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Atlas of

Neurosurgical Anatomy

John L. Fox

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

With 171 Illustrations in 329 Parts, 133 in Full Color

Springer-Verlag New York Berlin Heidelberg

London Paris Tokyo

JNtN L. Fox, M.D.

Clinical Professor of Surgery. Division of Neurosurgery, Uni"ersity of Nebraska Medical
Center, Omaha, NE68105, USA

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



Medical lIIustralOr. Ed ucational l\ledia Production and Services. GeorgelOwn University

Medical Center, Washington, DC 20007, USA
Portions of the wor k on this atlas were carried OUI by Dr. J. L. Fox at the following institutions: Universi ty of Zurich, Zurich, Swiuerland (1973-1974); West Virginia University Med
ical Center. Morgantown. West Virginia (1975-1982); King Faisal Specialist Hospital and Research Centre, Ri yadh, Saud i Arabia (1983-1985); Georgetown Unil'ersity Medical Center,
Washington. D.C. (1985-1987); and University of Nebras ka 1-.ledica l Center. Omaha, Nebraska (1987 -1988). The senior author is grateful for their support in this academic en
d eavor.

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

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

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

Republic of Germany.

9 8 765 4 3 2 1
e-[SBN-1 3: 978-1-4613-8823-4
lSBN- 13: 978-1-4613-8825-8
00[: 10. 1007/978-1-46 13-88234

Dedicated to James Winston Watts, M.D., Professor Emeritus,

Department of Neurological Surgery, George Washington University
Medical Cente'r, Washington, D.C.


During the past 15 years, several publications on neurosurgical techniques, often with special emphasis on surgical anatomy. have appeared
in the literature. Howevel; this book by J ohn L. Fox goes far beyond an
ordinary effort. This extraordinary work, Allas of Neurosurgical Anat011o/:
The Pte1'ional Perspective, has its or igins in the author's many years of devotion, exhaustive labors, and experience as a teacher in the operating
theater (to wh ich his many residents will attest). This surgeon, born in
Billings, Montana, in the ycar of 1934, authored one of his first publications as a senior resident in 1964. The tide, " Differentiation of Aneurysm
from Infundibulum of the Posterior Communicating Artery," presaged
his future recognition as an intracran ial aneu rysm surgeon. Now Professor Fox is known throug hout the world not only for h is many publications on su bjects in neuroscience and clinical neurosurgery, but also for
his teaching methods, which utilize both television demonstrations a nd
color slides of live neurosurgical anatomy in realistic depth and clarity.
Such talents as a teacher have led J ohn Fox to be called forth as an instructor and lecturer in many neurosurgical seminars and courses both
here and abroad, East a nd West. His presentations with color photographs showi ng true visual images now are captured with perfection in
this atlas. Such photographs, with accompanying instructions and descriptions on approaches to aneurysms and tumors, have left a prominent and lasting impression on everyone who has had the opportunity to
attend his lectures.
This book gives us images in livin g color, images curremly unsurpassed by any other work and well illustrated as the su rgeon actually sees
them. The excellent accompanying and instructive drawings help carry
the reader and observer step by step through the intricacies of cisternal
anatomy and pathways of intracranial surgery. This publication is divided into e ight chapters, starti ng with the history of the pterional approach in neurosurgery. The inclusion of this interesting and instructive
chapter gives us an added evolutionary insight. It is co-authored by Professor Bengt Ljunggren, whose interest and expertise in neurosurgical
history and aneurysm surgery are well known. Professor Ljunggren,
from the University Hospital of Lund in Sweden, fascinates the reader
with his accounts of the early evolution of techniques for turning the cranial fl ap. The next three chaplers by Dr. Fox carry us through in strumentation and positioning, photographic technique, and cranial anatomy.
His final four chapters take us from the sylvian fissure into and thro ugh



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


Professor of Neurological Su rgery and

Research Professor of Anatomy
University of South Carolina
Charleston , South Carolina


After completing a three-volume book entitled inlmcranial Aneurysms

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

L. Fox


Foreword by LUDWIG C. KEMPE.

Preface . . . . . . . . .



H istory of the Pterional Approach

and JOHN L. Fox


Instrumentation and Positioning


Photographic Technique . . .


Cranial Anatomy and the Cranial Flap


5 The S),lvian Fissure


6 The Carotid Cistern and Environs.


7 The Chiasmatic Cistern and Environs


8 The Ambient and I nterpeduncular Cisterns


Ind ex

20 1

History of the Pterional Approach

Many surgical a pproaches have been proposed
in order to facilitate exposure of lesions in the
skull-base region wi th a minimum of brain retraction [I, 3, 12, 15, 18, 19,24,29,32-34,37,
39, 40, 49]. The pterional a pproach [0 th e circle of Willis and its environs is routinely used by
many surgeons. A pterional approach implies
that a small skull flap is raised with the pterion
(Creek pterion, wing [ II ]) - the craniometric
point located undern eath the tcmporalis muscle and form ed by the junction of the fronta l,
parietal , and te mporal bones with the g reat
sphe noid wi ng bone - in the center of the base
of the flap (Fig. 1.1 ). Additional drillin g down
of the sphe noid ridge allows a low basal exposure along the skull base. Equipped with

Fig. 1.1. Close-u p view of left

side of dry skull with sutures

between the frontal (F),
parietal (P), temporal (1),

sphenoidal (S), and zygomatic

(l) bones outlined by black

and JOH N L. Fox

instrume nts,
ne u rosu rgeon finds that the pterional approach to skull-base lesions is a more natural
and easier procedure than earl ier-day operations. Yet, there is a fascinating hiSlOrica l background over the last 100 years, that form s the
basis o f the present-day pterional approach.
There are several pioneers who made mo numental contributions to the development of
this access to deep-seated cran ial-base lesions.

Wilhelm Wagner and His

Osteoplastic Method
followin g studies on human cadavers for several years, Wilhelm Wagner (1848 -1900) became the first su rgeon in the world to raise a

I. HislOry of the Pterional Ap proach

bone flap (temporal in site) out of the cranial

vault in a living person , kee p it attached to the
overlying soft tissue (perioste um, tempora l
muscle, and scalp), a nd then replace the fla p
(after evacuation of a la rge epidu ral
hematoma) [4, 44]. Wagner used hammer and
chisel to raise the bone flap. The patient, a 27year-old man with skull-base frac tures a nd the
clinical picture of increasin g intracranial pressure, underwent su rgery on the second day fol lowing a seve re head injury. He was in a poor
condition p rior to the ope ratio n. Following
evacuation of the hematoma, it was appa rent
thal the intracranial pressure had become normalized , bUl the patient did not recove r a nd
d ied 24 hou rs after surger y. At a uto psy
Wagne r fou nd no signs of di st urbed nutrition
in the te mporal, omega-sha ped fl ap that he
had raised to allow e vacuation of the now-absent hematoma. He concluded that his osteoplastic method was an excellen t procedu re that
resulted in a good ex posure of lace rations of
the middle me ningeal artery in the middle cranial fossa. He also suggested that his osteoplastic method could be used to ex plore and resect other intracra nial lesions such as brain
abscesses, e pile ptic scars, a nd brai n tumors
Two years later (1891 ) Wagne r rightly
claimed priority for the introduction of the use
of the above-described , intraoperative osteoplastic bone flap to ex plore intracran ial lesions. He e mphasized that such fl aps appea red
to heal quickly and withou t compl ications
when attachme nt to the soft tissue was retained
during surgery [45]: "The osteoplastic method
of trepanation is no morc difficult or da nge r.
ous than an explorative laparotomy. "
In 1895 Wagner publi shed two cases of success ful evacuation of e pidural hematomas
throu gh his then innovative osteoplastic procedure. In this paper [46) he again e mphasi;r.ed
th e adva ntages associated with tempora ry resect ion of a large bone fl ap for cx ploration of
the middle meningeal bra nches.
In 1909 Ha rvey Cushing [5] described
Wagne r's original procedure to explore and
decompress cerebral lll mors, which otherwise
proved to be inoperable, using" the usua l osteoplastic method of exploration ." He summarized [5]: '~ n osteoplastic resection, whatever tools may be e mployed , has doubtless
come to be made, in the hands of all , unde r

some form of tourniquet, with the omegasha ped fl ap broken off across the thin squamous wing of the temporal bone."
Wagner was a self-educated surgeon who,
like his great conte mporary colleague from
Berlin , Ernst von Bergman n ( 1 836 ~ 1907),
had been in volved in the Fra nco- Prussion War
in 1870. He devo ted his life to working in the
local hospi tal of Kon igshoue, a small tow n in a
mining d istrict in Upper Silesia, which in 1880
cou nted 27,600 in habitan ts. Silesia at this time
was incorporated into the newly founded German Re ich. In this small place Wagner became
a n absolute master surgeon, and like von
Be rgmann he ex hibited a pa rticula r interest in
cran ial and spina l surgery. While von
Bergmann strongly objected to the use of
o pening the skull with chisel a nd mallet. this
was the technique superbly practiced by
Wagner. T he lattcr also publ ished important
contributions concerning the operative management of complicated skull fractlll"es [4 3]
a nd on fracture di slocations in the cervical
spine [47]. His re port on the cli nical diagnosis
a nd o perative evacuation of e pidural
he ma tomas is a masterpiece [46] . The same ca n
be said of the remarkable volume, " Die Verletzu ngen der Wirbelsaule und des Rockenma rks" [47] whic h he published in collaboration with his colleague Stolpe r from nearby
Bresla u (Wroclav). Despi te a heavy clinical
dail), practice, he not only kept abreast with the
surgical litera tu re of the lim e but also followed
the litera tu re in general med ici ne and other related bra nches . Wagner was beloved by his patie nts, for he rad iated secu rity a nd goodness
and was widely recognized in the whole of
Silesia not onl y for his supreme skill but also
for his vast medical knowledge and his good reo
sui ts in the treatment of nonsurgical d iseases.

Crania] Saws
In 1891 Professor (" professeur a la Facuitc
libre") J ean Toison from Lille in France repon ed on his use of a chain saw to divide the
bone between burr holes from within outward
to facilitate raising of osteoplastic skull fl aps
[38]. This saw could replace ha mme r and
chisels previously used in o pening the cranial
va ult. I n his pape r Toison paid much attention
to Wagner (already in his title) as the true

de Martel's Skull Trephine and Metal Gu ide

pionee r behind the revolutionizing method of Heidelberg, Cermany, Kocher from Bern,
raising cranial flaps. He described Wagne r's Swi tzerla nd , Simpson from Edinburgh, Scot" historical con tribution which he first per- land , and Sklifassowsk i from SL Petersburg,
formed on a li vin g human on October 1st Russia. In his pioneer pa per Oba linski gives
1889" and continu ed [38], .. Aussi la nou vell e credit to Karl Dahlgren (1864 - 1924), a
methode opCraloire inauguree par W Wagne r Swed ish pioneer who, in 1896, had designed a
(de Konigshuue) qu i permetde creer une vaste new bone-cutting forceps fo r making linear
ouverture a la boite ossellse du crane et de re- cuts in the skull bone and which cut from the
fermer, a la fin de I'ope ration, avec de I'os, inside out [6]. With the increasing interest in
J'ouvertu re rendue tcmporaire de la trepana- cranial surgery in the first decade of this cention, constilUe-t-ci le un grand progres chirur- tury. the Cigli saw later became recognized also
gical. Ce chirurgie n a donne a celle methode in the United States by Harvey Cushing, who
operatoire Ie nOIll de rcseClion temporaire du adopted the use of this simplc instrument to dicrane . .,
vide the skull bone betwee n two burr holes
Toison's saw was fairl y cl umsy and was there- [36].
fore not much used [48]. T hree years later
(1894) Leonardo Gigli from Florence, Italy, dede Martel's Skull Trephine and
scribed his simple yet clever instrumem, a wire
saw to divide bone between two open ings, This
Metal Guide
tool has come to bea r his name, being called the
Gigli saw [ 16, 17). Origina lly, Gigli imemed his In 1908 Count Thierry de Manel (1875- 1940)
wire saw to facilit.ue sym physiotomy in obstetri- presented lhe perfect solution to the rest of the
cal surgery. He fini shed his origi nal re port {16], problem of trephinin g wi thout risk of producemphasizing that one dozen saws could be or- in g intracranial damage. As a bo)' de Martel
dered from the Hermann HarLel Compa ny in was alread y very inquisitive and enjoyed taking
Breslau at the price of 3 German marks plus mechanical things apart to learn how the), op40 pfe nnig for shipping com to an)' forei gn erated [31]. Frequently he dissected the fowl
country. He also added that chiefs of clinics being pre pared in the kitchen, and he bought
could obta in free samples by just sending in a a skeleton that he displayed as an amiable comrequest.
pan ion, de Martel, a dcscenda nt of the
Professor Alfred Obalinski from the Jagicl- Mirabeau fa mil)' who played an olltstanding
Ionian University of Cracow in Galicia (the role in the French Revolution, was an aristocrat
haven of Polish culturc at the time, although fully conscious of his ancestry. At fi rst he was
under the government of Vienna) had in- enrolled in a school for the training of entended to describe the use of the Gigli saw for gi neers and later was trained by several French
cranial trepanations at the Imernational Con- master surgeons . He beca me especially ingress in Moscow in August 1897. However, he terested in neurosurgical instrumentation . At
was prevemed from going and instead pub- the age of 33 he published an article [28] delished his innovative a pplication in the Cen- scri bing two new neurosu rgical instruments.
tro/blatt [il r Chimrgie that same ),ea r [30]. In his Today, 80 ),ears later, both are in dail y use by
paper Obalinski stated that it had occurred to many thousands of neurosurgeons all over the
him that by using a slightly bcnded cannu la as world. In his milestone paper the two instruan inserter, the fl ex ible Gigli saw was ideal for ments he described were (a) a motor-driven
introduction between burr holes. He em- tre phine equipped with an automatic disenphasized that the use o f the Gigli saw permits gaging gear that stopped the trephine as soon
the safest method of dividing the skull bone as it has penetrated the skull and (b) the metal
from the inside to the outside without th e type gu ide for the introduClion of the Gigli saw beof trauma usually seen from the use o f ham- tween separate burr holes.
mer and chisel [30]. In Moscow, Emile Doyen
When in Paris, de Martel presented his new
from Paris demonstrated his own method for automatic trephine, but it was received with deperforming a cra niectomy in front of many rision. He then performed a demonstration
prominent professors of surger)" including lI sing a dried skull with a balloon 0 11 the inside
von Bergmann fro m Berli n, Czerny from as an im itaLion of the dura mater. With his au-

I. History of the Pterional Approach

Fig. 1.2. The " hypop hyseal 0' a pproach of Heuer and
Dand y. From Dandy WE (1936) The braill , in Lewis
D (cd): WF Prior, P roc/ice of SUrgfly, vol 12.

[71 .

LOmatic trephine he drilled a hole in this sk ull

without puncturing the balloon a nd commented [31 ], "Well, as yo u call see, this
treph ine can be operated by a n imbecile" ("ct
bien comme valis voycz, Messieurs, cc trepan
pellt manie meme par un imbecile"). American neurosurgeons were even more reluctant
to accept de Mart.e1's e lectric dri ll. By the late
1930$ it was used routinely in Sca ndinavia,
France, Germany, a nd Central Europe. Yet in
Boston in 1948 its lise was rejected even at the
Massachuseus General Hospital. The burr
holes were done ma nuall y (and laboriously!)
with Hudson drills. It was said that electric
drills were not used because Cushing had once
stated that such drills caused too much vibration transmitted to the brain (Bakay L, personal communication, 1974).

de Martel a lso had designed a hemostatic

forceps, a self-reta ining cerebral retractor, and
a specia l surgical chair supporting the patient
for operatin g on posterior fossa tumors with
the patient in the siuing position. He was the
pioneer neurosurgeon in France who fou ght
a nd overcame the difficulties of blood loss and
inadequate posterior Fossa visualization common to neurosu r ger y during the first qua rter
of this centu ry. He had lost his only son in
World War I. In 1938, at the Annual Cong ress
of the De utsche Gesellschaft fUr Chirurgie. de
Martel gave an impassioned speech about the
necessity of continued friend ship between
French and German su rgeons, a speech that
was followed by thunderous applause. Two years
later, on Ju ne 14, 1940, as Hitler's troops occupied Paris, de Martel commited suicide [31].

Hagerstown, Maryland, pp 145, 583-585. Reprinted with permission of Practice of Surgery Ltd .

From a "Hypophyseal" to a More Pterional Approach

Fig. 1.3. Another view of the "concealed incision"

(behind the hairline) of Heuer and Dandy. From
Dand y WE (1936) The brain, in Lewis D (ed): WF

Prior, Practice of Surgery, \'01 12. Hagerstown, Mary

land, pp \45.583-585. Reprinted with permission
of Practice of Surgery Ltd . [7].

From a .. H ypophyseaJ" to a More

Pterional Approach

In 1962 George "{ayes, one of Dandy'S stud ents and former chief of neurosurgery at The
Walter Reed Army Medical Center 111
Washington, D.C., briefly illustrated his frontotemporal approach in a publication with
Slocum [20]. One of their figures showed " ...
the visualization of an aneurysm of the anterior communicating artery as exposed
through a small Dandy pituitary lype o f flap. "
Hayes and his colleagues commonly used this
approach to the base of the brain (Hayes GJ ,
personal com munication, 1974).
In 1963, before the period of microneurosurgery, Lougheed and co-workers [27]
stated that their operative procedure was car
ried out "through a fronto temporal bone flap

In 1918 Waller Dandy took the liberty to report

for George Heuer, one of his younger colleagues, on a " hypophyseal" a pproach to
pituitary tumo rs [23]. Heuer later described
this approach in more detail and used it for selIaI' and suprasellar LUmors [21, 22]. In the
1940s Dandy made some modifications [7 - 10]
and this lype of cranial opening became popularly known in the United States as the " Dandy
nap " (Figs. 1.2-1.4). This hypophyseal approach used a skin incision concealed behind
the hairline.

L History of the Plerional Approach


OpenonS .r.chnldl ~r


optic n.

GJrotid L


Fig. 1.4. Dandy's approach to an intracranial

aneurysm. Fro m Dandy WE (1944 , reprilHcd 1969)
Intracranial Arterial Aneurysms. New York, Hafner.

Ski n irn:: i$ion

Fig. 1.5. The ptcrional craniotOmy flap as o utlined

by Kempe. From Kempe LG [25] .

Copyright ]944 by Comstock Publishing Company,
Inc. Re printed by permission of Cornell University
Press [9].

with removal o f the pterion and a bit of the

outer third of the lesser wing ohhe sphenoid. "
Ludwig Kempe. who succeeded Hayes at T he
Walter Reed Army Medical Ce nter, Ilicely illustrated various features of the plcrional approach (Fig. 1.5) in his 1968 two-volume alias,
OPerative Neurosurgery [25] . Of interest is the description given to the critical burr hole placed
at the junction of the temporal line, the
zygoma tic process of the frontal bone, and the
orbital ridge. At The Walter Reed Army Hospital this became known as the " psychopathic
poi m " [14, 26, 4 1], probabl y in reference to the
disposition of the surgeon should the residem
fail to place the burr hole correctly! Subseque mly Fox learned the pterionaltcchnique
of cran ial ope ning [ 13, 14] by observing or assisting George Hayes, Lud wig Kempe, and
Hugo Rizzoli , Dand y'S last neurosurgical reside m o Barnes Woodhall, a nother of Da ndy'S
trainees, simila r! y used the pte rional a pproach
at Duke University (Woodhall B, personal communicatio n, 1980).
With the imroduction of microncurosurg ical techniques, Gazi Ya~argil illustrated his

Fig. 1.6. Diagram of skull with area
usually included in a pterional flap
although modified by various surgeons.
From Fox JL [14].

microtechnical pterional approach [51, 54],

which was a refinement of his 1969 frontotemporal descri ption [50]. He emphasized the
sma ll , low basal expos ure by drilling down the
sphenoid bone. At that time the basic difference between his published description and
that of Ke mpe's [25] was the use of microtechnique, sphenoid bone dri lling, a wider
opening of the sylvian fi ssu re, the placement
of the posterior burr holes more a nteriorly
(making it a frolHos phenoidal craniotomy),
a nd the avoidance of retraction on the temporallobe [54]. Ya~argil and co-workers used
the pterional approach for lesions in the interpeduncular cistern [52], in which situation the
posterior clinoid process is a landmark that, on
occasion, may hinder a clear ex posure [35].
The skin incision likewise has changed with
the needs and preference ofth e individual surgeon. Dand y's original incision is illustrated
in Figs. 1. 2 through 1.4. Kempe's incision
(Fig. 1.5) permitted greater exposure of the
temporalis mu scle as well as a more basal exposure . Various surgeons at times extend the
fronta l limb a shon distance into the skin of the
forehead above the junction of the medial twO
thirds and lateral one third of the eyebrow.
This might permit a shorter scal p incision, but
itdid make part of the surgical sca r visible after
hair regrowth . Ya~arg il 's incision was longer
but re ma ined concealed beh ind the hairli ne
while descending low enough to perm it a
lower, basal a pproach [53, 54]. The pterional
approaches at times can inju re the fromalis


branches of the facial nerve, a point of recent

discussion [2, 55].
Throughout the years neurological surgeons have altered and modified the a pproach
to the middle fossa and sellar region. In one
form or anOlher the pterion has been incorporated within the reflected bone fl ap in modifications of the "pterional fl a p " (Fig. 1.6). Its
evolution from the Heuer-Dand y flap to the
Hayes- Kempe flap posteriorly and basally and
then to the Yaprgi l nap a nteriorl y a nd basall y
has been accompanied by parallel advances in
imaging, anesthesia, magn ification, lighting,
retraction, instrumentation, and intraoperative e nergy transfer (by laser, ultrasound, electrocautery, and the like). The pterional approach is now finding its place as an important
surgical route to t he circle of Wi llis and itsenvirons. T he pioneers who laid the fund amental
cornerstones to this procedure include
Wilhe lm Wagner, Leonardo Gigli, Alfred
Obali nski, Thierry de Martel , George He uer,
and Walter Dand y. T hese are the men of years
long past to be r emembered by all ne urosurgeons who today regard the pterional approach to the skull base as a n elementary and
most obvious and fund a me ntal principle.

1. AI-Mefty 0 (1987) Supraorbital-ptcrional approach to skull base Icsions. Neurosurgery
21: 474-477

2. Aoki N (1987) Incision offacial nerve bra nch al

I. History of the Plerionai Approach

aneurysm surgery. (Leuer to the Editor) J

Neurosurg 66: 482
3. Brock M, Dietz H (1978) The small frontolateral
approach for the microsurgical treatment of
intracranial aneurysms. Neu rochirurgia (Stultg)
21: 185- 191
4. Buchfeldcr M, Lju nggren B (1988) Wilhelm
Wagner (1848- 1900). Surg Neural, in press
5. Cushing H (1909) A method of combiningexploratio n and decompression for cerebral tumors
which prove to be inoperable. Surg Gynecol
Obstet 9: 1-5
6. Dahlgren K (1896) Ein neues Trepanationsinstrument. Centralbl Chir 23: 217 -220
7. Dandy ,-\,IE (\936) The brain, in Lewis 0 (ed):
PracliceofSurgery, Hagerstown, Md, WI<- Prior, vot
12, pp 145,583-585
8. Dandy WE ( 1938) Intracranial ane urysm of internal carotid artery. Cured by operation. An n
Surg 107:654-659
9. Dandy WE (1944, reprimed 1969) Intracranial
ArterialAneurysms. New York, Hafner
10. Dandy WE (1945) Intracranial arterial
aneurysms, in: The Brain. New York, Harper &
Row (Reprinted 1969 from WF Prior, Lewis Practice o/Surgery, Hagerstown, Md)
II. Dorland's Illustrated Medical Dictionmy (1974) cd
25. Philadelphia, WB Saunders Co, p 1284
12. Dotl NM (1933) Intracranial aneurysms: cerebral arterio-radiography: surgical treatment.
Edinb Med J 40: 219-234
13. Fox JL (1979) Microsurgical exposurc of intracran ial ancurysms. J Microsurg I: 2-31
14. "oX JL (1983) Intracranial Aneurysms. Ncw York,
15. Frazie r CH (1913) An approach to the
hypophysis through the anterior cranial fossa.
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16. Gigli L (1894) Ober ein neues Instrument wm
Durchtrenncn dcr Knochen, die Drahtsage.
Centralbl Chir 21: 409-411
17. Gigli L (1897) Z UI" praktischen Vcrwertung der
Drahtsage. Cemralbl Chir 24: 785-788
18. Hakuba A, Liu S, Nish imura S (1986) The orbitozygomatic infratcmporal approach: A new
surgical technique. Surg Neurol 26: 27 1-276
19. Harris P, Udvarhelyi GB (1957) Aneurysms arising at the internal carotid-postcrior communicating artery junction. J Neurosurg
14: 180- 19 1
20. Hares GJ , Slocum HC (1962) The achievement
of optimal brain relaxation by hypervemilation
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21. Heuer GJ (1920) Surgical experiences with an
intracrall ial approach to chiasmallesions. Arch
Surg I: 368-381
22. Heuer G] (193 1) The surgical approach and
treatment of tumors and other lesions about the
optic chiasm. Surg Gynecol Obstet53: 489-5 18

23. Heuer C] , Dand y WE (1918) A new hypophysis

operation. ] o hns HopkillS Hosp Bu ll 29: 154
24. Jane JA, Park TS, Pobereskin LH et al (1982)
T he supraorbital approach: Technical note.
Neurosurgery 11:537-542
25. Kempe LG (1968) Operative Neurosurgery, wl/.
Cranial, Cerebral, and Intracm71ial Vascular Disease.
Berlin, Springer-Verlag
26. Kcmpe LG, VanderArk GO (197 1) Anteriorcommunicating artery aneurysms. Gyrus rectus approach. Neurochirurgia (Stultg) 14: 63-70
27. Lougheed WM. BOltereH EH, r..lo rley TP (1963)
Results of the direct attack in the surgical management of internal carotid and midd le cerebral
aneurysms. Clin Neurosurg9: 193-200
28. de Martel T (1908) Un point de technique
operaLOire dans la craniectomie. Presse Med
29. McArthur LL (1912) An aseptic surgical access to
the pituitary body and its neighborhood. J AMA
30.0balinski A (1897) Zur Technik del' Schadeltrepanation. Centralbl Chir 24: 857-859
31. Pecker ] (1980) T hierry de Martel, 1875-1940.
Surg Neurol 13: 40 1-403
32. PiteHi SO, Almeida GGM, Nakagawa EJ etal
(1986) Basilar aneurysm surgery. The subtemporal approach with section of the zygomatic
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33. Pool] L (196 1) Aneurysms of the anterior communicating artery. Bifrontal cranioLOmy and
routine use of temporary dips. ] Neurosurg
34. Pool ] L (1962) T iming and techniques in the
intracranial surgery of ruptured aneurysms of
the anterior communicating artery.] Neurosurg
19: 378-388
35. Samson OS, Hodosh RM, Clark WK (1978)
Microsurgical evaluation of the ptcr ional approach to aneur ysms of the distal basilar circulation. Neurosurgery 3: 135- 141
36. Seeger W (1973) Allgemeine neurochirurgische
Operations tech nik, in Sailer FX, Gierhake FW
(cds): Chirurgie histQrisch gesehen. Deisenhofen bei
t.H.inchen, Dustri Verlag: pp 237 -238
37. Sugita K (1985) MiC1"01liurosurgical Atlas. Berlin,
Spri nger-Verlag
38. Toison] (189 1) De la trepanation du crane par
resection temporaire d'un lambeau osteoplastique (procede de Wagner et procede personnel). Cong Fr Chir 5: 325-338
39. Tonnis W (1936) Erfolgreiche Behandlungeines
Aneurysma der Art. commun. ant. cerebri. Zentralbl Neurochir I: 39-42
40. Tonnis W, Walter W (1960) Ein neuer operativer
Zugang zu den sackrormigen Aneurysmen der
basalen Hirngef.isse. Wien med Wochellschr
110: 145-147
41. VanderArk CD, Kempe LG, Smith DR (1974) An-

terior communicating aneurysms: the gyrus
rectus approach. Clin Neurosurg 21: 120 - 133
42. Wagner W (1885) Uber Halswirbellu xationen.
Ard,iv fur klinische Chirurgie. Berlin, Verlag von
August Hirschwald , pp 192-2 16
43. Wagner W (1886) Die Behandlung der komplicirten Schadelfrakturen . Centralbl Chir
26: 2405-2510
44. Wagner W (1889) Die temporare Resektion des
Schadeldaches an Stelle der Trepanation. Ein
Vorschlag. Celllralbi Chir 16: 833-838
45. Wagner W (1891 ) Zwei Faile von temporarer
Schadelresektion. Ccmralbl Chir 18: 25 - 29
46. Wagner W (1895) Zwei Faile von HaematOm der
Dura mater geheilt durch temporare Schadelresektion. Berl klin \-I/ochenschr32 (7) : 13i - 140
47. Wagner W, Stolper P (1898) Die Verletzungen der
Wirbelsaule und des Riickenmarks, in von
Bergmann E, von Bruns P (eds): DeutscM Chirurgie, No 40, Stuttgart, Verlag von Ferdinand Enke,
pp 1-564
48. Walkcr EA (1951) A His/ory of Neu.rological Su.rgery.
Baltimore, Williams & Wilkins Co, p 50

49. Wolff J (1863) Die Osteoplasti k in ihren Bezieh ungen zur Chirurgie und Physiologic. Arch
klin Chir 4: 183-294
50. Ya~argil MG (1969) Microsurgery Applied 10
Neurosurgery. Stuttgart, G Thieme, pp 119- 143
51. Ya~a rgi1 MG (1984) Microneurosurgery. Stuttgart,
52. Ya~argil MG, Antic J , Laciga R et a1 (1976) Microsurgical pterional approach to aneurysms of the
basilar bifuf(:ation. Surg Neurol6: 83-91
53. Ya~argil MG, FoxJL(1975)The microsurgical approach to intracranial aneurysms. Surg Neurol
54. Ya~argi l MG, FoxJL, Ray MW (1975) The operative approach to aneurysms of the anterior communicating artcry, in Krayenbiihl H (cd): Advances and Technical Standards in Neurosurgery.
Vienna-New York, Springer-Verlag, pp 11 3- 170
55. Yaprgil MG, Re ichman MV, Kubik S (1987) Preservation of the frontotemporal branch ofthe facial nerve using the inter fasc ialtcmporalis nap
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Neurosurg 67: 463-466

-- 2
Instrumentation and Positioning

This chapter describes the surgical instrumenlS and equipment uti lized by the author
during the plcrional approach to intracranial
lesions. Since part of the instrumentation is
used to maintain the proper position and alignment of the patient, positioning is an intimately related subj ect.
The Japanese samumi was a dedicated and
courageous warrior skilled in battle. He and hi s
sword or bow-and-arrow were a si ngle fighting
unit. They were such an integral pan of each
other that activation of cerebral and muscle
memory effected ra pid and nearly subconscious communication, resu lting in precise,
"computerized" delivery of the weapon upon
its targeted foe.
The above simile is meant to emphasize the
conceptual and real changes occurring in the
modern ne urosurgical operating room. The
neurosurgeon (samurai), the instrumentation
(bow-and-a rrow), and the patient's lesion (foe)
are no lon ger separate en tities. Through extensive laboratory and clinical training, unlearning old habits, and learning new methods
of hand-brain-eye coordination , the modern
neurosurgeon now develops cerebral and muscle memory a kin to that of the samurai . The
operating microscope and microsu rgical instrume nts become an in tegral part of the surgeon who must deftly deliver his therapeutic
arrow on target. If this is to be done with minimal disturbance to the patient's brain, the
arrow's trajectory is limited to narrow pathways
between cran ial and intracranial structures.
It now ca n be appreciated that, in addition to
being able to work in small, optically magnified

spaces with delicate and long dissecting instruments, thc position of the neurosurgical patient nowadays is critical to the "stereotaxic"
alignment of the su rgeon's eye, the microscope, the dissecting instruments, and the
ta rgeted lesion. The surgeon must supervise
the positioning of the patient so that when the
target is reached later in the day, the surgeon is
comfonably situated for delicate dissection of
the tumor or vascular anomaly within very narrow spaces. As the patienland instrumentation
are being set up, the surgeon reviews a mental
check list(much as an airplane pilot does) based
on past experience and endeavors to control interlocking events with in the operating room.
Inexact patient posi tioning or imperfect alignment of the patient's head in the historical past
could be compensated by more brain retraction or by rotation of the patient's head resting
on a cranial "donut." Nei ther is acceptable in
most modern-day microneurosurgical procedures where the patient'S cranium is immobilized by a skull-fixation apparatus and the
brain is supported by self-retaining retractors
usually attached to the operating table. Thus,
an incorrect pos itioning of the skull-fixation
a ppa ratus, for ex.ample, may cause part of th is
a pparatus to intcrfer with later placeme nt of a
smail , self-retaining retractor 0 11 the in ternal
carotid artery and thereby hinder the surgeon's line-of-sight to the interpeduncu lar cistern . It is in this context that "interlocking
events" must be well thought out and controlled.
Because the neurosurgeon is working within
very narrow confines, it is even more incumbent upon the surgeon not on ly to have a
thorough knowledge of normal and aberrant


2.lnstrumemation and Positioning

Fig. 2.1. A. Top of skull with

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

Head Holder
neuroanatomy but also to be able to conceptualize the anatomy in its three dimensions
(stereoimage concept). The tomographic planes of computed tomography (CT) and magnetic resonance imaging (MR I) detract from such
conceptua lization (whereas stereoscopic images and pneumoencephalography [45J encourages it). The medical student lea rns his
anatomy from sta ndard cadaver dissections
a nd textbooks. The surgeon, at least in the
pterional approach illu strated in this atlas,
must view the patient's anatomy from an oblique a nd upside down oriemation (wi th respect to the patient).
Cranial openin gs have become smaller as
microsurgical techniques have advanced. In
theory, an intracranial lesion could be operated
on via a tiny (eg, I mill) cranial opening
(Fig. 2.1). In a sense, the operating microscope
brings the surgeon's eye closer to the cran ial
opening. If the surgeon's eye were at the ope ning like peering through a keyhole, a full view
of the intracranial spaces could be seen - if retractors cou ld fit through the opening - and
the lesion cou ld be removed or corrected - if
dissectOrs, like a laser beam, could fit through
the opening. Thus, among the factors limiting
the use of very small cranial openings in most
cranial operations are intracranial instrumentation and maneuverability.
Instrumentation continues to change, depending on surgical needs. There are va riations among specific types of instruments (eg,
retractor systems, cranial-fixation systems,
operating tables) , and an individual surgeon
often uses the system that he was trained in or
that fits his particular approach. T he instruments and equipmem herein described have
been the author's personal preference for the
pterional approach to various intracranial lesions. Much of the following is reproduced
from a previous publication [16].

External Instrumentation
Operating Room Table
We place the patient on the American Sterilizer
operating room (OR) table so that the patient'S
head is at the foot end of the table (Fig. 2.2).
This has several advantages: (a) the table pedals are not in the way of the sitting surgeon's
feet (the anesthesiOlogist or circulating nurse
manipulates these as needed); (b) there is more


room for the base of the microscope (which we

position to the left of the surgeon) ; (c) the normal opening in the OR table lies under the lumbar region of the patient's back, facilitating
lumbar cerebral spinal fluid (CSF) drainage
without turning the patient. The only disadvantage of this alignment is that the main
weight of the patient is off the center of gravity
for the OR table. An assistant often must assist
in elevation of the surgeon's end of the table by
lifting lip the table under the patient's shoulders when the patient'S head is raised (table
fl exed) to its final position (aboma 10- to 15-degree elevation of the patient'S head). This aclion lightens the unbalanced load on the table
wh ile the table is flexed. One must becareful to
avoid sliding the bUllocks into the opening,
which would risk sciatic nerve pressu re in short

Head Holder
In this era of minosurgical technique and selfretaining retractors, it usually is essential that
the head be immobilized by three-poim skull fixation. We use the Mayfield-Kees skull clamp
(Kees Surgical Specialty Company). T his clamp
(Fig. 2.3) is inserted into the normal foot end
of the American Sterilizer table. The horizontal part of the head holder should be nearly
parallel wi th the fl oor. We prefer to have the
two-point side of the clamp on the side of the
surgery, as the opposite one-point side may
project Out tOO fal: All joints are tightened securely (from above downward), a nd the head is
immobilized throughout the operation.
A study group sta ted (17):
Under the surgical microscope, the slightest
movement of the patient's head is magnified considerably. Microsurgery demands a precisely
maintained position of the firmly fixed cranium
throughout the entire opel'ation, whether one opcrates with the patient in the sitting. supine, or
prone position. This is beSt achieved by a pillion
head holder in which the essclllial clemem is a
clamp made to accommodate three relatively
sharp pins. The pins penetrate the scal p and are
then firmly fixed to the outer (able of the skull.
\Vhen placing the pins, the surgeoll shou ld take
care to avoid a spinal fluid shunt, surface vessels,
thin bone (such as over the frontal and mastoid
sinuses), and the thick temporal muscle where the
position of the pin tends to remain unstable, however tightly the clamp is applied. A pin on the
forehcad should , of course, be well away from the
eyc; and when the clamp is positioned too close to

2. Instrumentation and Positioning



fig. 2.3. A. Mayfield-Kees head holder with demonstration skull (bone flap re moved) in position for
rig ht fron(Oiatcrai craniotomy. 8 . Pa tient in position

with head turned 40 to left, tilted 15 to left. and

d ro pped back 15, From Fox [16].


Fig. 2.2. A. Sketch of American Sterilizer OR table.

The usual head end is to the observer's lefl. The
head rest has been rCII1O\'cd from this end and

placed at the normal foot e nd on the observer's

right. T he patient'S head initially rests on the head
rest on the observer's righ t with that end c!evated
10_ 15 and with the lu mbar region oflh e patient's
back res ting Mer the open ing (arrow) in the table.
B. Same after specially mad e maltress is in place with
opening for lumbar CS F drainage. A model skull
(see Fig. 2.3) is held by the skull damp (replaci ng the
head res t). An "ether screen" (bar with knob projecting toward observer) p rojects away from the le ft sid c
of the paticlll to late r ho ld the d ra pes alld suction

tubes. The Leyla self- retaini ng retractor bar (see

Fig. 2. 11 ) atl<lchcs (aITow) to the O R table just
cephalad to the ether screen attach me nt. The microscope stands JUS t cephalad to lhe ether screen , and
the anest hesiologist is positio ned caudal LO lhe et he r
screen. C. Preli mina ry dra ping of paticnt. Instruments are placed o n the overhead ins trume nt ta ble
(Phelan Manu fact uring Corporatio n, Minnea polis).
Note the steralized "C-clam ps" at each end with rubber tubing st retched between . T hese are covered
after fi nal draping and prel'cnt instruments from
falling offinto the a ncsthesiologist's no nsterilc field.
From Fox [ 16].


2. Instrumentation and Positio ning

the incision, a pincasing can be a hinderance.

Special smaller pins available for infants can also
be used for patients who have thin skulls. Pa rticular attention should be given to patie nts who have
had a long history of hydrocephalus. Having secured the clamp. the surgeon holds the head in
the desi red position wh ile the final attach ment to
the operating table is made. Man ipulation of the
head holder accurately and with safety may bcdi f
ficull at first, but with experience any obstacles e ncounlcred can usually be surmounted. This

method of skull fixation avoids the pressure injuries that may occu r to the scaJp or face when the

head has been resting on rubber pads for long


The time of insertion of the poinlS imo the

scalp and skull is a critical period . T he head
must be perfectly posiLioned accordin g to the
approach used by the surgeon . Any deficiency
wi ll cause defective alignment of the target,
cranial opening, microsco pe, and surgeon's
eyes. The alignment must be such that there
will be a dear view of the aneu rysm a t the focal
poim of the microscope with the surgeon in a
comfortable position. Upon insertion of the

poinlS, the patient's blood pressure and intracranial pressure will rise unless he is properly
anesthetized and his blood pressure is under
control. The surgeon must notify the anesthesiologist before he inserlS the poims. Colley
a nd Dunn (6] recomme nded local anesthesia
in the scalp at the point-insertion sites.

Surgeon's Chai r
Surgeons' chairs are available from various
companies, eg, Storz Instrument Compa ny,
Aesculap Company, Stryker Corporation, and
V. Mueller Company. Ya~a rgil el al [57] reported on their special chair; we have found
the rece nt modification sold by the Aescu lap
Company to be qu ite satisfactory. \Ve also have
used the pneumatic lift chair (style P390244)
available from lheC.C.R. Medical Corporation
of PitlSbu rgh (Fig. 2.4). A hard cushion may be
placed on the seal to give the surgeon a bit
more height. The stool height is adjustable by
pressing on the foot bar.

Operating Microscope
After years of experience with neurosurgery
sa ns microscope fo llowed by microneurosurgical ex per ience in his operating room, Cha rles
Drake concluded [12]:
The remarkable new surgical world revealed
under the operating microscope and the beautiful instruments available to work in it have und oubtedly played a m.yor role in placing the
safety and scope of aneurysm su rgery \\'here they
are today.

And Gazi

Ya ~argil

had advised [55]:

However, it should never be forgotten that the re is

much more to microtech niquc in neurosurgery
than the possession of a highly perfectcd optica l
instrument. This alone is o f little value without
special methods of bipolar coagulation, carefull y
ad apted instru ments, and, above all, atraumatic
operation techniques.

Fig. 2.4. Pneumatic lift chair (C.C. R. Medical Corporation, Pittsburgh). The dark cush ion is added for
extra height. From Fox [ 16] .

In 1865 Bischo ff [4] published his work on

dissections of the cranial nerves. He began wi th
lou pes and later graduated to the dissecting
microscope with up to 50x power. The evolution of the use of the operating microscope in
surgery is detailed in other publications [9, 17,
36,4 1, 43 ,55].
In 1978 a stud y grou p concluded the follow;ng [In

Operating Microscope
The use of the operating microscope and microtechnique is only one part ofthe modern trend in
the surgical treatment of certain cerebrovascular
problems. Coincidentally, a team of experts has
evoh'cd, each of whom is specially trained to carry
Out his or her wsk in this type of surgery ... Although we place major emphasis upon the microsurgical tedmi<lues, advances have occurred as
well in anesthesiology, nursi ng care, radiological
diagnostic methods, pharmacology, and available
monitori ng systems. Certainly the jud icious use of
vascular hypotension and of techniques to control
intracranial pressure has helped greatly to reduce
patient morbidity. Some operations would be extremely difficult if not impossible to perform
without today"s sophisticated personnel ... Both
reports in the recent literature and the increasing
use of the microscope by neurosurgeons confirm
the opin ion and experience of stud y group members that the application of the operati ng microscope and microtechnique has markedly reduced
the mortality and morbidity associated with intracranial aneurysm surgery. Parallel improvements
in equipment have contributed additionally to
these results. The cardinal factors , however, arc
the training, experience, and expertise of the
operating surgeon who utilizes these new
tech niques and the capabilities of his operative
Some of the technical as pects of optics, su pports, accessories, use, care, and sterilization of
the microscope and its accessories are given
elsewhere [10, 14, 15, 17,3 1, 35, 37, 40, 43, 55,
57]. The Zeiss operating microscope (Carl
Zeiss, Inc) is the unit most commonl y used at
this time (Figs. 2.5-2.7).
We have been using (he counterbalanced
Zeiss-Contraves unit (Figs. 2.6 and 2.7) with
electronic switches that release magnetic locks,
immobilizing the microscope in any desired position [57]. Our preference has been the OPM I
No. I Zeiss magn ification system rather than
the zoom lens system attached to the Contraves
stand . We also prefer the floor mount to the
ceiling mount. In our OR the television came ra
is attached to the left side of the beam spl itter,
and the binocular observation lUbe or still camera is attached to the right side. The newer inclinable binocular tube (Fig. 2.8) has improved
the versatility of this in strumenl.
With ex perience, the counterbalanced ZeissContraves microscope and the surgeon become a single entity, working comfortably
"hand-in-glove" in attacking the lesion. Normally we have one surgical assistant on the
right sid e of a right-handed surgeon. Thus,


this surgeon's left hand is his first assistant and

the other surgeon, in effect, is his second assistant. The counterbalanced Zeiss-Contraves
microscope, first used by Ya~a rg il [57] in
Zurich, can be auached to laser systems or used
in conjunction with an ultrasonic aspirator.
With the former, the mobile microscope comes
over the left shoulder of the surgeon while the
attached laser unit is off to the surgeon's direCt
left and siLS between the microscope stan d and
the anesthesiologist's equipment. Other excellent o perating microscope syste ms arc available. For exa mple. Kenichiro Sugita in Matsumoto, Japan, h as develo ped a highl y sophisticated system [48].
Although agreement is not universal as to
whe n the microscope should be brought into
the operative field, ex perience shows that a
more gentle, accurate, a nd rapid dissection ca n
be carried out if, once the dura is opened, the
entire approach to the a ne urysm and its dissection are carried out under the microscope.
With the patient supine, the angled position of
the incl inable binocula r lUbe is used most
often. This now can be easi ly altered to a
straighte r position when drilling the sphenoid
wing a nd to a sharper angle when dissection is
in the sylvian fi ssure or antcrior perforated
substance. With ex perience, the surgeon often
finds that he routinely uses the same highe r
magnification (eg, 6x or 8x true magnification) for the approach to the tumor or
aneurysm as he d oes for its dissection.
Several disadvantages to the o perating microscope have been mentioned [ 17]: Special tra ining is required for using the microscope.
microtools. a nd microsllture; it necessitates
o perating in a deep, narrow gap ; it requires
longer adaptation time ; it does not permit
good tissue palpation (i nstrume nts are used ,
not fingers) and requires visual manipulation ;
work is indirect; work is tiring to the eyes; stiff
neck, should ers, a nd back generall y result; distractions are poorly toleraLCd; equipme nt and
training a re expensive; it lakes up space in the
o perating room; and the operating time for
most surgeons is longer.
The advantages for the ne urosu rgeon far a
outweigh any drawbacks, however [17]: Fewer
parallax problems occur because the objective
le ns brings the largetcloser to the surgeon's vision; binocular vision is improved; ill umination
is incrcased ; the foc us is sharper; a nd magnification permits a smaller cran iotomy, less brain


2. Instrumelllation and Positioning

Fig. 2.5. Standard Zeiss operating microscope with zoom lens system. f\lounted on
Zeiss Universal S3B noorstand. Counesy
of Carl Zeiss, Inc.

retraction, a smaller cortical incision , and better delineation of normal a nd abnormal

anatomy. Structures that are beller idcmified
by the microscope are the arachnoid space,
compartments, and bands; the perforating ar
tcries; vascular variations in the circle of Willis;
aneurysmal anatomy; microaneurysms; the impending rupture of an aneurysm; small bleeding points for bipolar coagulation; and the
nerves [17]. The advantages to the patienlarc a
smaller wound, beller repair or nerves a nd vessels, the fact that some inoperable lesions become operable, optimal hemostasis, fewer surgicallcsions, and fewer postoperative complications [ 17 ]. Educational advantages include

use of the observer tube, television with tape

recording, and cinematogra phy or still photography. I n addition, the television system allows the scrub nurse and anesthesiologist to
know the state of the surgery from moment to
As the microsu rgical era began, Drake in
1965 stated [11]:
The ability to see the minute details of the structures about an aneurysm has been, in my opinion,
the source of much trouble in this as ill other
fields of neurosurgery ... There is a new world
waiting for us. The dissecting microscope with its
superb illumination is ideal.

Operaling Microscope


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

o llCrat ing micrOKope. B. Closeup of microscope.
From Fox [ 16]:courlCsy ofC:lrI Zeiss. Inc.


2. Instrumenta tion and Positioning

Fig. 2.7. A. Zeiss-Contravcs o perating microscope in

position at surgery. The bone flap has been turned.
Note the rubber wbi ng that holds the drapes firm ly
down and caudally. Abo\'c arc two suction tubes in
readiness. In the background is a telc\isio n monitor.

B. Close-u p of microscope and alLach ments. Left:

Sony lclc\ision camera and microphone. Cn!Ur:
binocular system and beam-spiller. RighI: assistant's
observation tube. The lauer is rcmo\'cd when stillcamera photographs arc made. From Fox [ 16].



~" icroscope

Fig. 2.8. Inclinable billoclliartube (Carl Zeiss. Inc) flanked by SonyT V camerit on left and Contax still camera
on right. A. In straight positiull . B. 111 angled positiun.


2. Instrumentation and Positioning

Gillingham cautioned , however [22]:

This is a moment 1O reflect on the use of magnification. [\ may make us len times morc gentle but
it leads to obsessive over dissection in an endeavor
to find the neck ofa sac which is nonexistent orcxcessivc manipulation in the region oftbe neck.

As memioned above, television has imponant
ed ucational adv3mages (live visualization of
microanatomy and taping procedures for fulure teaching) as well as practical advantages
[17,32]. Operating room physicians and nurses
alter their anesthetic techniques a nd ongoing
activities as wel l as morc efficiently prepare for
anticipated operative CVClllS based on information received from the television monitor.
Color television systems (see Fig. 2.7 B) for
the microscope arc in a state o f rapid evolution
in terms of image clarity and brighmess,
weight, durability, and freedom from need for
frequem repa irs. Hence, il is pointless to recommend specific systems allhis time.
Many of the newer television cameras can
operate at a lowe r light level. Yct it is still advantageous to obtai n good lighting to allow a smaller diaphragm ope ning and consequently a
greater de pth of fie ld and sharper focus.
Table 2. 1 su mmarizes some methods to improve lighting for the surgeon and for the television or pho1.Ographic cameras.

Overhead Table
In our experie nce, the overhead table (sec
Fig. 2.2 C) made by the Ph elan Manufacturing

Corporation (Minneapoli s) has provided

maxi mum advantages for the surgeon, anesthesiologist, scrub nurse, and patien t. The cranial e nd of the table should bejustcaudal to the
patien t's shoulder (more caudal if the cervical
carotid a rtery needs 1.0 be exposed). The table
height is easily adjusted , and the nurse or technician has clear and rapid access to in strumems a nd the su rgeon's hanet.

I ntraoperative Instrumentation
The use of improvised tissue-retraction hooks,
or "fishhooks," connected to rubber bands has

Table 2.1 . Methods of improvi ng lighti ng for the surgeon and/or camer<ts."
I. I ncrease voltage in transformer (s hortcns bulb life).
2. Use an cfficiem lighting system (currently in state ofim
3. Keep hull>s and optical system clean.
4. Discard bulbs ",it h blue or dark spots in light image.
5. Usc add-on light sources.
6. Usc short focal length objecti\'e lens.
7. Avoid zoom !ens system. which absorl>s more light.
8. Turn off bright lights in opcr.lting room (bener conu'ast; surgeon's pupils arc d il'lIcn. rcrruiring less light ).
9. ~ I ake use of inlernal rencctions in surgical wound;
a,-oid rencclions back in to the microscope.
10_ Remo" e black paint border aruund glass light dencctor
behind objecti ve lens (present in some microscopes).
II. Usc 30-70 beam splitrer (70% to side arms. onl), 30%
(0 surgeon) inslead of 50-50 beam spliuer.
12. Use greater magnification in e)'cpicces. thercby requ iri n~ less rnagn.i fic3tion (hence less light loss) inside
mrr.ros<;ope unll.
13. OllCn diaphragm to camera (with loss of sharpness and
depth of focus).
14. l'rollCrI}, adjust TV camera power supply and TV
15. SeleCl efficient TV camera or film that can OllCrale wit h
less light.

Certain mClhods listen ha\'e particular \'"Iue in some circumstances, whereas in others they may pro\'e unnecessary or impractical. Items I through 10 also increasc
brightness for the surgeon . Item II decrease~ image
brightness to the surgeon. From Fox et al [ 171.

been used by many surgeons to retract scalp,

muscle, and du ra. More recently a fi shh ook retractor device using springs (Aesculap Instrumelll Co.) instead of rubber bands has been
suggested [57]. We prefer the "disposable"
Week Durahooks (Edward Week and Company), a lthoug h one can remove their rubber
bands fo r repeated usc.
The hooks a re used to retract the froillolemporal scalp flap tlIrned over the patient's
forehead as follows (Fig. 2.9): The sterile
drapes between the overhead table (neu rosurgical instrume ll t table; Phelan Manufactllring
Corporation, Minneapolis) and the patient's
head are -held firml y downward and caudall y
by standard rubber suction tubing of appropriate length. The looped e nds of this tubing
arc secured LO stirrup cla mps on each side of
the OR table. This lube (a) firmly holds the
drapes in place and (b) allows a convenient site
of allachmem fo r the rubber bands that retract
both the scalp hooks and the bone flap. I n this
way the drapes of the pcrioperalive field are

Intraoperati\"e Instrumentation


Fig. 2.9. Close-up view of ru bber tube holding

drapes firm ly (sec Fig. 2.7 A). Here the samc tubi ng
is used to attach the rubber b..1nds hold ing thc fishhooks. T hese fis hhooks retract thc oxrccllu lose-co-.
vcred scalp nap forward . The rig ht fromolateral

bonc nap is attachcd to the lcm poralis musclc (at

cemcr of figure). Dural lack-up sutures and boncnap sutures are in place in the cranium before the
dura is opened. From Fox [ 16].

smooth , firm , and dear of unnecessary damps

and other retractors.

slruCled to allow regulation of suction strength

by adjusting the degree to which the thumb
occludes the ai r ho le. T hese ho lcs ca n be enlarged [5, 29]. and/or venting needles can be
placed in rubber suction tubes. T he trap bottles ca n have pressure-regu lating gauges.
When dissecting delicate SlnlClUres, it may be
helpful to use specia l smooth-tipped suction
tubes and negative pressures o f about 2 m of
WaleI' (a pproximatel y 0.2 alln) [57]. I n place of
wa ll sllction, some sllrgeons prefer an electric
suction pump, easily regulated by adjusting the
dia ls on the pum p.
Irrib'<lting flu id in cunjunction with the suction apparatus is essential during the surgical
proced ure. In addition to keeping tissues from
drying and the aneu rysm wall from becom ing
briule, it discourages the formalion of small
blood clots and herence to the dissected surfaces; it also increases the effectiveness

SUClion an d SUClion- l rrigation Devices

SUClion tubes usually are sized (diameter) by
the "French" (Fr) designation: a 3- Fr size has
an oLlterdiameter of 1 mm ; a 9- Fr size is 3 mm ;
ctc. Standard sizes for aneurysm surgery are
3- Fr, 7-Fr, 9-Fr, and II -Fr, al though there are
many other variations. There are a multitude
of types of suction lubes with variation s in
length. angulation, tip co nfi guration, and vacuum pressure [3, 5, 17,28,29,44,56, 57J.
A SUClion system with a mechanism to controlthe negative pressure at ve ry low levels is
essential . The suction should be finel yadjusled
to eliminate the ha7...1nl of small anatomica l
structures bein g entrapped and damaged.
Many neurosurgica l suction tubes are con-


2. Instrumentation and Positioning

We commonl y use the Le ksell, Echlin , a nd

Lempert rongc urs for frontotemporal
craniolOmy, where bone is rongeured away at
the base. The fl at-j awed Lempert rongeur is
especiall y helpful for removing that portion of
the sphenoid wing sticki ng Out as a ridge toward the sylvian fissue.
The neurosurgeon needs a small , highspeed electric or pneumatic drill for removing
the sphenoid ridge, the clinoid process, and
other protrusions of the cranial base; however,
only after he has become acquainted with a nd
skilled in its application in the laboratory
sho uld he use a h igh-speed drill in a neurosurgica l operation [17J . A drill that ca n reve rse its
direction is pre fe rred by some to one that cuts
in only one di rection . A constantsuctioll-irrigation system with physiological saline ca n be
used to cool the drill ; o therwise, heat is transmitted to nearby neural structures. One obmins a more accurate a nd controlled use of the
drill when it is operated at high speeds; o nly
very slight pressure shou ld be used to remove
the bon e. Dangero us skiddi ng may OCClll" at
slow speed s or with dull drill bits because of the
greater pressure needed to cut bone. When
using lightweight drills or burrs, steel burrs are
used when the drilling is remote from the
dura. Diamond burrs are sa fer close to the
du ra or vital structures, for they tend less to
tea r SOfllissue. We use oxycellulose rather than
cotton sponges to cover the nearby galea, muscle, and bone fl a p , as no harm occurs if these
get caught in the drill. Couon , on the mher
hand , may cause serious damage if caught in
the drill.
When using bonewax under the microBone-Removal Instruments
scope, we have fo und the fo llowing to be helpIn 1930 Rogers [46] gave an excellent historica l ful: The scrub nu rse applies a small bit of
account of cra niotomy methods. He noted that bonewax to one side of a small , d ry COllonoid
the Horsley trephine had its origins in the time a nd hands it by bayonet forceps to the center of
of Hippocrates (ca 400 years Be) . The the surgeon's operative field. The surgeon
technique of bone flap removal made a signifi- then can use his bipolar forceps (without curcam ad vance with C igli's applicatio n of the rent applied ) or his finger to push the C01wi re saw (the C igli saw) in 1894 [19, 20]. This tonoid against the wax, which is pressed into
saw is still routinely used by many surgeons - the bleeding bone. Usually we use this
especially in elderly patients where the dura tech nique on the sphenoid wing a fter drilling
may be stuck to the inner table of the skull . T he it under magnification.
present-d ay use of power (pneumatic or electric) drill s a nd cran iotomy for lifting skull fl aps
is well known and requires no further discussion here.
Electrocautery for coagulation of vessels and
Ro ngeu rs for biting away the base of the vascular tissues has been an in1.egral pa rt of
bone flap are standard in a ny cra nio lOmy set. neurosurgery ever since the advent of the

of bipola r coagulation and reduces tissue adhesiveness. Constant bathing with CSF has the
same effect. Some surgeons prefer a combination suctio n-irrigation unit.
We usuall y use a n angulatcd Frazier suction
tube of varyi ng lengths. The II-Fr a nd g-Ff
sizes are used for cra nial work and the 7-Fr for
aneurysm dissection. We use the 7- Fr size
rathe r than smaller suction tubes because of its
usc as a dissector and retractor as well as a suction device. Moreover, the large r diameter provides less air a nd liquid veloci ty for the same
vacuum pressu re. The metal suction tube can
also be used for resting microscissors or other
instruments to reduce tremor when making a
delicate d issection . The suction lube is held in
the su rgeon's left hand , often with his ha nd or
fifth finger resting on the Leyla retractor bar
of the skull. (This "resting fi nger" serves more
to provide proprioceptive feedback rather
than comfol"( to the su rgeon. ) The SUClion is
often used against small dental cotton balls
(Richmond Dental Colton Company, Charlo tte, North Carol ina) or small cottonoids for
suction protection and retraction. Rubber tubing is preferred to plastic tubing, the latter
being too stiff for com fo rtable usc. We
routinely put 1,000 units of he parin in each
liter of irrigating solution 1.0 limit dotting,
which could cause o bstruction within the tubing; this practice may retard undesirable d Olting in the basilar ciste rns as well. The on ly
time we use a suction-irrigation apparatus
(House-Radpour unit) is during bone
(sphenoid wing or clinoid process) drilling.

Imr3oper.uivc Instrumentation
Fig. 2. 10. Fox bipolar electrocautery forceps in three
lengths: 16, 18, and 20 em.
Each of the straight forceps
cOl11es in 0.5- and 1.0-111111
diameter tips; curved and
angled tips also are available.
From Fox [ 16]; counesy of V.
Mueller Compau)'. Chicago.

.. Bovie" electrosurgical un it, reponed by

Cushing and Bovie in 1928 [7]. Light [38] gave
a good historical ove rview of the subject in
1945. In 1967 Malis [39] reviewed the de,'elopments and evolution of bipolar cle<.:trocoagulation since thc ti me of Grcenwood in 1940 [23].
" Monopolar" elcctrocoagulation has been
and continues to be commonly used to coagulate or cut tissues. (Of course, it is reall y bipolar: One pole is the "ground plate" and the
other is the hand-hcld electrode.) Bi pola r electrocoagulation of the type whcre both poles
arc in the forceps was developed by Grcenwood [23-26] to cauterize small blood vessels
on the spinal cord , whcre minimal heat and
electrical spread ,.,rere essential. Accordin gly.
the bipolar force ps basically consists of a modification of ordinary bayo net forceps or jewelers' force ps in which each blade of the forceps
is one of the electrodcs or poles; the blades are
isolat.ed from each Other by insulation, which
separates them at thei r base.
intracran ial
aneurysm surgery and ford issection of tumors
fro m the bra instclll , bipolar electrocautery
un its have become essential. There have been
many mod ifica tions in both the fo rceps and the
po"crsupply [8, 13, 18,23-27,33,34,39,47,
52.53, 56,57]. Malis [39] improved th e power
supply ( 0 provid e a damped wave spark un it
that was electricall y bener isolated. This un it
(Cod man and Shurtleff Company) has bee n
one of the more popular and reliable un its for
neurosurgery (and is preferred by us). The
unit was designed specificall y to provide the
best coagulation at the lowest voltage with the

least muscle stimulation. At the same time, it restricts the current to the shon cst path between
the tips of the twO blades of the forceps, with
no currenL of consequence nowing from tip to
ground or tip to patient. The greater safety of
bipolar coagulation compat'ed with monopolar
coagulation around brain stem structures was
demonstrated by Gestring et al [ 18].
Some tried to provide a single unit for both
mono polar and bipolar electrocoagulation [ 18,
27]. Sugita et al (52, 53] uscd a thermister at
the tip of their forceps to aUlomaticaliy cut o rf
the eleclriccurren t when a preset temperature
was rcached . Oth ers developed a suction [47]
or irrigation [13, 34] systcm attached to one
blade of their forceps. Del ong and Fox [8] described an automalic cyclin g on-off bipolar
electrocautery power supply.
We used to prefer the Ya~a rgi l bipolar forcc ps [56, 57] (Mathys & Sohn, Zurich), but we
now use the stai n less-steel Fox bi polar bayonet
force ps (V. Mu eller Company, Chicago)
(Fig. 2.10). T hesc forccps come in 16-, 18-, and
20-cm lengths and with 0.5- and I.O-mm tip
diametcrs . Other popu lar bipolar forceps fo r
surge ry include the Rhoton round-handled
forceps and the Malis forceps with the blades
slightly angled downward rather than parallel
lO the hand le. Titan ium or stai nless steel are
commonly used metals, the former being
liglllcr. We prefer the heavier weight of the
stainless-steel for ceps for bettcr balance, com fo rt, and proprioceptive feedback. It is important nOl to sterilize titanium and stain less-steel
instruments in the same package, for the different. metals in close proxi mity may create an


2. Instrurnentation and Positioning

electrical potcmial conductive to rusting a nd

pOOl; resu lting in poor coagu lation and a tcnde ncy for vcssels to ex plode or be incised. ProDe Long and Fox [8} recommended the fol - longed or illlensh'C use, even in one patie nt,
lowing care of t hese forceps to lim it thc slicking may res ult in a need for a n elCClrical overhaul.
oftisslICS to thei r tips:
Thcre fore, twO o r more such bipola r powcr
supplies should be ava ilable. We use a 15-foot
I. Do not short-circuit the electric curre nt by
cord between the power supply and the fortouching the forceps lips together.
ceps. Longer cord s may cause de fecti ve electri2. Clea n the lips frequemly only with a damp
ca l o utput at the forceps. We set the power supd oth (not with the sca lpe!!)
ply at the foot of the OR L:'l ble. I n this positio n
3. Polish the lips periodically (or obtain new
it does not add to th e instrument cluneI' near
force ps) when the tips become pitted a nd
the surgeon, a nd ilS electromagnetic noise
emission is a suffi cie nt di stance from the televi4." Knead " the tissue between the forceps tips
sion system so as to not c"eatc any significalll
by gelltly squee zing and releasing the fora udiovisual in tcr ference. For the same reason,
ceps blades.
the wa ll socket plug-i n sites for the television
5. Lift lhe force ps from tissue contact freand the bipolar I)()\\'er supply units should be
quentl y.
at a considerabl e dista nce from each o ther. The
6. Kee p the tissue moist with CSF or saline.
" monopolar " a nd bipolar electrocautery cords
7. Avoid high current settings.
sho uld not be dose to each other.
8. Apply t he currCIll in shon bursts to allow
heat dissipation.

corrosive activit),.

Wc usc the bipola r forccps as the principal

d isscCling a nd tissuc-separating instrument
intracranially. Fo r this reason the blades o f the
fo rceps must have proper spreading tcnsion,
yct not be so tense as to ma ke tip approximation uncomfortable. T hey must not rotatc inappropriately in the surgcon's hand. In terms
of timc, its actual a pplication for e lectroca utcri zation is quite short compared with
its use as a tissue dissector, pcrforator,
spreader, separatet; a nd grasper. It is uscd to
place a nd remove cotlonoids , cotton balls, gelatin sponge, gelatin paste, oxycellu lose, and I'LIbbel' or plastic sheclS. On tcrms of frequenc ),
a nd duratio n of usc, for us the suction lube (in
the surgeon's left hand) and the bipolar electrocautcry forceps (in the right hand) havc become thc main micros urgical inSlrulllcnlS during intracranial surgcr)',
For most of o ur extracra nial cauterization
we usecither the monopolarorthe bipolar unit
with the Malis powcr supply dial set at 30 or 35.
On cerebral cOrtcx wc use the Malis bipolar
power supply d ial al the 25 to 30 seuings: on
the brainstem we use the 15 to 25 settings.
"iner-tipped force ps increase thc cun'ent density at the tips. If higher settin gs are required,
lhe spark ga p in the unit probabl y needs resettin g. With faulty spark gap distances or other
electrical proble ms, o ne ca n use hig her power
settin gs to obtai n more current, but the qualit y
(waveforms) of the e lectrica l OLitput will be

In past yea rs mOSt brain retraction wasdonc by
assistant surgeons. Such retraction was often
inconsistcnt, inaccurate, and dangerous, as
brain retraction prcss urc exceeded cerebral
pcrfusion pressure. In 1958 Gi llin gham [21]
warned that bleedin g from an a neurysm at
surgery (causing reve rsal of blood now from
vital brain tissues a nd a drop in blood pressure)
may result in ischem ia of nearby brain tissuc.
He wa rned that thi s wou ld be aggravated by excess or prolonged brain retraction. Add itionall y, he ca utio ned that inaccurate o r excessive
retraction may place traction o n vital perforators, producin g vasospasm a nd inadequate ce rebral perfu sion. Albin e t al [ I. 2,
17] havc shown that brain retraction pressures
exceeding 20 I.o rr cause underlying brain damage. I f induced hypote nsio n is used, evcn Icss
bra in retraction prcssUl'e is IOlerated .
A number o f authors have described the use
of self-rel.aining b rain retractors [17,29,30,40,
42,57], Various t)'pes, eit her in the literature
or in commercial catalogs, have included the
de Ma nel , Dolt (Edinburgh), Hamby, Greenberg, Ya ~a rgi l (Leyla), Dohn-Ca rton. Malis,
Clowa rd , Enker, Miskimon, and J annclta retractor syste ms.
Self-reta inin g retractors also have become
indispensablc to aneurys m surgery because
they allow th e surgeon to work in a relativel y

Other Microsurgical Instruments

confined space unhinde red by the presence of'

an assistant's hands, which are less dependable
for maintain ing constant retraction of the
brain . Sel f-reta ining brain retractors arc of two
basic types [ 17]. One is composed of a series of
stra ight shafts attached by small clamps to give
the co rrect arm length and con fi guration requ ired for holding the brain spatula in place.
T he otherconsislS of a series of ball-and-socket
un its resembling a cha in of peads with an internal cable that when tightened, remai ns in the
desi red position .
Of greatest impon a nce in intracranial
surge ry is the minimal brain retraction necessary (Table 2.2), ascribable not on ly to use of
the su rgical microscope and microtechnique
bu t also to improvemenls in exposure techniq ues that allow a lowel; basal, and ta ngential
approach to the base of the sk ull and the circle
of Wi llis, which is partly aided by removal of a
portion of the sphenoid wing and lhe use of
special self-retaini ng brain retractors. However, these aids wo uld be totall y useless without
a relaxed brain effected by proper timing of
surgery and by supe rior anesthetic a nd lifesupport methods.
T he selection of a self-retaining retraClor
system is up to the ind ividual surgeon's preferellce and habit. Many prefer systems that attach on ly to the sku ll . T hey are concerned that
table-mounted retractors may move relative to
the brain even if the skull is immobilized by
three-point fixa tion [40]. We have foun d that
the Aescu l a p -Ya~argi l (Lcyla) retractor system
(Fig. 2. 11) is ideal for most cases of intracran ial
aneurysm surgery. We auach the bar to the left

Table 2.2. Minimal brain retraction.

I'crmincd by:
I. Usc of microS(ope. mi<;rotC(;hnique
2. Low oosal. tangemial approach
3. Self-retaining br.lin retractor
4. CSF drainage
:1. Neumanest hetic techniques
I. Removal of significant brain for exposurc of lesion
2. CUlling of Olfactory nCf\'c
3. Dil'iding of SOIllC bridging I'eins
4. Secondary brain contusion o r edema, vascular spasm
5. Vascular compression by retractoror stretched arachnoidal bands
6. Tr.letion on aneurysm
7. UnnC(;essary exposure of AI and M-I arterial segmcl11s
From Fox et al r17 1.


side of the O R table just cran ial to the "ether

screen" attachmen t (wh ich holds drapes that
separate the m icroscope from the anes+
thesiologist; see Fig. 2.2 B). Two or three fl exible (unless tightened) retractor ar ms are at+
tached to the con nectors on the bar. All joi nts
must be firmly tightened to avoid drift.
Fi rst, set the retractor blade (i n the flex ible
a rm) neal" the planned retraction site. T hen
tighte n the flex ible bar by turning [he screw,
which pulls the internal wire taul. Last, "toein" the retractor blade to its desired position
a nd retraction press ure an d then tighten its
wing nut. Drift is minimal or absent if done
properly. Always have the poi lll of connection
between the retractor blade and flexible bar
away from the cra nial opening. This requires
auaching the flexible arm ncar the end of the
retractor blade and bending the blade at its
proper poi nt for descent into the cranial cavi ty.
T his ma neuver gives better in tracranial exposure wi thout the ends of the fl exible retractor
arms being in the way.
Although these retractors a re usually
ap plied against brai n tissue or its coverings, on
occasion a narrow retractor ca n be used to
gently retract nerves, aneurysms, or aneries
such as the internal carotid anery or the middle cerebral artery d uring frontotemporal approaches to the interped uncular cistern [ 16,
48,50,51]. Such retraClion requires d isplacement and protection of these arteries \I'jthout
occluding them.

O the r Microsu rgical Instrume nts

T here are now a large number of microsurgica l instruments in the fie ld of neu rosu rgery.
We ca nnot review all of them in this rapidly
changi ng field .
Figures 2. 12 and 2. 13 ill ustrate some of the
instruments we most commonly use for microdissection. The j ewelers' fo rceps is used to pick
up the arachnoid over the sylvian fiss ure to in itiate opening of this fissure. T he Aescu lap
bayonet scissors (cu rved and stra ight) come in
three lengths (16 cm for surface work, 18 cm
for work about the anterior circle of Willis, and
20 cm for deeper work, eg, aboulthe posterior
circle of Wi llis). T here is also a 22-cm scissor.
The bipolar forceps have been described in the
earl ier section on electrocautery. T he Rhoton


2. Instrumemation and Positioning


Fig. 2.11. A- D. Leyla (Ya~ar

gil) retractor system. Courtesy of Aesculap-\'\'erke AG,
TUlli ingen, \Vest Germany.
B. Close-up view of auachmCIlt head between the bar
(left) and retractor a rm connector (right). C. Close-u p
view of connector bell,'ceo
bar and OR table. D. Retractor h.1r and attachment head
in prcliminaryposition.Above
is the draped scalp with an
outline of a righl froruolateral cran iotomy incision.
From Fox [ 16] .

Olher Microsurgical Instruments


fig. 2.11

instruments shown in Fig. 2.13 are the four

types most commonly used by us. The "Iong
flat instrument" (a ,. micro-Penfield No.4 ") is
used to retract nerves, arte ries, and the
aneurysm. The "short fl at instrument" is ideal
for se parating adhesions between an aneurysm
and adjacent tissues because the edges of its
angled, flat end are somew hat sharp. The 40
hook is sa fer to use than the right-angled hook,
for it will not catch and tear tissues upon iLS removal fro m the field. A ball-tipped hook also is
I nstruments and sutu re for reanastomosing
or repairing blood vessels and nerves should
be available along with the expertise to do so.
These are detailed in many articles on microvascular anastomosis.
These microsurgical instruments require
some trai ning and ex perience in their use and
manipulation through a small openi ng and insid e a deep narrow cavi ty. The su rgeon can rest

his hand on the skull oron the Leyla retractor

bar (named after the daughter of Ya~argil) ,
which holds the self-retain ing retractors.
Often the surgeon rests only his fifth finger as
a point of proprioceptive feedback. This allows
sensory orientation a nd reduces tremor. One
instrument can also be rested on the suction
tube of the surgeon's left hand to red uce tremor in critical moments.
On occasion a mirror a t the tip of a probe
can be useful for seei ng behind and around
va riou s structu res . Wilson and Spelzler 154]
used a denta l mirmr, Sugi ta et al [49] a 5-mm
mirror, and Ya~argil and colleagues [57J a mirror that changes positions when the grip handle is squeezed.
There now are many types, sizes, and configurations of vascu lar and aneurysm dips a nd
clip-appliers. These are in a continual state of
evol Ulion, a nd lhe reader is referred to other
articles on the subject [14, 16]. T he technology


2. Instrume ntation and Positio ning

fi g. 2.13. Enlarged view of microsurgical dissecti ng

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

fig. 2.12. uft: J c\\'clc l's' forceps (Ed ward Week &
Co.). C~lIlf'r; Bayonet sha ped microscissors (Aesculap Instrume nts). Rig"': Ua),oncI shaped bipola r
electrocautery forceps (Math)'s & Soho). From Fox

of e ne rgy tran sfer (lase r, ultrasound) in the

ope rating room is a large and changing field
that will not be addressed here.

Bibliograp hy
I. Albi n MS, Buncgin L, Be n nclt MH et 31 (19i7)
Clin ical and experimemal brai n retraction pres-

sure monito ring. Acta Ncurol Scand (supp! 64)

56: 522-523

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

Brain retraction preSS urC during intracranial
procedu rcs. Surg ,"brum 26: 499 - 500
3. ll.1dcr DC H ( 1975) ~'I icro-su rgical treatment of
intracranial ancurys ms. J Neu ros urg Nu rs
7:25 - 27
4. Bischoff EPE ( 1865) Mikrru1wJ!~ht Analyst der
ArwstomoStn der Kopfr!trotrl. Munich , Vcrlag der
JJ Lentnc r'sche n Buch handlung. See 'Hicroscopic
Arw{ysis of tht Allas/olllos;s Up/weer! /IU! emllia{
Nerves, translated by Sachs EJr, Va ltin W ( 1977)
Hanover, N H , Un i\'ersity Press o r New England
5. Bo ndu ra nt C P ( 1977) Alte ration or suctio n lip
prcssure. J Neuros u rg 46: 559
6. Colley PS, Du n n RC J r (1979) Pre\'ention o r
blood pressu re respo nsc 10 sku ll-pin head holder by local anesthesia. Anesth Analg (Cle\'e)
7. Cushing H , BO" ie WT ( 1928) Electro-su rgery as
,III aid to the rc moval or im rac ra nial tu mors.
Su rg G}'llccol Obstel 4 7: 751- 784

8. De long \V B, Fo x J L (1977) Automatic q-cling
bipola rcoagulator. Surg Neurol8: 15- 16
9. Donaghy Rfo.IP (1979) The history of microsurgery in neurosurgery. Cli n Neurosurg
10. Donaghy R t\.H~ Ya~argil MG (1967) MicrQ-WSWlar Surge/yo Stungart, G T hieme
II. Drake CG (1965) On the surgical treatment of
Cl in
Neurosurg 13: 122 - 155
12. Drake CG (l976) Ccrcbral aneurysm surgeryan uJXIatc, in Scheinberg P (cd): Cerebrqvascular
Disease. Tenth Prineeton Conference. New ' ork,
Ral'en Press, pp 289 - 3 10
13. Dujovny M, Vas R, Osgood CP et al (1975) Automatically irrigated bipolar forceps. Tech nical
note. J Neurosurg 43: 502-503
14 . Fox J L(1976) Va~cularclips fort he microsurgical
(reat melll of stroke. Stroke 7: 489-500
15. Fox J L (1979) Miu osurgical cxposure of intracranial aneurysms. J Microsurg I: 2- 31
16. Fox J L (1983) Intracranial Aneurysms. New York,
Springer-Verlag, pp 678 - 707
17. Fox .I L, Albin MS, Bader DCH et a1(1978) Microsurgical treatme nt of neurovascular d isease.
Neurosurgery 3: 285-337
18. Gestri ng FG, Koos WT , Boeck FW (1972) Bipo la r
coagulation with modified cOtl\'emional electrocoagulators. Technical note . .I Nellrosurg
37:50 1- 504
19. Gigli L (1894) Ober ein neues Instrument zum
Du rchtrcnnen der Knochen, die Drahtsage.
Centralbl ChiI' 21: 409 - 4 11
20. Gigli L (1898) Zur Technik der temporaren
Schadelresektion mit meiner Drahtsiige. Celltralbl Chir 25: 425 - 428
21. Gill ingham fJ (1958) The management of ru ptured intracranial aneurysm. Ann R Coli Surg
23:89-1 17
22. Gi llingham FJ (1976) Twent)'-five yea r~' experience with midd lc ccrcbral aneurysms. Rev Ins[
Nac Ncurol (Mcx) 10; 16-21
23. Greenwood J J r (1940) 1\\'0 point coagu lation. A
new principle a nd instru ment for applying
coagulation current in ncurosurgery. Am J Surg
24. Grecnwood .I JI" (1942) 1\\'0 point coagulation. A
fo llow-u p report on a new techni<llIe and instrument for electrocoagulation in neurosurgcry.
Arch Phys T her 23: 552 - 554
25. Greenwood J J r (1955) Two-point or interpola r
coagulation. Review after a twelve-}'car period
with !lotcs on add ition of sucker tip. J Neul"Osurg
12: 196- 197
26. Greenwood J .I I' (1974) ElcClrocaagulation in
neurOSUl-gcry. Surg Neurol 2: 4
27. Gurdjian ES, Thomas LM, Gurdjian ES (1968) A
singlc unit for bipo lar, rnollopolar coagulation,
and cutting . ./ Ncurosurg 29: 567 -568


28. Hamby \VB (1952) Intracranial Anellrysms.

Springfield , IL. Charles C Thomas Publisher
29. Hamby \VB (1969) Intracra nial surgery for
a neurysms. Prog Neurol Surg 3: 1-65
30. Hamby \VB (1970) Remarkscollcerni ng intracranial aneurysm sU Igery. Clin Neurosurg 17: 1- 17
31. Hocrenz P (1980- 198 1) T he operating microscope. J Microsurg I: 364-369, 419-427;
2: 22-26, 126-139: 3: 179- 182
32. Housepian EM, Ungcr \VH. Scharff TB et al
(1975) Expericnce with videotape monitOring of
microscopic neurosurgical procedu res. J
Ncurosurg 42: 204 - 208
33 . Jacques S, Bullara LA, rudcnz RH (1976) Microvascular bipolar coagliJator. Technical note. J
Neurosurg 44: 523 - 524
34. King TT, Worpo!e R (1972) Sel f-irrigating bilar diathermy forceps. J Neurosurg 37; 246247
35. K riegel' AJ (1978) The Use of the Operating Microscope. New York, Carl Zeiss
36. Kurze T (1964) Microtechniques in neurological
surgery. Clin Neurosurg II : 128-137
37. Kurze T, A puzzo Mq , \\'eiss MH et aJ (1977) Expericnces with sterilization of the operating
microscope. J Neurosurg 47: 861-863
38. Light RU (1945) Hemostasis in neul"Osurger r .I
Neurosurg 2: 414-434
39. Malis LI (1967) Bipolar coagulation in microsurgery. in Dtmaghy RMP, Yaargil MG (cds) :
Micro-vascular Surgery. Sw ug;m , G Thieme,
pp 126- 130
40. Malis Ll (1979) Instrumentation and techn iques
in microsurgery. Clin Neuros urg 26: 626-636
41. Nylen CO (1954) Thc microscope in aural
surgery. IIS first use a nd later development. Acta
O[olaryngol [Suppl] (Stockh) 116: 226- 240
42. Peerless SJ (1974) The surgical approach to middle cerebra l and posterior commu nicati ng
,IllC\lIysms. Clin Ncurosurg 21: 151- 16.?
43. Rand RW (1985) Micronellrosmgel)i cd 3 SI Louis,
CV Mosby Co
44. Khoton AL, Merz W (1981) Suction lUbeS for con\'eI1lional and microscopic neurosurgery. Surg
Neurol 15: 120 - 124
45. Robertson GE (1967) Pllellmoenuphalogm//hy,
ed 2 Springfiel d, 1L, Charles C T ho mas Publisher
46. Rogers L (1930) T he history or craniotomy: an
account of the methods which have been practiced and the instruments used for o pening the
hu ma ll sk ull during life. Ann Med Hist 2:49:)514
47. ScarffTB (1974) A nell' bipolar suction-camery
forceps fo r microncurosurgical use. Surg
Neurol 2: 213
48. Sugita K (1985) Mic1"01Ie1lrOSlagicai Atlas. Berlin,
49. Sugita K, Hirota T, Tsugane K (1975) Applica-


2. I nstrumentation and Positioning

lion of nasopharyngeal mirror for aneurysm operation . Tech nical note. J Neurosurg 43: 244246
50. Sugita K, Kobayashi S, Shintani A el al (1979)
fl. licroneurosurgery for aneurysms o f tile basilar
artery.] Ncurosurg 51: 615-620
51. Sugita K, Kobayashi S. TakemaeT et al ( 1980) Direct retraction method in aneurysm surgery. J
Neurosurg 53: 417 -419
52. Sugita K. Tsugane R (1974) Bipolar coagulator
with automatic thcrmocomrol. Technical note. J
Neurosurg 41: 777 - 779
53. Sugita K, Tsuganc R, Kagcyam3 N (1975) Bipolar coagulator with automatic thcnnocontrol
and some impro\'cmciltsofmicrosurgicai insl!"u-

melliS, in Handa H (cd): Microneurosurgery. Baltimore, University Park Press, p 17

54. Wilson CB, Spetzler RE ( 1979) Operative approaches to aneurysms. Clin Neurosurg
26:232 - 247
55 . Ya~argil Me ( 1969) MicrosUlgery Applied to
NeuroSllrgery. StUttgart, G Thieme, pp 119 - 143
56. Ya~argi l MG. FoxJL, Ray MW (1975) The operative approach to aneurysms oflhe anteriorcolllmunicating artery, in Krayenbiihl H (cd): AdMilas and Technical Stlllu/mtis in Neurosurgery,
vol 2. New York, Springer-Verlag, pp 113- 170
57. Y.1.~argil MG, Vise WM, Bader DCH (1977) Technical adjuncts in neurosurgery_ Surg Neurol
8:33 1-336

3-Photographic Technique

T he color illustrations of live microsurgical
a natomy as shown in this atlas were re produced from photographic color slides . The
photogra phs were taken du ring actual ope rative proced ures per form ed by the author since
1975. They represcnL visual records o f selected
surgical cases treated at the West Virginia University Medical Center in I'vlorgantown, West
Virginia; the King Faisal Specialist Hospital
and Research Centre in Riyadh , Saudi Arabia;
a nd the Georgetown University Med ical
Center in Washin gto n, D.C. T he majority of
these cases were palie nt5 with illlracranial
a ne u rysms, bu t the e mphasis he re is o n live
anato my such as may be seen in the pterio nal

a pproach to many other lypeS of neurosurgical

problems. Pho tog raph ic slides were selected
for demo nstratio n o n the basis of ill ustrating
clarity of features, having absence of significant tissue disto rtion by tumo r o r hemo rrhage,
showing no rmal a natomic var iations, and/o r
portraying special neuroa nalOmical points.
From a recent historical stand point, the a uthor learned the photographic technique described herei n from trial-and-erro r expe rience a nd fro m lectures given by Leo nard
Malis, Chairman of the De partmen t of
Neurosurgery, Mount Sinai School of
Medicine, New Yor k City. Earl y in his ex pe rie nce the a uthor VLF) was under the misconception that increased lightin g, a wide opening
of the ca mera d iaphragm (small I-stop
numbe r), and short time exposures were necessary lO gain sufficient ex posure of the image
on the film in the prese nce of moveme nt of

neural and vasc ular intracran ial tissues refl ected by card iac pulsatio ns (directly on the
blood vessels) and res pi ratory pulsations (indirectly via the venous circulation). Many surgical photogra phers still pho tograph through
the operating microscope with these concepts
in mind . However, in many instances, pholOgraphs taken with such techniques have lacked
shar pness of image. appeared somewhat flat ,
and fa iled to provide a good de pth of fi eld .
The key lO improving the q uality of the colo r
photographs is to na rrow the le ns a perature
(we use an f -StOp o f 44). T his results in a significant improvemen t in clarity a nd shar pness of
images and in dep th of foc us (reducing the flatness of image effect). To accomplish th is o ne
must increase the brightness of the ligh t source
and/or increase the du ration of film exposure.
The light inte nsity can be increased to some extent by overloading (increasing the voltage) the
tra nsfo rmer of the 30- or 50-W tu ngsten bulb.
Stro nger halogen o r xenon lig ht sou tcescan be
used . But excess light ene rgy, even with the use
of fi beroptic trans fe l~ dries out intracranial tissues rapidly and reasonable lim its a re finite.
One can, however, extend the film expos ure
time la, for example. 1 second . Because a rteria l systolic pu lsations are quite brief compared wi th the entire duratio n of one pulse.
this movi ng (blurred) image is not detected by
thc hu man eye o bserving the resultin g photo..
graph . In oth erwords, th is systolic movemem
(or " noise") is ave raged out by the stable image
of relatively much longer duration [4]. The surgical pho tographer muSl ta ke care to avoid any
respiratory- induced move me nt by as king the
anesthesiologist to hold the paticm 's respirations d u ring the du ration of fi lming if possible.


3. Photographic Tcch ni<Jue

In the a uthor's early yea rs of fi lming with use the right; the TV came ra is on the left; see
narrow lens aperature and I-second exposu re Fig. 2.7). We have tried using special adapters
limes, excel le nt color slides were obtained with allow in g the TV camera a nd still camera to be
any sim ple came ra bacK (film holder) and with attached to the same side of the microscope's
30-\V incandescen t lig hting (givi ng a 2,800 to beam spl ineI' (permitting an observer's tube to
3,100 K color te mperature). Recen t a nd more be attached LO the other side), but the ca mera
sophisticated ca meras, optics, and microscope lens aperatu re had to be wide ned (smaller [lighting systems have not improved the quality stop number) with a res ulti ng degradation of
of the phoLOgraphs, and in many situations the the photographic image.
quality deteriorated. The conve rsion o f some
As reported previously [I, 2], the following
Zeiss microscopes to the usc of halogen, were utilized by the author. For photography,
tungsten-filament lam ps (giving a 3,200 to we used a Zeiss OPM I- I operating microscope
3,400 K color temperalUre) has improved the equipped wi th a 275-mm objective le ns, a 160lig ht inte nsity without noticeable degradation mm focal-l ength binocular tube, 12.5X
in the photogra phic image on tungsten (ASA eye pieces, a 30-70 beam spli tter (70% of the
o r ISO No. 160) Kodak Ektachrome film (ba- lig ht is deflected and divided equally between
lanced for color temperatures of 3,200 K [4, the film on the right and the camera on the left;
5]). We have been satisfi ed with this light.
30% goes to the surgeon's eyes), a Zeiss came ra
More recently we temporarily switched to adapter and 2x magnification auachment, a
the use of the much brighte r xenon ligh t Contax camera body, a nd ISO (formerl y called
source (shown on microscope in Fig. 2.5). How- ASA) No. 160 (tungste n) Ektachrome 35-mm
ever, its color temperature is aro und 6,000 K. fi lm. T he tungsten- halogen light source was
ils e miued liglll energy is stronger in the blue- used without auxiliary lig htin g but with the
"overload "
green spectrum (com pared wi th light from trans former constantly on
tungslen-filamentlamps), and hence one must throug hout the operation. (If the heat is a luse daylight color slide film (Kodak's Ekta- lowed to escape directly into the room, the light
chrome fi lm, ISO No. 200, is ba lanced at a bulb usually la sts throughout several operacolor temperature of 5,500 K). Unfortu - tions.) Before 1980 no drapes were used, but
nately, the heat-absorbing (red-a bsorbin g) the microscope, camera, film, and T V system
path ways of the microscope's optical system were cold-gas-ste rilized for 12 to 18 hours with
further reduced the red speClrum in the lig ht, pure ethylene oxide gas. (New federa l regulaand the resulting photograph (even with day- tions have now restricted this method of sterililig ht film) portrayed defective color reproduc- zation.) Any black-paint border around the
tion. White or g ray tissues had a yellow-green glass pris m deflecting the light through the obcast a nd red blood vessels had a browni sh cast jective lens was removed. Overhead lights in
(due to the red and g reen color mixture). Al- the operating room were turned offLO provide
though proper filters may improve the colo r, beller contrast and LO facilitate dilation of the
the liglllioss may resu ltin no signi ficant netim- surgeon's pupils.
provemem in bri ghtness with the xenon light
Photographs \...e re made with respirations
source compared wi th the tungsten-halogen temporarily stopped or during the ex piratory
light source. Accordingly, we have return ed to phase of the automatic respi rator and with the
the tungsten-ha logen la mp on the Zeiss-Con- [stop on the Zeiss photoada pter set at44 . With
lI'aves o peratin g microscope.
nona utomatic cameras, the ex posure time was
set at I second. Wi th automatic cameras the exposure time approxi mates this duration. We
Current Techniques
use the delayed sh utter-release mode so that a ll
camera and microscope movements have
Except for the Zeiss camera adapte r and 2x ceased by exposure time occurring about
magnification attachme nt, the o ptics is that 12 seconds after pressing the exposure button.
which is contained within the Zeiss operating Self-retaining retractors a nd while cottonoid s
microscope system [3]. The still ca mera (cam- were posi tioned to provide lig ht reflcClions
era back to hold and move the film; Fig. 3.1 ) within the wo und while avoid ing refl ectio ns tocan be any good-quality model and is attached ward the microscope. Unless otherwise indito the rig ht or left side of the beam splitter (we cated, the photographs presented were made

Currenl Techn iques


Fig. 3.1. Contax camera attached 10 microscope beam

splitter via ad apter (not
seen) alld 2x magnification
attachment (arrow).

with the Zeiss magn ification dial set at its third

magnification selling (the old No. 16 01' the
new No. 1). providing a true 6x magni fication
for the surgeon . Although lhe photographs
lhemselves do not provide stereoscopic vision
and sufficie nt depth of fi eld, which may be
6 em from the skull surface, the reader's knowledge of analom), wi ll compensate for this.

Bibliogra phy
L Fox J L (1979) r.,I icrosurgical exposure of imracranial aTleurysms . .1 Microsurg I: 2- 31

2. Fox J L (1983) llitracranial Al1eUl ysms. New York,

Springer-Verlag, vol 2
3. Hoerenz P (1980 - 1981) The operati ng microscope, J Microsurg I: 364 - 369, 419-427;
2: 22 - 26, 126 - 139;3: 179- 182
4. Malis LI (1981) Neurosu rgical photography
thro ugh the microscope. Clin Neurosurg
28: 233 - 245
5. MartIn-Rodriguez JG (1985) Colo l' still and motion pholOgraphy and color tcle\isioll recording
through the operating microscope, in Rand RW
(00): MicrQrlclI.rosllrgery. SI Louis, CV Mosby Co.
ed 3, pp 83-9)

--4 -Cranial Anatomy and the Cranial Flap

The pterion has been defined in Chapter I.
Figure 4. 1 illustrates that the pterion is not a
specific point but rather a general region of the
skull lying under the tcmporalis muscle and in
dose prox im ity to the frontal, parietal, temporal, and sphenoid bones. The frontoparietal
(coronal) sutu re and the sphenoidotemporal
suture do not meet at a common point but in stead come to a "T' intersection (Fig. 4. 1) with
the parietotemporal, parietosphenoidal. and
frontosphcno idal sutures (the latter two forming a relatively straight posterior-ta-anterior
extension of the parietotemporal suture). This
anatomical arrangement allows a short common boundary betwee n the parietal and
sphenoid bones and causes a separation between the fronta l and temporal bones.

Fig. 4.1_ View of left side of skull model .

TIle suture lines between JX)rtions of the
skull arc outlined in ink. F, frontal;
P parietal; T, temporal; S, sphenoidal; and
Z, zygomatic bones.

Figu re 4.2 shows the anatomical arra ngement of these bones at the inner base of the
skull [I]. Although not prominent on the outside, the sphenoid bone represents the "keyslOne" of cranial-base analOmy. The word
sphenoid is derived from the Greek word
sphenoeides, meaning wedge-like [6]. From its
body this interesting struclllre (Fig. 4.3) sends
out lalerallesser and greater wings, a ppearing
rather like a butterfly in flight [2]. For the surgeon operating at the base of the skull and
brain, this hidden keystone contains landmarks of orientation as well as structures that
may have to be removed by rongeurs and highspeed drills. The latter structures include the
sphenoid wings, anterior clinoid process, posterior clinoid process, roof of optic canal,
tubercu lum sellae, floor and septum of the
sphenoid sinus, and floor of the sella turcica.



Fig. 4.2. Base of skull, upper surface. Note that

Ihe anlerior clinoid process is a posterior projection of the origin of the lesser wing o f the
sphenoid oone. Components of the sphenoid
wing include lu, lesser wing; gu'. greater wi ng;
ls, tuberculum sellae; ae, alilcrior clinoid process; sl, sell a lUrcica; pc. posterior clinoid pro ccss;fo, foramen ovate; ds, dors u m sellae. Redrawn from Clemente CD (ed) (198S)Al!alomyoj
tht H/lInol! Body by H em)' Gmy, 30th American
ed . Philadelph ia, Lea & l<"ebigcr, p 17 1 [ IJ.






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

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


The Cranial Flap

By whatever approach to basal structures, the
surgeon must have intimate knowledge of the
sphe noid bone.
The basal cran ial anatomy ta kes on a different pers pective when viewed in the surgica l upside-down, oblique position (see Figs. 2.3 and
4.8). Figures 4.4 and 4.5 illustrate a skull model
with a small pterional cra nial opening. T hesc
show the value of removing mu ch of the
sphenoid wi ng (ie, lesser and greater wings) [3,
4]. Before the sphenoid win g is removed , the
surgeon's view of the suprasellar region is
blocked by the latcral projcClion of the win g
unless greater and haza rdous brain retraction
is a ppl ied . Partial removal of thc sphc noid
wing, practiced for years by Walter Dand y's disciples, pcrmits a lowcr, basal, ta ngential a pproach to the circle of Willi s. Once the surgeon
uses this tcchniquc rOUlinely a nd then omits it
from an operative case, he will appreciate its
significant value for permitting easie r visuali zation of basa l cistern s. This technique ,
coupl ed with the skilled usc of sel f-ret.'lining
retractors and of the operating microscope on
a relaxed brain , allows thc surgeon to manipulate microinstruments in small but sa tisfactoril y visualized spaces.
If we take the same dry skull model shown in
Figs. 4.4 a nd 4.5 , one can see the relationship
of the basilar artery to the anterior a nd posterior cl inoid processes as visualized through a
pterional exposu re (Figs. 4.6 and 4.7). One ca n
unde rstand fro m Fig. 4.7 that removal of
much of thc sphc noid wing on one side a nd a
widely opened sylvian fi ssure on the othcr side
arc necessary to approach the midbrain, pons,
and inlerped uncular cislern wilh mi ni mal
brain retraction. T he posterior clinoid process
of the sphenoid bone then becomes a critica l
la ndmark , lying medial to the oculomotor
nerve passing forwa rd from the midbrain .

The Cranial Flap

All surgica l photogra phs in this atlas arc shown
as a right-sided pterional cran iotomy. Those
that originally were left-sided have bee n reversed to permit consistency in anatomical il lu stration. Much of the following in th is cha pter is mod ified from a previous publication of
the author [4 ].


For a right frontola tcral cra niotomy, the

head is held in a t hree~point skull-fi xation apparatus (see Fig.2.3) and lUrned approximately 300 t045 to the left, tilted 150 to the left ,
and dropped back about 150 (Fig. 4.8). This
brings the " psychopathic poi nt" (see Chapte r I) into the center and to thc highest point
of the opc rative field . (When a right-handed
surgeon operates on the left side of the head , a
40 0 to 450 rotation to the riglH is used.) For
aneurysms of the middle cerebral a rtery or the
internal carotid artery bifurcation, the head
is dropped back further so that thc surgeon's
line of vision is as perpendicular as possible
to the M-I portion of the middle cerebral artcry.
T he skin incisio n is kept behind the hairline
rather than curvi ng for ward into the exposed
forc head. This requi res a long incision, but the
cosmetic resul t is better after the hair grows
back. T he incision (Fig. 4.8) begins at the midline. curves laterally behi nd the hai rline, and
terminates one fingerbreadth in front of the
ear at the level of (or slightl), below) the
zygomatic arch. T he skin flap and galea are
stripped from the temporal is fasc ia a nd perios~
teum, covered with oxycellu lose gauze (colton
may get ca ught in the high-speed drills), and
pu lled fo rward with fi shhook retractors.
An incision is made in the ante rior and postcrior lim il of the ex posed lemporalis muscle.
T he anterior portion of the temporalis muscle
is stripped posterioriy from the zygomatic process of the frontal OOne . Herc one may have to
clectrocoagulate one or two bra nches of the anterior deep te mporal artery (from the imc rnal
maxillary a rter y). Also. tiny art.eries pe rforating the frontal bone just behind its zygomatic
process may have to be coagulated (wilh cuttin g current) and/or sealed with bonewax . The
periosteum is stripped along the line of incision from the exposed fronta l, parietal, and
lemporal bones. Howe,'er, a tria ngle of periosleum (Fig. 4.9) is preserved a nteriorly for later
suturing to the te mporalis fasc ia, thereby coverin g the anterior frontal burr hole at the end
of the operation. This piccc of periosteum ,
with its base anteriorly, is laid on the galea of
the skin flap, covered with oxycellu lose, a nd
held by a fi shhoo k retractor.
The frontotempo ral bone fl ap itself is similar to that illustrated by Lud wig Kempe (sec
Fig. \.5) with the fo llowing modifications
(Fig. 4.10) ,


4. Cranial Anatomy and the Cran ial Flap

I. The first burr hole is just behind the

"psychopathic point" and its anterior ed ge

touches on that point.
2. The second burr hole is also in the frontal
bone. This hole lies more medial than that illustrated by Kempe (see Fig. 1.5). There are
three advantages to this: (a) It allows more
room for frontal lobe retraction without the
retractor striking the fron tal bone. (b) It permils ple nty of room for maintenance oftemporalis muscle attachment to the frontOlcmperosphenoparietal bone flap, thereby reducing the incidence of later temporalis
muscle atrophy. (c) T here is enough exposed bone flap for placement of flap-edge
holes for suturclrubber band retraction of
the bone fl a p.
3. The third burr hole is placed in the parietal
bone just inferior to the temporal line.
4. The fourth burr hole is drilled in the temporal bone just in front of the ear a nd above
the zygomatic arch. If placed too far back,
temporal bone air cells may be encou ntered.
The bone dust is saved and used to fill the
burr holes after closure of the bone flap ,
thereby helping to preven1. a ny future inde ntations of the scalp into the burr holes.
In patients younger than 55 years, the dura
is not usually tightly adherent to the skull bone.
In these cases we often utilize the ai r-driven
craniotome to cut the sk ull fl ap in a similar design between two holes: only the most a nterior
and the most inferoposterior burr holes.
Otherwise a Gigli saw is used to cut the skull
bone between the four burr holes. Prior to
either of these techniques of craniotomy,
rongeurs are used (we usually use the Echlin
ronge ur) to bite away as much of a channel in
the fronto-spheno-temporal bone as possible
between the two basal burr holes under the
temporalis muscle. Doing this before sawing
the bone between the upper calvarial burr
holes allows this inferior bony channel to be cut
without the bone flap inad vertently fracturing
too high above the base.
After the bone fl a p is cut free, its inferior
edge is rongeured (Leksell rongeur) until it
presents a smooth , nonprojecti ng surface.
Heavy si lk sutures are passed through two of
the small edge holes (already drilled for future
reattachment of the bone fl ap to the calvarium). The sutures are each connected to a
rubber band that has been wrapped around

the rubber tubing shown previously in

Figs. 2.7 A and 2.9. In this manner, the bone
fl ap, still attached to the te mporalis muscle, is
retracted over the zygomatic arch, thereby exposing the du ra (Fig. 4.11). The bone flap is
waxed at its edges and then covered with wet
oxycellulose. T he calvarial ed ges are also
waxed . The dura is the n tacked up with sutures
that are passed through the calvarial edge
holes (also to be used for reattachmen t of the
bone fl ap. T he sphe noid wing is rongeured infe riorly as far as possible and then waxed . In
cases where an even more basal ex posure is required , we cut the zygomatic arch anteriorly
and posteriorly. It can be left attached to soft
tissues while the b ulk of the temporalis muscle
is d isplaced inferiorly. The zygoma is reattached at the en d of the surgery.
The superficial temporal artery runs in
fron t of the ear and j ust su perficial to the
galea. Preservation of this arte ry is useful,
especially if the su rgeon pla ns an extracranialto- intracranial anastomosis . This may be necessary if one pla ns on a trapping procedure or an
arterial occlusion. In such a circumstance,
meticulous technique is needed to prevent superficial temporal arter y injury.
The frontalis branches of the facial nerve
pass forward between the galea a nd lemporalis
fascia a nd are usually seen passing anteroinfe rior to the first burr hole. They can sometimes be preserved by turning a superfical
layer of the temporalis fascia forward over the
zygomatic process of the fro ntal bone before
incising the tcmporalis muscle a nte riorly. Electrocoagu lation in the area must be ke pt at a
minimum. T he ner ves a r e ofte n injured, and
the patient may have an immobile forehead on
the ipsilateral side foll owing surgery. In most
such cases, frontalis mu scle function returns
wi thin 6 month s.

Sphenoid Wing Removal

The operating microscope is now brought into
the surgical field and used unti l dural closure.
The Leyla self-retaining retracto rs are attached to the operating table (see fig. 2.1 1).
The dura of the frontal and temporal lobes are
retracted gently from the sphe noid bone and
the lateral roof of the orbit. If necessary, some
cerebrospinal fluid (CSF) ca n be drained by

Sphenoid Wing Removal

lumbar puncture to relieve pressure on the
brain. Release only a sufficient amount of CS F
to perm it a relaxed brain, as excess removal
risks premaLUre rupture of an aneurysm, tearing of vcin s bridging the dura and the brain , or
downward hern iation in cases with mass lesions. The dura of the temporal lobe is often
quite vascular and will require bipolar electrocoagulation, oxycellulose application, and
occasionally th e use of malleable dips.
With a suction-irrigation apparatus in the
left ha nd and a high-speed drill in the right
ha nd (of a right-handed surgeon), the surgeon
removes projections of the sphenoid win g and
latera l orbital roof. Keep all couonoid s out of
the immediate field to avoid injury by their
being caught in the drill. The steel drill bit is
used in itially because ofiLS more ra pid removal
of bone. As the base of the anteriordinoid process is approached, the drill bit is changed to
the d iamond type, which tends less to tear the
nearby dura. The Lempert rongeur is very
helpful in removing sliver-like projections of
the sphenoid wing. A tiny bit of bonewax on a
small , dry couonoid is a pplied against the bone
with the bipolar forceps to stop bone bleeding.
One mllst be careful to avoid drilling into the
orbital cavity. I f this occurs, the patien t will
have greater temporary swelling a nd ecchymosis of orbital tissues during the postoperative period. In some patiellLS there is a
partial, congeni tal absence of the greater wing
of the sphenoid bone behind the orbi t.
The sphe noid wing is removed with a
rongeur and then burred down with the highspeed drill dose to the base of the anterior
clinoid process, a medial depth of about 5 cm
(Figs. 4.12 and 4.13). As one approaches this
point, the meningo-orbital artery (su praorbital
branch of middle men ingeal artery) is a landmark seen in the dura; it passes from the middle men ingeal artery through its own "lacrimal" forame n (Hyrtl's canal) in the sphe noid
wing or through the lateral corner of the
su perior orbital fissure to communicate with
the lacrimal a rtcry in the orbit. (This artery is
one of the remnanLS of the e mbryonic stapedial
arterial system [5]). The meningo-orbital artery usually is electrocoagulated and severed,
allowing further drilli ng ofthe sphenoid wing.


At this point the faster steel drill bit is swi tched

fo r a d iamond bit. The base of the amerior
cl inoid process appears as a glistening while
bone often contain ing a single small vascular
channel (Fig. 4.13).
The dural ope ning is considerably smaller
than the craniotomy defect. The bony open ing
is larger for the reasons stated earlier in this
cha pter. The dura is perm itted to cover the
brai n as much as possible to protect the brai n
from the drying effecLS of air a nd light. T he
dura is opened in a modified, shallow horseshoe-shaped man ner (Fig. 4. 14). The dural
na p is retracted over the smoothed-out
sphenoid bone by suturing it to the galea.
Often a secondary dural inci sion over the sylvia n fissure is needed if the fi ssure is to be
opened widely. At this point, some CS F can be
removed by lumbar drai nage or by aspiration
from the chiasmatic and adjacent ciste rns
under a minimally elevated frontal lobe
(Figs. 4.14 and 4.15). Auention must be paid to
the one or more veins bridging the temporal
lobe and the sphenoparietal sin us. Although it
is good practice to preserve venous drainage
where possible, we have not seen any com plications from electrocoagu lating and severin g
these vei ns. I n cases where minimal temporal
lobe retraction is necessary, these veins may be
preserved . The following chapter details the
anatomy of the sylvian fissure in the approach
to the basal cisterns.

(ed) ( 1985) Anatomy of Ille Human
Body by Henry Gmy, 30th American ed. Philadelphia, Lea & Febigcr, p 171
2. Etter Lf. ( 1955) A/las of Roentgen Anatomy of lhe
Skull. Springfield, 1L, Charles C Thomas PubI. Clemente C D

lisher, pp 16-44
3. FoxJL (1979) Microsurgical exposure of intracranial aneurysms.J Microsurg I : 2-31
4. Fox JL (1983) Intracranial Aneurysms, vol 2. New
York, Springer-Verlag, pp 877-887, 1030

Lie TA (1983) Variations in cerebrovascular

anatomy, in Fox J1. (ed): Intracranial Aneurysms,
\'01 I. New York, Springer-Verlag, pp 432-489
6. Sin/man's Medical DicliOl!l1ry, ed 24. (1982) Baltimore, Williams & Wilkins Co, p 1312



4. Cranial Anatomy and the Cranial Flap

Fig. 4.4. View of dry skull in the same surgical position as in figs. 2.3 and 4.8 prior to removal of the
sphe no id \~il\g. The right orbit is at the upper left
corner. spit, L1.leral aspect of greater sphenoid wing;

pel, pClrous pyramid; ac, anterior clinoid proces; pc,

tip of ]X>sterior clinoid process; crossed an-ow, exposed lOp of red rubber eraser ("lUmor" or

Analo my



Fig. 4.5. Same dry skull as in Fig. 4.4. The sphenoid

wing (sPh) has bee n drilled away. Crossed arraw: red
rubber eraser ("tumo r" or "aneu rys m") sitting on
lhe tuberculum sellae n anked by both ame rior

clino id processes. ac, Right amerior clinoid process;

pel, right petrous pyra mid ;,,;, righl posterior clino id

process. From Fox [3] .


4. Cranial Anatomy and the Cranial Flap

Fig. 4.6. Same dry skull as in '-igs. 4.4 and 4.5. Skull
is in upright, oblique position with view over lateral
roof of orbil. zy. Frontal processofzygoma;pet. right
petrous pyramid; ac, anterior clinoid processes

flank ing tubercu lum sellae (ts); PC. right posteriur

clinoid process; 00, red pen representing basilar artery. (Behind the latter would be the midbrain and


Fig. 4.7. Same dry skull as in Figs. 4.4-4.6. Sku ll

now is in surgical upside-down, oblique position.
Thesurgeon's view is more caudal to view the region
of the "basilar artery" (00, a red pen) as seen via the
pterional approach. The orbit is in the upper left


corner of the figure. pc, Right posterior clinoid process; pel, petrous pyramid; *, right anterior clinoid
process: sph, drilled down sphenoid wing. From Fox


4. Cranial Anatomy and the Cranial Flap

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

The Cranial Flap

Fig. 4.9. Scalp nap turned for right pterional

craniotomy. Paticnt in position shown in Fig. 4.8.
Ga/~a exposed. Crosstd 01'7'01/,\ junction of tcmpo""dl
line with orbital ridge a nd zygomatic process of f ron-


tal bone; fb. fronta l bone; If, tClllporalis fasc ia; pt.
perioste um ; re, raney clips on scal p edgc; s, suction
tube: If, thumb forceps elevating triangular patch of
perioste um offfrontal bone Vb).


4. Cranial Anatomy and the Cranial Flap

Fig. 4.10. The oxycellulosc (ox) covered galea and

scalp flap arc held by fishhook retraCLOrs (fit). A retractor (ret) is pulling the incised lcmporalis m uscle
forward. One parietal (P). one temporal (I), and lWO

frontal if) burr holes have been drilled and covered

with bonewax. fe, Periosteum; el, elevator; if, ternporalis fascia.

The Cranial Flap

Fig. 4.11. The bone flap (bj), covered byoxycell ulose

has becn turned laterally o\e r the zygomatic
arch. It rcmains attached to the temporalis muscle



(t1ll). lph, Sphenoid ....,ing;td. temporal dura;fd. frontal dura : su, suture for later reattachment of the

bone flap .


4. Cranial AnatOmy and the Cranial Flap



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

Sphenoid Wing Removal

Fig. 4. 13. The right sphenoid wing (spl!) has been

burred away. Crossed arrow, vascular channel ill lesser
wing of sphe noid wing near base of anterior clinoid
process; mo, mcningo-orbital artery. On right is a re-


tractor on the dura of the tempo ral lobc (/d). On left

is a suction tube (5) and retractor (ret) 0 11 the dura of
the right frOlllallobe ifd). Zeiss dial SCl at magnification Hu mber 0.6 (old no. 10). From Fox [3].


4. Cranial Anatomy and the Cranial Flap

Fig. 4. 14. Initial exposure of carotid cistern. Magnificatio n reduced. Retractors (rtt) elc\'ating the right
Ic mporallobe (about') and frontal lobe (below) I em
frOIl1 right spheno id wing co\'c red by the turned-

down dural flap (dura), The sylvian fissure (sf) is not

yet opened. 2, Optic nerve; ica, ime rnal carotid aftcry. Zeiss magnificatio n dial set at number 0.4 (old
no. 6). From Fox [3].

Sphenoid Wing Removal

Fig. 4.15. View along sphenoid wing to the right anteriorclinoid process (*). ti. "I"emporal lobc;j1, fronlai
lobe. The internal carotid artery (ica) and optic


nerve (2) are covered by arachnoid. J, Right olfactory tract ; s. suction lube. Zeiss dial set at 0.6 (old
no. 10). From Fox (3).

5-The Sylvian Fissure

Even though the pterional approach to skullbase lesions has become more widely used by
neurosurgcons, significam separation of the
frontal and tcmporal lobes by opcning the sylvian fissure is often not done. However, as we
have gained morc experience. we have o pened
the sylvian fissure more and morc. This has
seve ral benefits [3, 5): (a) small vessels arc not
compressed by arachnoidal bands during retraction of the brain; (b) there is less resistance
(and he nce less bra in-retractor pressure) to retraction of the fronta l lobe; (c) traction 011 onc
lobe does not pull and injure Lhe other lobe;
(d) fewer bridging veins need be sacrificed; (e)
the olfactory nerve usually can be preserved;
and (f) there is minimal traction on perforating
arteries and on a n a neurysm.

Fig. 5.1. CT scan after injection of iopamidol into CS F.

Arrow runs from posterior
cerebral artery (at junction of
ambient cistern with interpedu ncular cistern) to optic
tract. Arrowhead. middle cerebral artery in sylvian fissure.
Section is at level of midbrain
and optic chiasm. Note an
tcrior cerebra l arteries in
chiasmatic cistern (trianglt)
and interhemispheric fi ssure.

Figure 5. 1 is a computed tomography (CT )

scan that nicel y ill ustrates the significant cerebral spinal fluid (CSF) space (sylvian cistern)
between noncom pressed frontal and temporal
lobes. This space, containing the midd le cerebral artery and its branches. is quite prominent
in the older 01" the atrophied brain. h may be
minimal in the edematous or compressed
bra in. The sylvian cistern is larger near its basal
zone, as seen in Fi g. 5.1. and becomes smalle r in
the more peripheral zones. At the surface the
sylvia n fi ssure may appear to be absent (i t is
not) owin g to the close approximation of the
froma l pia and temporal pia mater. This zone
is covered by fi r mly adhering arachnoid
strelched over th e pia, and at first observation
the untutored observor may be mislead into believ ing that an opening of the sylvian fi ssure is
too difficult to wa rrant performing. Indeed.


5. The Sylvian Fissure

the difficulties e ncountered with opening the

sylvian fissure compressed by sofland edematous brain contai ning friable , nonautoregulating vessels may make the procedure LOa
hazardou s. But in most circumstances the fissure can be widely opened, thus pe rmitting excellent exposure of basal anatomy between a
drilled-down sphenoid wing and a widely exposed sylvian fissure.

Figures 5.2 thro ug h 5.8 illustrate the initial
opening of the sylvian fi ssure in five cases (all
photographs in this alias a re presented as viewing the right side). With initia l elevation of the
frontal and temporal lobes (Fig. 5.2), the surgeon will see fine arachnoid bands passing in
the subdural space between the arachnoid and
dura (both being mesodermal le ptomeningeal
tissue of similar embryonic origin). I n some
cases the arachnoid over the sylvian fi ssure is
distended by contained CS F (Fig. 5.3). This
often occurs when the brain has been mildly
shrunken as water is transferred from the
brain into the CS F space owi ng to controlled
hyperve ntilation [7] .
The sylvian fissure is usually opened on the
frontal lobe side of the sylvian veins (Figs.
5.4-5.8). Initially, we use ajeweler's forceps to
pick up the arachnoid (Fig. 5.6), which is incised with microscissors . The self-retaining retractor blades are e mployed to separate the
frontal and temporal lobes, thus gently stre tch
ing the arachnoid in the fi ssure. This facilitates
exposure of the next, dee per layer of arachnoid and its con tai ned peripheral branches of
the middle cerebral arter y (Fig. 5.7). Close inspection via the operating microscope reveals
the eve r-present, fine arachnoid bands or fibers supporting the arteries within their bath
of CS F. This anatomical phenomenon, to be
emphasized throughout this atlas, has been
stressed by Arutiunov an d colleagues in their
drawings [1]. They related mechanical distortion of these supporting fi bers to the evolution
of vasospasm after aneurysmal subarachnoid
We no longer hesitate to coagulate and incise
veins and supe rficial arteries passing between
the two lobes. In this manner the surgeon, with
the suction tu be in his left hand and the bipolar
forceps o r microscissors in his right hand ,
works his way down toward the base of the sylvian fissure (Figs . 5.8-5.12). Meticulous ca re is

taken with the small a rach noid adhesions and

bands adjacent to middle cerebral artery
branches deeper in the fi ssure. When released ,
these bands will not compress a nd compromise
vessels as the lobes are se parated, and the surgeon will find the fissure sudden ly opening up
to sign ificant advantage. A small cotton paddy
or dental cotton ball (counted ) is hel pful for
compressing bleed ing vessels with the suctio n
tube prior to their electrocoagulation.
One finally reaches the much tougher
arachnoid fibe rs at the base of the sylvian fissure (Figs. 5.9-5.1 1). When these arc cut, the
surgeon ga ins immediate entra nce into the
carotid cistern and more CSF is released. During this approach, the surgeon must decide
whether or not to electrocoagu late a nd cutone
or more bridg in g veins between the sylvian
vei ns of the lemporal lobe and the dural
sphenoparietal sin us (Figs. 5. 10-5 .1 3). Preservation of bridging veins generall y is a good policy, bUllheir presence may lim it adequa te exposu re in some cases. Also, these veins may lear,
resulting in venous bleeding at a difficult time
during the operation. We rarely, if ever, had a
complication due to removal of these particular veins. Figure 5.13 shows the preliminary
anatomy in one patient after opening the sylvian fissure.
The following figures ill ustrate va riatio ns in
surgical anatomy of the right sylvia n fissure.
Figures 5.14 a nd 5. 15 are twO separate cases
where on ly the d istal zone of the sylvian fissure
(similar to site of jeweler's forceps in Fig. 5.6)
has been o pened. In each case branches of the
middle cerebral a rtery project out and
arach noid bands a re noted. In Fig. 5.15 the
morc superficial part of the sylvian fissure has
been obliterated la terally by adhesions (from
previous hemorrhage) between the frontal a nd
temporal lobes. Figures 5.16 and 5. 17 are illustrations (at different magnifications) of middle
cerebral arterial bra nches projecting outward
after the lateral portions of the frontal and
te mporal lobes in Fig. 5.15 have been scparated. Emphasis is placed on the arachnoid
bands of Arutiunov ( I], which are clearly revealed in these photographs. Of course, normally they are bathed in CS F within the sylvian
cistern .
Figure 5.18 indicates a later state of dissection where the tough arachnoid between the
base of the frontal lobe a nd the base of the temporal lobe is being severed by microscissors
(compare with Fig. 5. 11 ). Figure 5. 19 shows a

variation in the M-I and M-2 arterial anatomy
after cutting basal arachnoid fibers. Figure
5.20 is an example of a long M-I artery projecting laterally through an early superficial opening of the sylvian fissure. Figure 5.21 illustrates
another long M-I artery ta king the more usual
course deep in the sylvian fissure. Figures 5.22
and 5.23 are exam ples of a long M-l artery and
a short M-l artery, respectively. In both instances, the M-1 a rtery is best seen with the su rgeon's view aimed perpendicular to the axis of
the artery, and this is best obtained by a greate rthan-usual extension of the patient's head
when lesions along the M- l artery and internal
carotid anery bifurcation are treated surgicall y.
As the sylvian fissure is opened more widely
at the base, the bifurcation of the internal
ca rotid artery into its M-J and A- I branches
comes into view. A structu re often seen but not
commonly recognized here is the optic tract
(Figs. 5.23-5.29). In this region the optic tract
forms the lateral border of the lamina terminalis and its cistern , is crossed by the A-I artery, a nd lies deep to perforators passing to the
a nterior perforated substance from A- J, M-I,
a nd the carotid bifurcation vasculatu re. Figures 5.24 and 5.25 a re good examples of important anatomy seen at and just beyond the
widely opened sylvian fi ssure. In addition to
that described above. this anatomy includes the
anterior choroidal artery, stria thalamic perforators. reCUITent artery of Heubncl; and the
anterior temporal artery. Figures 5.26and 5.27
are additional examples where the internal
carotid artery is short. The multitude of stria
thalamic perforators as seen in Figu re 5.28 will
be obscured by a n a neurysm at the bifurcation
of the internal carotid artery (Fig. 5.29).
In a n occasional case, gentle retraction to
separate the fromal and temporal lobes will expose middle ce rebral artery branches usually
deeply hidden in the sylvian fissure (Fig. 5.30).
With microlechnique to open the arachnoid
membrane and to sever the fine arachnoid
bands supportin g the a rteries, the arteries (distended a nd pulsating with blood) may project
outward toward the surgeon (Fig. 5.31). Usually a seco nd layer of arachnoid me mbrane is
found covering the larger M-2 branches and
must be removed to see these branches clearly
(Fig. 5.32). These arteries then can be followed
down to the M- I artery and its pe rforators
(Fig. 5.33). It is thi s author's opinion that the
brain is covered by a double layer of arachnoid


as if the brain had settled down onto a balloon

made of arachnoid membrane. As the brain
"settled," the opposing arachnoid walls approximated, leav ing an inner layer (wrapped
around and supporting the arleries at the base
of the brain) a nd a n outer layer (covering the
brain and stretched between neu ral protrusions so as to form CS F-comaining cisterns and
fi ssures). Ju st as fine arachnoid ba nd s and fibers run between the dura a nd the arachnoid
(see Fig. 5.2), similar ba nds and fibers (of
Arutiunov) run from the inner arachnoid layer
(surrounding arteries) to other nearby inner or
outer arachnoid layers (see Fig. 5.17). Often
the inner layer of arachnoid el1\'elops not only
the conduit arteries but also the perforators
running in the CSF space between the artery
and the brain (the anterior thalamic perforators from the posterior communicating ar'tery shown in Cha pter 8 bein g the best example). Thus, these perforators a ppear to be
lined on both sides by a layer of inner
arachnoid membrane [4]. This membrane becomes stretched, perforated, and discontinuous with growth of the child.
Figures 5.34 and 5.35 are two illustrations of
a leash of stria t halamic perforators passing
from the M-I artery, through the base of the
sylvia n cistern , over the optic tract, and into the
a merior perforated substance. Figure 5.36 is
an angiographic example of such perforators.
The nex t chapter will ta ke the obser ver deeper
into the carotid and adjacent cisterns.

I. Arutiunov A, Baron MA, Majorova NA (1974)The
role or mechanical ractors in the pathogenesis or
short-term and prolonged spasm or the cerebral
ancries. J Neurosurg40: 459 - 472
2. Fox JL (1979) Microsurgical exposure orintracranial aneurysms.] Microsurg I: 2-31
3. Fox JL (1983) Intmcrallial Aneurysms. vol 2. New
York, Springer-Verlag, pp 877 - 1069
4. Fox JL, J erez A (1974) An unusual aCOustic
neurinoma loca lized between brain stem and basilar arlery using emulsified Pantopaque cisternography. Surg Neurol 2: 329- 332
5. Fox JL, Albin MS, Sader DCH et al (1978) Microsurgical treatment of neurovascular disease.
Neurosurgery 3: 285-337
6. )<ox JL, Nugent GR (1976) Recent advances in
intracranial aneurysm surgery. \V Va Med J
72: 104- 106
7. Hayes GJ , Slocum HC (1962) The achievemem of
optimal brain relaxation by hypervcntilation
technics or anesthesia.J Neurosurg 19: 65-69


5. The Sylvian Fissure

Fig. 5.2. In itial intradural exposure down rig ht

sphenoid wing. dum, Dura rencctcd over drillcddowlJ sphenoid wing: tlr, arach noid hands between

d ura and a rachnoid mcmbranc;jf, frolllal lobe;

brain rClraClOrs; II. tcrnporallobc; ~ \'cin.













. ..


fig. 5.3. Arachnoid membrane (ar) in sylvian fi ssure

d istended by CS F. Prom inent sylvian vein (v) cov
ered by this arachnoid and divides peri pherally into
twO branches (single-crossed arrows) entering

sphenoparietal si nus. clp. Malleable clips on d ural

ed ge; If. lem porallobc;jl. fro ntal lobe; (lolJbie-crossed
arrau~ a rachnoid on fronta l lobc side of sylvian veins.


5. The Sylvian Fissure

Fig. 5.4. In itial incision into sylvian fissure (arrows).

This is 0 11 the fronta l lobe (jl) side of the syl\jan veins
(v). Arachnoid membrane (ar, lOP) is stretched over

the sylvian fissure. A rach noid bands (ar. bottom) cross

a peripheral branch (a, bottom) of the middle cerebral

artery. Abo\'c is a surface branch (a, toP) of the middle cerebral artery on the temporal lobe. rei, RetracLOr ; cot, cOllonoid.


Fig. 5.5. Same case ("ig. 5.4). Distal ponion of right

sylvian fissure widely opened, exposing a large fron
tal M-2 arlery (m-2, bottom) and a smali lemporal M-2


anery (rn -2, loP). ica , Imernal carolid ancry (oU( of

focu s) ;col,COltonoid u nder rClracLOr;j1, frontal lobe;
If, lc mporal lobe;ar, arachnoid band.


5. The Sylvian Fissure






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





Fig. 5.7. Furthe r opening or syJvian fissure comaining entwining vessels. ar (toP), Arach noid on
atherosclerotic internal carotid artery (ica); Ie, te ntorial edge; liret, temporal lobe rei ractor;jl-rel, rrontal

JolJe re tral:tor; v, syl vian veins. Note arachnoid bands

(ar, bottom) octween sylvian vessels and pia. From Fox


5. The Sylvian Fissure




Fig. 5.8. Another case to illustrate use of forcep

blades ifcPl to open and separate arachnoid (ar) o n
frontal lobe side of syl\'ian veins. /l-ret, Temporal lobe

rct ractor;jl-rel, fro ntal lobe retracLOr; col, small cott Oil

ball (from dental supply house).


Fig. 5.9. Arachnoid at base of sylvia n fissure is usu

ally thicke ned (ar) and needs to be cut to expose basal
cisterns. gr, Gyrus rectuS; 2, optic ne .... ej ita, illlernal


carotid artery; dum, dura o,'cr sphenoid wi ng; 3,

oculomotor nerve; v, veins;ti, temporallobe;fcp. forceps.


5. T he Sylvian fissure

Fig. 5.10. Another case after partial opening of

arachnoid (ar, lOP) over sylvian fissure. Arachnoid
bands (ar, hottom) connect branch (a) of middle cere
bral artery with pia. cot, Cottonoids under retractors;

fl. frontal lobe; 2, optic nerve; ica, internal carotid artery; pc, posterior clinoid process; v, sylvian veins; It,
temporal lobe. T h e vei n (v, lOP) is entering the
sphenoparietal sinus.


Fig. 5.11. Same case (Fig. 5.10) after further separation of arachnoid (ar, below) b)' blades of forceps
ifcp}, or (toP), Arachnoid band O\'er optic nen'eJ


carotid arrer)' ju ncuon;pc, I>ostenor clino id process;

V, vein; I'll, retractor on tcml>oraiiobe.


5. The Sylvian Fissure


Fig. 5.12. Same case (Fig. 5.10) after clearocoagulalion of vein (v) to sphenoparieta l sin us. dura, Dura
over drilled-down sphenoid wing; te, tentorial edge;

me m, membrane of Liliequisl ill background (pointer

crosses more supe rficial frontal lobe and internal
carotid artcry) ;sc, microscissors.


Fig. 5.13. S.. me case (Fig. 5. 10) a rter rurthe r separalion o r rrontal lobe (j1) and te rn pordl lobe. The
a rachnoid membrane or LilicquiSl (mem) has beCI1
partially opened. re\'ealing the basilar artcry (ba) in


the inter peduncula r cistern. T he uncus (un) is still

adhercnt to thc ocu lo motor nerve (3). s. Suction
tube; 2, optic nervc;pt:. posterior clinoid process; at ,
a nterio r clinoid process.


5. The Sylvian Fissure

/1- 't

fig. 5.14. Another case after opening peripheral

part of right sylvian fissure. Note arachnoid bands
(ar) between arteries and between arterial branches
and pia. The temporal (I) and frontal if) branches of


the middle cerebral artery are projecting out of the

depths of the sylvian fissure and toward the observer. rei, Retractor; Il, temporal lobe; fl. frontal


Fig. 5.15. Anothe r case after partial opening of right

sylvian fissure (crossed arrow). Branch (a) of middle
cerebral arter y lies on island of Reil (*) and comes
from depths of sylvian fi ssure. ad, Adhesions (elec-


trocoagulated) between frontal lobe (jl) and temporallobe (If). col, Coltonoids under brain retractors;
ar, arach noid band .


5. The Sylvian Fissure

Fig. 5.16. Same case (Fig. 5. 15) after further opening

of sylvi3n fissure . dura, Dura over drilled-down

sphenoid wing; or, arachnoid membrane stretched
between frontal and temporal lobes; Ii-ret, temporal
lobe retractOr; floret, frontal lobe retractor. Note

many arachnoid bands between branches (a) of lhe

middle cerebral artery and between arteries and pia
(shown under greater magnification in the next figure).


Fig. 5.17. Same case (Fig. 5.16) and vicw undcr grcater magnification (old Zeiss dial No. 25 or new Zeiss
dial No. 1.6). Crossed arrows, examples of the many


arachnoid bands: col, coltonoid under retraclor;fl.

frontal lobe.


5. The Sylvian Fissure

Fig. 5.18. Another case where arachnoid at base of

sylvian fissure is being cut by microscissors. A suclion tube (s) is in the surgeon's Jcrt hand and microscissors are in his righl. The optic nerve (2) and the
i/Hernal ca rotid artery (ica) a rc still covered by

arachnoid. cot, Small cOlton ball ; rtt, retractor o n

frontal lobe ; v, vein from temporal lobe to
sphenoparietal si nus; II, temporal lobe. From Fox


Fig. 5.19. Example of 1\\'0 (I:Mmom) and o ne

te mporal (top) M-2 branches (m-2) arising from the
M-I artery (m-/). on, Base of aneurysm with dome


buried in temporal lobe (If) ; ala, anterior temporal

artery; v. \eins;j1. frontal lobe.


5. The SyJ vian Fissure

Fig. 5.20. Exampleof middlecerebral arter y pmjecting through partial o pening o f sylvian fi ssure. cot,
Coltonoids under retractor;jl. frontallobc; an , twO
microanc urysms of 1\'1- 1 artery (m - I) bifurcation; pia,

posterior temporal artery: fl, temporal lobe; I, tempol-al M-2 branch; G, small artery; v, vcins;f, frontal
1\'1-2 brauch.



Fig. 5.21. View along a widely opened right sylvian

fissure uncler less magnification (old Zeiss dial
No. 10 or !leI,' Zeiss dial No. 0.6). flrel, Fro ntal lobe
retranor; 2, optic nerve; ica, imernal carotid artery;
double-crossed arrfJUl, origin of anterior choroidal artery; single-crossel{ arrow. crosses dome of ica
aneurysm and poims to posterior com mu nicati ng a r-

tcry dcep to aneurysm; ala, antcrior tcmporal artcry; Il-,.et, temporal lobe retractor; cot, couonoid ; 1/12, M-2 arteries arisi ng with multilobulated
aneurysms at bifurcation of the M- I artery (m-/); ox,
ox),cellulose (Surgicel);ar, arach noid bands;a-I, A- I
artery. From "ox [3].


5. T he Syl\'ian Fissure


Fig. 5.22. Example of long M-l artery (m-/) bu ried
deep in right sylvian fissure. rei, Retractor on the
tem poral lobe; cot, cOltonoid; v, \'ci ns; an, small
aneurysm flanked by tempol'a] M-2 artery (loP) and

rronlal M-2 artery (bottom). NOle perforators sUlek to

dome of aneurysm. ala , Anterior temporal artery.
From Fox [2].


Fig. 5.23. Example of short M I artery (m.I) at base

of sylvian fissure. slw, Superior hypophyseal artery;
ica, bifurcation of internal carotid artery ; ala, a n
terior temporal artery; an, small aneurysm nanked
by temporal M2 artery (t) and frontal ~1 -2 aner), (j);


p, perforating arteries ar ising from the A-I artery (a-I)

and entering the a nterior perforated substance; at,
optic tract. The M- I perforators are mostly hidden
behind the M-l arte ry. From Fox [2].

ar, arach noid fibers enveloping perforators;


5. The S)'lvian Fissure

. r?lu

Fig. 5.24. Example of atherosclerotic internal

carotid a rle ry (*) bifufcation seen after a wide opening of the sylvian fissure. mem, Dceply located membrane of Liliequist; a-I, A- I anery; mol, M-I arter),;
ach, amcriorchoroidaJ artcry;ar, arachnoid band be-

tween artery and temporal lobe; I, temporal M-2 aftery;f, frontal M-2 artery; p, perforators from A-I
and M-l anerics;o/, optic tract; v, veins; 110., ret:ur reru
artery of Heubner; ch, optic chiasm.


Fig. 5.25. Internal carotid artery (ica) bifurcation at

base of sylvian fissure (at higher magnification: old
Zeiss dial No. 25 or new Zeiss dial No. 1.6). hp,
hypothalamic perforators from internal carotid ar
lery (ica); acll, anterior choroidal artery; mem, deepl y


located arachnoid membrane of Liliequist; m-l, M-I

artery entering sylvian fissure; p, perforators from
internal carotid and M-J arteries; ho., artery of
Heubner; a-J, A-I artery; ret, frontal lobe retractor;
ot, optic tract; eh, opticchiasm;ar, arachnoid bands.


5. The Sylvian Fissu re


'" gel


Fig. 5.26. Transsylvian view of M-J (m-l) and A-I (aJ) origins from internal carotid artery (ica). CrOSJed
arrow, origin of anterior choroidal anery; pea, min iscule posterior communicating artery whose anterior
thalamic perforaLOrs (p) are notable; 00, basila r artery in backgrou nd; sea, right superior cerebellar ar-

terYi 1'-1, large P_I artery; /l.ret, tcmporallobe retractorian, base of aneu rysm (from bi furcation o f basilar
artery); ot, optic tract (see a<ljacent perforators from
A-I l;jl-ret, frontal lobe retractor; gel, gelatin sponge
(Gclfoam); ch, optic chiasm; 2, optic nerve; Pit, piLUilary stalk. From Fox [3].


Fig. 5.27. Another exam pic of transsylvian view of

A-I (a-I) and M- I (m-l) origins fro m short internal
carotid artery (iea). Note anterior thalam ic perforators a nd arachnoid bands coming off posterior
communicating arlcry (pea) . Retraction of the uncus
(unc) causes angulation of the oculomotor ncl"'-'c (3)


lateral to the postel-ior clinoid process (pe).fib, Fibrin

from previous hcmorrhage; ala, anterior temporal
arlery; m-2, M-2 artery; 01, optic tract; p, perforator
fro m anery of Heu bner;jl-ret, fro ntal lobe retractor;
cit, optic ch iasm; 2, optic nerve; ac, anterior clinoid
process. From "ox (3].


5. T he Sylvian Fissure

Fig. 5.28. Another case where the internal carotid arlCry bifurcation (crQSMd arrow) is well seen after the
sylvian fi ssure is widely opened. Note leash of
arach noid bands and perforators (p) passing from A-

I (a-I) to the anterior perforated substance. ell, optic

chiasm; Qt, optic tracl; 00, basilar artery;slm, superior
hypo physeal arlcry;o7l, aneurysm orica at rakeoffof
anterior choroidal aftery; m-I, M-l artery.


Fig. 5.29. Base of aneurysm (an) at bifurcation of inlernal carotid artery (ica), transsylvian view. Artery
of He ubner (1m) is adherent to aneurysm. a-I, A- I artcry; If, lamina terminal is; ot, optic tract; adm, a n-


terior choroidal artery; pea, posterior commun ic.1.ting artery; If, temporal lobe; m_l. M- J aner)';cof, cOttonoid ; 1111, rctractoTs;j1, frontal lobe. From Fox [3] .


5. The Sylvian Fissure

Fig. 5.30. Anothe r case illustrating the anatomy o f

the right syJvian fissure. Arachnoid still CQ\'c r s the
sylvian fissure (between crossed arrows) in which the

arteries arc exposed by separation of the frontal (jl)

and temporal (tf) lobes. rei, Retractor; spit, dura rcnected over sphenoid wing; v. vein.


Fig. 5.31. Same case (Fig. 5.30) after the arachnoid

over the sylvian fissure has been opened.
Peripheral branches (a) of the middle cerebra l artery
project the mselves toward the surgeon. Deeper M-2



branches remain covered by a deeper layer of

arachnoid (crossed arrow). Note strands of arachnoid
fibers supporting the arteries. *, Unseparated
deepe r portions of the froma l and temporal lobes.


5. The Syh'ian Fissure

Fig. 5.32. Same case (Fig. 5.30) after removal of the

deeper arachnoid layer. The frontal M2 branch
(single-cros.sed arrow) and the temporal M-2 branch

(dQuble-trOSMd an-ow) are seen. ala, Aillcrior temporal




Fig. 5.33. Same easc (Fig. 5.30) aflcrcxposurc of the
M- I arter}' (m-l) deep in the sylvian fiss ure. T he M- I
division into the frontal (single-crossed arrow) and
temporal (double.crossed arrow) is seen. Note leash of
stria thalamic perforators (perf) passing from M-l.

crossi ng the right op tic tract (ot), and enter ing thc antcrior perforated substance under the frontal lobc
retractor (ret). fl, Temporal lobe; an, giant internal
carotid aneurysm; ala, anterior temporal arter y.

5. The Sylvian Fissure


Fig. 5.34. Samccase (Fig. 5.30) with more magni fied

view of ]\,1 I (1/1+ 1) perforators. pel[. One of man)' M-l
perforaLOrs; m-2, M-2 arteries; rei, fro mal lobe re-



optic tract; an, aneurysm;

arachnoid fibers from art.eries.





Fig. 5.35. Another case showing arterial anatomy of
base of right sylvian fissure. Note unusually large
perforator (double-crossed arrow) arising from the M1 arte ry (m-/). II, Te mporal lobe ; ala, anterior temporal artery; lia, arte ry of Heubner; 01, optic tract;j1,

fmnla1 lobe; aI; arachnoid fibers; a- I, A- I artery; eh,

o ptic chiasm; iea, internal camtid artery; pea, posterior communicating artery; single-crossed arrow. anterior choroidal anery.


5. The Syh"ian Fissure

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

6-The Carotid Cistern and Environs

The carotid cistern, the chiasmatic cistern, and
the cistern of the lamina lcrminalis lie rostral to
the arachnoid membrane of Liliequist (membrane of Key and Retzius). Surgical observations regard ing the cerebral spinal nuid (CSF)
cisterns and their companmental divisions arc
described elsewhere [3]. Fig ure 6.1 is a coronal
com pUled tomography (CT) image (a cisternogram) that nicely illustrates the rela tions hip
of the illlcrnal carotid artery to the carotid cis-

tern bounded late rall y by the medial portion of

the temporal lobe. Posteriorly the carotid cistern is separated from the interpeduncular cistern (see Chapter 8) by the arachnoid membrane of Lilicquisl; mediall y the carotid cistern
joins the chiasmatic and lamina terminalis ciste rns and superiorly it joins the sylvian cistern
(fi ssure) . In Fig. 6 .1 note the bifurcation of the
internal carotid artery into the middle cerebral
artery (r..'I- 1 segment) and the anterior cerebral
artery (A- I segment). This occurs altheconfluence of thc uppe r pan of the carotid cistcrn,

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


6. The Carotid Cistern and Environs

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

the lower-medial pan of the sylvian cistern

(containing the M- I origi n), a nd the upper-late ral part of the chiasmatic ciste rn (containing
the A- I origin ). This confluence is bounded
superiorly by the anterior per forated substance of the fronta l lobe .
In earlier years when pneumoencepha lography was a common intracranial imaging pro-

passes from side to side between both

oculomotor nerves (see Fig. 8.1). Normally it is
either a solid , translucent sheet with openings
on either side or a multi perforated membrane
allowing passage of CSF from the posterior
fossa into the anterior cisterns, from whe nce
CSF circulation continues ove r the surface of
the brain. After subarachnoid hemorrhage or
cedure, the injected gas (usually air), which re- meningitis, ad hesions a long this membrane
placed or displaced some of the CS F. often was may sea l offCSF passageways a nd ca use a comtemporarily trapped in the interpeduncular municating hydrocephalus. Opening eithe r
cistern (Fig. 6.2). The air was prevented from this mem bra ne or the la mina terminalis at
passing throu gh me mbrane openings and into surgery releases much CSF and may be a perthe anterior cisterns by the membrane of manent cure for patients with hydrocephalus.
Liliequist until a sufficien t pressure differen- Unless one is approaching a lesion in the intertial developed to overcome adhesive forces be- peduncular cistern or attempting lO release
tween the air bubbles and the moist a rachnoid CS F from the posterior cisterns, it is bette r to
leave the Liliequist me mbrane intact. It acts as
membra nes .
The membrane of Liliequist. known origi- an effeCli ve barrier to surgical blood entering
nally as the membrane of Key and Retzius. is an the posterior basal cisterns. Further details are
important arachnoid landmark [2]. The mem- given in anothe r textbook [2].
brane run s from the dorsum sellae and posterior clinoid processes upward toward the
mammillary bodies of the hypothalamus. It


The surgical anatomy prcscmcd in this alias is
oriented as the surgeon sees it through the
operating microscope at surgery. It is always
de picted on the right side of the patient for observer consistency, and the reader may need to
refe r to the figures in Chapter 4 (especially
Fig.4.8) for occasional orientation of the
supine patie nt's head. T he right olfactory tract
will always head toward the upper-left corner
of the figure (towa rd the paticm's nose), and
the righl lcmporallobc (usually its uncus) will
lie und er a ribbon retractor 011 the right side o f
the field (toward the paliem's riglll ear).
Now that the sylvian fi ssure has been
opened (Cha pter 5), the surgeon recognizes
normal (or abnormal) va riations in surgical
anatomy as seen between the basc of the sylvian
fissu re a nd the dura reflccted ovcr the drilleddown a nd surgically fl attc ncd sphenoid wing
( ~igs. 6.3 a nd 6.4). The fi rst visible branch of
the internal carotid artcry is usuall}' not lhe
ophthalmic a rtery, for the origin of the
ophthalmic artery invariably is hidden by the
superiorly a nd medially overlapping optic
nerve. The ophthalmic a rtery usually arises on
the medial side of the carotid artery just below.
above. or at the level of the exit of the carotid
a rte ry from thc cavernous sinus. Most commonly the surgeon first recognizes the ori gin
o f the posterior communicating artery on thc
latcral , poste rior, or posterolateral side of the
ca rotid artery; but on close inspection onc can
see more proximal (ie. toward the heart) arterial branches, which are the superior hypophyseal a rtery (Fig. 6.4) and hypophyseal perforators. Throughollt this cha pter the reader
will note how close the internal carotid artery
comes to the posterior clinoid process. and at
times its bifurcation is behind the level of the
dorsum sellae. The oculomotor nerve (third
cra nial nerve) always lies external to the posterior cl inoid process. as this nerve passes forward under thc a nterior reflcction of the tentorium and into the top of the cavernous sinus
(sec Figs. 8.2 and 8.3).
T he intracran ial portion of the internal
carotid artery may be fairly long, as noted in
Figs. 6.3 a nd 6.4, or short, as demonstrated in
~igs. 6.5 a nd 6.6. T he shorter this internal
carotid ar tery segment. the more readily the


su rgeon can expose the origins of the A-I and

M- I branches.
A leash of vital perforating artcries arises
from the posteroinferior side of the internal
carotid artcry and the posterior communicating a rtery (Figs. 6.7 and 6.8). Often one has to
retract the carotid artc ry medially or laterall y
to sce thcm. Thcse perforators include the
superior hypoph yseal artcry. hypophyseal perforators, and anterior thalamic perforators. As
the surgeon retracts the frontal lobe. the olfactory tract a nd gyrus rectus come into view.
Co mmonly, thc r ecurrcnt artery of Hc ubner
(pc rforator fro m the antcrior cerebral artery)
is seen in the Cl"cvicc between the retracted
frontal lobe and the optic nerve (Fig. 6.7).
Whc n la rge, this may be mistaken for the A-I
artery, which lies behind (o r in front) and
below the artery of Hcubner.
As one retracts the temporal lobe, a major
inte rnal carotid artery branch within the
carotid cistern will be the an tcriorchoroidal artcry or arteries (frequently there may be two or
evcn three) as illustrated in Figs. 6.9 and 6.10.
This a rtcry arises laterally, postcriorly, or posterolatera lly from the internal carotid artery
and passes posteriorl y under the uncus of the
tempora l lobe. II. enters the choroid fi ssure
and passes thence into the temporal horn . As
this a rte ry travels back, it may come in close
proximity to the bifurcation of the internal
ca rotid artcry and its perforators.
The poste rior communicating artery may be
seen dec p to the space between the carotid ar
tery a nd the optic nc rve (see Figs. 6.6 and 6.9).
or it may bowolltlatc raliy as show n in Figs . 6.11
and 6.12. Even when the posterior CO Ill municating artery is small (Figs. 6. 13 a nd 6.14),
it will contain vital a nterior thalamic perforators to the brainstem. Ofte n an infundibulum of the posterior communicating artery is seen, a nd its a ppearance suggests a
prcancurysmal a nomaly (Fig. 6.15) dcveloping
at the d istal angle between internal carotid artery and the posterior communicating artery,
the classical si tc of such ane urysms (Fig. 6.16).
Although the pituitary stalk lics in the back
of the chiasmatic cistc rn, it often is readily
identificd upon exposure of the carotid ciste rn . As shown in Figs. 6.7 and 6. 11, for example, the ptcrional approach renders the pituitary stalk visible through the space betwecn thc

6. The Carotid Cistern and Environs


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


Internal carotid artery

Origin of the ophthalmic artery (not always)
Origin of the superior hypophyseal anery
Origin of the posterior communicating anery
Origin of the anterior choroidal artery
Origin orlhe middle cerebral artery (M- I)
Origin orthe anterior cerebral arte ry (Al)
Origins of the hypothalamic perforators from the carotid artery
Origins of the more rostral anterior thalamic perforators
Some stria thalamic perforatorll
A portion orthe artery of Heubner
A portion of Ihe ante rior perfo ralCd substance of the frontal lobe
Medial surface orthe temporal lobe
Lateral border orlhe optic nerve
Sympathetk fibers on the internal carotid artery
Rostral edge of the posterior clinoid process (dural covering)
Anterio r cli noid process (du ral covering)
A portioll of the tentOrial edge between the anterior and postcrior clinoid

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

oplic apparatus a nd the carotid artery. The

slalk lies between the arachnoid membrane of
Liliequisl posteriorl y and the optic chiasm anteriorly. It appears as a reddish, vascu larized
projection passing inferiorl y through the
opening in th e diaphragm sellae. T he su perior
hypophyseal artery a nd hypothalamic perforators provide a rich ane rial blood supply,
and the ponal plexu s of veins also are visible
under microscope.
Regard less of the location of the lesion, we
not only open the sylvian fiss ure substantiall y
but we also lyse adhesions and arachnoid
(which separates the carotid and chiasmatic
cisterns) between the ipsilatera l optic nerve
a nd the base of the frontal lobe whe n usi ng the
pterional approach (Figs. 6.1 7 and 6. 18). This
allows: (a) gentle retraction of the frontal lobe
without adhesions pulli ng on the optic nerve,
(b) less brain retraction press ure, (c) occasional inspeClion of the anterior communicating complex in aneurysm cases, (d ) exposure
of the lamina tcrminalis in cases with hydrocephalus, and (e) assessment of local anatomical variations and e nhance ment of the surgeon's knowledge of surgical anatomy. In our
experience the latte r is done at no risk [Q the
patient a nd has bee n extremely important in
honing the surgeon's skills. in patients without
lesions in the anterior communicating region,

actual exposure of the anterior communicating a nery is not done in pa tients who would require significant frontal lobe retraction .
Figures 6.19 a nd 6.20 illu strate how, in some
cases, the internal ca rotid artery ca n exte nd or
project above and behind the level of the poste rior clinoid processes and the dorsum sellae.
Here we are looking med ially behind the optic
apparatus (nerve, chiasm, and traCl) ; the lOp
and side of the dorsum sellae are brought into
Although not proved histologically in this
case (Fig. 6.21), we believe that sympathetic fibers are seen traveling on the adventitia of the
internal carotid anery in the carotid cistern.
T hey ca n be mistaken for arachnoid bands and
vIce versa.
Upon elevation of the fro ntal lobes in the
nonswollen brain , a view of the medial side of
the opposite carotid cistern can be visualized
(Fig. 6.22). Note how the medial side of the
temporal lobe forms the lateral boundary of
the carotid cistern. Figures 6.23 a nd 6.24 again
show how the carotid cistern is bounded behind by the arachnoid membrane of Lil iequist,
above by the a nte rior perforated substance,
laterally by the tem poral lobe, and mediall y by
the chiasmatic cistern. T he membrane of
Liliequist appears blue whe n CSF remains behind it in the interped uncular cistern. The


color turns black when the CS F is drained (eg,
by aspiration or lu mbar puncture) so as to leave
only a shadowed space without the reflecting
and refracting water (CSF). Note the unusual
veins (bilateral) from the unseen cavernous
sinus to the unseen basilar vein of Rosenthal ,
the unusual position of the pituitary gland in a
shallow pituitary fossa, the portal veins on the
pituitary stalk , and the opposite posterior communicating artery seen through the space between the optic nerves.
Figures 6.25 and 6.26 represent another
exam ple of the carotid cistern and environs.
Note the su pe rior hypophyseal artery, pituitary stalk, and anterior thalamic perforators
with hypophyseal perforators (displaced me-

dially by giant aneu rysm). Table 6.1 summaries the various structures found in the
carotid cistern. The next chapter will take us
i~to the more med ial chiasmatic and adjacent

I. Fox JL (1979) Microsurgical exposure ofintracranial aneurysms. J Microsurg I: 2-31
2. Fox JL (1983) IntmcranUiI Aneurysms. New York,
Springer-Verlag, frontispiece, pp 877 - \069
3. Ya~argil MG, Kasdaglis K, Jain KK et al (1976)
Anatomical obser vations of the subarachnoid cisterns of the brain during surgery. J Neurosurg


6. The Carotid Cistern and Environs

Fig. 6.3. View of right carotid cistern and environs.

aI', Arachnoid membrane between the optic nerves;
1, olfactory trdct; gr, gyrus rcctus; 2, right optic

nerve; Ttl, retractor on frontal lobe; crossed arrow, origin of the posterior communicating artery; ica, internal carotid artery; 3, oculo motor nerve passing forward uncler the morc lateral tentorial edge (Ie), by
the more medial posterior clinoid process (PC) and
thence imo the C3\'e rn OUS sinus; mem, a refleClion of

Liliequisl's mcmhl<tlle. Between the ocu lomotor

nerve and Liliequisl's membrane is a black, dear CSF
passageway into the interpeduncular cistern. Note
the attachment of Liliequist's arachnoidal membrane to the posterior clinoid and adjacent dors um
sellae. Opening this membrane between the
oculomotor ne rve and the internal carotid artery is
the usual frolllolatcra l route to the interpeduncular
cistern. From ~ox [ I].


Fig.6.4. Carotid cistcrn in another patient. or,

Arachnoid between optic nerves; 2, right optic
nerve; slUJ, superior hypophyseal artery; ica, internal
carotid artery; Ie, anterior reflection of tentorial
edge, 3, oculomotor nerve passing late ral to duraon


posterior d inoid process (PC); pea, posterior com

municating anery; mem, membrane of Liliequist;fl
rei , fro mallobe retractor; 1, ol factory tract; v, vein 011
gyrus rectus (gr). From Fox [2].


6. The Carotid Cistern and Environs

Fig. 6.5. Right carotid cistern with shon internal

carotid artery (ica). 2, Optic nerve; ac, anterior
clinoid process; mem, membrane of Liliequisl (cover.
ing posterior clinoid process); pea, origin of posterior communicating artery; ), oculo motor nerve;

ad, adhesions between aneurysm (an) and temporal

lobe (/l);cot, couonoid;ata, anterior temporal artery;

crossed arrow, origin of anterior choroidal artery; bif,

bifurcation of carotid artery; fri, origin of A-I artery;ft. frontal lobe. From Fox [2].


Fig. 6.6. Anotherexample of a short internal carotid

artery (ica) . Note yellow atherosclerotic plaque. pea,
Origin of posterior commun icating artery (lateral
pea) passing behind carotid artery and reappearing
deep to space betwcen optic nerve (2) a nd carotid ar


{cry; gel, Gelfoam on optic nerve; a-I, right A- I artcry; bif, bifurcation of carotid artery; ret, temporal
lobe retractor; an, a neurysm ; ad, adhesions between
aneurysm and tentorium (te). From Fox [ I].


6. The Carotid Cistern and Environs

Fig. 6.7. Example of long atherosclerotic internal

carotid artery (ica) and environs. Many
hypothalamic (including superior hypo physeal artery) and anterior thalamic perforators (enclosed in
an envelope of arachnoid) arc seen passing back and
medially from the carotid artery and the posterior
communicating artery (pea). peif, One of these per-

rorators coming off the carotid ancry;), oculomotor

nerve, tl, uncus of temporal lobe;jl. frOlltal lobe; ret,
retractOr ; J, olfaClory tract; ar, arachnoid between
optic nCfI'CS; 2, right optic nerve; JUl, recu rre nt artery of Heubner;pil, vascular pituitarystalk ;pc, d u ra
on posterior clinoid process. f rom Fox [2].



,, /


Fig. 6.8. Greatly magn ified view between right optic

tract (ot) and internal carotid artery (ica). Zeiss dial
set at No. 2.5 (old No. 40). Anterior thalamic perfOTawrs(jJeifj from carotid aneryand posterior com -

municating artery (pca) are seen. 2, Optic nen-e;

mem , membrane of Liliequist; pro probe retracting
carotid artery laterally. From Fox [I].


6. The Carotid Cistern and Environs


Fig. 6.9. Carotid cistern with origins of posterior

communicating artery (pea) and anterior choroidal
artery (acha) from internal carotid artery (jea). mem,
Membrane of Liliequist; an, aneurysm; 3, oculo-

mOLOr ncrvc;ad, adhesions between frontal lobe and

optic tract (ot); pit, pituitary stalk; 2, optic nerve; 00,
origin of ophthalmic artery; ret, retractors. From
Fox [2].




Fig. 6.10. View of carotid cistern showi ng relationship of anterior choroidal anery (acha) to the uncus
(tine) of the temporal lobe./I(1., Anery of Heubner; J,
olfactory tract; gr. gyrus rectus; 2, optic nerve; iea. inlel'llal ca rotid arlery; pea, origin of posterior com
munica ting anery; Ie, tentorial edge; all, aneurysm

(shrunken and elongated by bipolar electrocoagulation) ; ad, adhesions and fibrin between aneurysm
and temporal lobe and tentorium. Deep to the anterior choroidal a n e ry (adUJ) lies the arachnoid
me mbrdne of LiliequisL From Fox [I].


6, The Carotid Cistern and Environs

Fig.6. 1I. View o f carotid cistern with laterally d i

rected posterior communicating artery (pea). mol,
M-l origin;peif, perforators from A-I (a-I); ot, right
optic tract; Jryp, hypothalamic perforaLOrs from
carotid artery; pil, pituitary stalk; ch, optic chiasm; 2,
left and right optic nerves; (-ica, medial side ofleft ill-

lernal carotid artery; dia, diaphragm sellae; pc, left

posterior clinoid process; crossed arrow, superior
hypophyseal artery; r-ica, right internal carotid artery; r-pc, right posterior clinoid process; ), oculomotor !len"e. From Fox [2J.


Fig. 6.12. A very athcrosclerOlic imcrnal carotid artery (ica ) with the posterior communicating artery
(fxa) goi ng latcrally. Crosud arr~ crosses dome or
atherosclerotic ane urysm and points to perforator.
adm, Ante rior choroidal artery; 00, basitar arter),
lying in imerpeduncular cistern a nd seen arter re-


mova l of membralle or Lilicquist (In.!m) still attached

to oculomOlOr ncn'e (J) and posterior clinoid process (PC), rtt, Retractor on right temporal lobe; te, tenlorial edge; at:, anterior clinoid process; 2, optic


6. The CarOlid Cistern and Environs

--=- ---

Fig. 6.13. Example of small, short posterior communicating artery (crossed arrow) connecting internal
carotid artery (ica) with posterior cerebral artery (p2). cot, Cotlonoid; unc, uncus of temporal lobe; an ,
small aneurysm at takeoff of anterior choroidal artery ;


m- I, origin of M-I artery; a- I, origin of A-J artery;lUl,

artery of Heubner; 01, optic tract; 2, optic nerve; ac,
anterior clinoid process; pc, posterior clinoid process; te, tentorial edge; ), ocu lomotor nerve. From
Fox (2].




Fig. 6.14. Same case as Fig. 6. 13 with probe (pr) displacing carotid artery medially. Crossed arrow, site of
anterior thalam ic perforators from posteriOl com-

municating artery; 01, optic tract; pc, posterior

clinoid process; p- J, P-l artery; 3, oculomotor nerve;
unc, uncus;p-2, P-2 artery.


6. The Carotid Cistern and Environs

Fig. 6.15. Example of prcaneurysmal type of infu ndibulum (croSMd af7"ow) of posterio r com municating
artery (pea). perf. Anterior thalamic perfor.uors;
adm, aillcrior choroidal anc!)' ; V, vein; a-l, A-I artery; Qt, OPlic tract; fl-rt/, frama l lobe retractor ; pro

probe retracting carotid artcl1' i Pit, pituitary stalk; 2,

optic ncn'c;llC, anlcrio r di no id process; un, internal
ca rotid artery; Ie, te ntorial edge; pc. postcriordinoid
process; J, oculomotor Ilcn'c; II-rei, temporal lobe rctractor. From ,"ox [2].




Fig. 6.16. Carotid cistern after bipolar eleclrocoagu

lalion of aneurysm (an) with ad hesions (ad) to
ocu lomotor nerve (3) and uncus (unc) of tcmporal
lobe. col, Cottonoids; mem , membrane of Liliequist


(or Kcy and Retzius); ac, autcrior clinoid proccss; ica,

internal carotid artery; pc, posterior clinoid process;
pea, origin of postcl'ior communicati ng artcry. From
Fox [2].


6. The Carotid Cistern and Environs

Fig. 6.17. Anatomy of carotid cistern and e nvirons.

Arachnoid membrane of Liliequisl(mem) is well seen
deep to and between the internal carotid artery (ica)
and oculomotor ne rve (3). Crossed arrow, anterior
choroidal artery; IInc, uncus; ml, origin of M-l artcr),; an, base of aneurysm at bifurcation of carotid
artery; a-1, righ t A-I al"ter}'; a-a,junction of right A- I
and unseen rig ht A-2 and anterior communicating

(aea) arteries; gr, r ight gyrus rectus; perf, per forators

from anterior communicating artery; hr, bridging artcry from anterior communicating artery to left A-2
artery (connection out of view); a-2, Icrt A-2 artery;
2, optic nerves; ch. optic chiasm; ft, lamina terminalis;
ot, r ight optic tract; ac, ante rior clinoid process; ds,
diaphragm sel lae; pc, posterior cli noid process; pea,
posterior communicating artery.


Fig. 6.18. Sa me case as Fig. 6.17. Upper internal

carotid artery (ica) and the M- I origin (m- /) are retracted by a probe (pr) to \'iew perforators (crossed arrows) and optic tract (ot) beh ind aneurysm (an) and
bifurcation of carotid artery. pea, Posterior COIll-


municating artery; -UIIC. uncus; acha, anterior choroidal arte ry;s, suction lube; perf. perforators; 00, recurrem artery of Heubner;jl, frontal lobe; a-I, A-I artery; Ma. anterior com municating artery; it, lamina


6. The Carotid Cislern and Environs

Fig. 6.19. Ano ther case with view of carOlid cistern

and e nvirons, looking morc medially. Appearing deep
between right internal carotid artery (r-iea) a nd o ptic
apparatus a re seen perforators (peif). pituitary stalk
(Pit), right posterior clinoid process (PC), lOp of lhe
dorsum sellae (ds), le ft superior cerebellar artery (lsell), and left oculomotor nerve (3). Lateral to the
right carotid artery 3rc noted the tentorial edge (te),
side of the dorsum sellae (ds), a dural venous si nus

(us) behi nd the dorsum sellae, the posterior communicating artery (pea) and its adjacent aneurysm
(crosud arrow), the P-2 artery (p.2). basilar artery (00),

and right oculomotor !len 'c (3). 2, Optic nerves; ch,

o ptic chiasm ; 01, right o ptic tract;foo. right (bottom)
and left (toP) fronto-orbital arteries;gr, right (bottom)
and left (lOP) gyri recti; l-ita, med ial side of left internal carotid artery; a.-I, A- I artery_


Hg. 6.20. Same case as Fig. 6.19 emphasizing reo

lationship of intcrnal ca rotid artcry (ica) and poster ior clinoid proccss (PC). Ids. Top of dorsum sellac
covcrcd by dura ;fds, front of dOT5um seUae;sds. side
of dOT5u m sellae; vs, vcnous sinus in dura beh ind
dOT5u m sellae; J, oculomotor ncrve; col , cottonoids;
P01lS, rostral pons; sea, right superior cerebellar arte ry behind 3rd ncrvc;p-2. P2 artcry in front of3rd


ne rve; une, uncus;a1l. second aneurysm at takeoff of

anterior choroidal a rlery (hidden); CTossed arrow, first
aneurysm at takeoff of posterior communicating artc ry (hidden); rtf, r ight temporal lobe retractor; m J,
M- I a rte ry origin; 00, basilar artery ; Iry, hypophyseal
perforator from ica; a- I , A- I a rte ry; 01, optic tract.
Note Icft lateral medu llary pe rfo rator from basilar
;lrtCI,), a nd in shadows behind dorsum sellae.

6. The Carotid Cistern and Environs


Fig. 6.21. Ano ther case illu.n rating sympathetic fi
bers (5)'"') o n internal carotid artery (ica). ar (]alen]),
Arachnoid band ; Ie, tcnlorial edge; an, aneurys m at
takeoff of [.N)Sterior communicating artery (hidden:
most of aneurysm is below lcnloriu m);cot, cottonoid:

frontal lobe rclrdctQr; ar (medial), arachnoid

membrane between optic nerves; 2, right optic
ncn'c; mem, membrane o f Liliequist; ac, anterior
clino id process. From Fox [ I].
Il t,


Fig. 6.22. Another tase showing view of medial side

of opposite (kfl) carotid cistern. reI, Retractor on
right frontal lobe (fl); ch, optic chiasm; 2, both optic
nerves; cot, cotton ball; clp, shank of aneurysm clip ;
ac, right anterior clinoid process; ar, arachnoid fi-


bers; 1.5, tuberculum sellae; unc, medial side of left

uneus;foa, left fronto-orbital artery on left fronta l
lobe; m- I, origin ofleft M- I artery; v. vein ; ica, left internal carotid artery (medial side near bifurcation);
a- I, origin ofleft A-I a rtery.


6. The Carotid Cistern and Environs

Fig. 6.23. Another case with view of carotid and

chiasmatic cisterns. The pituitary gland (pit) projects
superior to the level of the diaph ragm sellae. Sing/to
crossed arrow, portal veins o f pituitary stalk ; 2, optic
nerves; ell, optic chiasm; r-ica, right internal carotid
artery; hy, hypothalamic perforators from internal
carotid artery; pc. dura of posterior clinoid process;
mem omembrane o f Liliequist; v, unusual vein arising
from cavernous sinus; double-crossed arrow, posterior

communicating artery; aella, one of two alllerior

choroidal arteries;tl-ret, temporal lobe retractor; 111-1,
M- l pordon of midd le cerebral artery; fmi, perforators from bifurcation of jea to alllcrior perforated substance; ot, right o ptic tract; a-I, A-I portion
of anter ior cerebra 1 artery;fl-rel, fro mal lobe retractor; l-ica, left imernal carotid artery; l-pea, left posterior comm unicating artery. From Fox [2].


Fig. 6.24. Some case as Fig. 6.23. View is looking med ially toward the le ft internal Gl.rotid artery (i-ica). 2,
Optic nerves; Pit, pituitary st.alk; l-pea, le ft posterior
communicating artery; ch, optic ch iasm; a-1 , A- I portion of left anterior cerebral artery; cot, COtton strip;


1/j.-1, M-l portion of left middle cerebral artery;jl-ret,

frontal lobe retractor; v, unusual vein on left arising
from cavernous sinus; pr, probe retracting the vein ;
crossed arrow, medial left temporallobc. ,"'rom Fox [2].


6. The Carotid Cistern and Environs

Fig. 6.25. Another case illustrating internal carotid

artery (ita) and environs. pc, Posterior clinoid p rocess; an, giant aneurysm o f right P1 artery; tl, right
temporal lobe; mol, M-I artery; a-i, A-I artery; ret, retractor on frollla!lobe;a-2, right A-2 artery;gr, gyrus

rectus; am, anterior communicating arter y; 2, optic

nerves; ch, optic chiasm; sha, superior hypophyseal
artery; crossed arrow, one of several hypophyseal and
anterior thalamic per forators in an arachnoid
sheath; Qt, optic tract.


Fig. 6.26. Same case as Fig. 6.25. Probe (pr) is retracting right optic nenc (2) mcdially to show pituitary
stalk (pit). pc, Posterior clinoid process; all. giant


ancurysm; te, telltorial edge; UIIC, uncus; ),

oculomOlOr llen'c; I'll, temporal lobe retractor; bif,
bifurcation of right internal carotid artery.

7- The Chiasmatic Cistern and Environs


lamina terminalis is behind and above, and the

olfac tory cisterns pass an terior to the chias-

As the surgeon d issects medially from the ptcriona l exposure, he or she enco unters a confl uence of cisterns in the ccn ter of which is the
chiasmatic cistern . T he computed tomography
(CT) scans with cerebral spinal fl uid (CSF) contrast e nhancement show the ch iasmatic cistern
and adjacent cisterns (Figs. 7. 1 and 7.2). The
ca rotid cisterns are lateral, the cistern of the

matic cistern. T h e o lfactory cistern lies between the gyrus rectus and medial orbital
gyrus. I n the mid li ne between the fronta l lobes
is the pericallosai cistern and interhemispheric
fiss ure (cistern).

Fig. 7. 1. Axial \icw of CT scan after injection of

iopamidol into the CSF by lu mbar pu ncture: cisternogram of chiasmatic cistern containing optic
chiasm (black arrowhead) and medial poI-lions of optic
nerve. Closed black arrow crosses ant.el-im-clinoid process and poi nts to lateral portion of optic nerve in
carotid cistern; open arrow lies in confluence of upper

carotid cistern with med ial chiasmatic cistern from

which arter ial shad ows of A-I (medially) and M-I
(laterally) can be seen 10 originate; white arrow points
to optic tract lying lateral to the laleral portion of the
cistern o f the lamina terminalis and medial to the
confluence of the two cisterns (carotid and sylvian);
while triangle lies on lamina termi nalis.


7. The Chiasmatic Cistern and Enviro ns

Fig. 7.2. Coronal (fro mal) view of CT scan after injection o f iopamidol into the CSF by lumbar
puncture: cistcrnogram of olfactory cistern. Black arruws lie in olfactory cistern and poim to olfaClory

branch of anterior cerebral artery in interhemispheric fiss ure; open arrow, contrast medium in sub
arachnoid space (optic cistern) surrounding optic
nerve in orbit.

tracts; while triangle, gy rus rectus; while dosed arrow,

As the surgeon elevates the frontal lobe, the olfactory tract may be stretched if the brain is
vcry relaxed . If thi s ha ppens, vei ns near the
midline and traversing bcnveen the frontal
lobe (gyrus rectus or adjace nt medial orbital
gyrus) and nearby dural si nuses may lear and
bleed . When such occurs, it will be necessary to
expose the olfactory cistern (Figs. 7.3 and 7.4).
This maneuver is not necessary unless bleeding occurs, requiring bipolar electrocoagulation of these veins.
The olfactory tract appears as a white ba nd
lying in the olfactory cistern. Posteriorly, it
arises from the medial a nd lateral olfacto ry
stria , formin g the from border of the anterior
perforated substance. The tract is adherent to
the fromallobc between the gyrus rectus (medially) and the medial orbital gyrus (laterally).
further anteriorly the olfactory tract se parates
from the brain (figs. 7.2 and 7.5) and passes toward the olfactory bu lb la teral to the crista galli
(Fig. 7.6). From this olfactory bu lb pass the hidden fil a me nts of the olfactory nerves down
through the cribiform plate and into the mucosa of the nose.
As the dissection proceeds med ially from

the carotid cistern and into the chiasmatic cistern toward the anterior com municating complex, the surgeon may fo llow the A- I artery ifit
is easily seen. Th is usually occurs if the inte rnal
carotid artery is fairl y short. In cases where the
inte rnal carotid a rtery is long a nd the A- I artery is hidden posteriorly, the surgeon shou ld
avoid retraction of the frontal lobe to ex pose
the A- I artery. If an anterior communicating
artery aneurysm is the target. the approach is
then directl y through the gyrus rectus [2-4].
T he la ndmarks for the I-cm incision in the
gyrus rectus are illustrated in Figs. 7.7 and 7.8.
The triangular or quadrangular zone inferior
and lateral to the franta-orbita l artery lying on
the gyrus rectus is described in the legends for
these figures.
If the sylvian fissure has been widely
opened, elevation of the frontal lobe will brin g
the optic chiasm, optic tract, and lamina terminalis (betwee n the optic tracts) into view in
cases with a prefixed optic chiasm (ie, short
optic nerves intracran ially). Figures 7.9and 7.10
a re two examples of a prefixed chiasm. The
lam ina termina li s appears as a thin , translucent me mbrane retain ing third ventricular
CS F inside. The CS F on its outer, visible side
lies in the cistern of the lamina terminal is,

which contains the medial portion of the A- I
arteries, their interconnecting anterior communicating artery, and the recurrent artery of
Heubner (Figs. 7.10-7. 12). The cistern of the
lamina terminalis me rges with the chiasmatic
cistern below and a nteriorly a nd with the interhe misphe ric fi ssure (cistern) superiorly.
Laterally, the cistern of the lamina terminalis
me rges with the confluence of the sylvian a nd
carotid ciste rns lateral to the optic tract.
Figures 7.13 and 7.14 are intraoperative
photographs of the same patient. In I-igure 7.13 we see through the right carotid cistern a nd the lamina terminal is and ch iasmatic
cisterns into the left (opposite) carotid cistern .
The tented la mina tenninalis is prominent.
The medial side of the left internal carotid a rtery is seen superior and inferior to the image
of the left optic nerve. The left posterior communicating artery is visualized deep to the
pituitary stalk. Pa nicularly important are the
hypophyseal perforators from the carotid a rteries. If the A- I arteries are fo llowed medially
and superiorly, the anterior communicating artery is seen lying in the cistern above a nd a nterior to the tented-up lamina terminalis
(Fig. 7. 14).
Figures 7.15 through 7. 18 are four exam ples
of variations in the a natomy of the chiasmatic
and lamina terminalis cisterns. In each case the
inferoanterior zone of the lamina terminalis is
visuali zed . In Figs. 7. 15 and 7. 16 the r ight late ral
margin of the pituitary stal k is seen. This pituitary stalk, along wi th the optic nerves and
chiasm, lies in the chiasmatic cistern (bounded
caudally by the arachnoid membrane of
Liliequist) . However, in many cases the me mbrane of Liliequist, which lies caudal to the
pituitary stalk, sends an ante rior reflection of
arachnoid membrane in front of the pituitary
stalk. This situation puts the pituitary stalk inside its own hypophyseal cistern (Fig. 7.16). In
l'ig. 7.16 note that the frontal lobe retraction is
stretching arachnoid bands at the lateral margin of the cistem of the lamina terminalis.
Figu res 7.17 and 7.18 add itionally illustrate
the many variations in the pathway of the recurrent a rtery of He ubner. Generall y, this artery
a rises from the A-I a rtery or the A-2 arte ry
near the a nterior communicating artery (refer
to Fig. 7.40). There may be two arteries of
Heubner on one side. The artery passes later+
ally and lies superior to and behind or in fron t
of the A-I and medial origi n of the M- ) arteries


and sends branches into the anterior perforated substance. Freque ntly the anery o f
Heubner is seen before the A- I artery is iden+
tified, and it may bequite large (as in Fig. 7. 11 ).
Figures 7.19 and 7.20 are photographs of the
same patient before a nd after per foration of
the lamina terminalis to treat hydrocephalus.
One of the many variations in the anteriorcommunicating artery complex inside the lamina
terminalis cistern is shown here. Such variations, with duplications and cross-bridges, are
common (refer to Fig. 7.39). This is a triplicated anterior communicting artery complex
with a bridge between two of the arteries. The
artery of Heubner is well see n.
Figures 7.2 1 through 7.24 de monstrate two
patien ts in whom the artery of Heubner is the
same diameter as the A- I artery (Figs. 7.21 and
7.22) or larger tha n the A- I artery (Figs. 7.23
and 7.24). In Fig. 7.21, the A- I artery is almost
t... .:: size of an adjacent large M-I perforator,
and the M- I arter y is equal in size to the internal cal"Otid artery. In Fig. 7.22 the pituitary
stalk is surro unded by arachnoid (Liliequist's
me mbrane beh ind and an a nterior reflection
of the same me mbrane in front). He nce the
pituita ry structures are 111 their own cistern
(hypophyseal ciste rn).
The same is true In another patient
(Fig. 7.23) whe re part of the a nterior arachnoid
enclosing this cistern has been opened by the
surgeon . The pituitary stalk is redd ish due to
the marked arterial and portal venous vascular+
ity (which partly accounts for its enhancement
on CT scans with contrast medium). Figure 7.24 in the same patient shows a ve ry
hypoplastic right A-I artery a nd a large right
artery of Heu bn er. Additional anomalies are
the low takeoff of the frontopolar arteries. The
large left A- I artery supplies this unusual anterior commu nicating complex. Because the
anterior communicating a rtery is lifted up by
an a neurysm in the cistern of the lamina tel'minalis, descending "hypothalamic" perforato rs are well shown .
Figure 7.25 is a n example of a patient with a
prefixed chiasm and short internal carotid arteries. Without the surgeon go in g through the
gyrus rectus, the right A- I, anterior commun icating, and left A- I arteries are seen upon
elevation of the frontal lobe. Im ponan t perforators from the right A- I a rtery to the right
optic tract, chiasm, and nerve are seen. I-igure
7.26 also is a photograph of a shon internal

7. The Ch iasmatic Cistern and Environs


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


Optic chiasm
Optic ner\'es. medial border
Surface of the gyrus rectus of the frontal lobe
Tuberculum sellae (dural covering)
Arachnoid membrane of Liliequist (Key and Retzills), rostral surface
Arachnoid between optic neTl'es
Superior hypophyseal artery
Hypothalamic perforators
A portion of the fronto-orbital artery
Pituitary stalk (often lies within its own cistern)

Items 2-5 can be considered to form portions of the margins of the chiasmatic cistern.

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

II .

Outer surface of the lamina terminalis

Surface of the optic tracts
Surface oflhe gy rus rectus of the frontal lobe
Anterior cerebral artery, A-I portion
Anterior cerebral artery, origin of A-2 portion
Origin of the fronto-orbital artery
Artery of Heubner, proximal portion
Hypothalamic perforators from A-I and anterior communicatinganeries
St.ria thalamic perforators from the A-I arte ry
O rigin of an occasional accessory anterior cerebral artery

Items 1-3 can be conside red to form portions of the margins of the lamina
terminalis cistern.

carotid artery and a prefi xed chiasm . An unThe common ly duplicated a nterior comusual arterial anomaly is also illustrated: the ar- municating artery again is seen in Fig. 7. 33. Figtery of Heubner an d th e frolltopolar artery ure 7.34 shows the underside of a n anterior
arise from a common trunk . This arterial com municati ng artery and nearby perforators.
trunk origi nates at the right A- IIA-2 ar terial
The optic tract is rarely well seen unless the
junction. Branches from the ascend ing fron- sylvian fiss ure has been opened. Figures 7.35
topolar artery suppl y the territory of the ab- through 7.38 are examples ill ustrating this
tract in two patients. I n fi gure 7.35 the origin
sent franta-orbital a rtery.
Figures 7.27 through 7. 30 reveal a common of an accessory anterior cerebral ar tery is seen
variation in the amerior communica ting artery (someti mes mistaken for the base of an
complex . In Figs. 7.27 through 7.29 the an- a ne urysm) . Figur e 7.36 (sa me patient) isa more
terior communicating artery form s a "Y" with magnified view of the la mina terminalis seen
one limb on the right a nd two limbs on the left. between a large artery o f Heubner and the A- I
the superior one a nastomosing higher up on ane ry. A large ve in tur ns posteriorl y and passthe left A-2 artery. In Fig. 7.30 the an te rior es along with the optic tract to join the unseen
com municati ng artery is duplicated ; the basilar vein of Rosenthal.
superior one is hidde n by a layer of arachnoid .
Figures 7.37 and 7.38 are twO views of the
Figures 7.31 and 7.32 ill ustrate a nothe r right optic tract and chiasm. The A- I arteries
example of a V-shaped anterior communicat- join the anterior communicating artery well
ing arte ry with the common trunk on the right above the lamina terminalis, a nd the left A- I arand the two limbs on the lefl. Additionall y a tery has an unu sua l bridging artery retu rning
large perforalor and an accessory ame rior back to the left A-I. Note the arachnoid band
cerebral artery (a third, midline A-2 artery) (com pare with that in Fig. 7. 16) over the right
arise at the division of this V-shaped anterior A-I artery at the lateral border of the cistern of
communicating a rte ry.
the lamina terminalis. Tables 7.1 and 7.2 sum-



marize the various structures found in the

chiasmatic and lamina terminalis cisterns.
The duplications and bridges ofte n seen as
the a nterior communicating artery complex
were illustrated by Bremer [1] in 1943
(Fig. 7.39). But it was only with routine use of
the operating microscope that surgeons saw
how commonly such va riations occurred. Figure 7.40 is Westberg's representation of the
usual course of the recu rrent artery of
Heubner [5]. This large perforator sends
branches illlo the anterior perforated substance along with the stria thalamic perforators
from the A- I a nd M- l arteries.

I. Bremer J L (1943) Congenital aneurysms of the

cerebral arteries. An embryologic study. Arch

Pathol35: 819~83 1
2. Fox J L (1979) Microsurgical exposure of intracranial ane urysms. J Microsurg I : 2 - 31
3. Fox J L ( 1983) Intracranial Aneurysms, vol 2. New
York , Springcr-Vcrlag, pp 877 - 1069
4. Kempe LG (1968) Operative Neurosurgery, vol I : Cranial, Cerebral, ami Intracranial Vascular Disease. New
York, Springer-Verlag, pp 1- 75
5. Westberg G (1963) The recurrent artery of
Heubne r and the arteries of the central ganglia.
Acta Radiol (Diagn) 1: 949-954

7. The Chiasmatic Cistern and Environs



Fig. 7.3. Lower portion of olfactory tract (1). gr,

Gyrus rcclus;2, right optic nerve;dura, dural margin
of optic canal; ar, arachnoid covering internal

carotid artery (carotid cistern); ac, anterio r clinoid

process; v, vein on temporallobe; s, Sliction lube; ret,
retractor on fro ntal lobe.


Fig. 7.4. Same case as Fig. 7.3. Middle portion of

right olfactory tract (1) in olfactory cistern. V, Vein in
sulcus between frontal lobe (jT) and olfactory tract;


dura, dura covering orbital roof (floor of anterior

fossa) projections; nt, retractor on frontal lobe.


7. The Chiasmatic Cistern and Environs

Fig. 7.5. Same case showing olfactory tract (1) passing through subarachnoid space from frontal lobe

(jl) toward cribi form plate and nose. v, Vein; a, artery;cg, dura of crista galli.


Fig. 7.6. Another case demonstrating olfactory bulb

(ob) and upper olfactory tract (I). cg, Crista galli; ret,


retractor;jZ, base of frontal lobe ; dura, dura covering

orbital roof projections.


7. The Chiasmatic Cistern and Environs

Fig. 7.7. Initial exposure of gyrus rectus (gr) during

an approach to an amerior com municating artery
aneurysm where the A-I artery is not followed medially. Note the quadrangular zone bounded by the
edge of the frontal lobe retractor blade (jl-ret), the
fTOlllo-orbital artery fjo), the frontallobe/optic nerve
junction (dQuble-crossed arrow), and the olfactory tract

(/). T he incision in the gyrus rcelusis made here and

the fronto-orbital artery is followed to the aneurysm.
v, Vein; ar, arachnoid between optic nerves; 2, rigln
optic nerve; ica, interna l carotid artery; Ie, anterior
reflection of tentorial edge; Ii, temporallobc; II/em,
membrane of Liliequisl; cot, cotton strip lying on sylvian fissure. From Fox [3].


Ag.7.8. Another case illustrating the initial exposure of gyrus rectus on the right (r-gr) where the
right A-I anery (a-I, hottom) is fo llowed medially.
Crossed arrow, interhe mispheric fissure. Note quadrangular zone oounded by the frontal lobe and right
A-I j unction, the olfaclOry tract (/), the front.allobc
retractor blade (jI-ret), an d the f!"OOlo-orbital artery
I/o). The initial incision is made within this zone. r-gr,
Right gyrus rectus; lIa, left artel-Y of Heubncr; i-gr,


medial surface of left gyrus rct:lus; i-10, left fronloorbital artery; aT, arach noid between optic nerves; 2,
left and right optic nerves; Ii, temporallobc; ch, optic
chiasm;it, lamina terminalis;o/, right optic tract;mca,
branch of middle cerebral aner}, in sylvian fissure;
a-l, left (toP) and right (hoI/om) A-I arteries converging lOward the hidden anlerior comm unicating ar
ter y. From Fox [3J.


7. The Chiasmatic Cistern and Environs

Fig. 7.9. Another case illustrating prefixed optic

chiasm (ch). Lamina terminalis (it) and its cistern be
tween the optic tracts (ot) arc seen. Within the cistern
oftbe lami na terminalis is pari of the A- I anery(a- J)
and a duplicated amerior communicating artery
(aca). ar, Arachnoid between optic nerves (2); ica, internal carotid arte ry; ac, anterior dinoid process; pc,

posterio r clinoid process; Mm, arachnoid membrane o f Liliequist; te, tentorial edge; ata, anterior
temporal artery; It, temporal lobe; hij, bifurcation o f
iea; tUmble-crossed arrow, origin of hidd en anterio r
choroidal artery; single-crossed arrow, origin of hidden posterior com municating artery; /w., artery of




Fig. 7.10. Another case with prefixed chiasm (ch) and

short intracranial optic nerves (2). T he carotid,
chiasmatic, and lamina terminalis cisterns appear
here without identifiable boundaries after dissec

tion. ica, Imernal carotid artery; Ii. temporal lobe;

al, AI artery; !Ia, artery of Heubner;j1, frontal
lobe; 1$, tuberculum sellae; it, lamina terminalis; ot,
optic tract. From Fox [2).


7. The Chiasmatic Cistern and Environs

Fig. 7.11. Same case as Fig. 7.10. A short imernal

carotid artery has permitted exposure of the anterior communicating artery (aca) by followi ng the
right A- I artery (a-I, bottom). The upper chiasmatic
cistern and the cistern of the lamina tcrminalis are

exposed. ch, optic chiasm; It, lamina terminalis; ot,

optic tract; ha, right (bottom) and left (toP) a rteries of
Hcubner; gr, right gyrus rectus; a- J (lOP), left A-I arterYi/o, left [ront()-orbital artery on left gyrus reclus.
From Fox [2 ] .


Fig. 7.12. Same case after removing about Iem

length of gyrus rectus to expose an anterior commun icating artery aneurysm (an) surrounded by left
(lap) and riglll (bottom) A-2 arteries (a-2). Above are
the left and below are the right A- I arteries (a-I), ar-


teries of Heubner (ha), and frorlLO-orbital arteries

1/0).//, Lamina lerminatis;gr, teft gyrus rectus. These
st ructures lie within the lamina terminalis and interhem ispheric cisterns. From Fox [2].


7. The Chiasmatic Cistern and Environs

Fig. 7.13. Another case with exposure of all the anterior cisterns bounded by the left and right temporal lobes (l-Il, r-el). s, Suction tube above bifurcation ofleft internal carotid artery (l-ica); (1- 1, both A-I
arteries; ii, lamina terminal is; ot, right optic tract;fl.
right frontal lobe; 2 , both oplic nerves; ky. left and
right hypophyseal perforators; Pit, pituitary stalk
(and its hypophyseal cistern) surrounded by

arachnoid (ar), which splits and surrounds it; pc,

posterior clinoid process; mem, me mbrane of
Liliequist; l-ica and r-ica, both internal carotid arteries;l-pca and r-pea, both posterior communicating
an eries. The left one (i-pea) lies in froOl of Liliequist
membrane and is seen through the space between
the pituitary stalk (pit) and [he right carotid artery
(r-ica). From Fox [3].





Fig. 7.14. Same case after exposure ofrwo aneurysms

on the anterior communicating artery. The
small one projecting upward is obvious. The large
one projects downward and is hidden by the anterior
communicating artery (aca). Above and below arc
the left and right A-I arteries (a-I) and A-2 arteries

(a-2) . 111. left frontal lobe , Lt, lamina terminalis, 01,

right optic tract; bif, bifurcation of right internal

carotid artery; col. couonoid; JUl, right artery of
Heubner; fl-ret, right frontal lobe retractor. From
Fox [3].


7. The Chiasmatic Cistern and Environs

Fig. 7. 15. Another case showing chiasmatic cistern

both rostral and abo\'c (to observer's left) and caudal
a nd behind (to observer's right) the optic ap pa ratus.
$, Suction tube ; l-fl, left frontal lobe; ar, arach noid be
tween left oplie nerve and frontal lobe and separating left carotid cistern from chiasmatic cistern; 2.
bolh optic nerves; fo, le ft fronto-orbi ta l ancl}'; ha,
left arteries of Hcubnc r ; ell, optic chiasm; 01, right
optic tract; ac, right anterior clinoid process; Pit,

pituitary gland projecting above (with rcspca to paliem) sella lUl'eica; ita, internal carmid artery; frs,
pituita ry stalk; ft, la mina terminalis; rei, rctractoron
right fro mal lobe; an, aneurysm arising from anterior commun icating artery; a-I and a-2, left (toP)
and right (bol/om) A- I and A-2 artcrics:fp, low !.akrofr
of le n frolHopolar artcr)' ;col, small coHon hall. From
Fox [3}.


Fig. 7.16. Another case showing surgically induced

communication between chiasmatic cistern rostrally
and inter ped uncular cistern caudally. T he latler contains the basilar artery (ha) seen after opening the
membrane of Liliequisl (mem). Note Liliequ ist's
membrane sends an anterior reflection around
pituitary sta lk (pit), thus enclosing the hypophyseal
cistern. Double-crossed arrow, reflections of light from
CS F in interped uncular cistern; ji"gle-crossed an-ow.

14 1

lies on short internal carotid artery and points 10 origin of posterior communicating artery; /l-ret, temporal lobe retracto r ; m}, M- I artery; perf, largest of
several perfo ratOrs from A-I artery (a-1); ot, right
optic tract; ar, arachnoid bands at lateral margin of
cistern of the lamina tenninalis; fl, lami na terminalis
(covered by A- I artery);j1-rel, frontal lobe retractor;
ell, optic chiasm; 2, both optic nerves; ac, anterior
clinoid process. FrOIll Fox [2] .


7. The Chiasmatic Cistern and Environs

Fig. 7.17. Another example of structures in chiasmat

ic, carotid, and lamina lerminalis cisterns. 2, both
optic nerves; ch, optic chiasm; ii, lamina terminalis;
Q/, right o ptic tract; ac, aillerior clinoid process; d()Uble-cro5Sed arrow, origin of posterior communicating

artery from internal carotid artery;


M-l artery;

perf, perforator from A-I artery (a-I); ha, artery of

Heubner;fo, franto-orbital artery; rei, retractor on

frontallobe;sillgle-crossedarrow, interhem ispheric fissure; gr, left gyrus rectus.


Fig. 7.18. Another example of the lamina terminalis

A bilobed anterior communicating artery
ane urysm (an) is surrounded by the lert A-2 artery
(a-2, loP), the anterior com municating artery (aca),
and the rig ht A-2 artery (a-2, boltom). The termination of the lert A-I artery (a-I, toP) is seen. 2, both



optic nerves; ell, optic chiasm; ot, right optic tract; a-I
(bottom), right A- I artery;ha, artery of Heubner; r-[o,
r ight fronto-orbital artery;Jl, right frontal lobe; ret,
retractors; V, vei n on lert gyrus rectus (gr); l-fo, left
fronto-orbita l artery.


7. The Chiasmatic Cistern and Environs

Fig. 7,19. Another case illustrating lamina tcrminalis

(ll), its cistern, and a variation of the anterior communicating complex with 3 arteries (uca) and a
bridge (brl between 2 of them. a-I, Left (lOP) and
r ight (bollom) A- I arteries; eh, optic chiasm; ot, righ t
optic tract; single-crossed arrow, origin of posterior
commu nicating artery: douhle-crrused arrow, origin of
anterior choroidal artery; mol, M-I artery; v, vein; r-

JUl, rig ht artery of Hcubncr; ju,junction of anterior

communicating artery and hiddell right A-2 artery;
r-fo, right franto-orbital artery; an, microaneu rysm
on anterior communicating artery; a-2, left A-2 artery; ar, arachnoid in interhemispheric fissure ; l-fo,
left frollto-orbita.l artery; t-fla, Icrt artery of
I-Ieubnc r. From Fox [3].


Fig. 7.20. Same case as Fig. 7. 19 after putting musli n

(mu) on microaneurysm and open ing (singk-U05Std
arrow) the lamina terminalis (It); ica, internal carotid


artery; doublt-cro.s.std arrow. anterior choroidal anery;

nt, frontal lobe retractor; ot, optic tract;3v, third ventricle; tot, small cotton ball .


7. The Chiasmatic Cistern and Environs

Fig. 7.21. Chiasmatic cistern in case with hypoplastic

right A-I artery (a-l). The recurrent artery of
Hcubncr (ha) is as large as the A-I artery. p. Perforators; mol, M- I artery; m-2, fronta l (bottom) and
temporal (top) M-2 arteries; aT, arachnoid over sylviall fissure; II, temporallobe;jl, frontal lobe; cot, cot-

tonoid; rei, fronta l lobe retractor; ft, lamina lcrminalis; ot, right optic tracl jch, opticchiasm;gr, right
gyrus rectus; 2, both optic nen'es; l-ica, left internal
carotid artcrYipit, pituitary stalk; mem, membrane of
Liliequisl j T-ica, right internal carotid artery.


Fig. 7.22. Magnified view of Fig. 7.2 1. Arachnoid

membrane of Liliequist (num) sends anterior sheet in
fro nt of pituitary stalk (pit). ac, Anterior clinoid process; r-ica, atherosclerotic right internal carotid artery; cot, cottonoid; aM, anterior temporal anery
from internal carotid artery; ret, temporal lobe re-


tractor; m-I, M-l artery; a-I, hypoplastic A-I artery;

p, perforator; IUl, artery of Heubner;foa, fromo-or-

bital anery; r-gr, right gyrus reClUS; ihf, interhemispheric fissure ; l-gr, left gyrus rectus; l-ica, left internal carotid anery; 2, both optic nerves; ch, optic
chiasm; ft, lamina tenninalis; ot, right optic tract.


7. The Chiasmatic Cistern and Environs

Fig. 7.23. View of opposite imcrnai carotid cistern

and ch iasmatic cistern. 2, both optic nerves; {-gr, left
gyrus reclUs; i.oa, left ophthalmic artery going
unde r left o ptic nerve; l-iea, atherosclerotic left internal carotid artery (medial sidc);is, tuberculum sellae;
r-oo, origin of right ophthalmic artery; r-ica. right in-

lernal carotid artery; mem, part of membrane of

Liliequisl (opened) passing in front of pituitary stalk
(pit); p, hypothalamic perforator; ot, right optic tract;
it, lam ina terminalisj ch. optic chiasm; ar, arachnoid
between optic nerves. From Fox [3].


Fig. 7.24. Same case as Fig. 7.23 after removal of ,I

small amount of right gyrus rectus (r-w) to view ciste rn of the lamina terminalis. Another example of a
hypoplastic right A-I artery (a-I. !mllom) and a large
right artery of Heubner (r-ha). The left A-2 artery is
hidden by the right A-2 artery (a-2). an. Aneurysm
projecting back against the lamina termi llalis (It); p.
hypothalamic perforators stuck to alllerior COIl1-


1T1unicating ,1Itcry aneurysm; *, anterior communicating artery; r-/pa, right frontopolar artery
(unusually low takeoff from the A-2 artery); I-[pa,
left frontopolar artery; l-gr, left gyrus rectus;[oa, left
fronto-orbital artery; I-ha, left artery of He ubner ; aI (loP), le ft A-I artery; 2, both o ptic nerves; ch, optic
ch iasm; Pit, pituitaty stalk; ot, right optic tract. From
Fox [3].


7. The Chiasmatic Cistern and Environs

Fig. 7.25. Example of chiasmatic cistern with prefixed oplic chiasm (short intracranial optic nerves).
gel, Gelfoam on left optic nerve; 2, both optic nerves;
ch, optic chiasm; iCG, internal carotid an ery; elp,
shanks of two aneurysm dips; 01, oplic tract ; a-I,

right (bottom) and left (toP) A-I arteries; aca, anterior

communicating artery; it, lamina terminalis; ha,
right artery of Heubner; T-fl, right fronta l lobe; ihj,
interhemispheric fissure (covered by arachnoid);
l-fl, left f rontal lobe; l-foa, left fronta-orbital artery.


Fig. 7.26. Another case revealing an unusual common trunk (*) from which arise the right frontopolar
artery (r-fpa) and the artery of Heubner (ha) . gr,
Right gyrus rectus; a-2, right A-2 artery from which
the above-mentioned trunk arises; l-fpa, left frontopolar artery; 2, left optic nerve; ch. optic chiasm;


a-I, left (toP) and right (bottom) A- I arteries; it, lamina

terminalis; 01, optic tract; mem, membrane of
Liliequist; ac, anterior clinoid process; ica, internal
carotid artery; col, coltonoid. Note xanthochromic
pigment (bilirubin) from hemoglobin of recent subarachnoid hemorrhage.


7. T he Chiasmatic Cistern and Environs

Fig. 7.27. Allother example where chiasmatic,

carotid, and interpedu ncular cisterns arc all seen
(from observer's left to right). 2, Both optic nerves;
ch, optic ch iasm; 01, right optic tract; ito, internal
carotid artery; single-crossed arrow, hidden o rigi n of
poster ior com m u nicati ng artery; dQu.ble-crossed arrow,

hidden ongm of anterior choroidal artery; ac, anterior clinoid process; pc. posterior clinoid process;
bo, basilar artery;3.ocu lomotor nerve; un, uncus; rei,
fron tal lobe retractor; 00, artery of Heubner; a-I,
right (bottom) and left (toP) A- I arteries_ See next two
fi gures for anterior communicating artery complex .


Fig. 7.28. Same case as in Fig. 7.27. T}'pical variation

in anterior communicating artery complex illustrated . a-I, Left (toP) and right (!mllom) A-I arleries;
a-2, left (top) and right (bol/o.m) A-2 arleries; aea, anterior communicating arlcry; co, connecting bridge
fro m anterior communicating arler}, to left A-2 ar-


tery; in!, arachnoid over interhemispher ic fissure;

lIa, arler}' of Heubner; ar, arachnoid fibers; iea, inter-

nal carotid artery; sillgle-crossed arrow, origin of posterior communicating artery; *, bifurcation of internal carotid artery.


7. T he Chiasmatic Cistern and Environs

fig. 7.29. Same case as in Figs. 7.27 and 7.28. Anterior com municating artery complex magnified .
foa, Franto-orbital artery; ilif, arachnoid over interhemispheric fissure; a-2, left (toP) and right (bot10m) A-2 arteries; a-1, le ft (lOP) and right (hoI/om) A-I

arteries; Ma, anterior commun icating artery; co, connecti ng branch to the left A-2 artery; 2, both o ptic
ne rves; ch, optic chiasm; ot, optic tract; 1m, artery of






Fig. 7.30. Another case illustrating relationship of

anterior communicating artery (aca) to chiasmatic
and lamina terminalis cisterns. a- I , Left (toP) and
right (bottom) A-I arteries; a-2 left (lOP) and right (bot10m) A-2 arteries; 00, artery of 1Il~ ubner and
branches covered by arachnoid and blood ; ar,
arach noid over interhemispheric fi ssure and cover-

ing a second anterior communicating artery; r-gr.

right gyrus rectus; rtl, frontal lobe retraClOr; I, olfactory tract;jl, right frontallobe ;fpa, left frontopo lar
artery (low takeoff); foa, left fronto-orbital artery;
l-gr, left gyrus rectus; 2, both optic nerves; ts, tuberculum sellae; ch, optic chiasm; 01, right optic tract; It,
lamina terminalis.


7. The Chiasmatic Cistern and Envil"Ons

Fig. 7.31. Another variation o f the anterior communicating artery comple x. From the anterior communicating artery (aca) arises both a connecting
bridge (co) to the left A-2 (sec Fig. 7.32) and an accessory (third) anterior cerebral artery (ace) ascending
between the two A-2 arteries. a I , Left (toP) and right
(bottQm) A- I arlc i-ies; a-2, left (lOP) and right (OOllom)
A-2 arte ries; r-foa, right fronto-orbital artCl-Y; I, right

o lfactory tract; r-gr, right gyrus rectus; l-gr, left gyrus

rectus; i-roa, left fronto-orbital artery; ar, arachnoid ;
2, both optic nerves; at, anterior clinoid p rocess; ica,
internal carotid artery; *', bi furcation of the internal
carotid artery (from wh ich unseen aneurysm arises);
ot, right optic tract; cit, optic chiasm; It, lamina terminalis.


Fig. 7.32. 5."lme case as in Fig. 7.31 with right frontal

lobe d isplaced by retractor (rei). a-1, Left (lOP) and
right (hottom) A-I arteries; a-2, left (loP) and right (bot10m) A-2 arter ies; aca, anterior commu nicating artery; p, perforatOr; co, con necting branch fro m anterior communicating artery to the left A-2 artery; V,
\'ei n; ace, accessory (third) anterior cerebral artery;


foa, left fronto-orbita l artery; I-JUl, left artery of

Heubner; 2, right optic nen 'c; ac, right anter ior
clinoid process; ch, optic chiasm (lateral side); ot,
right optic tract; it. lamina terminalis; *, bifurcation
of internal carotid artery from which arises base of
aneurysm (an); m-2, M-2 artery; r-Iw, right a rte ry of


7. The Chiasmatic CiSlern and En"irons

Fig. 7.33. AnOlher case of anterior communicating

artery (aca) duplication. a- I , Right A-I artery; M. artery of Heubner; 0-2, right (bottom) and left (top) A-2
arteries; Ttl, right frontal lobe retractor; ihf, interhemispheric fissure;gr, le ft gyrus rectus; I , left 01-

faclO ry tract; 2, both o ptic nerves; i-loa, left frollloorbital artery; an, aneurysm; Pit, pituitary stalk ; ica,
internal carotid a rtery; ., bifurCllion of inlernai
carotid artery; 01, right optic tract; ii, lamina terminalis; ch, optic chiasm; p. perforator.


Fig. 7.34. View of underside of an anterior com

municating artery complex in chiasmatic and lamina
te rminalis cisterns. s, Suction tube; ua, internal
carolid artery; ot, right optic tract; fI, lamina ter
minalis; p, hypothalamic perforators; a-J , right (001-


tom) and left (toP) A I arteries; a-2, origin of left A-2

artery; (Ua, anterior communicating arte ry; ha, left
artery of Heubner; 1-[00, left fronto-orbital artery; 1,
left olfactol}' tract; 2, both optic nerves; ts, tuberculum sellae.


7. The Chiasmatic Cistern and Environs

Fig. 7.35. AnaLOmy o f lhe lamina terminalis and

chiasmatic cisterns. 2, Both optic nerves; ar, vascular
arach noid betweell optic nerves; cit, oplicch iasm;all,

aneurysm a rising from most of the internal carotid

artery; a-I, righ t (bottom) and left (lOP) A- I arteries; it,

lami na tcrminalis; JUI, artery of Heubner; ret, frontal

lobe retrano}"; 0-2, right (boltom) and left (lOP) A-2 arteries; ace, origin o f accessory anterior cerebral artery; i/l[, arachnoid over interhemisphe ric fissure .


Fig. 7.36. Same case as in Fig. 7.35 with magnified

viel\' of the lamina terminalis (It) between the right
A-I artery (a-I) and artery of Heubner (ha). The
lamina ter minalis is bordcred latcrally by the optic


tract (vi). Note arachnoid bands (or) and many PCI~

forating arteries (P). v, Vein: gr, gyrus reclus; all,


7. The Chiasmat ic Cistern and Environs

Fig, 7.37. Another exa mple of carotid, ch iasmatic,

and lam ina tcnninalis ciSlCrnal analOmy. ica, intcrnal carotid artcry; Ie, edge of anterior reflection of
tentori um ; pc. posterior clinoid proccss; /KO, posterior communicating artcry; oclw, anterior choroidal artcry; m-I, M-l ancr)'; QI, optic tract; (1"1, right
(hollom) and Icft (loP) A- I arteries; dr, arachnoid

b<uld ; II, lamina lerminalis; dCd, anterior communicating artery; hr, bridging artcry from left A- I
loanterior corn municati ngancry:Joo, left fronto-OI'bital artery; gr, left gyrus rectus; lUi, left anery of
Heubner; eh, optic chiasm; 2, both optic ncn'CS; p,


Fig. 7.38. Same case as in Fig. 7.37, different view. iea,

Internal carotid artery; pea, posterior com municating artery: aelta. anterior choroidal anery: mol, M- I
arte ry; (I- I, right (bottom) and left (lOP) A- I arteries; P,
perforator ; ill; arachnoid band; IIUI, right artery of
Heubner and branches; r{oa . right fronLO-orbita l ar


tery;a-2, origins of right (bottom ) and left (lOP) A-2 arteries; v, vein; aea, anterior communicating arter),; {100, left fronto-orbital artery;gr, left gyrus reclUS; 2,
bOlh optic nerves; 'IUl, left artery of Heubner; 01,
optic tract; fl, lamina tenninalis.

Fig. 7.39. A historic, diagrammatic example of an alllerior communicating arter ial complex form ing duplications and bridges. On
( ither side are the righ t and left A-IIA-2junctions. Fl"Om Bremer JL

( 1943) Congenital aneurysms o f the cerebral ancrics. An embryologic study. Arch Pathal 35: 8 19-83\; copyright 1943, American fo.'leclieal Association [I].

Fig. 7.40. Photograph of a plastic cast (toP) and d iagram (bottom) o f the rec ur rent artery of Hcubncr as
seen in front with two somewhat different p rojections. In the diagram the artery Heubncr is shown in

interrupted lines. From \Vcstbcrg C (1963) T he recurrent artery of Heubner and the ancrics of the
central ganglia. Acta Radiol (Oiagn) I: 949-954 [5].

--8-The Ambient and Interpeduncular


This cha pte r focuses on the pterional approach toward the ambien t and interpeduncula r cisterns. The surgical orientation of the patie nt's head (sec Fig. 4.8) is similar to that for
the plerionai approach to the syivian, carotid ,
a nd chiasmatic cisterns . However, the o perating microscope is shifted from a more rostral
d irection (see Fig. 4.5) to a mo re caudal line-of-

sight (see Fig. 4.7).

T he ambient cistern is a ce rebral spinal flui d

(CS F) compartme nt made u p of the body and
wing of the ambient cistern o n each side. T he
body is borde red laterally by the medial surface of the te mporal lobe and the med ial ed ge
of the te ntorial notch. It is borde red medially
by the lateral surface of the midbrain a nd the
pontomesencephalic junction. T he wing (not
seen anato mically in this atJas) is a lateral extension of the body a nd lies betwecn the pul vinar
of the thalam us anterio rly and the temporal
lobe posterio rly. The bod y of the ambie nt cistern as seen in this atlas conta ins those structures following the tentorial edge and lying
within the space between the carotid cistern
rostra ll y and the inter peduncular cistern ca udall y. Some of these structu res (such as the a nte rior cho ro idal artery) arc assigned to a separate cru ral cistern by some authors [8}. T he
basilar vein of Rosenthal a nd the terminus of
the optic tract ca n be considered eithe r to lie
within the ambient cistern or to make up pan
of the med ial wall of the cistern . The third
(oculo moto r) ne rve lies within both the interpeduncu lar cistern a nd the ambient cistern
since the arachnoid membra ne of Lil iequ ist

(separating the rostral chiasmatic cistern from

the caudal interpedu ncular ciste rn) usually is
adherent along its lateral margin to the medial
a nd caudal side o f the oculomo to r nerve. This
me mbrane may sto p at or before the
oculomotor nerve so that CS F in the interpedu ncular cistern mixes with CS F in the ambient cistern at a conflue nce lateral o r medial
to the oculo motor nerve (Fig. 8.1; also sec
Fig. 6.3). In some cases the Liliequist membrane ex te nd s la terall y to the tentorial ed ge
(see Fig. 8. 10), a nd CS F fl ow must be through
perforations in th is arach noid membra ne. T he
posterior communicating artery and the P-2
portio n of the posterior cerebral artery as well
as th e fourth (trochlea r) nerve and superior
ce rebellar arter y also are partly within the
body of the ambie nt cistern .
Figure 8.2 shows the anatomy at the le,'el of
the tentorial notch a nd midbrain . Figure 8.3
diagrams the anatomy of the auachmc nts of
the tentorium ante riorly to the poste rior and
a nterior clinoid processes. During the pteriOlla l a pproach to the inter peduncular cistern ,
the posterior cli noid process is an imponan t
landmar k latera l to which is the oculomo to r
Within the interpeduncular ciste rn lie the
o rigins of the oculomoto r nerves, the tip of the
basilar artery (Fig. 8.4), the origins of the P- I
segments of the posterior cerebral arteries and
the ir poste rior thala mic per forators (Fig. 8.4),
and the origins of the superior cerebellar arte ries. I n the case of a shor t P- l artery, the
caudal e nd of the poster ior communicating a rtery also may lie more medially a nd within the
interped uncular cistem.

8. The Ambient and Interpeduncular Cisterns


Fig. 8.1. Diagram of sagittal sections of a normal

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


opt.< <hi"""
1 ,,{ u. ru\.. bulwn.
i-Bo.,ilor rut.,.~


,,-,- 0,,"

lY NeT""




ou.du.c.t of



Fig. 8.2. Incisu ra of the te ntorium. The m idbrain

was sectio ned transversely, and the he mispheres
have been removed. Note relation of the bifurcation
of the basilar artery to the environs in terms of a pIer
iOllal approach lO lhis region. From Taveras Jr-..[

(1960) T he roentgen diagnosis of intracranial incisura l space occupying lesions. Am J Roentgenol

84: 52-69 [7]. Copyright by American Roentgen
R'ly SocielY. 1960.



Fig. 8.3. Relatio nship of posterior clinoid p rocess o n

the left (A) and right (B) to the oculo motor nerve
and circle o f Wil lis. Note relation ofposter iorclinoid
process. posterior cOlllm un icating artery. 1'- 1 a rte ry,
and oculo motor nerve t.o tip of basilar artery in
terms of the pterio nal approach \0 the interped uncular ciste rn . Reprod uced by permission from Malkasian I) R. Rand RW ( 19i8) 1\'licrosurgical anatomy,
in Ra nd R W (cd ): Microl1tllroslllgtry. cd ~ . St Louis,
CV 1\losby Co, PI' 3i - iO [6]. A. Su perio r view view
o f the le ft sellar and p,uasellar region de mo nstrating the d ural reneClions and the "oculomotor
trigolle." /.ines wilh adjaunl OfN'11 arrOW.J. boundaries
of the ocu lomotor trigone: .t, medial renections of
the tentorium cerebclli : y.. posterior clinoid process;
~. anterior clinoid p rocess; d. d ia phragm sellae; laltra/ slmighl black arrow. ostium of the ilUernal carotid
a rtc!)' : cw"Vtd (lITOU\ O\'c r o ptic nen'e and under falcifo rm ligamcnt;dolltd Ii/It. o pe ning to the o ptic foramcn; mtdial slmiglit arrow (black cMcurt'd), opening in
d i:l ph ragm sellac fo r pituita ry stalk ; broke71 arr~
oculomotor ostium ; long black arrOW/lead, ostium of

the fou rth cranial ner\"c; l'lI/all black arrows. "Y" du ral
fold. B. Su perior view of the sella illustrating the reo
lationship o f the a n le rior clinoid process (11), midd le
cerebr:11 art ery (C). poste rio r communicating arte ry
U), oculo motor Ilc n e (fl, trochlear nerve (D), pos
te rior ce rebral anery (C) and te ntorium cerebclli
Illed i<l l renectio ll (1-:- /). Note that the oculo motOr
ne rve is slightly lateral a nd inferior to the posterior
commun icati ng an ery at the oculo motor ostium as it
pe netrates the du ra in the oculomotor trigone. Howe\'er. as the oculomotor nerve P.1SseS inferior to the
posterior communicating artery (prox imal to the
midbrain), it may be im med iately inferior or slightly
medial to the posterior cerebral artery-postcrior
com municali ng artery ju nctio n. The anterior
cho roid,ll artery has not been included . Unl1UJrked
arrou~ falciform liga mell t o\"er the optic ne n 'c as it
e nters the optic ca nal; E, frce edge o f the te ntorium
cerebclli and its medial renection; H, basilar arte ry;
I , posterior clinoid process; K. antc rio r cerebral artery.


8. T he Ambient and Interpeduncular Cisterns

Fig. 8.4. Lateral vicw of vertebrohasilar arteriogram
(subtraction technique) to show example of posterior thalamic pel-foratofs (arrow) arising from the
pol artery and the basilar ancry bifurcation. From
Fox [2].

Fig. 8.5. Diagrams illustrating various relatio nships

of the basilar artery termination to the dorsum sellae
(A) and the th ird ventricle (B). From Greitz T, 1...Of5-

ted S (1954) The relationship between the third ventricle and the basilar artcry. Acta Radiol4 2: 85 - 100



Fig. 8.6. Two cxamplcsofiopamidol cislcrnography

wilh axia l cr sections at leleI of midbrain. Thc cistcrnal CSF is whitc. A. UtIV)' black OrTout. from in
tcrhcmisphelic fissure to cistern of thc lamina lcr'
millalis (poims to lamina tcrm inalis behind which is
black unenhanced CSF in third ventricle): simigllt
solid black OITOW lies at union of syl\'ian. chiasmatic
and ambient cisterns and points to optic tract; wavy
wllile aITow p<"lSses from lateral syl\'ian cistern (fissure) to medial sylvian cistem; jlmigllt solid wllile
aITow lies on medial temporal lobc and points to the
body of the ambient cistern lateral to midbrain : slum
.wiid wllilt Qrrow lies on vcrm is of cercbellum and
pOill lS 10 (illad rigc milial cistern : shorl o/lell Muck arrow
lics in interpcdu ncular cistern and poims to mam-

millall' body of hYj>othalamus. B. BfackaITuwhead lics

in j unction of ambient and intcrpedullcular cisterns
and poillts 10 ocu lomotor nerve that separates these
cisterns; doubit-headtd aITOW lies in interpeduncular
cistcrn and points (a) anteriorly to pituitary stalk
(surrounded by arachnoid enclosing less enhanccd
CS F in hypophyscal cistern) and (b) posteriorly 10
ol1e of the two ascending P_I afleries;so/id black aITOW
lies in intcrpeduncu la r cistcrn and extends from
othcr asccnding Pl artery to postcrior clinoid process (whiter than tllC enhanced CSF);solid whitton'OW
lies 011 peduncle of midbraill and points to body of
ambient cistern ; opm arrow lies on anterior clinoid
process aud points to internal carotid artery.


8. The Ambienl and In terpeduncular Cisterns

Within the interpeduncular cistern , the terminus of the basi lar artery may have various
relationships with the dorsum sellae and its
posterior clinoid processes as well as with the
brainstem (Fi g. 8.5). The imaged anatomy of
the structures about the ambie nt and interpeduncular cisterns can be see n in cross-section on the computed tomography (CT) scan
after instillation of water-sol uble contrast
medium into the CSF (Fig. 8.6). Figure 8.7 is a
photograph of a plastic model of the brai n
orie nted as the neurosurgeon will sec the
brainstem, basilar a n e ry, superior cerebellar
artery, oculomotor nerve, and poste rior cerebral a n e ry (P- I segment) . In Ihis view fro m the

plc riona l perspective, Lhe right temporal lobe

and cerebellar hem isphere have been removed
(a lso see Fig. 4.7).

The surgeon follows th e posterior co mmunicating artery cau dally. Adhes ions between the uncus of the temporal lobe and
oculomotor nerve are removed. The temporal
lobe and its uncus are retracted. After openin g
the a rachnoid membrane of Li licq uist (membrane of Key and Retzius), the surgeon sees the
follow ing in a caudal-to-rostral direction
(Figs. 8.8 and 8.9): the rostral pons, su perior
cerebellar artery, oculomotor nen'e, posterior
cerebral artery, posterior communicating a rtery a nd its anterior thalam ic perforators, a nI.erior choroidal artery. inl.ernal carotid artery.
and optic nerve. The oculomotor nerve will be
seen passing imo the dura of the oculomotor
trigone (Fig. 8.3) just latera l to the posterior
clinoid process. From there the oculomotor
nen'e en ters the cavernous si nus.
At this stage ofthe exposure, only the lateral
termination of the P-I artery will be seen at its
junction with the P-2 artery and the posterior
communicating artery (Fig. 8.8). Usuall y the
P- I artery is obscured by the a nterior thalam ic
perforators as the artery curves ca udall y and
medially away from the surgeon a nd lOward
the basilar a rte ry tip. The upper trunk of the
basilar a rtery may come into view (Fig. 8.9).
At times the membrane of Liliequist will be
thickened and imper fo rate from a previous

subarachnoid hemorrhage or me ningitis

(Fig. 8.10), resulting in an obstruction to the
fl ow of CSF a nd subsequent hydrocephalus.
An incision in this thickened me mbrane
(Fig. 8. 11 ) will result in a sudden flow of CSF
a nd relaxation of the brain. Note thal now the
a mel'ior thalamic perforators are seen on their
lateral side whe reas views of the carotid cistern
earlier showed these small arteries on their medial side (sec Figs. 6.7 and 6.8).
In a rare patie nt the posterior clinoid process and its dural cover may project up between
the caudal surfaces of the internal carotid artery and o ptic nerve or ch iasm (Fig. 8.1 2). In
the majority of patients the posterior clinoid
process projects upward in a parasagiual plane
late ral to the in ternal carotid a rtery (Fig. 8.13).
On occasion both posteriorclinoid processes
and the top of the dorsum sel lae ca n be seen
(Fig. 8. 14). This same figure shows the right
posterior com municating artery clipped with
small malleable clips (avoidi ng perforators)
prior to severing this aner y between the cl ips.
The P2 artery passes laterally between the
temporal lobe an d oculomotor nerve. The P- I
artery takes its typical course away from the surgeon ; it loops superiorl y, caudally, a nd medially lOwa rd the rostral tip of the basi lar artery. In Fi g. 8.14 the midd le half of the P- I artery is hidden by the P-2 artery.
Figure 8.15 is the sa me case after severin g of
the right posterior communicating artery. Th is
is a n unusual view of both P- I arteries, both 1'-2
arteries, and the left (opposite) posterior communicating a rtery.
Figures 8.16 and 8. 17 a re two se parate examples of prev iolls su ba rachnoid hemorrhages
that have caused adhesions in the arachnoid
sheath enclosing the anterior thalamic perforators. T hese adhesions have ca used many of
the perforators to stick together. This situation
requires slow, del icate d issection to prevent
perforator injury.
Figures 8.18 and 8.19 are two se parate examples of approaches to the interped uncular cistern where the intracranial internal carotid artery is short. Re traction of the fronta l lobe
brings A- I and M-I perforators into " iew at the
bifurcation of the internal carotid artery. In
Fig. 8. 18 the uncus, which hides the P2 artery,
is still ad herent to the oculomotor nerve. In
Fig. 8. 19 the internal carotid artery hides the
posterior communicating arte ry.


Fig. 8.7. Plastic model of brain: viewed as from a

right pterional appro.1ch to the anatomy around the
interpedu ncular cistern (see Figs. 4.6 and 4.i). The
right temporal lobe and right cerebellum have been
removed, btu the view is similar to that afte r wide
opening of sylvian fiss ure. r-fl. Right front.allobe; J,
both olf.lclory tracts; 1-1l, medial side of left (opposhe) temporal lobe; p-J, le ft Pol artery; i-sea, left
supe rior cerebellar artery; ), right oculomotor
lIerve; ba, b;:lsilar artery; 'va. left vertebral a rte ry: J~
va . rig ht I'enebral artery; //lcd, medulla oblo ngata ;


aiea, right anterior inferior cerebellar artery; 7 and

8. origins of facial and acoustic nerves; 6, right abd ucent nerve; 5. right trigeminal nerve arising from
POllS: mep. sectioned middle cerebellar peduncle;
ebllll, medial surface of le ft cerebellum (right side cut
away); r-sea, right superior cerebellar artery; p2,
right 1'-2 ;1Itel'}'; I'ed. pedu ncle (pyramidal tract) of
midbrain: il'[. interpeduncular fossa of midbrain ;
pea, right poste rior communicating artery; pil, pituitary bod y; 2. right optic nen'e; lIIam, mamillar}'
bod y.


8. The Ambient and Imerpeduncular Cisterns

Figures 8.20 th rough 8.23 are examples of pending on the exaCl direction of the optics of
the right latcral zone, middle zone, and left lal~ the microscope, the surgeon now sees both
eral zone of the interpeduncular cistern as superior ce rebellar arteries (origins), both
viewed progressively from the right pterional oculomoto r nerves, both P- I arte ries (origins),
approach. In each res peClive case the micro- and the left mesence phalic peduncle (pyramiscope is tilted from a partial cauda-med ial di- daltract), T he anterior (frolltobasa l) surface of
reclio n (ie, direction of the surgeon's view) to a the upper basilar a rtery is viewed by the surcaudal , yet morc medial, direction. Atthc same geon.
time the righ t internal carOlid artery and the
Figures 8.24 and 8.25 represent another
proximal M- J artery arc displaced gently to the example of the transition from a view of the
left (med iall y) by a llalTOW self-reta ining re- junClion of the a mbient and interped uncular
tractor. Care is take n not to occlude the carotid cisterns (Fig. 8.24) to a view of the center of the
artery (es pecially if vascular hypotension is interpeduncular cistern (Fig. 8,2 5), Note how
used) or fracture atherosclerotic plaques in the the P-1 artery on the right tul"llS caudall y away
a rtery. In some cases it may be necessary to clip fro m th e surgeon whi le the P- I artery on the
(with sma ll malleable cli ps) and sever the post- left ta kes a more lateral course. Large and vital
e rior com mu nicatin g artery (see Figs . 8.14 and ante rior a nd posterior thalamic perforators
8. 15), avoiding occlusion of anterior thalamic are presen l.
pe rforato rs by the clips.
Figure 8.26 gives a view of the anatomy of
In Fig. 8.20 a clear view of the oculomotor the lamina termi nalis, chiasmatic, carotid , amnerve separating the superior cerebellar artery bient, a nd interpeduncular cistcl"Ils in one paand the P-2/posterior com municating junClion tient. Figme 8.27 demonstrates anatomy about
is present. T his th ird cranial nerve begins, as it the carotid, ambient, and prepontine cistel"lls.
typically does, as a broad neural band fro m the
Figures 8.28 through 8.30 represent
midbrain in the interpeduncular fo ssa. This another example of transi tion from viewing
broad band gathers together rostral to the the lateral zone to viewing the central zone of
pons and passed forward under the tentorial the interpeduncular cistern in a case of lowedge and into the oculomotor trigone (see lying basilar artery bifmcation. Figures 8.31
Fig. 8.3)just lateral to the posterior clinoid pro- through 8.33 il lustrate the ma ny anterior
cess . The midbrain, from whence the thalamic perforators arising from the inte rnal
oculomotor nerve originates, is hidden from carotid a nd posterior communicating arteries.
view owing to the buckli ng of the brainstem They lie e nsheathed wi thin their own filmy
during the e mbryonic stage of development. arachnoid envelope. Th e anter ior choroidal a rThe forward buckling of the developin g pon s tery takes a prominent course from the interaccounts fo r the rostral pons being seen by this nal carotid artery and' disappears behind the
surgical ap proach.
With retraction of the in temal carotid anery
Figure 8.33 additionally gives a panoramic
and a more medial til t of the aim of the micro- view of the anatomy of the lamina terminalis,
scope, the center of the inter ped uncu lar cis- chiasmatic, carotid, ambient, and interpeduntern ca n be seen in Fig. 8.21. An even sharper cu lar cisterns. The relationshi p of th e posmedial angulation of the microscope aimed terior communicming artery to the P-I and P-2
caudal to the carotid a nery a nd hypothalamus arteries is illustra ted. Figure 8,34 gives a dear
permits the surgeon to see beyond the inter- view from the bifurcation of the internal
ped uncular midline as is revealed in Figs. 8.22 carotid a nd adjacent optic tract to the bifmcaa nd 8.23. In thi s circumstance the observer is tion of the basilar artery. The last two fi gures
looking through the space between the back of dea rl y demonstrate that the pterional a pthe dorsum sellae and clivus (see Figs. 4.7 and proach permits access to lesions situatcd any8. 1) and the fron t of the brainstem (see where about the circle of Willis, It is ideally
Fig. 8.7). With this right pterional approach , suited for multiple lesions (eg, aneurysms) prethe dorsum sellae (Fig. 8. 14) lies in the upper, sen t in diffcrent loci, yet within reach from the
left-ha nd field of the observer's view, and the chiasmatic to the interpeduncular cisterns.
basilar artery and rostral pons lie in the lower, The approach requi res sign ificant removal of
right- hand field of the observer's view. De- the sphenoid wing and , in many cases, a wide


opening of the sylvian fissure. Add itional details of the neurosurgical techniques used by
the author for lhis approach are given elsewhere [2].

I. Fox J L (1979) f\I icrosurgical exposure of intracranial aneurysms.J Microsllrg I: 2-31
2. Fox J L (1983) Intracranial Ancwysms, vol 2. New
York. SpringerVerlag, PP 877 - 1069
3. Fox JL (1985) Microsurgical exposure of venebrobasi lar aneurysms, in Rand RW (ed): Micra'
neurosurgery, cd 3. St Louis, CV ]\'Iosby Co,
PI' 589-599


4. "ox J L, AI-Mefty 0 (1980) Suprasellar arachnoid

cysts: an extension of the membrane of Liliequisl.
Neurosurgery 7: 615-618
5. Greilz T, Uifsled S (1954) The relationshi p between the third ventricle and the basilar anery.
Acta Radiol42: 85 - 100
6. Malkasian DR, Rand RW (1978) Microsurgical
anatomy, in Rand RW (ed): Micronfuroslllgcry,ed 2.
St Louis, CV Mosbr Co, pp 37- 70
7. l avaras J M (1960) The roentgen diagnosis of in
cisural intracranial space occupring lesions. Am J
Rocntgenol84: 52 - 69
8. Ya~rgil MG, Kasdaglis K, J ain KK el al (1976)
Anatomical observations of the subarachnoid cisterns of the brai n during surgery. J Neurosurg
44: 298 - 302


8. The Ambient and Interpeduncular Cisterns

Fig. 8.8. Plcrional approach to ambient and interpedu ncular cisterns (see Fig. 8.7 and Fig. 4.7). pr,
Probe retracting the illternal carotid artery (ica); 2,
right o ptic nerve; ac, anterior clinoid process; aI',
arachnoid: pc, posterior clinoid process; Ie , tentorial
edge;), oculomotor ncn"c at lateral oordcr of interpedu ncular cistern and emering cavernous sinus
th rough oculomotor ostium (see FIg. 8.3); sea,
super"jol" cerebellar artery; col, cononoid: rei, tem-

\Xlra! lobe retractor; pons, rostral pan of pons; pea,

posterior communicating anery entering posterior
cerebral artery at the pol (P- / )/P-2(P-2) junction; p,
anterior thalamic perforators; !lIIC, urlCUS: adw, duplicated anterior choroidal artery; v, \'cin. Note: P-2 artery and basal vein of Rosenthal lie ill ambient cistcrn between pontomesencephalic region and temporallobe. From Fox lll.


fi g. 8.9. Same case as in foig. 8.8. Probe (pr) isretrac ting posterio r commu nicating artc!"y (pea) to show
origin of superio r cerebel lar a rtery (.sta) from basilar
an ery (ha) in imcrpc duncula r cistcl"lI . m; Arach noid :
porlS, rostral pa rt of pons; J, base of ocu lomo tor
ne rve naring out at its midbra in origin: /1-/,1'-1 ar-


ter)'; p-2, 1>-2 arter), entcrin g ambien t cistern: Ii-rei,

tempo ral lobe retracto r: ac}w, d u plicated anterio r
choroidal artery ; Ime, uncus; V, vein : fl-rrt, frOlltal
lobe rctractOl'; 2, optic nervc: iea, inte rnal carotid artcry:pc, posterio r clinoid process.


8. The Ambient and Interpeduncular Cisterns

Fig. 8.10. Path of posterior communicating anery

(pea) in anothe r case. The thickened (horn previous
subarachnoid bleed) arachnoid membrane of
Liliequist (mem) separates unseen interpeduncu lar
cistern from carotid cistern. The posterior communicating anery (pea) follows posterior extension
of carotid cistern to join (*) the posterior cerebral artery (p-2) in the ambient cistern. The 1'-2 anery
(P-2) ascends in the wing of the ambient cistern. ica,

Internal carotid artery; at, alllerio r clinoid process;

tentorial margin: 3, oculomotor nerve; /lrel, temporal lobe retractor; p, anterior thala mic perforators; ar, arachnoid membrane e nsheathing posterior communicating artery and its perforators (p);
rei, relractor displacing Ml artery and carotid ar
lery bifurcation median),; a'/, ol'igill of A] ,trtery; 2.
right optic nerve; at, anterior clinoid process. From
Fox [2].



Fig. 8.11. Same case as in Fig. 8. 10. Membrane or

Liliequist (mem) has been opened, revcaling intcrpeduncular cistern. ), Right oculomotor nen'e; p,
lateral medullary perforators: bo, basilar artery; r-


sea, right superior cerebellar artery; p-2, P-2 artery;

pea, posterior communicating artery; INd, medial
side or lert (opposite) peduncle of midbrain. From
Fox [2).


8. The Ambiem and Imerpeduncular Cisterns

Fig. 8.12. Another case illustrating an unusual presentation of the posteriordinoid process (PC) projecting up between o ptic nerve (2) and internal carolid
artery (ica). gr, Gyrus rectus; a-J, A- I artery; v, vein;

unc, UIl CUS; J, ocu lomotor nerve; an, collapsed

aneurysm at posterior communicating artery; clp,
clip on aneurysm; Ile, anterio r clinoid process.


Fig. 8.13. Anothe r case with view through ca rotid

cistern into interpeduncular cistern. m-l, t.I- 1artery;
a- l , A- I artery; ot, optic tract; p, hypothalamic and
anterior thalamic perfor,llors; ch, opLic chiasm; 2,
right optic nerve; ac, amerior clinoid process; ica, internal carotid arterY;CTossed arrow, origin of posterior


communicating artery (pea); ac/uJ., anterior choroidal

a rtery; pol, P_I arte ry; p-2, P-2 artery; 3, oculomotor
nerve; br, branch from superior cerebellar artery
(sea); PO/IJ, rostral pons; an, aneurysm of basilar artery (00) at origi n of superior cerebella r artery (sea);
pe, posterior clinoid process;ds, lOp of dorsum sellae.


8. The Ambient and Interpeduncular Cisterns


Fig. 8.14. Same case as in Fig. 8.13, looking leftward

across interpeduncular cistern. fl. Frontallobc; ret,

retractor on internal cal"Olid artery (ica) and its bifurcation; p, ilnterior thalamic perforators; 2, right
optic nerve; ac, amcrior clinoid process; l-pc, left (op'

posite) posterior clinoid process; tis, LOp of dorsum

sellae; pc. right posterior clinoid process; I-sea, left
superior cerebcll,ll" artery; ped, medial side o f left

peduncle of midbr.aiu; 3, left and right oculomotor

nerves; cmssed Ulnm', one of twO malleable clips on
posterior communicating ancry (pea); b-Ul!. base o f
bifurcation aneurysm of basilar anery (00); /1-1, right
pol anery; /1-2, right P-2 artery; UIlC, uncus; If-ret, ternporallobe retractor; pons. rostral pons; an, dome o r
aneurysm at hidden origin or I'ight supcliorcerebcl.
lar artery (r-sea).


Fig. 8.15. Same case asin Figs. 8.13 and 8.14. showing
posterior circle of Willis in interpeduncular cistern.
2, Right optic nerve; iea, internal carotid altery; ae,
anterior clinoid process; i-pea , left poster ior communicating anery: p-2, left and right P-2 arteries;
p-I.leftand right 1'- 1 aneries ;J, left (labeled twice)
and right oculomotor nerves: l-pc, left posterio r


clinoid process; r-pc, right posterior clinoid process;

00, tip o f basilar artery; an, aneurysm at bifu rcation
of hasilar artery; p, posterior thalamic perforators;
ped, medial side of left peduncle of midbrain; sea,
right superior cerebellar artery: pons. rostral pons;
crossed arr~ malleable clip on caudal end of severed
right posterior communicating artery; !Inc, uncus.


8. The Ambient and Inter peduncular Cisterns

Fig.8.16. Anothe r case illustrating the posterior

comm unicating artery (pea) and its amerior thalamic
perforators (p) stuck together by adhesions from
previous hemorrhage. WIC, Uncus; aeM, anterior

choroidal artery; mol, M-I artery; pr, probe retracting internal carOlid artery (ica); a-I, A-I artery; 2,
optic ne rve; pc, posterior clinoid process; mem, thickened membrane of Liliequist;;, ocu lomotor nene.


Fig. 8.17. Anothcr case wherc the amerior thalamic

perforalOrs (p) are stuck IOgether by adhesions in
their cnclosing arach noid sheath. pr, Probe retracting intcrnal carotid artcry (ita); acha, duplicated an
terior choroidal artery and perforators ; crossed arrow,
origi n of antcriorchoroidal aner),jan, aneurysms at


origin antcrior choroidal artcry (bottom) and pos

terior communicating artery (toP): 2, optic ncn'c;
boo, bifurcation of basilar artcry: 00, trunk of basilar
artcry;), oculomotor ncrve;sca, superior ccrcbellar
artcr),; p-2, P-2 an ery; pol, P_I artcry; pea, posterior
comm unicating artcry; !II", uncus.


8. T he Ambient and Interpeduncular Cisterns


" I

Fig. 8.18. Following posterior comm u nicating artery

(pea) toward interped uncular cistern hidden behind
membrane of Liliequisl (mem). col, Coltonoicl; rei,
temporal lobe retraCLQr; J, oculomotor nerve; unc,

uncus;p, anterior thalamic perforators and A-I perforators; akl, anterior temporal artery; mol, M-l af-

tery; a-I, A-I artery; 2, optic nerve; aeM, atHerior

choroidal artery; ica, internal carotid artery; crossed
arrow, origin of posterior communicating artery
(pea); all, aneurysm at origin of posterior communicating artery; It, tentorial margin;pc, posterior
clinoid process.




Fig. 8.19. View ofrightlatcraJportion ofintcrpcduncular cistern after opening membrane of LiliequisL
jl-rtl. Frontal lobe retractor; p, perforators from
bi fu rcation of internal carotid artery (iea); 01, optic
tract; a- I, A- I artery; mem, med ial jX>rtion of membrane of Liliequist; pc, posterior clinoid process; 00,

basi lar artery; an, aneurysm of basilar artery at origin of superior cerebellar artery (sea); p-l, P_I artery;
p-2, P-2 artery; m-J, M-l artery; m-2, M-2 artery; It-nl,
temjX>ral lobe retractor; unc, uncus; 3, ocu lomotor
nerve; fe, tentor ial margin.


8. The Ambient and Intt:rpWuncular Cisterns

Fig. 8.20. Another case with view of right lateral portion o f interpeduncu lar cistern after remm'al of of Liliequisl. Notc how oculomotor
nerve (J) gathers together from a broad band exiting
the midbrain. pons. Rostral pons; sea, su perior cerebellar artery; 00, basilar artery near its bifu rcation: Ie,
margin of te ntori um; /1, temporal lobe; col, cotlOno id ; rei, retractor: p-2, P2 artery; p, perforators;
111-2. M-2 artery : mol, M- l artery; ot, optic tract; a-I.

A-I artery; 2, optic ne rve; mem, membrane of

Liliequisl (anterior re n ectioll around pituitary
stalk); ial, internal carotid artery; pea, posterior communicating artery; aciUl, anterior choroidal artery;
pol, P_I artery. Reproduced by permission from Fox
JL ( 1985) Microsurgical exposure ofvertebrobasilar
aneurysms, in Rand RW (cd): MicrmleUrQS1I1gery, cd 3.
Sf Louis, CV Mosby Co, pp 589-599 [3].


Fig. 8.21 . Same case as in Fig. 8.20. Internal carotid

artery (ica ), middle cerebral artery (m-I), and posteriorcomm unicating artery (pea) retracted med ially
by na rrow retractor (rtt ) to expose ceme r o r imerped uncu la r cistern contai ning aneurysm (an) at
bi rurcation or basilar artery (ba). Except at its base,
aneurysm is covcred by a carpet or fi brin. p-I. Left
(loP) and rig ht (bottom) P- l arteries;sca, right su perior
cerebellar a rtery: Ie, margin or tentorium : J,


oculomOlOr nen'C; pons. rostral pons; p. one o r several anterior thalamic perrorators rrom postcrior
com municaling art.ery; 2. optic nerve; /le, anterior
clinoid process:pc, posterior clinoid process. Reprod uced by permission rrom Fox J L (1985) Microneurosu rgical exposure or vertebrobasilar ane urysms. in Ra nd RW (cd): M icrotll'UfOsmgery,ed 3. 51
Lou is. CV Mosby Co, pp 589 - 599 [3).


8. The Ambient and Interpeduncular Cisterns


Fig. 8.22. Example of ventral surface of basilar arlcry (ha) in interpeduncu lar cistern flanked by
oculomotor nerves (3) . The membrane of Liliequist
has been removed. t-sea, Left superior cerebellar aftef),; r-sea, right superior cerebellar artery; ], right
and left oculomotor nerves; lie, right posterior
clinoid process; pol, left and right P-l arteries; I),

posterior thalamic perforators from pol; *, base of

basilar tip aneurysm; ica, internal carotid artery; ret,
rClraClOr displacing iea bifurcation medially; aelia,
anterior choroidal artery; fl. frontal lobe; col, cottonoid; /l-ret, right temporal lobe re tractor; crossed
arrow, malleable dip on caudal end of severed right
posterior communicating artery. From Fox [2J.


Fig. 8.23'. Another example of ventral surface of

bifurcafion oflhe basilar artery (bba) in Ililerpeduncular cistern between both oculomotor nerves (3).
prd, Left (opposite) peduncle (pyramidal tract) of
mid brain ;sca. lcft superior cerebellar artery ; bo. basi-


iiiI' artery; Ie, margin oftentorium;p-l, right and left

pol arteries; all, base of aneurysm at tip of basilar artery; fl-rel, frontal lobe retractor; Col, cottonoids; 11rtt, temporal lobe retractor. From Fox [2].

8. The Ambient and Interpeduncular Cisterns



Fig. 8.24. Another case illustrating anatomy at j unction o f carotid , interpeduncular, and ambient cisterns after removal of arachnoid membrane of
Lilicquist. rei, Retractor displacing internal carotid
arte l")' medially; CQl, cou onoids; p, perforators; mol,
M- I artery;aw, duplicated anter ior temporal artery;

v, veins; pons, rostral pons;), oculomotor nerve;sco,

superior cerebellar artery; 00, basilar artery; pea,
posterior communicating artery in carotid cistern;
p-2, P-2 artery emering wing of ambient cistern be
tween pons and lemporallobe;p-J, pol artery going
medially in interpeduncular cistern. From Fox [2J.





Fig. 8.25. Same case as in Fig. 8.24. View of ventral

aspect of bifurcation of basilar artery (boo) and inter
peduncular cistern between oculomO{Qr nerves (3).
00, Basilar artery: sea. right superior cerebellar artery; p-l, right (labeled twice) and lef! P_I arteries; p2, right P-2 arter y; pons, rostral pons; v, veins; ala, an-

terior temporal artery; mol. M-I artery; col, (ot{Qnoid; rel, retra({Qr on ica; p, posterior thalamic perforators; i-sea, left superior cerebellar artery; an,
aneurysm of tip of basilar artery;crossed arrow, caudal
end of severed posterior commu nicating artery
(with malleable dips on it). From Fox [2] .


8. The Ambient and Interpeduncular Cisterns

Fig. 8.26. Another example of anatomy at confluence of carotid. lllle rpeduncular, and ambiem cislerns. cau-an, Dura of cavernous si nus containing
giant internal carotid artery aneurysm; ica, internal
carotid artery exiting from C3\'CrnOUS sinus; 00, basilar ancry; $la, superior cerebellar artery: J,
OCU lO ll1 010 l' nerve entering cavernous sinus; pmlJ,

rostral pons; p-2. P-2 artery; crossed arrow points to

posterior communicating artery hidden by internal
carotid artery; unc, uncus; p. anterior thalamic perforalOr ; acha, anterior choroidal artery; *, bifurcation of internal carotid artery; col, cOllOnoids; fl,
froma l lobc; QI, right optic tract; II, lamina terminalis;
eli, o ptic chiasm; 2. both optic ne rves. t'rom Fox [2).





fig. 8.27. A vicw through carotid a nd interpeduncular cistel'lls into prepoilline cistern anterior to the
pons (PO"s). llrtt , Temporal lobe retractor; col, cot
tonoid; flret, fro ntal lobe retractor; clp. shank of
aneurysm clip on an 3mcriorcommunicating a rte ry
ancurysm; a l. A- I artcry; mol . M-l an ery; tmc,

uncus; sea, superior cerebellar anery; an, a neurysm

of basilar arte ry (1M) at takeoff of amerior inferior
cerebellar anery ; J, oculomotor nerve; pc. posterior
cli noid process; ica. internal carotid artery. From Fox


8. The Ambicni and Jnterpeduncular Cisterns

Fig. 8.28. Another case with view of carotid , interpeduncula r, and rostral prepontine cisterns. Ie, Ma rgin o f te ntorium ; mem, remainde r of membrane o f
Lilicquisl (most removed): rti, temporal lobe retraeLOr ; pons, rostral pons; J, oculomotor ncn'c;jK. post-

crior clinoid process; ac, anterior clinoid process; ica,

jlllcrnal carotid artery; 2, o ptic nCl've; QI. optic tract;
a-I, A- I artery; m-l, M-I artery; p-2, P-2 artery;p- J. p.
I artery; crossed arrou, origin of posterior communicating artery.


fig. 8.29. Same case as in ~ig. 8.28 with medial retraction (1"(/) of the internal carotid artery (ica). 2.
Optic ne rve: ac, anterior clinoid process; pc, posterior clinoid process;pl, left (obscured with blood)
and right P- J arteries; " bifurcation of basilar artery;
an, aneurysm of b.1silar artery at takeoff of hidden


right su pcrior cerebella r artery; ), oculomotOr nen'e

entering cavernous sinus; POtU, rostral pons; p, perforator; p-2, right P-2 artery: pea, posterior communicating artel")'; m-l, MJ artel")'; 0-1, A- I artery;
01, optic tract.


8. The Ambient and Interpeduncular Cisterns

Fig. 8.30. Same case as in Figs. 8.28 and 8.29. View of

bifurcation of basilar artery (boo) in center of imerpeduncular cistern. pol, Left and right po l arteries;
J, ocu lo motor ncn"c; all, aneurysm at o rigi n of

superior cerebellar artery (sea); Ie, margin of tenLOriu m; pons. rostral pons; *, bifurcation of imernal
carotid artery; ret, retractor displacing imernal
carotid artery medially.


Fig. 8.3 1. Another case, following arachnoid sheath

of posterior communicating artery (pea) and iL" an
terior thalamic pe rforators (I) caudally toward inlerpeduncular cistern hidden behind membranc o f
Lilic(IUist (mem). Ie, f\hrgin ofte nlOriull1 : ulle. uncus;
Ifrel, temporal lobe retractor: fl, fronta l lobe; PI',
probe rctracting M-I artery (m-I) medially; 01, o ptic


tracl;jl-J'et, frontal lobe retractor; a-I, A-I artery; fl,

lamina te n ninalis; cit, optic chiasm; iea, internal
carotid artery: 011, aneurysm at origin o f posterior
communicafing artcry; Gclla, amcrior choroidal artery passing under uncus toward choroid fissurc of


8. The Ambient and Interpeduncular Cisterns

Fig. 8.32. Same case as in Fig. 8.31 at higher magnificatio n to show anterior thalamic perforators (p)
from postcfiorcommunicating artery (pea) and thei r
ensheathi ng a rachnoid. ar, Thickened arachnoid

bands within envelope of arachnoid about perforators and posterior communicating artery; un"
uncus of right tern poral lobe; adm , anterior choroidal artery; ica, interna l carotid artery; QI , o ptic tract.


Fig.8.33. Same case as in Figs. 8.3 1 and 8.32.

Arach noid membrane of Liliequ ist has becn dissected away. Note how pterional approach can gi\c
panoramic vicw of chiasmatic, lamina terminalis,
carotid, ambielll, and interpeduncular cisterns. 2,
Both optic nerves; eh, optic chiasm; It. lamina termi nalis; 01, right optic tract; a.-I, A-I artery; p, per-


forators ; m-J, M-l artery; m-2, M-2 artery; ar,

arachnoid sheath; aeM, anterior choroidal artery;
ita, internal carotid artery; an, aneurysm; pea, posterior communicating artery; 00, basilar artery; p- l ,
P-I artery; p-2, P-2 a rte ry:), oculomotor nerve ; sea,
origin of right superior cerebellar artery.


8. T he Ambient and Interpeduncular Cisterns

Fig. 8.34. Another case illustrating bifurcation of

basilar artery (boo) in interpeduncular cistern. I-sea,
Left superior cerebellar artery; pc. posterior clinoid
process; ), left (h idden in shadows) and right
oculomotor nerves; v, vein; r-sea, or igin of right
superior cerebellar artery; {1-J, right and le ft pol ar-

teries in interped uncular cistern; pea, posterior communicating artery; p-2, origin of right P2 artery; p,
perforators; Il-ret, temporal lobe retractor ; unc,
uncus; mol, r.1- 1 artery; ot, optic tran; ha, artery of
Heubncr;jl, frontal lobe; a-I, A- I artery; aCM, anterior choroidal artery; ica, internal carotid artery.


Abducens nerve, 171
Acoustic nerve, origi n of, 17 1
arachnoid membra ne, 94
between fro ntal and te mporal
lobes. 56, 71
carotid arlery aneurysm to
ocu lomoto r nerve, 111
fron tal lobe to oplic tract,
Ambient ciste rn, 165-200
anatomy of, 172, 199
body of, 169
j unction with ca rotid and interpeduncular ciste rns.
169, 172, 190, 192
j unction wi th sylvian and
chiasmatic cisterns, 169
Aneurys m
anterior cere bral artery A- I,
92, 16 1
anle rior choroidal artery. 92.
at o rigin, 84, 115, 183
anterior communicating ar
lery, 124 , 132, 137, 139,
140, 143- 144, 193
hypothalamic perfo rators
stuck to, 125, 149
basilar artery_ Stt Basilar aftery. aneurys m o f
internal carotid artery. See
Carotid artery, internal,
a neurysm of
middle cerebral arte ry M- I
al bifurcation, 76-77
d ome in temporal lobe, 75
fl anked by tem poral and
fro ntal M-2 arte ries, 7879

posterior cerebral an ery P- I,

posterior commun icati ng ar
tery, 11 4. 178
at o rigin. 11 5- 11 6, 183184,197
at superio r cerebellar artery
origin , 180. 185, 196
Aqueduct of Sylvius, 166
Arachnoid , 156, 174- 175
anterior re fl ection at pituitary sta lk, 125, 186
between frontal and tem poral
lobes, 72
sc\'e red by microscissors,
between left optic nerve and
frolltallobe. 140
between optic nerves, 98-99.
102, 116, 132-134, 148,
coveri ng inte rnal carotid artery and o ptic ne rve, 53,
d iste nded by cerebrospinal
fl uid , 56. 59
at inte rhemispheric fissu re,
144, 150, 153-155, 160
at pituitary stalk, 138, 169
surgica l opelling of, 57, 8788, 177
and sepa ration by fo rceps
blades, 64-65, 67
at sylvia n fissure. 146
Arachnoid bands o r fibers, 57,
87.90-91, 11 7. 153
at anterior cerebral artery
A- I, 84, 127, 16 1- 163
in arachnoid envelope of thalamic perfo rators and
posterio r communicating

artery. 198
between hypothalamic perforators and o ptic tract,
between midd le cerebral arte ry branches, 56, 70-

between middle cerebral M- l
artery and temporal
lobe. 80
between sylvia n vessels and
pia, 63
at illlernal carotid artery, 67.
11 6
at lamina terminalis cistern ,
125.14 1
at o ptic nerve/carotid a rtery
j u nctio n, 67
at posterio r communicating
artery, 83
in subd ura l space, 56, 58,
60-6 1
at sylvian fissure base. 56,
Arachnoid membrane of Liliequist, 68-69, 93-94, 98100, 103- 104. 107, 111 112, 116. 11 8. 125, 134,
138, 141 , 146- 148, 15 1,
165- 166, 184
adhesions o f, 94
attachme nts of, 98
coloratio n o f. 97
medial portion of, 185
at pituita ry stalk, 125, 138.
147- 148, 186
reflection of, 98
removal of, 188
surgical opening o f. 177
th ickening after he morrhage.
170, 176, 182



Arachno id sheath
of posterior communicating
artery. 176
o f thalam ic perforators, 120
from posterior communicating an ery. 172, 197-


Basilar ane ry. 39, 44-45, 69,
84, 107, 114 , 152. 171 ,

177, 190,192,199
aneurysm of. 179
at anterior infe rior (erebel
lar artery takeoff. 193
at bifurcation, 82, 18018 1, 187
at superior cerebellar arteryorigin, 185, 195
at tip. 18S-189, 191
bifurcation of, 166. 168, 183,
195--196, 200
between oculomotor
nerves, 19 1
medullary perforators from,
11 5
near bifurcation, 186
origin of superior cerebellar
artery. 165. 175, 179
relation to dorsum sellae, 168
relation to third ventricle.


lip of, 165, 18 1

tru nk of. 183
ventral surface of
at bi furcation, 189, 191
nan ked by ocu lomotor
nerves, 188

Basilar vein of Rosenthal, 165,


Bone nap
attached to temporalis muscle, 40, 49
frontotemporal, 39-40
sutures for reattachment of,
40, 49
Bone-removal instrume nts, 24
Bonewax, use of, 24
Bridging artery from anterior
communicating artery
to left A-I, 126, 162
to left A-2, 11 2, 126, 153154, 157
Bridging veins between temporal lobe and sphenoparietal sinus, 4 1, 56,

electrocoagulatio n of, 56, 68
BUTT holes, 40, 48, 50

Carotid artery, internal, 52, 6 1,
65-66, 77, 91, 110- 112,
135, 140, 145, 150-153,
159, 162- 163, 166, 169,
174- 176, 179- 184,IS6ISS, 193- 195, 197- 198
aneurysm of, 89-90, 104,
160, 192, 199
ad hesion to ocu lomotor
nerve, II I
adhesion to temporal lobe,

adhesion to tentori um ,


at anterior cho roidal artery

takeoff, 84
at bifurcation , 57,85. 112113, 121 , 156- 157
arachnoid bands on, 67 ,11 6
arachnoid co,"ering of, 53, 74
athe rosclerotic, 63, 80, 10 1102, 107, 147- 148
bifurcatwn of, 79, 81, 84,
134 , 153, 156- 158, 192.
branches of, 57, 79
exit from cavernous sinus,

lateral retraction of, 103
left, 106, 114, 117- 11 9, 138,
bifurcation of, 138
long, 95, 98--99, 102
medial retraction o f, 109
origi n of anterior choroidal
artery, 95, 100, 104, 13'1,
144, 152, 183
origin of posterior communicating artery, 95, 98,
100-101 , 104-105, I I I,
134, 141-142, 144 , 152153, 179,184, 194
ostium of, 167
perforatOrs from , 11 3- 114 ,

to anterior perforated substance, 118
at bifurcation, 11 8, 185
hypo physeal, 95, 99, l iS,
120, 125, 138
hypothalamic, 8 1, 95, 102-

103, 106, 11 8, 148, 159,

thalamic, anterior, 95,
102- 103, 120,172, 179
relation to carotid cistern, 93
relation to posterior clinoid
process, 96, 114- 115
unusual, 170, 178
relation to posterior communicating artery, 192
right, 106, 114 , l iS, 138,
146, 148
bifurcat ion of, 12 1, 139
short, 95, 100-10 I
sympathetic fibers on , 96,
11 6
view 10 optic tract, 103
Carotid cistern , 93- 12 1, 123,
128, 14S, 152
analOmy of, 93-97, 162, 172,
exposure of, 52
j unction with ambient and interpeduncular cisterns,
172, 190, 192
structures in, 96
Cavernous sinus, 95, 98
internal carotid artery exit
from , 192
oculomotor nerve in , 170,


e ntrance of, 192, 195

unusual veins in , 97, 11 8-- 119
Cerebellar artery. anterior inferior
aneurysm at takeoff from
basilar artery, 193
right, 171
Cerebellar artery, superior,
165, 166.170, 174 , 183,
190, 192- 193
aneurysm at origin o f, ISO,
IS5, I96

branch of, 179

le ft , 114 , 17 1, ISO, 188-- 189,
origin from basilar artery,
rig ht, S2, li S, 17 1, 177, l SI,
187- ISS, 191
aneu rys m at takeoff from
basilar artery, 195
origin of, 199,200
separated by oculomotor
nerve, 186
Cerebellum, 166
middle peduncle of, 17 1


tentorium of. See Tentorium
vermis of, 169
Cerebral arteries, anterior, 124,

A- I artery, 77, 85, 91, 93- 94,
10 1, 11 0, 11 3- 115. 118,
120, 123, 124, 133-135,
178-179, 182, 193-195,
197, 199-200
aneurysm of, 92, 16 1
arachnoid band over, 84,
127, 161- 163
hypoplasia of, 125. 146147, 149
left, 11 9, 125, 126, 136140,143- 144,149- 157,
159- 160. 162- 163
bridging artery to anterIOr communicating
artery, 127, 162
origi n of, 82-83. 100, 108.
11 7,176
perforators from, 57. 7980,82,84,92,106.141142, 161 - 163, 170, 184,
186, 199
relation to artery o f Heubner, 95
right. 125. 126, 136- 140,
143-144 , 150-163
j unction with right A-2,

11 2
transsylvian view of, 82-83
A-2 artery, 126, 156-157
and common tru nk for artery of Heubner and
right fro ntopolar artery,
126, 15 1
left. 137. 139- 140, 144,
153- 158, 160
bridging artery from anterior communicating
artery. 112, 126, 1 53~
154, 157
origin of, 159. 163
rig ht, 120, 137. 139- 140,
143, 149. 153- 158, 160
j unctio n with anterior
communicating artery,

ju nction with rig ht A- I ,

11 2
origin of, 163
accessory. 126, 156- 157
o rigin o f, 127. 160
in chiasmatic cistern, 55

Cerebral arteries, mid d le. 55

branches of, 56, 57,60,66,
M- I arte ry. 84-85, 93, 94,
118, 120, 123, 14 1- 142,
144, 162-163, 179,182,
193-195, 197, 199-200
aneurysm o f
at bifurca tion, 76-77
dome in temporal lobe,

nan ked by temporal and
frontal M-2 arteries,
deep in sylvian fissu re, 89
emering sylvian fissu re, 8 1
frontal artery from, 75, 89
left, 11 9
long, 67, 78
origin of, 82-83, 106, 108,
112- 11 3, 11 5, 117
perforators fro m, 57.798 1,89-92,125,1 46- 147,
170, 181, 184-187, 190191,200
short, 57, 79
transsylvian view of, 82-83
variations in, 57 , 75
M-2 artery, 83, 90,157, 185186,199
aneu rys ms at bi fu rcation at
M- I.77
dee p branches of, 87
fronta l artery from, 61, 76,
80,88, 146
variations in, 57, 75
Cerebral arteries, posterior.
108-109, 166- 167
1'-1 artery, 175 , 179, 183,
185-186, 194
aneurysm of, 120
ascending. 169
course o f, 170, 172, 190
left, 17 1, 181, 187- 189,
191. 195-196,200
origi n o f. 165
perforators from, 165, 168,
right, 180- 18 1, 187-189,
191, 195-196,200
short, 165
P-2 artery, 109, 114-1 15,
165, 176- 177,179. 183,
185, 192. 194
course of. 170
entering ambient cistern,
175, 190

left, 18 1
perfo rators from, 186,
190--19 1
right, 171, 180- 18 1. 19 1,
origin of. 200
relatio n o f P- 1 and 1'-2 to
posterior communicating
artery. 170, 172, 174.
Cerebral peduncle, 166
Cerebrospinal fluid
circulation of, 94
in d istension of arachnoid
membrane, 56, 59
drainage by lu mbar puncture, 40-4 1
fl ow through interpedu ncular cistern, 165, 166
in midbrai n se<:tions, 169
Chair, surgeon's, 16
Chiasmatic cistern. 93, 123- 164
anatomy o f, 123- 127. 172,
structures in. 126
union with sylvian and ambient cisterns, 169
Cho roidal artery, anterior. 57.
77,80--82,85,9 1,107,
110, 112- 113, 11 8, 145,
162- 163, 179,182,184,
186, 188, 192. 198-200
aneurysm of, 92, 108
at origin , 84. 115, 183
cou rse of, 172. 197
duplicated, 174, 175, 183
origin of, 95, 100, 104, 134,
144, 152, 183
perforato rs from, 183
relation to uncus of te mporal
lobe, 95, 105
Circle o f Willis
posterior, 18 1
relation to posterior clinoid
process, 167
Clinoid process of sphenoid


anterior, 37-38, 4 1-44. 5 1,

69,83, 100, 107- 108,
11 0- 11 2. 11 6- 11 7. 123.
128, 134,141-142, 147,
151-152. 156, 167, 169.
174, 176,178-18 1, 187,
194- 195
attach ment to tentorium,


rig ht, 140, 157

Clino id process (to'I/.)
posterior, 37-38, 42-45, 6667 ,69,83,98,100, 106108, 110- 111 , lJ 8, [20121, 138,152, 162, 167,
169, 174-175, 179, 182,
184-185, 187, 193- 195,
at tachment to tCllloriutn,
dura on, 99, 102. 118
left, 170, 180-- 18 1
relation to internal carotid
artery. 96, 114- 115
right, 114, 166, 170, 18018 1, 188
unusual presentation or.
170, 178
Com municating artery. anterior, 11 3. 120, 150, 159,
aneurysm of, 124, 132, 137,
139- 140, 14 3- 144 , 193
hypothalamic perforators
stuck to, 125, 149

bridging artery from left A I,

127, 162
bridging artery to left A-2.
112. 126, 153- 154, 157
duplicating, 126, 127, 134,
ISS, 158. 164
ju nction with AI and A-2
arteries, 112, 144
perforators from , 11 2, 157
triplicating complex of, 125,
variations in complex of, 126.
127, 153- 157
V-shaped. 126. 152- 154.
Communicating artery. poster
ior, 77, 85, 91, 99. 11 211 3, 162- 163. 175,177.
195, 200
adjacent aneurysm, 114
aneurysm of
collapsed, 178
at origin , 115- 11 6, 183184, 197
in carotid cistern, 190
caudal end in interpeduncu
lar cistern, 165
clips on, 170, 178, 180- 18 1,
188, 191
course o f, 176
ensheathed by arachnoid
membrane, [76

hidden by internal carolid artery, 192
junction with P I and P2 ar
teries, 170, 172, 174 , 186
lateral direction of, 95, 106107
left , 11 8- 119, 138
origin of. 95. 98.100-10 1,
104- 105.11 1. 134, 14 1142, 144,152- 153,179,
perforalOrs frOm
hypoph yseal,95, 102
hypothalamic, 95. 102- 103
thalamic, anterior, 82-83,
95, 102- 103, 109- 110,
172.174,176, 180, 184,
187.190, 192, 197- 198
adhesions in arachnoid
sheath of. 170. 182183
in arachnoid sheath . 198
preaneurysmaltype of infundibulum . 95. 1[0
relation to P I and P-2 arteries, 170, 172. 174. 186,
right, 138, 17 1
small, 95, 108
Cranimomy, right frontolateral,
Cribriform plate, 124, 130
Crista ga lli, 124 , 130-13 1
Cushing, Ha rvey. 2, 3. 4

Dahlgren. Karl , 3
Dandy, Walter, 4, 5-6
De Martel, Thierry. 3-4
Diaphragm sellae, 106. 112,
opening for pituitary stalk,
Dissecting instruments, 29, 30
Dorsum sellae, 166
front of. 115
relation to basi lar artery te r
mination, 168
side of, 114- 115
to p o f, 114- 11 5, 170, 179180
Doyen, Emile, 3
Drake, Charles, 16, 18
Drills and burrs, 24, 41
of crista g'dlli . 130

exposure o f. 40, 49-50

margin of, 62
as o ptic canal margin, 128
of orbital roof p rojections.
129, 13 1
of posterior cli noid process,
99, 102, 118
of sphenoid wi ng, 65, 68, 72,
of sylvian fi ssure, 50
tempordl, 50
venous sinus in , 114-115
Dural flap , 4 1

Electrocautery, 24-26, 39. 40-

Facial nerve
fro ntalis branches of, 40
origin o f. 17 1
"'alciform ligament, 167
Fishhook retractors. 22-23, 39,


cranial. 39-40
scalp. 39. 47-48
Foramen ovale. 38
electrocautery, 24-26
jewelers, 27, 29. 56. 62
to open and separate arachnoid , 64-65, 67
"' rontal M-2 arteries, 61, 70,
75-76. 88-89
microaneurysllIs of. 76
frolll middle cerebral M-I artery. 75. 89
from middle cerebral M-2 artery. 6 1, 76, 80, 88, 146
aneurysm flanked by, 78-


Frontal dura. 49-50

Frontal lobe. 53, 58-59, 6 1-64,
81-83,85-87,9 1,180.
adhesion 10 optic tracl, 104
adhesion to temporal lobe,
base o f, 131
c1evillion o f, 52, 124

le ft, 139- 140, 150
in quadrangular zone of
chiasmatic cistern, 132-


righi , 139, 143, 150, 155, 171

Frontolaleral craniotomy, right,


Fronto-orbital arteries, 114 ,

124 , 132-133, 137, 14 2,
14 7, 154
left, 117, 133, 140, 143-- 144.
149- 15 1, 155-159,162-


right, 14 3- 144 , 156. 163

fo-rontoparietal sutu re line, I , 37
Frontopolar arte ries
left. 140, 149
low ta keoff o f. 155
low ta keoff o f. 125, 149, 155
rig ht, 149
common trunk with anery
o f Heubner, 126, 15 1
Fron tosphenoidal suture li ne,
Fro ntotemporal bone nap, 39-


Gigli saw, 3, 24, 40
Gyrus rectus, 65, 98, 105, 120,
123, 124. 128, 16 1, 178
initial exposu re o f, 124, 132-


le ft, 114, 137, 142, 14 7-149,

155-156, 158. 162- 163
medial surface o f, 133
rig ht, 112, 11 4. 133, 136,
146- 147,151. 155- 156
ve in on, 99, 143

Hayes, George, 5
Head holder, 13-16
Hemorrhage, suba rach noid
and adhesions in arachnoid
sheath of thalamic perforalOrs, 170, 182- 183
thicke ned arach noid membra ne of Liliequ ist fro m,
170. 176
and xanthoch romic pigment
from hemoglobin, 15 1
Heu bner recurrent arte ry, 57,
80-8 1,9 1. 102, 105,108,
113, 134- 135, 142- 143,

14 7, 152- 155, 158. 170171,200

adherent to aneurysm al carotid arte ry bifu rcation,


cOlllmo n trunk with right

fromopolar artery. 126.
15 1
course o f, 127, 164
variations in, 125
large size of, 125, 14 6, 149
left, 133, 136- 137, 140, 144,
149, 157,159, 162- 163
perfo rato r fro m, 83
relation to anterior cerebral
a rtery. 95
right, 136- 137. 139, 144,
150, 157, 163
Heuer, George, 4 , 5
History o f pte riona! a pproach,
cranial saws in, 2-3
hypophyseal nap in , 5-6
osteoplastic method o f Wagner, 1-2
skin incisio ns in , 7
tre phine and melal guide of
de Martel in, 3-4
Hydrocephalus. commu nicating, 94
Hypoph y.seal a pproach of
Heucr a nd Dandy. 4, 56
Hypo physeal a rtery, su perior,
79,84, 95, 99, 102. 106,
Hypophyseal cistern , 125. 138,
14 1, 169
Hypophyseal perforators
from imernal carotid artery,
95,99, 11 5, 125, 138
arachno id sheath o f, 120
fro m posterior communicating artcry, 95, 102
Hypothala mic perforato rs
from internal carotid artery.
81,95, 102- 103, 106,
11 8, 14 8, 159, 179
from posterio r commun icating artery, 95, 102-103
stuck to anterior commu nicating artery aneu rysm,
125, 149
Hypothalamus. mammillary
body of, 166, 169,
17 1
Hyrtl's ca nal, 4 1

Incisions in skin, 7. 39, 46
Instrumentation, 11-30
bone-removal, 24
d issccting, 29, 30
electroca u tery, 24-26, 39,
40-4 1
external, 13-22
fishhook retracto rs, 22-23,
39, 48
intraoperative, 22-30
jewelers' fo rceps, 27, 29, 56,

mirrors, 29
opcrating microscope, 16-22
overhead table, 22
retf3clOrs, 26-27. 28. 48. 5 152,56,58
scissors, 27, 29, 68, 74
suction and suctioll-i rrigatio n
devices, 23-24, 4 1
surgeon's chair, 16
television systcms. 22
Inte rhe mispheric fiss ure (ciste rn), 123, 124. 133, 142,
147, 158, 169
arach noid covcring of, 144,
150, 153-- 155. 160
Interpedu ncu la r cistern , 69,
9l-94, 14 1, 152, 165200
anatomy of, 165- 173, 199
ap proaches to. 170. 184-185
basilar artery bifurcation in.

cente r of, 172, 187, 194196

fro nlOlateral ro ute 10, 98

j unCtio n with a mbient and
C.t rOlid cisterns. 169.
172,190, 192
right lateral ponion of, 185-


Interpeduncu la r fossa o f midbrain, 17 1

Irrigating flu id , 23--24

J ewelers' forceps. 27, 29, 56, 62

Kempe. Ludwig, 6, 39
Kcy and Retzius membra ne. Set
Arachnoid membrane o f
Lilieq uist


Lacrimal artery, 5 1
Lamina lerminalis, 85, 112-

11 3, 123. 124, 125, 133148, 150- 151 , 155- 160,

162- 163, 192, 197
anatomy 0[, 172, 199
Lamina terminalis cistern, 93,
125, 134- 136, 144 , 149,
anatomy of, 160-- 162
arachnoid bands at margin
of, 125, 141
structures in, 126
Liliequist membrane. See Arachnoid mem brane of Liliequist

Mammillary body of hypot halamus, 166, 169, 171
Medu lla oblongata, 17 1
Medu llary perforators from
basilar artery. 115, 177
Meningo-orbital artery. 41, 5 1
Microscissors. 27.29.68, 74
Microscope, operating, 16-22
advantages of, 17- 18
disadvantages of, 17
anatomy of, 165, 166
interpeduncular fossa of, 171
peduncle of (pyramidal
tract), 169, 171- 172, 189
left. medial side of, 177 ,
180- 181
Mirrors at tip o f probes, 29

Obalinski, Alfred, 3
Ocu lomotor nerves, 65, 69, 94,
98-100, 102. 104, 106110, 11 2, 11 5, 12 1, 152,
169, 176, 178- 179.182183. 185. 187, 190, 193194, 196, 199
adhesion to carotid artery
aneurysm, III
adhesion to uncus of temporal lobe, 170, 184
angulation of, 83
base of, 175
course of, 172
entering cavernous sinus,

le ft , 114. 180- 18 1, 188,200

origins of, 165
oSlium o f, 167, 174
relation to basilar artery bifurcatio n. 19 1
right, 114 , 166. 171, 177,
180- 18 1, 188,200
separating superior cerebellar
artery. 172, 186
Oculomotor trigone, 167, 172
Olfactory bulb, 124, 131
O lfactory cistern , 123, 124,
Olfactory nerves, 124
Olfactory stria, medial and lateral, 124
Olfactory trace, 53, 95, 98--99.
102, 105, 124, 132-133,
155, 17 1
lower portion of, 128
left. 158-- 159
middle portion of, 129
rig ht, 156
upper portion of, 130, 13 1
Operating microscope, 16-22
Operating room table. 13
Ophthalmic artery, 95
left, 148
origin of, 104, 148
Optic canal, 38, 167
dural margin of, 128
Optic chiasm, 80-84, 9 1, 106,
112, 11 4, 11 7- 120, 123,
133, 136, 140- 144, 146152. 154-156, 158, 160,
162, 166,179,192,197,
lateral side of, 157
prefi xed, 124 , 125-126, 134135, 150
Optic cistern, 124
Optic nerves, 52, 66, 69, 77,
82-83, 100-101, 103105, 107- 108, 110, 112,
11 4, 11 8-- 120, 167.175,
182- 184. 186-187, 194195
arachnoid band over, 67
arachno id between, 98--99,
102, 11 6, 132- 134,148,
arachnoid covering of, 53. 74
lateral portion in carotid cistern, 123
left, 106, 117, 133, 138, 140143, 146- 152, 154-156,
158--160,162, 192, 199

in orbit, 124
right, 98-99, 102, 106, 11 6117.121, 128,133.138,
141 - 14 3, 146-- 150,152,
154- 160,162,171, 174,
176, 179- 181 . 192,199
unusual relation to posterior
clinoid process, 170, 178
Optic tract, 79-85, 89-9 1, 106,
108- 110, 11 5, 120, 123,
135-136, 145,150- 15 1,
154, 161- 163, 169,179,
185-186, 194-195, 197198, 200
adhesion to frontal lobe, 104
right, 112, 114 , 118, 133,
138--1 44 , 146-- 149, 152,
155-159, 192, 199
terminus of, 165
view to inte rnal carotid artery, 103
dura covering roof projections, 129, 13 1
in surgical position, 42-45
Orbital fissure, superior. 38
O rbital gyrus, medial. 123, 124

Parietosphenoidal suture line,
Parictotemporal suture line, I,
cerebellar, middle, 17 1
cerebral, 166
interpedu ncular cistern. Set
Interpeduncular cistern
midbrain. 169, 171-172, 189
Perforated substance, anterior,


front border of, 124

perforators to, 57, 79, 84, 89,
Perforating arteries
on aneurysm dome, 78
from anterior cerebral A- I
artery, 57. 79-80, 82, 84,
92,106, 14 1- 142, 16 1163,170,184,186, 199
from anterior choroidal artery, 183
from anterior communicating
artery, 11 2, 157
to anterior perforated substance, 57, 79, 84, 89, 11 8


arachnoid fibers from, 57,
from artery of Heubner, 83
hypo physeal. Su Hypophyseal perforators
hypothalamic. Su Hypothalamic perforatOrs
from internal carotid artery.
Su Carotid artery. internal, perforators from
medu llary, from basilar artery, 115, 177
from middle cerebral M- I artery, 57, 79-81, 89-92,
125 , 146-147,170,181,
184-187, 190-191, 200
from posterior cerebral arter-


P_I, 165, 168, 188, 195

P-2, 186, 190-19 1
from posterior com municating artery. Su Communicating artery, posterior,
perforators from
stria thalam ic, 57, 89-92
thalamic. See Thalamic per
foralO rs
Pericallosal cistern, 123
Periosteal patch elevated from
frontal bone, 39, 47
Petrous pyram id , 42-45
PhoLOgraphy, 33-35
current techniques in, 34-35
Pituitary gland, 97, 118, 140,

in fu ndibulum of. 166
Pituitary stalk , 82, 95-96, 102.
104, 106, 11 0, 114 , 119,
12 1,125, 138, 140- 14 1,
opening for, in diaphragm
sellae, 167
portal veins of, 11 8
surrounded by arach noid,
125, 138, 147-148, 169
rostral paft of, 115, 170, 172,
174-175,179-1 8 1,186187, 190-192, 194- 196
trigeminal nerve arising
from, 171
Positioning of patient, 39
importance of, II , 16
Prepontine cistern, 193, 194
Psychopathic point, 6, 39
Pterion, defin ition of, 1,37
Pterygoid plates, 38

Quadrangular zone in chias

matic ciste rn , 124. 133163
Quadrigeminal cistern , 169
Quadrigeminal plate, 166

Raney dips, 47
Recurrent artery o f Heubner.
Set Heubner recurrent
Reil island, 7 1
Retractors, 26-27, 28, 48, 5 152, 56, 58
fishhook, 22-23, 39, 48
self retaining. 26-27
Rongeurs, 24, 40
Rosenthal vein , basilar, 165,

Saws, cranial, development of,
2-3, 24, 40
Scalp nap, 39. 47-48
Scissors, types of, 27, 29, 68, 74
Sella turcica, 37-38
Skin incisions, 7, 39, 46
Skull fixation, threepoim, 1316,39
Sphenoid wings, 37, 38, 42-43,

dura over, 65, 68, 72. 86
prior to removal, 49-50
removal of, 39, 40-41
Sphenoidotemporal suture line,
Sphenoparietal sinus, bridging
veins to temporal lobe,
electrocoagulation of. 56, 68
Stria thalamic perforators, 57.
Subarachnoid hemorrhage
and adhesions in arach noid
sheath of thalamic perforalOrs, 170, 182-183
thickened arachnoid memo
brane of Liliequist from ,
170, 176
and xanthochromic pigment
from hemoglobin. 151
Suction and suction.irrigation
devices, 23-24, 4 I
Sutu re lines of skull, 1,37

Sylvian aqueduct, 166

Sylvian fissure (cistern), 52, 5592.93-94, 123
anatomy of. 56-57
arachnoid over, 146
dura over, 50
lateral, 169
medial, 169
surgical opening of, 56-91
union with chiasmatic and
ambient ciSlern, 169
veins in, 63, 66, 75-76, 78
branches of, 59
Sympathetic fibers on internal
carotid artery, 96, 116

operating room, 13
overhead , 22
Television systems, 22
Temporal arteries
anterior, 70, 75, 77-79, 83,
88-89,9 1, 100, 134, 147,
184,19 1
duplicated. 190
from middle cerebral arteries, 70
MI, 75, 89
M-2. 6 1,76,80,88, 146
aneurysm nanked by, 78,


posterior, 76
superficial . 40
Temporal lobe, 53, 56, 58-59,
6 1-62,65-66.69-70,74,
85-87,9 1,186
ad hesions
with carotid artery, 100
with frontal lobe, 56, 71
aneurysm dome in , 75
bridgi ng veins to sphenopa.
rictal si nus, 41,56.66,74
electrocoagulation of. 56,


dura of, 49-50

elevation of, 52
left, medial side of, 11 7, 119,
medial , 169
right, 120
uncus of, 69, 102, 108-109,
11 2- 113, 115, 121, 152,
174-1 75, 178, 180-183,
185, 192-193, 197-198,



Tcmporal lobe (conI.)

adherence to oculomotor
nerve, 170, 184
left, medial side of, 117
relation to anterior choroidal artery, 95, 105
retractio n of, 83
vein on, 128
Temporalis muscle. incision of,

T entorium cerebcUi, 166
anterior reflection of, 99, 162
attach ments to clinoid processes, 165
carotid artery aneurysm
adhesion to, 101
edge or margin of, 68, 105,
107-108, 11 0, 114 , 116,
121 , 134,174, 176, 184-

incisura of, 166
medial reflections of, 167
Thalamic perforators
from internal carotid artery, 95, \02- \03, 172,

in arachnoid sheath, 120
from posterio r communicating artery. 82-83, 95,
102-103, 109-110,170,
172,174,176,180, 184,
187, 190. 192, 197- 198
adhesions in arachnoid
sheath of, 170, 182-

in arach noid sheath . 198

posterior, from posterio r cerebral arteries

P_I. 165, 168, 18 1. 188. 195
P-2. 186, 190- 191

Third ventricle, 145

cerebrospinal fluid in, 169
relation to basilar artery, 168
Toison , J ean, 2-3
Tremor. reduction of, 29
Trephines, d evelopment of, 34
Trigeminal ne rve. right, a rising
from pons, 171
Trochlear nerve, 165, 166
ostium of, 167
Tuberculum sellae, 37-38, 4344,117,135, 148, ISS,


Uncus of temporal lobe, 69,
102, 108--109, 11 2- 113,
115, 121,152,174-175,
178, 180- 183,185,192193, 197-198,200
adherence 10 oculomotor
nerve, 170, 184
left, medial side o f, 117
relation to anterior choroidal
artery, 95, 105
retraction of, 83

in ambient cistern , 174- 175,

in interpeduncular cistern ,
190- 191,200
in lamina te rminalis cistern ,
127, 161
portal, of pituitary stal k, 11 8
in sulcus belween frontal lobe
and olfactory cistern ,


in sylvian fissure, 59, 63, 66,

75-76, 78
o n temporal lobe, 128
Venous d rainage, preservation
Venous sinus, dural, 114- 115
Ventricle, third, 145
cerebrospinal fluid in , 169
relation 10 basilar artery, 168
Vertebral arteries, 17 1
Von Bergma nn , Ernst, 2

Wagner. Wilhelm, 1-2,3
Willis circle
posterior, 18 1
relation 10 posterior clinoid
process, 167
Xanthochromic pigment from
hemoglobin of subarachnoid hemorrhage, 151


basilar, of Rosenthal, 165,


in carotid ciste rn, 110

in cavernous si nus, unusual,
97,1 18--119
in chiasmatic ciste rn , 163
on gyrus rectus, 99, 143

Yasargil, Gazi, 6-7, 16

Zygoma. frOll tal process of, 44