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International Congress Series 1240 (2003) 1101 1106

Blood supply of the trigeminal ganglion and nerve root


Milan Milisavljevic a,*, Slobodan Marinkovic a, Mila Cetkovic b, Jasna Jancic-Stefanovic c, Dusan Stefanovic d
a

Institute of Anatomy, School of Medicine, University of Belgrade, Dr. Subotica 4/2, 11 000 Belgrade, Yugoslavia b Institute of Histology and Embryology, School of Medicine, University of Belgrade, Belgrade, Yugoslavia c Clinic of Neurology and Psychiatry for Children and Youth, School of Medicine, University of Belgrade, Belgrade, Yugoslavia d Institute of ORL and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Yugoslavia

Abstract Great surgical significance and lack of relevant anatomic data were the reasons for this study. Twenty-five trigeminal nerve roots and ganglia were examined under the stereoscopic microscope. The nerve root received between two and six vascular twigs from two or three of the following arteries: the superolateral pontine (92%), anterior inferior cerebellar (88%), inferolateral or posterolateral pontine, superior cerebellar, basilar and trigeminocerebellar. The trigeminal twigs measured from 110 to 520 Am in diameter. A single trigeminal artery may supply either the motor portion of the nerve root or the sensory portion, or both. The superolateral pontine artery (88%) usually perfused the motor root. The same artery often supplied (64%) the ophthalmic part of the sensory root. The maxillary part was most often irrigated by the superolateral and inferolateral pontine arteries, and the mandibular part by the anterior inferior cerebellar artery (AICA). The trigeminal ganglion received the vascular twigs from the middle meningeal artery (92%), accessory middle meningeal artery (8%), inferolateral trunk (90%) and tentorial branch (8%). The obtained data in the trigeminal vasculature can be the anatomic basis for decompressive neurovascular operations and surgery of the cavernous sinus. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved.
Keywords: Trigeminal nerve; Trigeminal ganglion; Trigeminal arteries; Basilar artery; Middle meningeal artery

* Corresponding author. Tel.: +381-11-645-958; fax: +381-11-686-172. E-mail address: milmili@EUnet.yu (M. Milisavljevic). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)01031-8

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1. Introduction Only a few articles have been devoted to the blood supply of the trigeminal ganglion and the nerve root [1,2]. We still do not know the precise vascular pattern of the motor and the sensory root of the nerve nor of the ganglion.

Fig. 1. The blood supply of the motor root (1) and partially of the sensory root (2) of the trigeminal nerve. (3) The superolateral, (4) the posterolateral and (5) the inferolateral pontine artery; (6) the trigeminocerebellar artery or the trigeminal branch of the basilar artery. Note that a single artery may supply only the motor root (A, B, C), or both the motor and sensory roots (D H). The motor root can be perfused by two vessels originating from one parent artery (G) or from two sources (H, I). The percentages are given above each corresponding drawing.

M. Milisavljevic et al. / International Congress Series 1240 (2003) 11011106 Table 1 Blood supply of the motor root of the trigeminal nerve Parent vessels Posterolateral pontine artery Superolateral pontine artery Inferolateral pontine artery Basilar artery Trigeminocerebellar artery

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Frequency (%) 8 88 4 4 4

2. Material and methods The basilar artery of 15 brains, as well as the carotid arteries in 15 skulls, was injected with a radiopaque substance or a 10% mixture of India ink and gelatin. The vasculature of the 25 best-injected trigeminal nerve roots and ganglia was microdissected under the stereoscopic microscope.

3. Results The root of the trigeminal nerve consists of the motor portion (root) and the sensory portion (root). Both roots are supplied by the trigeminal arteries, which may originate from the basilar artery and its side branches: the superior cerebellar artery, the posterolateral, superolateral and inferolateral pontine arteries, the trigeminocerebellar and the anterior inferior cerebellar artery (AICA). The trigeminal vessels from these parent arteries varied in number from 2 to 6 (mean, 3.1) and in diameter from 110 to 520 Am (mean, 238 Am). 3.1. Blood supply of the motor root The motor root was most often perfused by the superolateral pontine artery (Fig. 1, Table 1). This root is usually perfused by a single parent artery (92%) (Fig. 1A G), and rarely by two arteries (8%) (Fig. 1H and I), either separately (28%) or in common with the sensory root (72%) (Fig. 1).

Table 2 Blood supply of the sensory root of the trigeminal nerve Parent vessels Superior cerebellar artery Posterolateral pontine artery Superolateral pontine artery Inferolateral pontine artery Basilar artery Trigeminocerebellar artery Anterior inferior cerebellar artery Frequency (%) 4 16 92 28 4 4 88

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3.2. Blood supply of the sensory root This root was most frequently supplied by the trigeminal vessels arising from the superolateral pontine artery (92%) and the AICA (88%) (Table 2, Figs. 1 and 2). The terminal and side branches of a single trigeminal artery, ranging in size from 40 to 210 Am (mean, 121 Am), may supply one, two or all three parts of the sensory root (Fig. 1G). The ophthalmic part was most often (64%) perfused by the branches of the superolateral pontine artery (Fig. 1D), the maxillary part by the superolateral and inferolateral arteries (Fig. 1E), and the mandibular part by the twigs of the AICA (Fig. 2).

Fig. 2. Four types (A D) of the vasculature of the trigeminal nerve root. (A) Two arterial rings; (B) a single ring; (C) discontinuous rings; (D) absence of the rings. (1) The motor root; (2) the sensory root; (3) the superolateral or, rarely, the posterolateral, superior cerebellar, trigeminal or trigeminocerebellar artery; (4) the inferolateral pontine artery; (5) the anterior inferior cerebellar artery or its branch to the middle cerebellar peduncle. The arrows indicate the anastomotic channels. The percentages are given in brackets.

M. Milisavljevic et al. / International Congress Series 1240 (2003) 11011106

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Fig. 3. Basal view of the superolateral pontine artery (1) whose trigeminal branch forms an arterial ring (smaller arrows) around the left trigeminal nerve root (2).

3.3. Vascular types of the trigeminal nerve root According to the branching patterns of the trigeminal arteries and the features of their anastomosing, four types of the vasculature of the trigeminal nerve root can be distinguished (Fig. 2). In the first type (12%), two arterial rings were noted around the nerve root, the proximal and the distal (Fig. 2A). In the second type (32%), a single vascular ring is present (Figs. 2B and 3). The third type (16%) comprises a discontinuous ring (Fig. 2C). In the remaining cases (40%), the arterial rings were not present (Fig. 2D). 3.4. Blood supply of the trigeminal ganglion The trigeminal ganglion is located between the sensory root and the three divisions of the trigeminal nerve. Our preliminary study showed that the ganglion was supplied by the branches of the middle meningeal artery (92%), accessory middle meningeal artery (8%), inferolateral trunk (90%) of the internal carotid artery and its tentorial twig (8%).

4. Discussion We presented in this study the origin, size, branching patterns and distribution area of the arteries to the trigeminal nerve root and the ganglion. The parent arteries of the trigeminal vessels, especially the superior cerebellar artery and the AICA, may sometimes compress the root entry zone of the trigeminal nerve and thus cause trigeminal neuralgia [3 5]. Our data in vascular anatomy may help the neurosurgeons to avoid damage to the trigeminal arteries during microvascular decompression of the nerve root [6].

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The known functional organization of the root of the trigeminal nerve [7] enabled us to determine the blood supply of the motor root, as well as of the ophthalmic, maxillary and mandibular part of the sensory root. These findings can be interpreted in light of occlusive neurovascular disease [8,9]. Thus, occlusion of the superolateral pontine artery, which most often supplies the motor root and the ophthalmic part of the sensory root, may lead to paresis of the masticatory muscles and to hypesthesia of the upper face, part of the lateral midpontine syndrome. Occlusion of the AICA, which most often perfuses the mandibular part of the sensory root, may cause impaired sensation over the lower face, followed by lateral inferior pontine syndrome. Since the twigs of the inferolateral trunk of the internal carotid artery most often supplied a large part of the trigeminal ganglion, great care must be taken to avoid damage to these tiny vessels during operations in the cavernous region [10].

References
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