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The Cerebellar Arteries

The Cerebellar Arteries

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CHAPTER 2
The Cerebellar Arteries
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Key words:
Anteroinferior cerebellar artery, Cerebellum, Cerebrovascular disease, Cranial nerves, Microneurosurgery, Posterior cranial fossa,Posteroinferior cerebellar artery, Superior cerebellar artery
O
ptimizing operative approaches to the posterior fossarequires an understanding of the relationship of thecerebellar arteries to the cranial nerves, brainstem,cerebellar peduncles, fissures between the cerebellum and brainstem, and the cerebellar surfaces (45). When examiningthese relationships, three neurovascular complexes are de-fined: an upper complex related to the superior cerebellarartery (SCA); a middle complex related to the anteroinferiorcerebellar artery (AICA); and a lower complex related to theposteroinferior cerebellar artery (PICA) (
Figs. 2.1
and
2.2
) (35).Other structures, in addition to the three cerebellar arteries,occurring in sets of three in the posterior fossa that bear aconsistent relationship to the SCA, AICA, and PICA are theparts of the brainstem (midbrain, pons, and medulla); thecerebellar peduncles (superior, middle, and inferior); the fis-sures between the brainstem and the cerebellum (cerebel-lomesencephalic, cerebellopontine, and cerebellomedullary);and the surfaces of the cerebellum (tentorial, petrosal, andsuboccipital). Each neurovascular complex includes one of thethree parts of the brainstem, one of the three surfaces of thecerebellum, one of the three cerebellar peduncles, and one ofthe three major fissures between the cerebellum and the brain-stem. In addition, each neurovascular complex contains agroup of cranial nerves. The upper complex includes theoculomotor, trochlear, and trigeminal nerves that are relatedto the SCA. The middle complex includes the abducens, facial,and vestibulocochlear nerves that are related to the AICA. Thelower complex includes the glossopharyngeal, vagus, acces-sory, and hypoglossal nerves that are related to the PICA.In summary, the upper complex includes the SCA, mid- brain, cerebellomesencephalic fissure, superior cerebellar pe-duncle, tentorial surface of the cerebellum, and the oculomo-tor, trochlear, and trigeminal nerves. The SCA arises in frontof the midbrain, passes below the oculomotor and trochlearnerves and above the trigeminal nerve to reach the cerebel-lomesencephalic fissure, where it runs on the superior cere- bellar peduncle and terminates by supplying the tentorialsurface of the cerebellum.The middle complex includes the AICA, pons, middle cer-ebellar peduncle, cerebellopontine fissure, petrosal surface ofthe cerebellum, and the abducens, facial, and vestibuloco-chlear nerves. The AICA arises at the pontine level, courses inrelationship to the abducens, facial, and vestibulocochlearnerves to reach the surface of the middle cerebellar peduncle,where it courses along the cerebellopontine fissure and ter-minates by supplying the petrosal surface of the cerebellum.The lower complex includes the PICA, medulla, inferiorcerebellar peduncle, cerebellomedullary fissure, suboccipitalsurface of the cerebellum, and the glossopharyngeal, vagus,spinal accessory, and hypoglossal nerves. The PICA arises atthe medullary level, encircles the medulla, passing in relation-ship to the glossopharyngeal, vagus, accessory, and hypoglos-sal nerves to reach the surface of the inferior cerebellar pe-duncle, where it dips into the cerebellomedullary fissure andterminates by supplying the suboccipital surface of thecerebellum.
THE SUPERIOR CEREBELLAR ARTERYOverview
The SCA or its branches are exposed in surgical approachesto the basilar apex, tentorial incisura, trigeminal nerve, cer-ebellopontine angle, pineal region, clivus, and the upper partof the cerebellum (18, 19).The SCA is intimately related to the cerebellomesencephalicfissure, the superior half of the fourth ventricular roof, thesuperior cerebellar peduncle, and the tentorial surface (
Figs.2.3
-
2.5
). The SCA arises in front of the midbrain, usually fromthe basilar artery near the apex, and passes below the oculo-motor nerve, but may infrequently arise from the proximalPCA and pass above the oculomotor nerve. It dips caudallyand encircles the brainstem near the pontomesencephalic junction, passing below the trochlear nerve and above thetrigeminal nerve. Its proximal portion courses medial to thefree edge of the tentorium cerebelli, and its distal part passes below the tentorium, making it the most rostral of the infrat-entorial arteries. After passing above the trigeminal nerve, itenters the cerebellomesencephalic fissure, where its branchesmake several sharp turns and give rise to the precerebellararteries, which pass to the deep cerebellar white matter andthe dentate nucleus. On leaving the cerebellomesencephalicfissure where its branches are again medial to the tentorialedge, its branches pass posteriorly under the tentorial edge
S29
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 
 
and are distributed to the tentorial surface. It usually arises asa single trunk, but may also arise as a double (or duplicate)trunk. The SCAs arising as a single trunk bifurcate into arostral and a caudal trunk. The SCA gives off perforating branches to the brainstem and cerebellar peduncles. Precer-ebellar branches arise within the cerebellomesencephalic fis-sure. The rostral trunk supplies the vermian and paravermianarea and the caudal trunk supplies the hemisphere on thesuboccipital surface. The SCA frequently has points of contactwith the oculomotor, trochlear, and trigeminal nerves.
Segments
The SCA is divided into four segments: anterior pontomes-encephalic, lateral pontomesencephalic, cerebellomesence-phalic, and cortical (
Fig. 2.1
). Each segment may be composedof one or more trunks, depending on the level of bifurcationof the main trunk (
Fig. 2.6
).
Anterior pontomesencephalic segment 
This segment is located between the dorsum sellae and theupper brainstem. It begins at the origin of the SCA andextends below the oculomotor nerve to the anterolateral mar-gin of the brainstem. Its lateral part is medial to the anteriorhalf of the free tentorial edge.
Lateral pontomesencephalic segment 
This segment begins at the anterolateral margin of the brainstem and frequently dips caudally onto the lateral side ofthe upper pons (
Figs. 2.1
,
2.7
, and
2.8
). Its caudal loop projectstoward and often reaches the root entry zone of the trigeminalnerve at the midpontine level. The trochlear nerve passesabove the midportion of this segment. The anterior part of thissegment is often visible above the tentorial edge, but thecaudal loop usually carries it below the tentorium. This seg-ment terminates at the anterior margin of the cerebellomes-encephalic fissure. The basal vein and the PCA course aboveand parallel to this SCA.
Cerebellomesencephalic segment 
This segment courses within the cerebellomesencephalicfissure (
Figs. 2.7
-
2.9
). The SCA branches enter the shallowestpart of the fissure located above the trigeminal root entry zoneand again course medial to the tentorial edge with its branches intertwined with the trochlear nerve. The fissure inwhich the SCA proceeds progressively deepens medially andis deepest in the midline behind the superior medullary ve-lum. Through a series of hairpin-like curves, the SCA loopsdeeply into the fissure and passes upward to reach the ante-rior edge of the tentorial surface. The trunks and branches ofthe SCA are held in the fissure by branches that penetrate the
FIGURE 2.1. Each of the threeneurovascular complexes in theposterior fossa includes one of thethree cerebellar arteries, one of the three parts of the brainstem,one of the three cerebellarpeduncles, one of the threecerebellar surfaces, one of thethree fissures between thebrainstem and the cerebellum,and one of the three groups of cranial nerves. The upper complexis related to the SCA, the middlecomplex is related to the AICA,and the lower complex is relatedto the PICA. The upper complexincludes the SCA, midbrain,superior cerebellar peduncle,cerebellomesencephalic fissure,tentorial cerebellar surface, andthe oculomotor, trochlear, andtrigeminal nerves. The middle complex includes the PICA, pons, middle cerebellar peduncle, cerebellopontine fissure,petrosal surface, and the abducens, facial, and vestibulocochlear nerves. The lower complex includes the PICA, medulla,inferior cerebellar peduncle, cerebellomedullary fissure, suboccipital surface, and the glossopharyngeal, vagus, accessory, andhypoglossal nerves. The SCA is divided into four segments: anterior pontomesencephalic (
green 
), lateral pontomesencephalic(
orange 
), cerebellomesencephalic (
blue 
), and cortical (
red 
). Each segment may be composed of one or more trunks,depending on the level of bifurcation of the main trunk. The AICA is divided into four segments: anterior pontine (
green 
),lateral pontomedullary (
orange 
), flocculonodular (
blue 
), and cortical (
red 
). The PICA is divided into five segments: anteriormedullary (
green 
), lateral medullary (
orange 
), tonsillomedullary (
blue 
), telovelotonsillar (
yellow 
), and cortical (
red 
).
A.I.C.A.
,anteroinferior cerebellar artery;
CN 
, cranial nerve;
Fiss.
, fissure;
Ped.
, peduncle;
P.I.C.A.
, posteroinferior cerebellar artery;
S.C.A.
, superior cerebellar artery.
S30
Rhoton
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 
 
fissure’s opposing walls. Identification of individual branchesof the SCA within this fissure is made difficult by the sharpcurves of the branches and by the large number of intermin-gled arterial loops.
Cortical segment 
This segment includes the branches distal to the cerebel-lomesencephalic fissure that pass under the tentorial edge andare distributed to the tentorial surface and, if a marginal branch is present, to the upper part of the petrosal surface(
Figs. 2.6
-
2.9
).
Origin
The SCA is the most consistent of the infratentorial cere- bellar arteries in its presence and area of supply (49). Absenceof the SCA, although rare, has been reported (50). In ourprevious study of 50 SCAs, 43 arose as a single trunk and 7arose as two (duplicate) trunks (19). Duplicate trunks werepresent bilaterally in only one of the brains we examined.Triplication of the origin is rare. All but 2 of the 50 SCAsexamined arose from the basilar artery. The two exceptionsarose solely or in part from the posterior cerebral artery andpassed above the oculomotor nerve, after which they followedthe typical distal course. The solitary trunk of nonduplicatedSCAs and the rostral trunk of duplicate SCAs usually arisefrom the basilar artery below, but directly adjacent to, theorigin of the PCA. The arteries not arising adjacent to the originof the PCA arise within 2.5 mm of the PCA origin.The origin of the right and left SCAs and PCAs frequentlytakes a cruciate configuration in which the limbs cross at theapex of the basilar artery (
Fig. 2.2
). The height of the bifurca-
FIGURE 2.2.
A
, anterior view of the brainstem and cerebellararteries.
, posterior view of thecranial base with the cranialnerves and arteries preserved.
A
and
, the SCA arises at themidbrain level and encirclesthe brainstem near thepontomesencephalic junction. TheSCA courses below the oculomotorand trochlear nerves and above thetrigeminal nerve. The SCA loopsdown closer to the trigeminal nervein
than in
A
. The AICA arises atthe pontine level and courses bythe abducens, facial, andvestibulocochlear nerves. In
A
,both AICAs pass below theabducens nerves. In
, the leftabducens nerve passes in front of the AICA and the right abducensnerve passes behind the AICA.The PICAs arise from the vertebralartery at the medullary level andcourse in relation to theglossopharyngeal, vagus, accessory,and hypoglossal nerves. The originof the SCAs are quite symmetricalfrom side to side. There is slightasymmetry in the level of origin of the AICAs and marked asymmetryin the level of the origin of thePICAs, especially in
A
.
A.
, artery;
A.I.C.A.
, anteroinferior cerebellarartery;
Ant.
, anterior;
CN 
, cranialnerve;
P.C.A.
, posterior cerebralartery;
P.I.C.A.
, posteroinferiorcerebellar artery;
S.C.A.
,superior cerebellar artery;
Sp.
,spinal;
Vert.
, vertebral.
Cerebellar Arteries
S31
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 

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