Anatomical observations of

the subarachnoid cisterns

of the brain during surgery

M. GAZI YASARGIL~M.D., KONSTANTINKASDAGLIS, M.D.,

KEWAL K. JAIN, M.D., AND HANS'PETER WEBER
University Neurosurgical Clinic, Kantonsspital Zfirich, Zfirich, Switzerland

Subarachnoid cisterns and their contents are described briefly in the light of
observations made during microsurgicalexplorations. The concept of intracranial sur-
gery in terms of moving from one cistern to another is presented here with particular
emphasis on the cisterns in surgical approaches to intracranial vessels and nerves for
the treatment of aneurysms, arteriovenous malformations, and for surgery of basal
tumors.

KEY WOROS 9 s u b a r a c h n o i d cisterns 9 microsurgery 9

cerebral vessels 9 c r a n i a l nerves 9 arachnoid membrane

HE subarachnoid cisterns are expan-

T
Anatomical Observations
sions of subarachnoid space situated
This summary of observations is based on
between the arachnoid membrane of the
approximately 1500 intracranial operations
brain and its pial surface. They are filled with
performed by one of us (MGY) under the
cerebrospinal fluid and traversed by fibers
microscope (Figs. 1-3). We stress the concept
and trabeculae which connect the two bound-
of performing intracranial operations by
ing membranes. The major intracranial
moving from one cistern to another. Par-
nerves and blood vessels ensheathed in
ticular attention is paid to cisterns in surgical
arachnoidal fibers pass through these com-
approaches to intracranial aneurysms, e
partments.
vascular malformations and basal tumors,
The first definitive work on the anatomy of
such as craniopharyngiomas, meningiomas,
subarachnoid cisterns was done by Key and
acoustic neuromas) epidermoids, and chor-
Retzius 1 100 years ago. There was no notable
domas/chondromas.
study on this subject until the monograph by
neuroradiologist Liliequist in 19597 Later
studies on this subject were done by
Leighton,~ and Wilson?
Cisterna Cerebellomedullaris Lateralis
Some authors have described cisterns for
each individual nerve and artery but for prac- The cisterna cerebellomedullaris ventro-
tical purposes the description is confined to lateralis contains
cisterns of interest to neurosurgeons. The 1. the vertebral artery and origin of
usual contents of each cistern are described. posterior inferior cerebellar artery;

298 J. Neurosurg. / Volume 44 / March, 1976

A n a t o m i c a l o b s e r v a t i o n s of s u b a r a c h n o i d c i s t e r n s

2. the ninth, 10th, l lth and the 12th Cisterna lnterpeduncularis

cranial nerves;
3. the lateral medullary and postolivary
veins; and
4. the choroid plexus.
Cisterna Prepontis
The cisterna prepontis contains
1. the basilar artery and origin of anterior the artery to the third cranial nerve;
inferior cerebellar artery;
2. the origin of the superior cerebellar connect with the midpoint of the peduncular
arteries;
3. the sixth nerve; and
4. the anterior and anteromedian pontine
veins.
Cisterna Pontocerebellaris
The cisterna pontocerebellaris contains
1. the seventh and eighth nerves;
2. the anterior inferior cerebellar artery;
3. the lateral pontine veins; and
4. the fifth nerve and the petrosal vein.
The cisterna interpeduncularis contains
1. the bifurcation of the basilar artery;
2. peduncular segments of the posterior
cerebral arteries;
3. peduncular segments of the superior
cerebellar arteries;
4. perforating branches of the posterior
cerebral arteries, one meningeal branch, and
5. posterior communicating arteries that
segments of the posterior cerebral arteries;
6. the basal vein of Rosenthal;
7. the interpeduncular vein and posterior
communicating vein; and
8. the third cranial nerve which is situated
on each side in the lateral wall of the cistern
and passes between the posterior cerebral and
superior cerebellar arteries.
Cisterna Cruralis
The cisterna cruralis contains
1. the anterior choroidal artery;

FIG. 1. Artist's concept of the subarachnoid cisterns at the base of the brain. Left." Relation of cranial
nerves to cisterns, Right: Relation of arteries to cisterns. The cranial nerves are designated by Roman
numerals. 1 = Olfactory cistern; 2 = Callosal cistern; 3 = Chiasmatic cistern with I and II nerves;
4 = Carotid cistern; 5 = Sylvian cistern; 6 = Crural cistern; 7 = Interpeduncular cisterns with III
nerves; 8 = Ambient cisterns with IV nerves; 9 = Prepontine cistern with VI nerves; 10 = Cerebellopon-
tine cistern on each side with VII and VIII nerves; 11 = Lateral cerebellomedullary cistern on each side
with IX, X, XI and XII nerves; 12 = Cervical subarachnoid space; 13 = Cisterna cerebellomedullaris.

J. Neurosurg. / Volume 44 /March, 1976 299


FI~. 2. Cisterns encountered in surgery of
cerebellopontine angle tumors. 1 = cisterna am-
biens and quadrigemina; 2 = cerebellopontine
angle cistern; 3 = lateral cerebellomedullary
cistern with choroid plexus; 4 = fourth ventricle; 5
= hemispherical cistern (cerebellar); 6 = superior
vermian cistern; 7 = cisterna magna; 8 = cervi-
cal subarachnoid space, spca = superior cerebellar
artery; aica = anterior inferior cerebellar artery;
~ ica = posterior inferior cerebellar artery; B =
asilar artery; V = vertebral artery; Vp = petrosal
vein; mV = medullary vein; F1 = foramen of
Luschka; PI = choroid plexus. The cranial nerves
are designated by Roman numerals. Solid black
lines represent the definite extent of subarachnoid
space. Dotted lines represent the probable extent
of subarachnoid space.
Fro. 3. Subarachnoid cisterns of the anterior
fossa. Note the thickened fibers over the A~ and M1
segments. 1 = medial basal part of Sylvian cistern;
2 = olfactory cistern; 3 = carotid cistern; 4 =
lateral upper part of the interpeduncular cistern; 5
= crural cistern; 6 = chiasmatic cistern; 7 =
cistern of lamina terminalis; 8 = callosal cistern.
300
M. G. Yaw et al.
2. the medial posterior choroidal artery;
and
3. the basal vein of Rosenthal.
Cisterna Chiasmatis
The cisterna chiasmatis contains
1. the anterior aspect of the optic chiasma
and optic nerves;
2. the hypophyseal stalk;
3. the origin of the anterior cerebral
arteries; and
4. the anterior communicating vein.
Carotid Cistern
The carotid cistern contains
1. the internal carotid artery;
2. the origin of the anterior choroid artery;
and
3. the origin o f the posterior com-
municating artery.
Sylvian Cistern
The Sylvian cistern contains
1. the middle cerebral artery;
2. middle cerebral (Sylvian) veins;
3. fronto-orbital veins; and
4. collaterals to the vein of Rosenthal.
Cisterna Lamina Terminalis
The cisterna lamina terminalis contains
1. anterior cerebral arteries; the A-I seg-
ment and the proximal part of the A-2
segment;
2. the anterior communicating artery;
3. Heubner's artery;
4. the hypothalamic arteries;
5. the origin of the fronto-orbital arteries;
6. the venous system of the lamina ter-
minalis.
Quadrigeminal Cistern
The quadrigeminal cistern contains
1. the vein of Galen;
2. the posterior pericallosal arteries;
3. the third portion of the superior cere-
bellar arteries;
4. perforating branches of the posterior
cerebral and the superior cerebellar arteries;
and
5. the third portion of the posterior cere-
bral arteries. The two arteries approach each
other and then continue posteriorly beneath
the splenium corporis callosi to the apex of
J. Neurosurg. / Volume 44 / March, 1976
A n a t o m i c a l o b s e r v a t i o n s of s u b a r a c h n o i d cisterns
the isthmus gyri fornicati to divide into two
cortical branches, the calcarine and parieto-
occipital branches.
Cisterna Cruralis
The cisterna cruralis contains
1. the anterior choroidal artery;
2. the medial posterior choroidal artery;
and
3. the basal vein of Rosenthal.
Cisterna Chiasmatis
The cisterna chiasmatis contains
1. the anterior aspect of the optic chiasma
and optic nerves;
2. the hypophyseal stalk;
3. the origin of the anterior cerebral
arteries; and
4. the anterior communicating vein.
Carotid Cistern
The carotid cistern contains
1. the internal carotid artery;
2. the origin of the anterior choroid artery;
and
3. the origin of the posterior com-
municating artery.
Sylvian Cistern
The Sylvian cistern contains
1. the middle cerebral artery;
2. middle cerebral (Sylvian) veins;
3. fronto-orbital veins; and
4. collaterals to the vein of Rosenthal.
Cisterna Lamina Terminalis
The cisterna lamina terminalis contains
1. anterior cerebral arteries; the A-1 seg- surgery. A good example of this is the open-
ment and the proximal part of the A-2 ing of the lateral cerebellomedullary cistern
segment;
2. the anterior communicating artery;
3. Heubner's artery;
4. the hypothalamic arteries;
5. the origin of the fronto-orbital arteries;
6. the venous system of the lamina ter-
minalis.
Quadrigeminal Cistern
The quadrigeminal cistern contains
1. the vein of Galen;
2. the posterior pericallosal arteries;
3. the third portion of the superior cere- membranes are noted to be regularly thicker
J. Neurosurg. / Volume 44 / March, 1976
bellar arteries;
4. perforating branches of the posterior
cerebral and the superior cerebellar arteries;
and
5. the third portion of the posterior cere-
bral arteries. The two arteries approach each
other and then continue posteriorly beneath
the splenium corporis callosi to the apex of
the isthmus gyri fornicati to divide into two
cortical branches, the calcarine and parieto-
occipital branches.
Cisterna Ambiens
The supratentorial compartment of the
cisterna ambiens contains
1. the basal vein; and
2. the posterior cerebral artery.
The infratentorial compartment contains
1. the superior cerebellar artery; and
2. the fourth nerve.
Discussion
Although the clinical pathophysiology of
the subarachnoid space is well known (as in
cases of subarachnoid hemorrhage, menin-
gitis, circulatory disturbances of CSF, and tu-
mors), it is surprising that the topography of
the basal cisterns has not been adequately
worked out. Knowledge of the neural and
vascular contents of each of the basal cis-
terns is of particular value in the planning and
execution of intracranial surgery.
The surgeon may chart his intracranial ap-
proach like a road map in terms of the basal
cisterns. The release of CSF from the basal
cisterns provides effective reduction of
cerebral volume and facilitates intracranial
prior to exploration of tumors, aneurysms, or
angiomas in the cerebellopontine angle. The
Sylvian, carotid, chiasmatic, and interpedun-
cular cisterns are opened for surgery of
aneurysms and parasellar tumors. Although
often considered as anatomically distinct
compartments, the basal cisterns are, in fact,
only separated from each other by a
trabeculated porous wall with various sized
openings. These apertures can become
plugged and partially or totally obliterated
after subarachnoid hemorrhage and in cases
of basal tumor. The arachnoid fibers and
301

and tougher where the arteries pass through
the trabeculated wall from one cisternal com-
partment to another. At these positions of
thickened arachnoid, such as over A1 and M1
segments (see Fig. 3), the arachnoid cannot be
safely opened and eliminated simply by
spreading with a forceps, but must be cut with
scissors or microknives.
Increased knowledge of the construction of
the basal cisterns and arachnoidal fibers and
their variations will greatly assist neuro-
surgeons in avoiding any trauma to the basal
nerves, brain tissues, or vessels during dissec-
tion.
References
1. Key EAH, Retzius MG: Studien in der
Anatomie des Nervensystems und des
Bindegewebes. Stockholm: Samson & Wallin,
1875
302
M. G. Ya~argil, et al.
2. Leighton RS: Neuroradiologic Anatomy -- A
Stereoscopic Atlas. Baltimore: Williams &
Wilkins, 1971
3. Liliequist B: The suharachnoid cisterns. An
anatomic and roentgenologic study. Acta
Radiol [Soppl] 185:1-108, 1959
4. Wilson McC: The Anatomic Foundations of
Neuroradioiogy of the Brain, ed 2. Boston: Lit-
tle Brown, 1972
5. Ya~argil MG, Fox JL: The microsurgical ap-
proach to acoustic neuromas. Sorg Neurol
2:393-398, 1974
6. Ya~argil MG, Fox JL, Ray MW: The operative
approach to aneurysms of the anterior com-
municating artery, in Krayenbfihl H (eel): Ad-
vances and Technical Standards in Neuro-
surgery, vol 2. New York: Springer-Verlag,
1975, pp 113-170
Address reprint requests to: M. Gazi Ya~argil,
M.D., Kantonsspital Zfirich, Neurochirurgische
Universit~tsklinik, R~imistrasse 100, 8006 Zfirich,
Switzerland.
J. Neurosurg. / Volume 44 / March, 1976