Cisternas y Memb Arac

SURGICAL ANATOMY
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MICROSURGICAL AND ENDOSCOPIC ANATOMY OF
THE SUPRATENTORIAL ARACHNOIDAL MEMBRANES
AND CISTERNS
Kohei Inoue, M.D. OBJECTIVE: A limitation of previous studies of the arachnoid cisterns and membranes
Department of Neurosurgery, is that the act of opening the sylvian and interhemispheric fissures and basal arachnoid
University of Florida, often led to destruction of the cisternal compartments and their membranous walls.
Gainesville, Florida
The goal of this study was to overcome this limitation by combining the surgical micro-
Askin Seker, M.D. scope and endoscope for the examination of the cisternal compartments and their mem-
Department of Neurosurgery,
branous walls.
University of Florida, METHODS: The supratentorial cisterns were examined in 22 cadaveric brains using
both the operating microscope and the endoscope.
Shigeyuki Osawa, M.D. RESULTS: There are 2 types of arachnoid membranes: outer and inner. The outer arach-
noidal membrane surrounds the whole brain, and the inner membranes divide the sub-
University of Florida, arachnoid space into cisterns. Twelve inner arachnoid membranes were identified in
Gainesville, Florida the supratentorial area: diencephalic, mesencephalic, medial carotid, intracarotid,
intracrural, olfactory, medial and lateral lamina terminalis, and proximal, medial, inter-
Luis Felipe Alencastro, M.D. mediate, and lateral sylvian membranes. These membranes partially or completely sep-
University of Florida,
arate the subarachnoid space into 9 supratentorial cisterns: sylvian, carotid, chiasmatic,
Gainesville, Florida lamina terminalis, pericallosal, crural, ambient, oculomotor, and interpeduncular. There
is a confluent area between the carotid, interpeduncular, and crural cisterns, which fre-
Toshio Matsushima, M.D. quently has no membrane separating these cisterns.
Department of Neurosurgery, CONCLUSION: Twelve inner arachnoid membranes and 9 cisterns were identified in
Saga University,
Saga, Japan
this study.
KEY WORDS: Cerebral arteries, Cerebrospinal fluid, Cranial base, Meninges, Microsurgical anatomy, Skull
Albert L. Rhoton, Jr., M.D. base, Subarachnoid space, Supratentorial cisterns
University of Florida, Neurosurgery 65:644–665, 2009 DOI: 10.1227/01.NEU.0000351774.81674.32 www.neurosurgery-online.com
G
Reprint requests: erardus Blasius identified, described, the posterior edge of the mamillary bodies, and
Albert L. Rhoton, Jr., M.D., and named the arachnoid membrane in a caudal leaf, called the mesencephalic mem-
Department of Neurosurgery, 1664 (26). Key and Retzius provided brane, which attaches to the junction of the
University of Florida,
McKnight Brain Institute,
the first detailed description of the arachnoid pons and the midbrain (17). In 1976, Yaşargil
P.O. Box 100265, cisterns in 1875 (14, 17, 26) and described the reported his intraoperative observations on the
Gainesville, FL 32610. membrane known as Liliequist’s membrane (1). microsurgical anatomy of the cisterns (32, 33),
Email: rhoton@neurosurgery.ufl.edu The development of pneumoencephalography and additional reports by neurosurgeons fol-
prompted neuroradiologists to further define lowed (1, 4, 13–17, 22, 30, 31, 35). Many neuro-
Received, January 16, 2009.
the arachnoid membranes and cisterns (1, 17). surgical operations are directed through the
Accepted, April 22, 2009.
Liliequist defined the cisterns based on ana- subarachnoid cisterns because they provide a
Copyright © 2009 by the tomic and pneumographic studies in the 1950s natural open pathway to many deep areas.
Congress of Neurological Surgeons (14, 17, 30) and noted that the membrane bear- Most operations for intracranial aneurysms,
ing his name is often seen in pneumograms as extra-axial brain tumors, and disorders of the
a fine line with a forward convexity extending cranial nerves are directed through the cisterns.
from the dorsum sellae to the mamillary bod- Some cisterns have sheet-like membranes,
ies. In our earlier study, this membrane was whereas others have indistinct, porous, trabec-
found to have 2 leaves: an upper leaf, called ulated walls with openings of various sizes
the diencephalic membrane, which attaches to (Figs. 1 and 2). A disadvantage of previous
644 | VOLUME 65 | NUMBER 4 | OCTOBER 2009 www.neurosurgery-online.com

SUPRATENTORIAL CISTERNS
FIGURE 1. Anatomic dissections of supratentorial A

cisterns. A, lateral view of a midsagittal section of
the brain showing the supratentorial cisterns. B,
inferior view of the basal cisterns. A and B, the
supratentorial cisterns defined in this study are the
pericallosal (white); lamina terminalis (orange); chi-
asmatic (red); interpeduncular (dark green); carotid
(yellow); crural (pink); ambient (brown); sylvian
(purple); and the oculomotor (light blue). The pre-
pontine (light green) and cerebellopontine (gray) cis-
terns are posterior fossa cisterns. The pericallosal
cistern is situated in the interhemispheric fissure on
the outer surface of the corpus callosum and con-
tains the anterior cerebral arteries. The lamina termi-
nalis cistern is positioned above the optic chiasm and
anterior to the lamina terminalis between the frontal
lobes and contains the A1 and proximal A2 seg-
ments of the anterior cerebral artery, the anterior
communicating and orbitofrontal arteries, some of
the basal perforating arteries, and the initial seg-
ment of the recurrent artery. The chiasmatic cistern
surrounds the optic nerves and chiasm and contains
the pituitary stalk and carotid perforating branches.
The interpeduncular cistern is situated between the
cerebral peduncles and the leaves of Liliequist’s mem- B
brane at the confluence of the supra- and infratento-
rial parts of the subarachnoid space and contains the
basilar bifurcation, proximal part of the posterior
cerebral arteries, thalamoperforating arteries, and
the initial segment of the circumflex perforating and
medial posterior choroidal arteries. The carotid cis-
tern is situated between the lateral edge of the optic
chiasm medially, the temporal lobes laterally, and
the anterior perforated substance above and contains
the internal carotid and posterior communicating
arteries and the origin of the anterior and middle
cerebral, ophthalmic, and anterior choroidal arter-
ies. The sylvian cistern is situated between the
frontal and parietal lobes above and the temporal
lobes below and contains the M1, M2, and M3 seg-
ments of the middle cerebral artery. The oculomotor
cistern is formed by the confluence of the inner and
the outer arachnoid membranes that converge to sur-
round the oculomotor nerve. The crural cistern is
located between the cerebral peduncle and posterior
part of the uncus. The ambient cistern is positioned
posterior to the crural cistern between the midbrain
and the part of the medial temporal lobe behind the uncus. The crural and tern; CN, cranial nerve; Interped., interpeduncular; Lam., lamina; Olf., olfac-
ambient cisterns contain the P2 segment of the posterior cerebral artery and tory; P.C.A., posterior cerebral artery; P.Co.A., posterior communicating
some of the perforating, cortical, and choroidal branches arising from the P1 artery; Ped., peduncle; Pericall., pericallosal; Pit., pituitary; Prepont., prepon-
and P2 segments. A., artery; A.C.A., anterior cerebral artery; Bas., basilar; tine; S.C.A., superior cerebellar artery; Term., terminalis; Tr., tract; Vent.,
Car., carotid; Cereb. Pont., cerebellopontine; Chiasm., chiasmatic; Cist., cis- ventricle.
studies is that the dissections and operative maneuvers, such as MATERIALS AND METHODS
opening the sylvian fissure, often destroyed the membranes The supratentorial cisterns were examined in 22 cadavers using
separating the cisternal compartments. This study’s use of both both the 4-mm endoscope and the operating microscope. Seventeen
the microscope and the endoscope aided in minimizing the brains, removed from the cranial cavity, with an intact outer arach-
destruction of the cisternal walls and membranes during their noid membrane provided the material for the examination of the
examination. cisterns and their membranous walls. The arteries and veins in 5
NEUROSURGERY VOLUME 65 | NUMBER 4 | OCTOBER 2009 | 645

INOUE ET AL.
FIGURE 2. A–B. Drawings of A

anatomic dissections. A, view
through a left frontotemporal cran-
iotomy (inset). The outer arachnoid
membrane and the sylvian fissure
have been opened to expose 10 of
the 12 arachnoid membranes seen
in this study. These membranes
are: the lateral, intermediate, medial,
and proximal sylvian; olfactory;
lateral lamina terminalis; medial
lamina terminalis; medial carotid;
intracarotid; and intracrural mem-
branes. The proximal sylvian mem-
brane extends from the posterior
orbital gyri to the anterior part of
the uncus, and it separates the syl-
vian and the carotid cisterns. The
lateral sylvian membrane spans the
outer margin of the fissure deep to
the outer arachnoid membrane. The
superficial sylvian veins are sand-
wiched into the narrow space
between the outer arachnoid and
lateral sylvian veins. The interme-
diate sylvian membrane extends
downward from the frontoparietal
operculum, at a deeper level than the lateral membrane, and attaches to the B
upper surface of the temporal lobe along the medial edge of the superior and
transverse temporal gyri. The M2 trunks course deep to the intermediate syl-
vian membrane. The medial sylvian membrane extends inferomedially from
the medial edge of the frontoparietal operculum and attaches to the insula. The
M2 trunks course on the inferolateral side of the medial sylvian membrane.
The medial carotid membrane extends downward from the lower surface of the
optic chiasm and attaches to the outer arachnoidal membrane covering the
posterior clinoid process and lateral sellar area, and it separates the carotid
and the chiasmatic cisterns. The intracarotid membrane extends downward
within the carotid cistern from the inferolateral surface of the optic tract and
attaches to the anterior segment of the uncus. The intracrural membrane
extends obliquely across the interval between the posterior part of the uncus
and the cerebral peduncle at the entrance into the crural cistern, and it sep-
arates the cistern into upper and lower parts. The lateral lamina terminalis
membrane extends from the gyrus rectus to the optic chiasm, and it separates
the lamina terminalis and the carotid cisterns. The medial lamina terminalis
membrane extends from the adjacent posteromedial edges of the paired rectus
gyri to the outer arachnoid membrane, and it separates the lamina terminalis
and pericallosal cisterns. The olfactory membrane extends from the posterior
orbital gyri and below the olfactory tract to the posterior part of the gyrus rec-
tus. B, enlarged view to show Liliequist’s membrane. Liliequist’s membrane
arises from the outer arachnoid membrane covering the posterior clinoid
processes and dorsum sellae. As this membrane spreads upward from the dor-
sum and across the interval between the oculomotor nerves, it splits into 2 sheet, the mesencephalic membrane, extends backward around the basilar
separate arachnoid sheets. One sheet, the diencephalic membrane, extends artery just below the origin of the posterior cerebral arteries and attaches
upward and attaches to the floor of the third ventricle at the mamillary bod- along the junction of the midbrain and pons to separate the interpeduncular
ies and separates the chiasmatic and interpeduncular cisterns. The second and prepontine cisterns. C, inferior view of the basal cisterns. (Continues)
specimens, with the skull and brain intact, were perfused with col- (Table 1). All dissections and observations were performed with the
ored silicone and dissected to define the arterial relationships of the operating microscope (Carl Zeiss Corp., Oberkochen, Germany) and
cisternal compartments. The 2 groups of specimens provided the the straight and 45-degree endoscope (Karl Storz Co., Tuttlingen,
material for the examination of 44 paired and 22 unpaired cisterns Germany)


TABLE 1. Supratentorial cisternal membranes
No. (%) of hemispheres/
Membranes brains in which membranes
were present
Paired membranes (n ⫽ 44)
Medial sylvian 44 (100)
Proximal sylvian 36 (82)
Medial carotid 36 (82)
Intracarotid 40 (91)
Lateral lamina terminalis 32 (73)
Olfactory 44 (100)
Intracrural 34 (77)
FIGURE 2. C, (Continued) the supratentorial cisterns defined in this
Unpaired membranes (n ⫽ 22)
study are the pericallosal (purple); lamina terminalis (bright green); olfac-
tory (aqua); chiasmatic (red); carotid (yellow); interpeduncular (green); Medial lamina terminalis 22 (100)
sylvian (dark blue); crural (rose); and oculomotor (light blue). The ambi- Diencephalic 22 (100)
ent cistern (not shown) is positioned posterior to the crural cistern between Mesencephalic 22 (100)
the midbrain and the part of the medial temporal lobe behind the uncus.
The confluent area at the junction of the carotid, interpeduncular, and
crural cisterns is not shaded. The pericallosal cistern is situated in the a barrier that normally prevents the cerebrospinal fluid from
interhemisphere fissure on the outer surface of the corpus callosum and escaping into the subdural space (27). The subarachnoid space,
contains the anterior cerebral arteries. The lamina terminalis cistern is situated between the pia mater and the outer membrane,
positioned above the optic chiasm and anterior to the lamina terminalis expands at the base of the brain, around the brainstem, and in
between the frontal lobes and contains the distal A1 and proximal A2 and
the tentorial incisura to form compartments that contain cere-
the anterior communicating arteries. The chiasmatic cistern surrounds
brospinal fluid and arteries, veins, and nerves. Numerous tra-
the optic nerves and chiasm and contains the pituitary stalk and carotid
perforating branches. The interpeduncular cistern is situated between the beculae, septae, and inner membranes cross the space between
cerebral peduncles and the leaves of Liliequist’s membrane at the conflu- the pia mater and the outer arachnoid membrane to divide the
ence of the supra- and infratentorial parts of the subarachnoid space and subarachnoid space into smaller compartments called cisterns
contains the basilar bifurcation and P1. The carotid cistern is situated (Figs. 1 and 2). Some cisterns have sheet-like membranous
between the lateral edge of the optic chiasm medially, the temporal lobes walls, while others have indistinct, porous, trabeculated walls
laterally, and the anterior perforated substance above and contains the with openings of various sizes (17).
carotid and posterior communicating arteries and the origin of the anterior The subarachnoid cisterns are divided into supratentorial
and middle cerebral, ophthalmic, and anterior choroidal arteries. The syl- and infratentorial groups. The supratentorial cisterns, plus the
vian cistern is situated between the frontal and parietal lobes above and the
interpeduncular cistern situated in the transition area between
temporal lobes below and contains the M1, M2, and M3 segments of the
the supra- and infratentorial spaces, were examined in this
middle cerebral artery. The oculomotor cistern is formed by the confluence
of the inner and the outer arachnoid membranes, which converge to sur- study. Our study of the infratentorial cisterns was reported
round the oculomotor nerve. The crural cistern is located between the previously (17, 22). Nine cisterns and 12 inner arachnoid mem-
cerebral peduncle and posterior part of the uncus. The crural and ambient branes were defined in this study (Figs. 1 and 2; Table 1).
cisterns contain the P2 segment of the posterior cerebral artery and some
of the P1 and P2 branches. A., artery; A.C.A., anterior cerebral artery; Membranes
A.Ch.A., anterior choroidal artery; Arach., arachnoid; Bas., basilar; Car., Twelve inner arachnoid membranes were identified in the
carotid; Chiasm., chiasmatic; Cist., cistern; CN, cranial nerve; Dien., dien- supratentorial subarachnoid space. Some of these membranes
cephalic; Int., internal intra; Intermed., intermediate; Interped., interpe- form boundaries between cisterns, and others divide a cistern
duncular; Lam., lamina; Lat., lateral; M.C.A., middle cerebral artery;
into compartments. The membranes surrounding the internal
Med., medial; Memb., membrane; Mes., mesencephalic; Olf., olfactory;
carotid artery will be reviewed first.
P.C.A., posterior cerebral artery; P.Co.A., posterior communicating artery;
Ped., peduncle; Pericall., pericallosal; Prox., proximal; S.C.A., superior
Proximal Sylvian Membrane
cerebellar artery; Term., terminalis; Tr., tract.
The proximal sylvian membrane arches laterally across the
proximal part of the sylvian fissure from the posterior part of
RESULTS the orbital gyri to the anterior part of the medial surface of the
uncus and surrounds the middle cerebral artery just distal to its
General Considerations origin (Figs. 2 and 3). It separates the sylvian and carotid cis-
There are 2 types of arachnoid membranes: outer and inner. terns. This membrane is thin and incomplete and was absent in
The outer arachnoid membrane surrounds the brain and forms 8 of the 44 hemispheres examined (18%).

INOUE ET AL.
A B

C D
FIGURE 3. A–D. Anatomic dissections. A, left frontotemporal craniotomy the optic nerve has been opened. The proximal sylvian membrane has been
and exposure of the basal cisterns (inset). The outer arachnoid membrane preserved. C, enlarged view. The proximal sylvian membrane arches across
covering the sylvian fissure has been opened, the frontal and temporal oper- the proximal part of the sylvian fissure from the posterior part of the orbital
culae retracted, and the membranes in the distal part of the sylvian fissure gyri to the medial part of the uncus, surrounds the middle cerebral artery
removed to expose the proximal part of the sylvian fissure and carotid just distal to its origin, and separates the sylvian and the carotid cisterns.
artery. The middle cerebral artery has been elevated to expose the proximal D, the outer arachnoidal membrane has been elevated to expose the proxi-
sylvian membrane. B, a forceps holds the part of the outer arachnoid mem- mal sylvian and olfactory membranes. E, the outer arachnoidal membrane
brane that has been preserved. The outer arachnoidal membrane covering has been opened to expose the lateral lamina terminalis (Continues)
Medial Carotid Membrane arteries and their perforating branches by many trabecula. If
This membrane extends downward from the lower surface of the medial carotid membrane is absent, the intracarotid
the optic chiasm, attaches to the outer arachnoidal membrane membrane becomes thicker with smaller openings. The
covering the lateral part of the sella and posterior clinoid intracarotid membrane was absent in 4 of the 44 hemispheres
process, and incompletely separates the carotid and chiasmatic examined (9%).
cisterns (Figs. 2 and 4). It has numerous perforations and was
absent in 8 of the 44 hemispheres examined (18%). Diencephalic and Mesencephalic Membranes
(Liliequist’s Membrane)
Intracarotid Membrane The diencephalic and mesencephalic membranes are consid-
This membrane extends downward from the inferolateral ered together because they are the 2 components of Liliequist’s
surface of the optic tract and attaches to the anterior segment membrane that border the interpeduncular cistern, which
of the uncus, the uncal part facing the supraclinoid carotid, straddles the anterior portion of the tentorial incisura (Figs. 2,
and the proximal part of the middle cerebral artery (Figs. 2 4, and 6). The interpeduncular cistern is situated between the
and 5). This membrane ranges from being a narrow band to cerebral peduncles and the leaves of Liliequist’s membrane at
a wide membrane with many perforations and is attached to the confluence of the supra- and infratentorial parts of the sub-
the carotid, anterior choroidal, and posterior communicating arachnoid space.

E F

G H
FIGURE 3. E–H. (Continued) membrane, which extends from the postero- sylvian fissure. The proximal sylvian membrane separates the sylvian and
lateral edge of the gyrus rectus to the lateral edge of the optic chiasm and carotid cisterns. The olfactory membrane extends from the posterior orbital
separates the lamina terminalis and the carotid cisterns. The anterior cere- gyrus and below the olfactory tract to the gyrus rectus. The proximal syl-
bral artery passes above the optic tract and through the lateral terminalis vian, olfactory, and lateral lamina terminalis membranes blend into each
membrane to enter the lamina terminalis cistern. The proximal sylvian, other along their margins. H, the optic nerve has been retracted down-
olfactory, and lateral lamina terminalis membranes blend into each other ward. The lateral lamina terminalis membrane extends from the posterolat-
near their attachment to the frontal lobe. The olfactory membrane extends eral part of the gyrus rectus to the optic chiasm, separates the lamina ter-
from the posterior orbital gyrus and below the olfactory tract to the gyrus minalis and carotid cisterns, and blends laterally into the olfactory
rectus. F, the frontal lobes have been retracted to expose the lamina termi- membrane, which extends below the olfactory tract. A., artery; A.C.A.,
nalis and pericallosal cistern. The medial lamina terminalis membrane anterior cerebral artery; Ant., anterior; Arach., arachnoid; Car., carotid;
extends across the adjacent posteromedial edges of the paired rectus gyri and Cist., cistern; Clin., clinoid; CN, cranial nerve; Front., frontal; Lam., lam-
separates the lamina terminalis from the pericallosal cistern. The proximal ina; Lat., lateral; M.C.A., middle cerebral artery; Med., medial; Memb.,
A2s penetrate this membrane to exit the lamina terminalis cistern and membrane; Olf., olfactory; Pericall., pericallosal; Pit., pituitary; Prox., prox-
enter the pericallosal cistern. G, inferior view of the proximal part of the left imal; Temp., temporal; Term., terminalis; Tr., tract.
Liliequist’s membrane arises from the outer arachnoid mem- mamillary (1, 4, 6, 12, 32) and retromamillary (17, 30). In this
brane covering the posterior clinoid processes and dorsum sel- study, the diencephalic membrane was attached to the posterior
lae. As this membrane spreads upward from the dorsum and edge of the mamillary bodies in 47% of brains, the apex of the
across the interval between the oculomotor nerves, it splits into mamillary bodies in 33%, and the anterior edge in 20%.
2 separate arachnoid sheets (Figs. 2, 4, and 6). One sheet, the The second sheet, the mesencephalic membrane, extends
diencephalic membrane, extends upward and attaches to the backward and attaches along the junction of the midbrain and
floor of the third ventricle at the mamillary bodies and separates pons to separate the interpeduncular and prepontine cisterns
the chiasmatic and interpeduncular cisterns. The posterior edge (Figs. 2 and 4). The lateral edges of the diencephalic and mes-
of the diencephalic membrane has been reported to be both pre- encephalic membranes frequently attach to the arachnoid sur-

INOUE ET AL.
A B

C D
FIGURE 4. A–D. A–D, H, and I, anatomic dissections; E–G and J, endo- through another left frontotemporal craniotomy. The optic chiasm has been ele-
scopic views. A, left frontotemporal craniotomy (inset). The oculomotor nerve vated to expose the medial carotid membrane through the opticocarotid trian-
is exposed on the left and the posterior communicating artery on the right of gle, the space between the optic nerve, the internal carotid artery, and the A1.
the carotid artery. The diencephalic membrane is exposed deep to the carotid The medial carotid membrane extends downward from the inferior surface of
and posterior communicating arteries. The diencephalic membrane may extend the optic chiasm, attaches to the outer arachnoidal membrane covering the lat-
laterally to attach to the oculomotor nerves. B, the internal carotid artery has eral edge of the sella and posterior clinoid process, and incompletely separates
been elevated to open the carotid-oculomotor interval and expose the mesen- the carotid and chiasmatic cisterns. D, the medial carotid membrane has been
cephalic leaf of Liliequist’s membrane, which surrounds the upper part of the removed to expose the diencephalic membrane, which extends downward from
basilar artery just below the origin of the posterior cerebral arteries. C, view the posterior edge of the mamillary bodies and attaches to the (Continues)
rounding the oculomotor nerves. There are conflicting descrip- tions so that it acts as a barrier to the passage of air or other
tions of the lateral attachment of the diencephalic and mesen- substances through the subarachnoid space. The mesen-
cephalic membranes. Some authors have reported that the lat- cephalic membrane, as it extends backward from the junction
eral edge attaches to the arachnoidal sheath surrounding the with the diencephalic membrane, changes its structure from a
oculomotor nerve (6, 17), whereas others have described the sheet-like membrane in its anterior part to a trabeculated
lateral edge attaching to the pia mater covering the uncus (1, membrane with many perforations near its attachment to the
30) or the tentorium (4, 35). We defined the lateral edge of junction of the midbrain and pons (Fig. 4). There is consider-
Liliequist’s membrane as being located at the oculomotor nerve able variability in the structure of the mesencephalic mem-
but did find that numerous trabeculae extended from the ocu- brane. Some are equal in thickness to the diencephalic mem-
lomotor nerve to the uncus and tentorium. brane and have small perforations, but most are thinner, are
The diencephalic membrane is the thicker of the 2 parts of more often incomplete, and have larger perforations. The mes-
Liliequist’s membrane and is more frequently without perfora- encephalic membrane is the site of an opening through which

E F

G H
FIGURE 4. E–H. (Continued) outer arachnoid membrane covering the dor- mesencephalic membrane attaches to the basilar artery, its branches, and the
sum sellae. E, endoscopic view directed through the opticocarotid triangle. oculomotor nerve. H, inferior view. The outer arachnoid membrane has been
The chiasmatic cistern is positioned anterior to and the interpeduncular cis- removed, except at the site of attachment of the inner arachnoidal membranes,
tern is behind the diencephalic membrane. F, the endoscope has been advanced to expose the lamina terminalis, carotid, interpeduncular, oculomotor, crural,
through the opticocarotid triangle shown in E. The diencephalic leaf of and prepontine cisterns. The mesencephalic leaf of Liliequist’s membrane
Liliequist’s membrane extends upward from the outer arachnoid membrane to extends posteriorly to surround the upper basilar artery. The interpeduncular
attach to the floor of the third ventricle. The mesencephalic leaf of Liliequist’s cistern is located above the mesencephalic membrane and between the dien-
membrane extends posteriorly and attaches to the pontomesencephalic junction cephalic and mesencephalic leaves of Liliequist’s membrane. I, inferior view of
and the basilar apex below the origin of the P1 segments. G, the endoscope has the mesencephalic membrane in another specimen. The sheet-like and trabec-
been advanced into the interpeduncular cistern. The trabeculated part of the ulated parts of the mesencephalic membrane are well developed (Continues)

INOUE ET AL.
I J

FIGURE 4. I–J. (Continued) and surround the upper part of the basilar Front., frontal; Interped., interpeduncular; Lam., lamina; Lat., lateral; Med.,
artery. J, endoscopic view of the mesencephalic membrane in another specimen. medial; Memb., membrane; Mes., mesencephalic; Olf., olfactory; P.C.A., pos-
The trabecula part of the mesencephalic membrane is poorly developed, so terior cerebral artery; P.Co.A., posterior communicating artery; Pit., pitu-
that the interpeduncular and prepontine cisterns have almost no barrier itary; Post., posterior; Pon., pontine; Pon. Mes., pontomesencephalic; Prepont.,
between them. A., artery; Ant., anterior; Arach., arachnoid; Bas., basilar; Car., prepontine; S.C.A., superior cerebellar artery; Term., terminalis; Thal. Perf.,
carotid; Cist., cistern; Clin., clinoid; CN, cranial nerve; Dien., diencephalic; thalamoperforating; Tr., tract.
the basilar artery ascends to reach the interpeduncular fossa. carotid cisterns. It is very thin, has multiple perforations, and
The mesencephalic membrane may form a tight cuff around was absent in 12 of the 44 hemispheres examined (27%).
the basilar artery, but it more commonly has a large opening
through which the basilar artery ascends (Fig. 4). Many arach- Medial Lamina Terminalis Membrane
noid trabeculae fan out from the superior edge of the dien- This membrane extends from the adjacent posteromedial
cephalic membrane to attach to the stalk of the pituitary gland, edges of the paired rectus gyri and separates the lamina termi-
the mamillary bodies, and the posterior cerebral and posterior nalis and the pericallosal cisterns (Figs. 2 and 3). It attaches
communicating arteries. anteriorly to the outer arachnoid membrane. Its posterior edge
The oculomotor nerves course in the lateral wall of the is free and forms the anterior edge of the opening between the
interpeduncular cistern and form the pillars to which the leaves lamina terminalis and pericallosal cisterns.
of Liliequist’s membrane attach if they extend that far laterally
(Figs. 1, 2, and 4). In addition, the oculomotor nerves are the Olfactory Membrane
site of attachment of other arachnoid membranes that separate This membrane extends medially from the posterior orbital
the cisterns at the junction of the supra- and infratentorial gyri bordering the anterior perforated substance and below the
areas. The membranes that converge on and form a sleeve olfactory tract to the gyrus rectus, where it blends into the lat-
around the nerves are the mesencephalic membrane, which eral edge of the lateral lamina terminalis membrane. It forms
separates the interpeduncular and prepontine cisterns; the the posteroinferior margin of the olfactory cistern. It merges
diencephalic membrane, which separates the interpeduncular anteriorly with the outer arachnoidal membrane below the
and chiasmatic cisterns; the anterior pontine membrane, which olfactory tract and laterally with the proximal sylvian mem-
separates the cerebellopontine and prepontine cisterns; the lat- brane (Figs. 2 and 3).
eral pontomesencephalic membrane, which separates the crural
and ambient cisterns from the cerebellopontine cistern; and the Intracrural Membrane
medial carotid membrane, which separates the chiasmatic and This membrane extends from the posterior part of the uncus
carotid cisterns (17). to the cerebral peduncle and adjacent part of the optic tract (Figs.
2, 5, and 6). The posterior part of the uncus is the part that faces
Lateral Lamina Terminalis Membrane the cerebral peduncle across the crural cistern. The intracrural
This membrane descends from the posterolateral edge of the membrane is a thin narrow band that extends across the anterior
gyrus rectus superiorly, to the upper surface of the lateral edge part of the crural cistern and separates the cistern into superior
of the optic chiasm (Figs. 2 and 3). It blends into the olfactory and inferior compartments. The anterior choroidal artery courses
membrane laterally and the medial lamina terminalis mem- above and the posterior cerebral artery courses below this mem-
brane medially and separates the lamina terminalis and the brane. It was absent in 10 of the 44 hemispheres examined (23%).

A B

C D
FIGURE 5 A–D. A, C, E, G, and H, anatomic dissections; B, D, F, I, and nerve has been elevated to expose the naked area along the initial segment of
J, endoscopic views. A, left frontotemporal craniotomy and transsylvian the supraclinoid carotid, where there is a paucity of arachnoid trabeculae.
exposure (inset). The outer arachnoid membrane has been opened and the The medial carotid membrane is exposed above the naked area. C, enlarged
frontal lobe elevated to expose the outer arachnoid membrane, which has been view of the multiple trabeculae forming the medial carotid membrane, which
opened above the optic nerve to expose the chiasmatic and carotid cisterns. extends from the lower part of the optic nerve and chiasm and attaches to the
The medial carotid membrane is exposed in the opticocarotid triangle, located outer arachnoid membrane covering the posterior clinoid process and lateral
between the carotid, A1, and optic nerve. B, endoscopic view. The optic margin of the sella. D, endoscopic view of the medial carotid (Continues)
Intrasylvian Membranes gin of the fissure deep to the outer arachnoid membrane. The
Three membranes, lateral, intermediate, and medial sylvian, superficial sylvian veins are sandwiched into the narrow space
were found in the sylvian fissure, distal to where the middle between the outer arachnoid and lateral sylvian membranes.
cerebral artery passed through the proximal sylvian membrane The lateral sylvian membrane is always thick. It blends into
(Figs. 2, 7, and 8). the lateral edge of the frontoparietal and temporal operculae
Lateral Sylvian Membrane. The most superficial intrasylvian and the outer arachnoid membrane at its upper and lower
membrane, the lateral sylvian membrane, spans the outer mar- margins.

INOUE ET AL.
E F

G H
FIGURE 5. E–H. (Continued) membrane. E, the A1 has been elevated to the carotid cistern. F, endoscopic view of the intracarotid membrane. G, the
expose the intracarotid membrane through the opticocarotid triangle. The medial carotid membrane has been opened, and the mesencephalic leaf of
intracarotid membrane is positioned above and lateral to the medial carotid Liliequist’s membrane has been exposed. The diencephalic membrane is hid-
membrane and extends from the optic tract to the uncus in the upper part of den under the optic chiasm. H, the A1 was divided to obtain (Continues)
Intermediate Sylvian Membrane. This membrane extends lateral and intermediate sylvian membranes have many perfo-
downward from the frontoparietal operculum, at a deeper level rations through which the multiple M3 branches of the middle
than the lateral sylvian membrane, and attaches to the upper cerebral artery pass to reach the cortical surface.
surface of the temporal lobe along the medial edge of the supe-
rior and transverse temporal gyri (Figs. 2, 7, and 8). Numerous Cisterns
trabecula cross the fissure between the lateral and intermediate Nine cisterns were defined in this study.
sylvian membranes. The M2 trunks of the middle cerebral
artery course deep to the intermediate sylvian membrane. Sylvian Cistern
Medial Sylvian Membrane. The medial sylvian membrane The sylvian fissure or cistern is divided into anterior and
extends downward from medial edge of the frontoparietal posterior compartments, and the posterior compartment is
operculum and attaches to the insula (Figs. 2, 7, and 8). The M2 divided into lateral and medial parts (Figs. 2, 3, 7, and 8).
trunks course on the inferolateral side of the medial sylvian Anterior Compartment. The anterior compartment, also
membrane. Many trabecula extend from the medial and inter- called the “sphenoidal compartment” because it borders the
mediate membranes to the M2 trunks and their branches. These sphenoid ridge, extends laterally from the origin of the middle

I J

FIGURE 5. I–J. (Continued) this view of the mesencephalic membrane. I, and the posterior cerebral artery passes below this membrane. A., artery;
the endoscope has been introduced through the opticocarotid triangle and A.C.A., anterior cerebral artery; A.Ch.A., anterior choroidal artery; Ant.,
into the carotid cistern to provide this view of the anterior part of the crural anterior; Arach., arachnoid; Bas., basilar; Car., carotid; Chiasm., chiasmatic;
cistern. The yellow circle approximates the superficial position of the tip of Cist., cistern; Clin., clinoid; CN, cranial nerve; Front., frontal; Int., internal;
the endoscope. J, the endoscope has been advanced to provide this view of the Med., medial; Memb., membrane; Mes., mesencephalic; P.C.A., posterior
intracrural membrane, which extends from the posterior segment of the cerebral artery; P.Co.A., posterior communicating artery; Ped., peduncle; Tr.,
uncus to the cerebral peduncle. The anterior choroidal artery passes above tract; V., vein.
cerebral artery to the limen insulae (Fig. 2). It has a superior cleft located between the insula and the insular surface of the
wall formed by the posterior part of the orbital gyri and the lat- operculae. The floor of the medial part, formed by the upper
eral part of the anterior perforated substance and an inferior surface of the temporal lobe, is the site of a shallow trough
wall formed by the planum temporale, which is positioned on along which the M2 trunks pass (Figs. 7 and 8). The medial
the superior surface of the anterior part of the temporal lobe. part narrows posteriorly where the intermediate sylvian mem-
The planum temporale has a trough-like upper surface free of brane extends posteromedially along the medial edge of the
gyri, along which the M1 segment of the middle cerebral artery anterior transverse temporal gyrus (Heschl’s gyrus) (Fig. 7).
passes. The middle cerebral artery, just distal to its origin, The M3 branches, as they pass laterally, penetrate the interme-
passes through the proximal sylvian membrane and courses diate sylvian membrane to exit the medial part and enter the
laterally in the anterior compartment to the area adjacent the lateral part of the posterior compartment.
limen insulae, where the M1 segment ends and the M2 segment The lateral part of the posterior compartment is located in the
begins at the genu, the site of a 90-degree turn (28, 32, 33). The lateral part of the cleft between the operculae. The medial wall
anterior compartment also contains the lenticulostriate perfo- of the lateral part is formed by the intermediate sylvian mem-
rating arteries, which originate from the middle cerebral artery, brane, the lateral wall by of the outer arachnoid membrane,
and the distal branches of the recurrent artery, both of which and the superior and inferior walls by the opposing operculae.
enter the anterior perforated substance (7, 25). The anterior half of the lateral part is narrow in the area where
Posterior Compartment. The posterior compartment is its floor is formed by the upper edge of the superior temporal
located behind the limen insulae and opens onto the lateral gyrus, but it expands posteriorly where the intermediate syl-
cerebral surface. The intermediate sylvian membrane spans vian membrane extends along the medial side of the transverse
the interval between the upper and lower walls of the poste- temporal gyri, which form the full width of the opercular sur-
rior compartment of the fissure to divide it into medial and lat- face (Fig. 7).
eral parts (Figs. 2, 7, and 8). The medial part is positioned The superficial sylvian veins pass along the lateral part
between the medial part of the opposing surfaces of the fron- between the outer arachnoidal and lateral sylvian membranes
toparietal and temporal operculae and extends into the insular (Figs. 2 and 8). The branches forming the M3 pass through the

INOUE ET AL.
A B

C D
FIGURE 6. A–D. A–F, anatomic dissections; G and H, endoscopic views. A, another specimen, anterior view. The optic chiasm has been elevated, and a seg-
subfrontal exposure of the chiasmatic cistern. The frontal lobe has been elevated ment of the right carotid artery has been has been removed to expose the dien-
to expose the chiasmatic cistern. The arachnoid trabecula in the chiasmatic cis- cephalic leaf of Liliequist’s membrane. C, anterolateral view of the diencephalic
tern has been removed to expose the diencephalic leaf of Liliequist’s mem- membrane, which separates the chiasmatic and the interpeduncular cisterns.
brane, which extends from the outer arachnoidal membrane covering the dor- D, the right carotid artery has been elevated. Some trabeculae from Liliequist’s
sum sellae and attaches to the floor of the third ventricle behind the pituitary membrane extend laterally to attach to the optic nerve. E-G, anterior views of
stalk. The superior hypophyseal artery ascends along the membrane. B, a stepwise dissection. E, the coronal section of the skull base (Continues)
lateral part of the posterior compartment and through the lat- medial carotid membrane frequently attaches to the dien-
eral sylvian membrane to reach the cerebral surface (Fig. 7). cephalic leaf of Liliequist’s membrane. This medial carotid
membrane separates the chiasmatic and carotid cisterns and
Carotid Cistern has some perforations, through which carotid perforating
The paired carotid cisterns are situated between the lateral branches pass to enter the chiasmatic cistern. The medial
edge of the optic chiasm medially and the anterior part of the carotid membrane was absent in 8 of the 44 hemispheres exam-
uncus laterally (Figs. 1, 2, and 4). The lateral wall of the carotid ined (18%); in these cases the carotid cistern communicated
cistern is formed by the medial surface of the temporal lobe medially with the chiasmatic cistern.
and the outer arachnoidal membrane covering the dura over The carotid cistern faces the sylvian cistern laterally, the chi-
the anterior clinoid process and the tentorial edge; the medial asmatic cistern medially, the interpeduncular cistern postero-
wall by the medial carotid membrane; the superior wall by the medially, the lamina terminalis cistern superomedially, and the
anterior perforated substance; and the inferior wall by the outer crural cistern posteriorly (Figs. 1 and 2). The division between
arachnoidal membrane facing the dura over the posterior cli- the carotid cistern and the crural cistern is approximated by the
noid process and the cavernous sinus. The posterior edge of the coronal plane passing between the apex of the uncus laterally

E F

G H
FIGURE 6. E–H. (Continued) shown in B has been extended posteriorly to courses below the intracrural membrane. H, endoscopic view of the intracrural
the level of the interpeduncular cistern just in front of the basilar artery. The membrane in another specimen. The anterior choroidal artery courses above the
oculomotor nerves pass between the posterior cerebral and superior cerebellar intracrural membrane, which separates the intracrural cistern into upper and
arteries. F, the right anterior choroidal artery and perforating branches have lower parts. A., artery; A.Ch.A., anterior choroidal artery; Ant., anterior;
been retracted laterally to expose the crural cistern located between the poste- Bas., basilar; Brs., branches; Car., carotid; Chiasm., chiasmatic; Cist., cistern;
rior part of the uncus and the cerebral peduncle. The intracrural membrane Clin., clinoid; CN, cranial nerve; Dien., diencephalic; Dup., duplicate; Hyp.,
extends from the posterior part of the uncus to the upper part of the cerebral hypophyseal; Int., intra; Interped., interpeduncular; Mam., mamillary; Memb.,
peduncle and separates the crural cistern into upper and lower parts. G, endo- membrane; P.C.A., posterior cerebral artery; P.Co.A., posterior communicat-
scopic view of the intracrural membrane and the crural cistern shown in F. ing artery; Ped., peduncle; Perf., perforating; Pit., pituitary; Post., posterior;
The anterior choroidal artery courses above and the posterior cerebral artery S.C.A., superior cerebellar artery; Sup., superior; Tr., tract; Vent., ventricle.
and the anterior edge of the cerebral peduncle medially. choroidal and posterior cerebral arteries also pass through the
Frequently, no membrane separates the carotid, interpeduncu- confluent area to enter the crural cistern.
lar, and crural cisterns, thus creating a confluent area through The cavernous portion of the internal carotid artery ends
which cerebrospinal fluid can communicate easily through the and the supraclinoid portion begins where the artery passes
posterior part of the carotid cistern (Fig. 2). The anterior through the dural roof of the cavernous sinus to enter the sub-

INOUE ET AL.
FIGURE 7. Anatomic dissections A B

of the intrasylvian membranes. A,
superior view of the left temporal
lobe. The yellow interrupted line
shows the site of the outer arach-
noid, and the light and dark green
interrupted lines show the site of
attachment of the lateral and inter-
mediate sylvian membranes. The
lateral sylvian membrane spans the
lateral part of the sylvian fissure
and extends from the frontoparietal
to the temporal operculum deep to
the superficial sylvian veins. The
intermediate sylvian membrane
attaches along the medial side of the
superior temporal gyrus anteriorly
and along the medial edge of
Heschl’s gyrus posteriorly. The
upper surface of the temporal lobe
medial to the intermediate sylvian
membrane is the site of a shallow
trough along which the M2 trunks
pass. The part medial to the inter-
mediate sylvian membrane narrows
posteriorly, where the membrane
extends posteromedially along the
medial edge of the transverse tem-
C D
poral gyri, which form the full
width of the temporal operculum in
the posterior part of the fissure. B,
superior view of the right temporal
lobe with the superficial sylvian
vein and middle cerebral arteries
preserved. The superficial sylvian
veins course between the outer
arachnoid and lateral sylvian mem-
branes. The M2 trunks course on
the medial side of the intermediate
sylvian membrane. The M3 trunks
penetrate the intermediate and lat-
eral sylvian membranes to reach the
cortical surface. C, inferior view of
the right frontoparietal operculum.
The medial sylvian membrane (blue
interrupted line) attaches along the
deep edge of the frontoparietal oper-
culum. The lower attachment of the
medial sylvian membrane is to the
midlevel of the insula on the medial
side of the M2 trunks. The inter-
mediate sylvian membrane attaches
along the medial part of the fron-
toparietal operculum. The lateral sylvian membrane attaches to the lateral positioned deep to the superficial sylvian veins. The M3 trunks penetrate the
edge of the frontoparietal operculum deep to the superficial sylvian veins. D, intermediate and lateral sylvian membranes to reach the cortical surface. A.,
inferior view of the right frontoparietal operculum with the arteries pre- artery; A.Ch.A., anterior choroidal artery; Ant., anterior; Arach., arachnoid;
served. The medial sylvian membrane attaches along the deep edge of the fron- Car., carotid; Cist., cistern; Intermed., intermediate; Lat., lateral; Med.,
toparietal operculum, extends downward on the medial side of the M2 trunks, medial; Memb., membrane; Operc., opercular; P.C.A., posterior cerebral
and attaches to the insular surface. The intermediate sylvian membrane spans artery; Perf., perforated; Quad., quadrigeminal; Subst., substance; Sup., supe-
the interval lateral to the M2 trunks, and the lateral sylvian membrane is rior; Temp., temporal, temporale; Trans., transverse; V., vein.

A B

C D
E F
FIGURE 8. A, drawing, and B–F, anatomic dissections of the intrasylvian part of the sylvian fissure and extends from the frontoparietal to the temporal
membranes. A, anterior view of a drawing of a coronal section extending operculum deep to the superficial sylvian veins. The intermediate sylvian mem-
through the left sylvian fissure showing the lateral, intermediate, and medial brane spans the interval between the medial part of the frontoparietal opercu-
sylvian membranes. The outer arachnoidal membrane forms the outer wall of lum above and the medial side of the superior temporal and Heschl’s gyrus
the sylvian cistern and fissure. The lateral sylvian membrane spans the lateral below. The medial sylvian membrane extends downward from the (Continues)

INOUE ET AL.
arachnoid space (8, 23). After passing through the outer arach- perforated substance, optic tract, and uncus. Numerous tra-

noid membrane, the artery enters the carotid cistern, where it becula attach to these arteries.
ascends posterolaterally to its terminal bifurcation into the The middle cerebral artery arises in the carotid cistern and
anterior and middle cerebral arteries. The initial few millime- passes through the proximal sylvian membrane to enter the
ters of the carotid artery, after passage through the outer arach- sylvian cistern (Figs. 2 and 3). The anterior cerebral artery also
noid membrane, are free of trabeculae, thus creating a naked arises in the carotid cistern and courses between the optic chi-
area, as first reported by Yaşargil (32). Most ophthalmic arter- asm and the olfactory stria and through the lateral lamina ter-
ies arise below the optic nerve in the naked area of the carotid minalis membrane to enter the lamina terminalis cistern (Figs.
cistern, course anterolaterally below the optic nerve, and pass 2 and 3).
through the optic canal inside the optic sheath before exiting
the sheath at the orbital apex (8, 23). The outer arachnoid mem- Chiasmatic Cistern
brane surrounds the optic nerve and ophthalmic artery in the The chiasmatic cistern is an unpaired cistern that surrounds
optic canal, but the medial carotid membrane separates and is the optic nerves and chiasm and borders on the lamina termi-
positioned between the optic nerve and ophthalmic artery and nalis cistern superiorly, the carotid cistern laterally, and the
also between the carotid and chiasmatic cisterns proximal to interpeduncular cistern posteriorly (Figs. 1 and 2). The lateral
the point where the ophthalmic artery exits the optic sheath. wall is formed by the medial carotid membrane, which sepa-
The posterior communicating artery arises from the postero- rates the chiasmatic and carotid cisterns; the anteroinferior wall
medial surface of the supraclinoid portion of the carotid and by the outer arachnoidal membrane resting on the dura cover-
passes backward and medially to join the posterior cerebral ing the tuberculum and diaphragma sellae; and the posterior
artery in the confluent area (8, 23) (Figs. 2 and 4). The anterior wall by the diencephalic membrane, which separates the chias-
choroidal artery usually arises from the posteromedial surface matic and interpeduncular cisterns and is located behind the
of the supraclinoid carotid nearer to the origin of the posterior pituitary stalk. The anterior limit of the chiasmatic cistern is at
communicating artery than to the carotid bifurcation (23, 24) the limbus sphenoidale of the sphenoid bone, which is posi-
(Figs. 5 and 6). The origin of the artery is lateral to the optic tioned at the posterior edge of the planum sphenoidale. The
tract, but the initial segment crosses to the medial side of the chiasmatic cistern contains the optic nerves and chiasm, pitu-
area below the optic tract and continues posteriorly along the itary stalk, and some carotid perforating branches including
medial side of the optic tract through the confluent area to the superior hypophyseal and infundibular arteries, which
enter the crural cistern. Dense trabeculae connect the arteries in penetrate the medial carotid membrane to enter the chiasmatic
the carotid cistern to the inferior surface of the optic chiasm and cistern and terminate on the infundibulum and optic nerve and
tract, medial carotid membrane, uncus, and mesencephalic chiasm (8, 23). The chiasmatic cistern opens into the subarach-
membrane. Frequently, the many trabeculae condense to form noid space surrounding the optic nerves in the optic canals
the intracarotid membrane, which attaches to the inferolateral (32). In addition, we found that the carotid cistern continues
surface of the optic tract superomedially and the uncus infero- forward around the ophthalmic artery to where the artery exits
laterally (Figs. 2 and 5). Ninety-one percent of the anterior the optic sheath at the orbital apex.
choroidal arteries and 25% of the posterior communicating
arteries attach directly to the intracarotid membrane when it is Lamina Terminalis Cistern
present. The intracarotid membrane is usually a narrow band, The lamina terminalis cistern is an unpaired cistern situated
but sometimes it extends posteriorly and blends into the above the optic chiasm (Figs. 1–3). The inferior wall is formed
intracrural membrane. by the upper surface of the optic chiasm and the anterior surface
The supraclinoidal carotid gives off a series of perforating of the lamina terminalis, the superior wall by the lower surface
branches in the carotid cistern with a relatively constant site of of the paired rectus and paraterminal gyri, the lateral wall by
termination. The proximal perforating branches arise from the the lateral lamina terminalis membrane, and the superior wall
posterior or medial aspect of the artery and course medially to by the medial lamina terminalis membrane. This cistern borders
penetrate the medial carotid membrane and enter the chias- the pericallosal cistern superiorly, the chiasmatic cistern inferi-
matic cistern. The distal supraclinoid branches arise from the orly, the carotid cistern laterally, and the olfactory cistern antero-
posterior half of the arterial wall and terminate in the anterior laterally. The lateral lamina terminalis membrane separates the
FIGURE 8. (Continued) medial edge of the frontoparietal operculum and toparietal operculum above to the temporal operculum below and separates the
attaches to the insula on the medial side of the M2 trunks. B, lateral view of a medial and lateral parts of the posterior compartment of the sylvian fissure.
left sylvian fissure. The outer arachnoid membrane covering the sylvian fissure This membrane is positioned superficial the M2 trunks and is penetrated by the
is intact. C and D, the outer arachnoid membrane has been removed to expose M3 branches as they pass laterally to reach the cortical surface. F, the medial
the lateral sylvian membrane. The lateral sylvian membrane is positioned deep sylvian membrane extends downward from the frontoparietal operculum and
to the superficial sylvian veins and blends into the outer arachnoid membrane attaches to the insula on the medial side of the M2 trunks. Arach., arachnoid;
along the margins of the sylvian fissure. E, the inset shows the area of view. The Fiss., fissure; Front., frontal; Intermed., intermediate; Lat., lateral; Med.,
intermediate sylvian membrane stretches from the medial part of the fron- medial; Memb., membrane; Sup., superior; Temp., temporal; V., vein.

lamina terminalis and carotid cisterns and has many perfora- Olfactory Cistern

tions, including those through which the A1 segment of the The paired olfactory cisterns are situated in the olfactory sulci
anterior cerebral artery passes to exit the carotid cistern and located between the rectus gyri medially and the posterior
enter the lamina terminalis cistern, where it joins the anterior orbital gyri laterally (Figs. 1–3). The inferior wall is formed pos-
communicating artery and turns anterosuperior to penetrate teriorly by the olfactory membrane and anteriorly by the outer
the medial lamina terminalis membrane to enter the perical- arachnoidal membrane, which encases the olfactory bulb and
losal cistern. The medial lamina terminalis membrane spans the tract. The olfactory membrane blends into the outer arachnoid
midline between the lower surface of the paired rectus gyri to anteriorly, the lateral lamina terminalis membrane medially, and
separate the lamina terminalis and the pericallosal cisterns. the proximal sylvian membrane laterally. The olfactory cistern
The recurrent artery, the largest artery arising from the A1 or borders the sylvian cistern laterally, the carotid cistern posteri-
the proximal 0.5 mm of the A2, takes a recurrent course above orly, and the lamina terminalis cistern medially. The orbito-
its parent anterior cerebral artery to exit the lamina terminalis frontal artery enters the olfactory cistern from the lamina termi-
cistern and enter the carotid cistern, where it passes laterally nalis cistern. The frontopolar artery also frequently gives rise to
above the carotid bifurcation and sends its branches into the a small branch that enters the olfactory cistern (19, 23).
anterior perforated substance (23, 25). The A1, A2, and anterior
communicating artery give rise to numerous perforating arter- Interpeduncular Cistern
ies in the lamina terminalis cistern that supply the chiasm, ante- The interpeduncular cistern is an unpaired cistern (Figs. 1, 2,
rior third ventricle, and anterior hypothalamic area (18, 23, 25). and 4). It is situated between the cerebral peduncles and the dien-
The orbitofrontal artery commonly arises from the A2 at the cephalic and mesencephalic membranes at the confluence of the
junction of the lamina terminalis and the pericallosal cisterns. supra- and infratentorial parts of the subarachnoid space (17).
From its origin, it passes down and forward to exit the lamina The basilar artery ascends in the prepontine cistern and
terminalis cistern and enter the olfactory cistern. passes through the opening in the mesencephalic membrane to
enter the interpeduncular cistern, where it gives rise to the pos-
Pericallosal Cistern terior cerebral arteries (Figs. 2 and 4), which course laterally to
The pericallosal cistern is an unpaired cistern situated in the join the posterior communicating artery at the lateral margin of
interhemisphere fissure on the outer surface of the corpus callo- the interpeduncular cistern and enter the crural cistern by way
sum (Figs. 1 and 2). The pericallosal cistern can be divided into of the confluent area. The P1 segment of the posterior cerebral
3 compartments; inferior, anterior, and superior. The inferior artery, which extends from the basilar bifurcation to the junc-
compartment is positioned above the lamina terminalis cistern tion with the posterior communicating artery, gives rise to the
and below the rostrum of the corpus callosum. Its superior wall posterior thalamoperforating, the medial posterior choroidal,
is formed by the rostrum of the corpus callosum, the lateral and the short and long circumflex arteries (23, 34). The poste-
wall by the paraterminal and paraolfactory gyri, and the anterior thalamoperforating arteries enter the brain by passing
rior wall by the outer arachnoid membrane. The A2 segments through the posterior perforated substance. The branches of
begin in the lamina terminalis cistern and ascend through the the posterior communicating artery that enter the same area are
medial lamina terminalis membrane to enter the inferior com- referred to as premamillary or anterior thalamoperforating
partment of the pericallosal cistern where the A2s turn antero- arteries. The majority of posterior thalamoperforating arteries
superiorly below the rostrum of the corpus callosum and frontal originate on the proximal third of the posterior or superior
horn to enter the anterior compartment, which is bordered ante- aspect of the P1 as the branch nearest the basilar bifurcation.
riorly by the outer arachnoid membrane, posteriorly by the The medial posterior choroidal arteries most frequently arise
genu of the corpus callosum, and laterally by the cingulate gyri. from the posteromedial aspect of the P1, course laterally, and
The A3s pass around the genu of the corpus callosum and ter- exit the interpeduncular cistern by way of the confluence area
minate where the arteries turns sharply posterior above the to enter the crural cistern (23, 34). The circumflex branches
genu to enter the superior compartment, which is located arise predominantly from P1 and encircle the midbrain paral-
between the body of the corpus callosum below and the outer lel and medial to the posterior cerebral artery. The superior
arachnoid membrane spanning the interval between the paired cerebellar artery usually arises near the basilar apex and
cingulated sulci above. This compartment narrows posteriorly courses laterally along the lower side of the mesencephalic
and ends on the superior surface of the splenium. The A4s and membrane to enter the cerebellopontine cistern (9, 20, 21).
A5s course posteriorly in the superior compartment just above
the body and splenium of the corpus callosum. The callosomar- Lateral Mesencephalic Cisterns
ginal artery most frequently arises in the anterior compartment, The crural and the ambient cisterns, with the crural cistern
but it may also arise in the inferior or superior compartments. It anterior, are paired cisterns positioned between the midbrain
courses just below the outer arachnoid membrane, in or near the and the temporal lobe (Figs. 1, 5, and 6).
cingulated sulcus. The frontopolar artery arises in the inferior Crural Cistern. The crural cistern is situated between the
compartment, the internal frontal arteries most commonly arise cerebral peduncle and the posterior part of the uncus. The
in the anterior compartment, and the paracentral and the pari- medial wall of the crural cistern is formed by the anterolateral
etal arteries arise in the superior compartment. surface of the cerebral peduncle, the lateral wall by the poste-

INOUE ET AL.
rior segment of the uncus, and the superior wall by the optic where it passes laterally through the choroidal fissure to enter

tract. Inferiorly, at the level of the tentorium, the crural cistern the choroid plexus in the temporal horn (5, 23, 24).
is separated from the cerebellopontine cistern by the lateral
pontomesencephalic membrane. Posterior Cerebral Artery Branches
The crural cistern borders the carotid cistern anteriorly, the The posterior cerebral artery gives rise to 3 types of branches;
interpeduncular cistern anteromedially, the ambient cistern circumflex and peduncular perforating, ventricular, and corti-
posteriorly, and the cerebellopontine cistern inferiorly. The cal branches (29).
crural, carotid, and interpeduncular cisterns communicate
through the confluent area. The intracrural membrane, which Perforating Branches
extends from the posterior segment of the uncus to the cerebral The circumflex branches arise from the P1 and P2 and encir-
peduncle, divides the cistern into upper and lower parts (Figs. cle the midbrain parallel and medial to the posterior cerebral
2, 5, and 6). The anterior edge of this thin membrane is located artery. The short circumflex branches reach only as far as the
at the anterior entrance into the crural cistern and may blend level of the geniculate bodies in the roof of the ambient cistern.
into the intracarotid membrane. The long circumflex branches reach the colliculi in the anterior
Ambient Cistern. The ambient cistern is situated between the wall of the quadrigeminal cistern. The peduncular perforating
midbrain and the temporal lobe and extends from the posterior arteries most frequently arise from P2a and pass directly into
edge of the uncus anteriorly to the lateral edge of the collicular the cerebral peduncle. The thalamogeniculate arteries arise
plate posteriorly. The medial wall is formed by the lateral sur- from the P2 below the lateral thalamus near the junction of the
face of the midbrain, the lateral wall by the parahippocampal crural and ambient cistern and enter the brain through the part
and dentate gyri, fimbria of fornix, and the choroidal fissure, of the roof of the ambient cistern formed by the geniculate bod-
and the superior wall, from anterior to posterior, by the optic ies and lower surface of the pulvinar (23, 29, 34).
tract, lateral geniculate body, and the pulvinar of the thalamus.
Inferiorly, the lateral pontomesencephalic membrane, identified Ventricular Branches
in a previous study from this laboratory, separates the ambient The medial posterior choroidal arteries most frequently arise
cistern and the cerebellopontine cistern (17). The ambient cistern from the posteromedial aspect of the P1 in the interpeduncular
borders the crural cistern anteriorly, the quadrigeminal cistern cistern and pass through the confluent area and the crural and
posteriorly, and the cerebellopontine cistern inferiorly. When ambient cisterns medial to the P2 to reach the quadrigeminal cis-
viewed in a coronal plane, the ambient cistern is shaped like the tern, where they turn forward to enter the velum interposition in
letter “C” and wraps around the medial surface of the parahip- the roof of the third ventricle and supply the choroid plexus in
pocampal gyrus (29). the third ventricle and body of the lateral ventricles. The lateral
Contents of the Lateral Mesencephalic Cisterns. The P2, which posterior choroidal arteries most commonly arise from the P2p,
courses through the lateral mesencephalic cisterns, begins at course laterally between the pulvinar and upper edge of the
the junction with the posterior communicating artery and is parahippocampal gyrus within the ambient cistern, and pass
divided into anterior (P2a) and posterior (P2p) parts. The ori- through the choroidal fissure to enter the choroid plexus in the
gin of the P2a is in the confluent area. It enters the crural cis- posterior part of the temporal horn and atrium (29).
tern, where it courses below the intracrural membrane and
around the cerebral peduncle and ends at the posterior edge of Cortical Branches
the uncus and crural cistern (23, 29, 34). The P2p begins at the From proximal to distal, the cortical branches include the
posterior border of the crural cistern and ends at the lateral inferior temporal, parieto-occipital, calcarine, and splenial arter-
edge of the collicular plate, which marks the posterior margin ies. The inferior temporal arteries comprise a group of vessels
of the ambient cistern, where it enters the quadrigeminal cis- that include the hippocampal, anterior temporal, middle tempo-
tern as the P3 segment. ral, and posterior temporal branches. These branches usually
The crural cistern contains the P2a and peduncular perforat- arise in the ambient cistern, but occasionally in the crural or
ing branches and a segment of the anterior choroidal, medial quadrigeminal cisterns. The parieto-occipital, calcarine, and
posterior choroidal, short and long circumflex, thalamogenicu- splenial arteries arise in the ambient or quadrigeminal cisterns.
late, and inferior temporal arteries. The ambient cistern con-
tains the P2p and lateral posterior choroidal arteries and a seg- Oculomotor Cistern
ment of the medial posterior choroidal, short and long The oculomotor nerves arise from the medial side of the cere-
circumflex, thalamogeniculate, inferior temporal and parieto- bral peduncles in the interpeduncular cistern (Fig. 1). Five inner
occipital arteries, and the trochlea nerve. arachnoid membranes, the diencephalic, mesencephalic, medial
The anterior choroidal artery enters the crural cistern above carotid, lateral pontomesencephalic, and anterior pontine mem-
or attached to the intracrural membrane. In the crural cistern, branes, and the outer arachnoidal membrane covering the pos-
the anterior choroidal artery passes below or along the medial terior clinoid process commonly attach to form a sleeve around
side of the optic tract and crosses laterally below the optic tract the nerve (17). The oculomotor nerve passes between the poste-
at the anterior margin of the lateral geniculate body to arrive on rior cerebral and superior cerebellar arteries and courses antero-
the superomedial surface of the posterior part of the uncus, laterally at the junction of the carotid, interpeduncular, prepon-

tine, and cerebellopontine cisterns to reach the dural roof of the terns and that tension on the arachnoid membranes may be

cavernous sinus. The arachnoid sheath along this portion of the transmitted to the fundus of the aneurysm even when dissec-
nerve is thin and incomplete. At the level of the roof of the cav- tion is being carried out at some distance (21, 22, 32, 33).
ernous sinus, the nerve passes through a dural porus into an In approaching aneurysms, it is helpful to know which mem-
outpouching of the outer arachnoid membrane that surrounds branes may be attached to the aneurysm. For example,
the nerve and extends to where the nerve becomes incorpo- aneurysms arising at the origin of the posterior communicating
rated into the fibrous lateral wall of the cavernous sinus near the and anterior choroid arteries may be attached to the intrac-
lower edge of the tip of the anterior clinoid process (16). arotid, medial carotid, and diencephalic membranes. Aneu-
rysms arising at the basilar apex and at the origin of the supe-
DISCUSSION rior cerebellar artery may project into the diencephalic and
mesencephalic leaves of Liliequist’s membrane. An under-
Since Yaşargil’s first report on the microsurgical anatomy of standing of the arachnoidal membranes is especially impor-
the cisterns (32, 33), several additional studies based on both tant in dealing with aneurysms pointing in the direction of the
endoscope and microsurgical examinations of the cisterns have oculomotor nerves. Five arachnoid membranes converge on
appeared (1, 4, 13–17, 22, 30, 31, 35). The endoscope has the the oculomotor nerve: diencephalic, mesencephalic, anterior
advantages of providing detailed views that are different from pontine, lateral pontomesencephalic, and medial carotid mem-
those seen in the operating microscope and permitting the view- branes. Traction on any of these membranes may rupture these
ing of deep membranes without extensive dissection of the aneurysms (22, 32). The outer surface of the arachnoidal mem-
superficial arachnoid. Recent refinements of endoscopic surgical branes that are adherent to an aneurysm may provide a plane
technique have made it possible to approach the basal cisterns of dissection that allows easier separation of the aneurysm
through the nasal cavity and paranasal sinuses (2–4, 10, 11). from adjacent structures. It may be necessary to leave some of
In this study, 12 arachnoidal membranes were found in the the arachnoid membrane attached to the fundus and wall of the
supratentorial area (Table 1). The most frequent paired mem- aneurysm to prevent rupture before a clip is applied.
branes were the lateral, intermediate, and medial sylvian and Every artery attaches to membranes, directly or indirectly, by
the olfactory membranes, which were found in 100% of hemi- way of the trabecula, which may need to be divided to mobilize
spheres. All of the unpaired membranes, medial lamina termi- the artery. Retracting the carotid superiorly may require division
nalis, diencephalic, and mesencephalic, were found in 100% of of the intracarotid membrane plus the membranes and trabecu-
brains. The least frequent membranes were the intracrural and lae that attach to its anterior choroidal, posterior communicating,
lateral lamina terminalis membranes, found in approximately and perforating branches. Retracting the carotid laterally may
75% of hemispheres. In the pterional (frontotemporal) opera- require division of the medial carotid and intracarotid mem-
tive approach, opening the outer arachnoid membrane over branes. In the subtemporal approach, opening the arachnoid
the sylvian fissure exposes the posterolateral compartment of attached to the lower surface of the oculomotor nerve while
the sylvian cistern. To enter the posteromedial compartment, maintaining the arachnoidal attachments above the nerve to the
where the M2 courses, the lateral and intermediate sylvian uncus will result in the nerve being elevated as the temporal
membranes are opened. In extending the approaches to the lobe is elevated. In the pterional approach, opening the arach-
carotid cistern, the proximal sylvian membrane is opened. noid above the oculomotor nerve while preserving the nerve’s
Opening the carotid cistern exposes the intracarotid and medial arachnoid attachment to the tentorial edge will aid in opening
carotid membranes. Opening the medial carotid membrane the interval between the carotid artery and oculomotor nerve.
allows entry into the chiasmatic cistern, and opening the dien- It is important to know in which cisterns aneurysms are
cephalic leaf of Liliequist’s membrane exposes the interpedun- located. Aneurysms arising at the anterior communicating
cular cistern. The anterior part of the crural cistern can be artery are situated in the lamina terminalis cistern; aneurysms
accessed at the posterior edge of the carotid cistern. In the sub- arising on the distal anterior cerebral artery are situated in the
frontal approach, the outer arachnoid and lateral lamina termi- pericallosal cistern; aneurysms arising at the origin of the pos-
nalis membranes are opened to reach the lamina terminalis terior communicating, anterior choroid, and carotid bifurca-
and carotid cisterns, and opening the medial lamina terminalis tion are situated in the carotid cistern; aneurysms arising at
membrane extends access to the pericallosal cistern. the origin of the ophthalmic artery may be situated in the
Pathological processes in the subarachnoid space may con- naked area or the carotid cistern; aneurysms arising on the
form to cisternal boundaries. The arachnoid septae and trabec- middle cerebral artery may be situated in either the carotid or
ulae separating the cisterns may prevent the spread of blood to the sylvian cistern but are most commonly in the latter; and
adjacent cisterns after aneurysm rupture. The resulting location aneurysms arising at the basilar apex are situated in the
of the blood, as seen on computed tomography, often provides interpeduncular cistern.
information pinpointing the site of a ruptured aneurysm. The Tumors frequently have relationships to the cisterns and
thickening and staining of the arachnoid membranes that fol- their membranous walls that can be used in selecting a plane
low subarachnoid hemorrhage may make the approach to an of dissection for their removal. Therefore, it is helpful to know
aneurysm more difficult. Yaşargil notes (33) that aneurysms in which layer the tumor is located; epidural, subdural-
may become invested with the arachnoidal walls of the cis- epiarachnoidal, subarachnoidal, or parenchymal. Rhoton (22)

INOUE ET AL.
classified tumors into 5 categories on the basis of their rela- Three-dimensional constructive interference in steady state MR imaging.
Radiology 229:360–365, 2003.

tionship to the cisterns: 1) growth within a single cistern; 2)
7. Gibo H, Carver CC, Rhoton AL Jr, Lenkey C, Mitchell RJ: Microsurgical ana-
growth within 1 cistern with compression of adjacent cisterns;
tomy of the middle cerebral artery. J Neurosurg 54:151–169, 1981.
3) growth within multiple cisterns; 4) growth in adjacent 8. Gibo H, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the supraclinoid
structures with extension into the cisterns; and 5) growth in portion of the internal carotid artery. J Neurosurg 55:560–574, 1981.
adjacent structures with compression of, but not extension 9. Hardy DG, Peace DA, Rhoton AL Jr: Microsurgical anatomy of the superior
into, the adjacent cisterns. The arachnoidal walls of a cistern cerebellar artery. Neurosurgery 6:10–28, 1980.
10. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R: Expanded endo-
containing a tumor may protect the neural and vascular struc- nasal approach: Fully endoscopic, completely transnasal approach to the
tures in adjacent cisterns from operative injury. Meningiomas middle third of the clivus, petrous bone, middle cranial fossa, and infratem-
commonly arise external to and compress the cisterns without poral fossa. Neurosurg Focus 19:E6, 2005.
extending directly into them and may be removed without 11. Kassam AB, Prevedello DM, Thomas A, Gardner P, Mintz A, Snyderman C,
Carrau R: Endoscopic endonasal pituitary transposition for a transdorsum
opening the outer arachnoid membrane. The arachnoid mem-
sellae approach to the interpeduncular cistern. Neurosurgery 62:57–74, 2008.
brane is frequently displaced around the surface of a menin- 12. Liliequist B: The anatomy of the subarachnoid cisterns. Acta Radiol 46:61–71,
gioma and provides a barrier to injury of adjacent arteries 1956.
and nerves during the tumor’s removal. 13. Lü J, Zhu XI: Microsurgical anatomy of Liliequist’s membrane. Minim
Craniopharyngiomas are subarachnoidal lesions that grow Invasive Neurosurg 46:149–154, 2003.
14. Lü J, Zhu XL: Characteristics of distribution and configuration of intracranial
within the cisternal spaces. At first, they grow within a single arachnoid membranes. Surg Radiol Anat 27:472–481, 2005.
cistern, usually the chiasmatic cistern, but as they expand, they 15. Lü J, Zhu XL: Cranial arachnoid membranes: Some aspects of microsurgical
will compress or enter the adjacent cisterns, including the anatomy. Clin Anat 20:502–511, 2007.
interpeduncular and carotid cisterns, or extend into multiple 16. Martins C, Yasuda A, Campero A, Rhoton AL Jr: Microsurgical anatomy of
the oculomotor cistern. Neurosurgery 58 [Suppl 2]:ONS-220–ONS-228, 2006.
cisterns and adjacent structures. They will change gradually 17. Matsuno H, Rhoton AL Jr, Peace D: Microsurgical anatomy of the posterior
from category 1 to category 2, 3, 4, or 5. Some gliomas of the fossa cisterns. Neurosurgery 23:58–80, 1988.
cerebrum and brainstem may develop exophytic extensions into 18. Perlmutter D, Rhoton AL Jr: Microsurgical anatomy of the anterior cerebral-
the cisterns. A small pinealoma or acoustic neuroma is usually anterior communicating-recurrent artery complex. J Neurosurg 45:259–272,
1976.
situated entirely within a single cistern. As they enlarge, they
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choroidal artery. Surg Neurol 12:171–187, 1979.
cially important in dealing with aneurysms and tumors involv-
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Disclosure Neurosurgery 45:152–157, 1999.
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COMMENTS This article is a “must-read” for all microsurgeons as well as endoneu-

rosurgeons. The cisternal spaces provide the critical corridors into these
I n this article, Inoue et al. describe in detail the arachnoidal mem-

branes and cisterns of the supratentorial compartment. The novel
aspect of this study relates to its ability to maintain the integrity of the
regions whether using a microscope for visualization or performing tran-
scranial or endonasal endoscopy. Understanding these relationships is a
prerequisite for proceeding with surgery. Once again, we are grateful for
cisterns during cadaveric dissection with the use of the endoscope. In Professor Rhoton’s contributions, which form the foundation of contem-
addition, angled endoscopes provide unique views, as demonstrated in porary neurosurgery.
the figures. This provides a new perspective into these spaces, defining Amin Kassam
their critical neurovascular relationships. Pittsburgh, Pennsylvania
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Cisternas y Memb Arac

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Cisternas y Memb Arac

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SURGICAL ANATOMY

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FIGURE 1. Anatomic dissections of supratentorial A

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FIGURE 2. A–B. Drawings of A

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FIGURE 7. Anatomic dissections A B

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COMMENTS This article is a “must-read” for all microsurgeons as well as endoneu-

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I n this article, Inoue et al. describe in detail the arachnoidal mem-

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