

matogenous metastasis. Primary tumors of the
Meckel’s cavity include trigeminal schwan-
noma, meningioma, and epidermoid cyst [1].
Pituitary fossa and cavernous sinus lesions
(Fig. 6) may extend to the Meckel’s cavity or
involve the cavernous portion of the trigemi-
nal nerve divisions. As many as one third of
patients with intracavernous carotid aneu-
rysms have trigeminal nerve manifestations
[1, 2]. Metastatic disease is the second most
common lesion to present as a cavernous si-
nus mass with trigeminal neuropathy [1].
The root entry zone is the cisternal part of
the trigeminal nerve just as it enters the pons
(Fig. 2). Lesions affecting the root entry zone
include vascular compression, primary and
secondary neoplasms, and infection. Vascular
contact with the root entry zone is thought to
represent the most common cause of idio-
pathic trigeminal neuralgia. Other conditions
leading to vascular compression include an-
eurysms, arteriovenous malformations (Fig.
7), dural arteriovenous fistulas, and verte-
brobasilar ectasia. Primary tumors involving
the prepontine cistern include meningioma
(Fig. 8), trigeminal schwannoma (Fig. 9), epi-
dermoid cyst (Fig. 10), vestibular schwan-
noma, and lipoma [1]. Secondary neoplasms
affecting the root entry zone include perineu-
ral spread of tumors from head and neck
malignancy, hematogenous metastasis, and
leptomeningeal spread of tumors [3] (Fig.
11). Benign inflammatory or infectious con-
ditions such as sarcoidosis (Fig. 12), viral en-
cephalitis, herpes neuritis [4], and Lyme
disease can also affect the root entry zone [1].
Brainstem
The trigeminal nerve has three sensory and
one motor nuclei. The sensory nuclei are the
principal, mesencephalic, and spinal sensory
(Fig. 2). The spinal trigeminal tract emerges
from the sensory root in the pons and extends
downward into the upper cervical cord. Fi-
bers of this tract end in the spinal trigeminal
nucleus, which merges rostrally with the
principal sensory nucleus. Cervical exten-
sion of the spinal tract explains why some pa-
tients with upper cervical disk herniation
present with trigeminal sensory neuropathy
[5]. The motor nucleus of the trigeminal
nerve forms an oval column of cell anterome-
dial to the motor root and the principal sen-
sory nucleus in the pons (Fig. 12). The
principal sensory nucleus lies lateral to the
entering trigeminal root. The mesencephalic
trigeminal nucleus forms a slender cell col-
umn near the lateral margin of the central
gray matter anterior to the upper fourth ven-
tricle and aqueduct. Afferent fibers of the
mesencephalic nucleus convey propriocep-
tion from teeth, hard palate, and tempero-
mandibular joint. Cells of the mesencephalic
nucleus form the sickle-shaped mesencepha-
lic tract, which descends to the level of the
motor nucleus and conveys impulses that
control mastication and the force of a bite.
Eventually all tracts from the principle sensory
and spinal trigeminal nuclei project to the
posteromedial nucleus of the thalamus, from
which they track through the most posterior as-

Fig. 11.—8-year-old boy with leptomeningeal metastasis from cerebellar medullo-
blastoma. Contrast-enhanced T1-weighted spin-echo MR image shows bilateral
symmetric enhancement and thickening of root entry zone of both Meckel’s cavitys.
In addition, nodular enhancement and thickening are seen on undersurface of both
temporal lobes, superior surface of cerebellum, anterior surface of pons, and lining
of lateral ventricles. (Courtesy of McKinstry CS, Belfast, United Kingdom)
Fig. 12.—28-year-old man with diagnosis of neurosarcoidosis. Coronal T1-weighted
spin-echo MR image shows bilateral asymmetric thickening and enhancement of
trigeminal (solid straight arrow ) and occulomotor (curved arrow ) nerves and hypo-
thalamus (open straight arrow ). Lateral ventricles are dilated.

250 AJR:176, January 2001

 Trigeminal Nerve Anatomy

Fig. 13.—45-year-old man with diagnosis of
multiple sclerosis. Oblong plaque of high signal
intensity (arrow ) involving right trigeminal sen-
sory nucleus on T2-weighted spin-echo MR im-
age. Note small area of high signal intensity
adjacent to fourth ventricle and high signal in-
tensity in white matter of temporal lobes.
Fig. 14.—42-year-old woman with lateral medullary
syndrome caused by spontaneous vertebral artery
dissection. Localized high signal intensity caused by
area of infarction on right side of medulla oblongata
(arrow ) on T2-weighted spin-echo MR image. Note
absence of flow void in right vertebral artery.
Fig. 15.—33-year-old woman with herpes zoster. Axial con-
trast-enhanced T1-weighted spin-echo MR image shows
enhancement along pontine course of trigeminal nerve and
low signal intensity at site of main trigeminal sensory nu-
cleus (arrow ).

pect of the posterior limb of the internal capsule
and project to the postcentral gyrus [1].
Multiple sclerosis (Fig. 13), glioma, and in-
farction (Fig. 14) are the most common brain-
stem and upper cervical cord lesions resulting in
fifth cranial nerve symptom. Less common le-
sions include metastasis, cavernous heman-
giomas [6], hemorrhage, and arteriovenous
malformation [1]. Rarely, rhombencephalitis
may develop as a result of retrograde extension
of herpes simplex virus type 1 from the trigemi-
nal ganglion into the brainstem [4] (Fig. 15).
In conclusion, a variety of conditions may
involve the different segments of the trigemi-
nal nerve. Knowledge of its anatomic course
allows an understanding of disorders involv-
ing the brainstem and adjacent skull base.
Acknowledgment
We thank C. S. McKinstry, Belfast, United
Kingdom, for his assistance in revising this paper
and for providing Figures 10 and 11 of this article.
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