The Cerebellar Arteries
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Anteroinferior cerebellar artery, Cerebellum, Cerebrovascular disease, Cranial nerves, Microneurosurgery, Posterior cranial fossa,Posteroinferior cerebellar artery, Superior cerebellar artery
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) (
) (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 (
). 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
Vol. 47, No. 3, September 2000 Supplement