Surg Radiol Anat (2010) 32:919925

DOI 10.1007/s00276-010-0655-z

O R I G I N A L A R T I CL E

Microsurgical anatomy of the medial tentorial artery

of BernasconiCassinari
Johann Peltier Anthony Fichten Eric Havet
Pascal Foulon Cyril Page Daniel Le Gars

Received: 13 December 2009 / Accepted: 18 March 2010 / Published online: 16 April 2010
Springer-Verlag 2010

Abstract
Objective In the current literature, there is a lack of
detailed map of the origin, course and relationships of the
medial tentorial artery (MTA) of BernasconiCassinari
often implicated in various diseases such as dural arteriovenous Wstulas of the cranial base, stenotic lesions of the ICA,
saccular infraclinoid intracavernous aneurysms and tentorial meningiomas.
Methods Using a colored silicone mix preparation, ten
cranial bases were examined using 3 to 40 magniWcation of the surgical microscope.
Results The MTA arose as a single branch in 95% of
cases from the MHT at the level of the C4 segment of the
internal carotid artery. The average length of the MTA was
21.7 mm (range 20.023.4 mm). The average diameter of
the MTA was 0.53 mm (range 0.490.60 mm).The MTA
passed just below the lower dural ring detached from the
lower margin of the anterior clinoid process. During its
course, the MTA drop over the intracavernous segment of
the abducens nerve twisted at its exit from the Dorellos
canal and overlay the trochlear into the thickness of the free
margin of the tentorium cerebelli. Vascular relationships of
the MTA were venous trabeculation of the cavernous sinus,
basilar plexus and branches of the inferolateral trunk. The
MTA sent two terminal branches: one medial rectilinear,
which pursued the initial dorsal course, and the other
J. Peltier E. Havet P. Foulon C. Page D. Le Gars
Laboratoire dAnatomie et dOrganogense,
Universit de Picardie Jules Verne, Amiens, France

shorter with a lateral course, which disappeared into the

lateral wall of the cavernous sinus. The medial branch of the
MTA curved laterally, ramifying within the free edge of
the tentorium cerebelli and anastomosing along the base of
the dorsal part of the falx.
Conclusion The implications of these anatomic Wndings for
surgery or endovascular procedure are reviewed and discussed.
Keywords Anatomy Cavernous sinus Dura mater
Internal carotid artery Tentorium cerebelli Medial
tentorial artery

Introduction
Described by Bernasconi and Cassinari [3] in 1956, the
medial tentorial artery (MTA), also called marginal tentorial
artery in other nomenclatures, arises from the intracavernous
part of the internal carotid artery (ICA). It contributes to the
supply of the medial portion of the tentorium cerebelli. It
plays a well-known role in the vascularization of tentorial or
petroclival meningiomas. Moreover, it can be enlarged in
dural arteriovenous Wstulas of the cranial base, stenotic lesions
of the ICA such as Moyamoya disease and may be the site of
formation of saccular infraclinoid intracavernous aneurysms
[2, 5, 10, 13, 14, 18, 24, 27, 30, 38]. To improve our understanding of this important vessel, we have performed a cadaveric microsurgical anatomical study of the MTA.

Materials and methods

J. Peltier (&) A. Fichten D. Le Gars
Service de Neurochirurgie,
Centre Hospitalier Universitaire dAmiens Nord,
Place Victor Pauchet, 80054 Amiens Cedex 1, France
e-mail: peltier.johann@chu-amiens.fr

Ten cranial bases of both sexes were examined using 3 to

40 magniWcation of the surgical microscope (Carl Zeiss
Inc., Gttigen, Germany). Saline irrigation was then used to

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wash out residual luminal clots. In one half, the internal

carotid arteries and internal jugular veins were dissected,
cannulated and perfused with colored silicon on fresh
cadavers (Latex, Fouche Chimie Service, Marseille); in the
other half, arterial injection was given on formalin-Wxed
normal adult human brains.

Surg Radiol Anat (2010) 32:919925

Relationships

The MTA sent two terminal branches: one medial long rectilinear branch which pursued the initial dorsal course; the
other was shorter with a lateral course, which narrowed to
disappear in the lateral wall of the cavernous sinus.

The ILT was the main vascular relationship of the MTA.

The ILT gave rise to a superior branch supplying the roof of
the cavernous sinus, and a lateral branch for the foramen
rotundum. More laterally, a branch supplied the gasserian
ganglion in the medial wall of the cavum trigeminal
(Fig. 2). Equally, the ILT gave oV these three branches,
which cushioned the intravenous segment of the abducens
nerve. The most lateral branch supplied the medial portion
of the abducens nerve, whereas the most ventral branch
supplied the anterior segment of the abducens nerve in the
vicinity of the superior orbital Wssure (Fig. 3).
Both proximal segments of the dorsal clival artery and
the MTA had a parallel course. The MTA draped over the
abducens nerve, which twisted at its exit from the Dorellos
canal (or petroclival conXuence) (Fig. 4). The MHT can
have a candelabra-like pattern with three to Wve branches
(inferior and superior hypophyseal arteries medially, MTA
laterally, and medial and lateral dorsal clival arteries dorsally). More ventrally, the falciform ligament covered the
Wrst few millimeters of the optic nerve, and the III, IV and
VI nerves converged into the superior orbital Wssure
(Fig. 5). The MTA was cushioned into the thickness of the
free margin of the tentorium cerebelli (Fig. 6).The peeling
of the free margin of the tentorium cerebelli showed the
MTA.
The MHT gave oV the inferior hypophyseal artery,
which passed over the clinoid venous space characterized
by the conXuence of diploic veins of the orbital roof close
to the dural collar. The medial long branch of the MTA
curved laterally ramifying within the free edge of the tentorium

Fig. 1 Lateral view of the cavernous sinus and of the ambiens cistern.
1 Optic nerve; 2 C5 segment of the ICA; 3 oculomotor nerve; 4 anterior
choroidal artery; 5 superior cerebellar artery; 6 basilar artery; 7 abducens nerve; 8 C4 segment of the ICA; 9 lateral branch of the ILT;
10 MTA; 11 posterior clinoid process; 12 free margin of the tentorium
cerebelli; 13 petrous pyramid; 14 trigeminal ganglion

Fig. 2 Lateral view of the lateral wall of the cavernous sinus.

1 Posterior cerebral artery; 2 superior cerebellar artery; 3 oculomotor
nerve; 4 MTA; 5 C5 segment of the ICA; 6 posterior clinoid process;
7 ILT; 8 lateral branch of the ILT; 9 lateral wall of the cavernous sinus;
10 dura of the clivus; 11 ventral face of the pons; 12 short perforating
branches of the basilar artery; 13 optic groove

Results
Origin
The MTA arose as a single branch in 95% of cases from the
MHT. The average length of the MTA was 21.7 mm (range
20.023.4 mm). The average diameter of the MTA was
0.53 mm (range 0.490.60 mm).
Course
The MTA passed just below the lower dural ring detached
from the lower margin of the anterior clinoid process also
called carotidooculomotor membrane, and had a horizontal
course toward the free margin of the tentorium cerebelli. It
draped over the intracavernous segment of the abducens
nerve and over the posterior clinoid process (Fig. 1).
Ending

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Fig. 3 Lateral view of the intracavernous ICA after opening of the

dura; 1 C2 segment of the ICA; 2 basilar artery; 3 oculomotor nerve;
4 MTA; 5 ILT; 6 lateral branch of the ILT; 7 tiny branch for supply of
both abducens and trochlear nerves; 8 abducens nerve; 9 ventral branch
of the ILT; 10 roof of the cavernous sinus; 11 carotid collar; 12 posterior clinoid process

Fig. 4 Lateral view of the tentorial incisura. 1 Free margin of the tentorium cerebelli; 2 superior cerebellar artery; 3 basilar artery; 4 abducens nerve; 5 oculomotor nerve; 6 MTA; 7 posterior clinoid process;
8 C3 segment of the ICA; 9 middle cerebral artery; 10 C5 segment of
the ICA; 11 optic nerve; 12 upper ring of the ICA; 13 anterior clinoid
process; 14 medial clival artery

and anastomosing along the base of the dorsal part of the

falx. The oculomotor nerve crossed the anterior incisural
space between the posterior cerebral artery and the superior
cerebellar artery and entered the roof of the cavernous sinus
through the oculomotor trigone. The abducens nerve
ascended from deep within the infratentorial part of the
anterior incisural space to pierce the dura covering the clivus and passed below the petrosphenoid ligament at the
level of the petroclival conXuent to enter the cavernous
sinus. The trochlear nerve had a long course within the tentorial incisura and was very intimately related to the free
edge. It ran for a short distance in the petroclinoid fold and
entered the lateral wall of the cavernous sinus (Fig. 7).

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Fig. 5 Superior view of the suprasellar region. 1 MHT; 2 dorsal meningeal artery; 3 oculomotor nerve; 4 MTA; 5 medial clival artery;
6 dura of the clivus; 7 basilar apex; 8 C4 segment of the ICA; 9 C6 segment of the ICA; 10 pituitary stalk and inferior hypophyseal artery;
11 optic nerve; 12 jugum; 13 falciform ligament of the optic nerve;
14 anterior clinoid process; 15 posterior clinoid process; 16 trigeminal
nerve; 17 oculomotor nerve; 18 trochlear nerve

Fig. 6 Superomedial view of the cavernous sinus and the tentorial

incisura. 1 tentorial edge; 2 MTA; 3 oculomotor nerve; 4 dorsum
sellae; 5 C5 segment of the ICA; 6 optic nerve; 7 pituitary stalk; 8
trochlear nerve; 9 basilar artery; 10 lateral wall of the cavernous sinus

Variations
In 5% of the specimens, the MTA unusually arose from the
ILT. During its course, the MTA overlay the trochlear
nerve. Medial and lateral dorsal clival arteries originating
from the MHT merged into the posterior intercavernous
venous sinus and basilar venous plexus (Fig. 8).

Discussion
The MTA may arise as a single branch in 64% of the cases
from the MHT and as two or more branches in 36% of the

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Fig. 7 Superolateral view of the cavernous sinus after opening of the

lateral wall. 1 optic nerve; 2 oculomotor nerve; 3 medial branch of the
ILT; 4 C4 segment of the ICA; 5 abducens nerve; 6 lateral branch of
the ILT; 7 venous trabeculations of the cavernous sinus; 8 trunk of the
MTA; 9 lateral branch of the MTA; 10 medial branch of the MTA;
11 free margin of the tentorium cerebelli; 12 C5 segment of the ICA;
13 pituitary stalk; 14 clivus; 15 basilar artery; 16 dura of the lateral
wall of the cavernous sinus

Fig. 8 Posterior view of the cavernous sinus. 1 ILT; 2 C4 segment of

the ICA; 3 MTA; 4 lateral branch of the ILT; 5 trochlear nerve; 6 MHT;
7 one dorsal meningeal artery; 8 medial clival artery; 9 other dorsal
meningeal artery; 10 venous trabeculations of the cavernous sinus;
11 posterior clinoid process; 12 tentorial edge; 13 temporal fossa; 14 C5
segment of the ICA; 15 venous trabeculations of the basilar plexus

cases [26]. In only 3% of the cases, the MTA arises directly

in the intracavernous ICA. The MTA supplies the transdural segments of the oculomotor nerve and the trochlear
nerve, the roof of the cavernous sinus, the medial third of
the tentorium and the posterior attachment of the falx cerebri to reach the straight sinus and the torcular [15, 20].
The MTA can have an anastomosis with the contralateral
medial tentorial artery creating an arcade. Anastomosis
with the lateral tentorial artery, petrosal branch and posterior division of the middle meningeal artery, dorsal menin-

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Surg Radiol Anat (2010) 32:919925

geal artery and inferolateral trunk of the ICA are also

possible. These arcades anastomoses across the midline
[31].
The intracavernous segment of the ICA gives rise to
branches, which supply the walls and enclosed structures of
sella, cavernous sinus and tentorium. Lasjaunias classiWcation divides the ICA into seven segments: 1, cervical segment; 2, initial ascending intrapetrous segment; 3, distal
horizontal intrapetrous segment; 4, segment ascending in
the sphenoid Wssure and through the cavernous sinus; 5,
horizontal segment of the carotid Wssure; 6, clinoid segment
and 7, terminal segment [16]. These branches can be
divided on the basis of the embryology into two groups: a
dorsomedial group (remnants of the trigeminal artery) and a
lateral group (which are the remnants of the primitive dorsal ophthalmic artery). The dorsomedial group includes the
inferior hypophyseal artery, the medial clival artery, the
dorsal meningeal artery, the medial tentorial artery (MTA)
and the Mc Connells capsular arteries [20]. The inferolateral trunk (ILT) belongs to the lateral group. The ILT has a
common origin with the MHT in 8% of the specimens [26].
The meningohypophyseal trunk (MHT), which is the
largest branch of the intracavernous ICA, arises lateral to
the dorsum sellae often at an acute angle, at or just proximal to the apex of the Wrst curve of the intracavernous ICA.
It takes origin from the superomedial part of the medial
loop of the ICA (C3 segment) in the posterosuperior area of
the cavernous sinus [9, 26]. It has the same caliber as the
ophthalmic artery. In its modal form, it trifurcates and gives
rise to the MTA, the inferior hypophyseal artery, medial
clival artery and dorsal meningeal arteries [19, 23, 30, 40].
The origin of the meningohypophyseal trunk can be
exposed through Parkinsons triangle, located in the lateral
view between the trochlear and ophthalmic nerves, except
when the ICA is elongated and tortuous, causing the posterior bend to rise above the trochlear nerve [8, 28, 29]. The
MHT can be absent [34].
The ILT arises from the C4 portion of the siphon and
bends over the abducens nerve. It usually gives rise to three
branches: a superior branch supplying the cavernous roof
and the III and IV nerves and anastomosing with the superWcial recurrent ophthalmic system; a ventral branch that
divides into a medial ramus toward the superior orbital
Wssure and a lateral ramus, extending toward the foramen
rotundum and anastomosing with the deep recurrent ophthalmic artery; and a dorsal branch that also subdivides into
a medial branch to the VI nerve and the medial third of the
gasserian ganglion, and a lateral branch for the lateral and
middle thirds of the gasserian ganglion, passing through the
foramen ovale and anastomosing with the accessory meningeal artery or the middle meningeal artery at the level of the
foramen spinosum. The ILT is visualized in only 11% of
ICA carotidograms [16, 17, 31].

Surg Radiol Anat (2010) 32:919925

Finally, there is a rich arterial anastomotic network

between the left and right ICA and between the external
carotid artery and ICA, especially on the clivus and the
dorsum sellae explaining the important arterial blood
supply of pathologic lesions arising here. These anastomoses
form the rete mirabileof the clivus [40].
The second source of the tentorial arteries is from the
superior cerebellar artery in 28% of cases. These branches
can be encountered when the tentorium is sectioned
through a subtemporal approach [22, 28]. The third source
of the tentorial arteries is the proximal part of the posterior
cerebral artery, which arises as a long circumXex artery that
courses around the mesencephalon to enter the tentorium
near the apex [22, 29, 41]. These various arteries and
venous sinuses may be encountered in sectioning the tentorium to alleviate pressure on the brain stem caused by large
incisural lesions that cannot be removed, such as giant
meningiomas [6, 28].
It is very important to be familiar with the detailed anatomy of the blood supply of the oculomotor nerve and trochlear nerve. Their distal segments are supplied by a branch of
the MTA, which runs on the nerves inferior surface in
87.5% of cases for the oculomotor nerve and in 67% of
cases for the trochlear nerve, respectively [1]. These
branches that arise from the MTA run with the trochlear
nerve to the superior orbital Wssure [4]. Ischemic injury
probably accounts for the majority of permanent cranial
nerve deWcits [4, 9, 33]. The Wrst branch of the gasserian
ganglion (ophthalmic nerve V1) is constantly supplied by
the ILT. The abducens nerve is also supplied by the ILT that
crosses it or eventually by branches of the MTA [40].
Embolization of MHT or inferolateral trunk for tumor
devascularization carries a risk of ischemic injury to the cranial nerve [12, 30]. Using particular larger than 150 m has
been suggested as a strategy to protect the small vasa vasorum, minimizing the risk of cranial nerve ischemia [18].
When visible during normal angiography, the MTA
ranges in length from 5 to 35 mm. A pathological lesion is
considered when the MTA can be followed, in the angiogram, for a distance longer than 40 mm [29, 32, 35, 37].
This long and serpiginous aspect with an anterosuperior
concavity can be seen in cerebral AVM, gliomas with tentorial invasion, trigeminal schwannomas and also in the
normal patient [3, 7, 11, 28].
Progressive occlusion and kinking of ICA siphons
related to moyamoya disease can lead to the development
of a meningeal contribution with a bulky and tortuous MTA
[24, 36]. The presence of embryonic arteries associated
with moyamoya disease has been previously reported usually with the trigeminal artery, but unusually with the MTA
[14, 24].
Tentorial dural AVM are relatively rare, accounting for
0.81.9% of dural intracranial AVM [2, 25]. More than

923

80% of patients with these AVM presented with aggressive

clinical features, such as intracranial hemorrhage and more
rarely trigeminal neuralgia related to ectatic petrosal or
leptomeningeal reXux veins with a remarkable varix compressing the root entry zone [27]. Carotid angiogram
usually demonstrates the AVM fed by the MTA (Fig. 9)
and by branches of the middle meningeal artery with
venous drainage through the petrosal vein, pontine and paramesencephalic veins and into the superior petrosal sinus
[25, 27, 39]. These tentorial dural AVM are actually treated
with a combination of endovascular surgery and radiosurgery, which provide symptom relief and durable response
[2, 21, 27].
Infraclinoid intracavernous internal carotid artery aneurysms are a rare entity. They carry a low risk of subarachnoid
hemorrhage. Hemodynamically, there are multiple potential
sites of incidental aneurysms formation in this region, such as
the superior hypophyseal artery or the MTA [10].
The tentorium cerebelli has a characteristic dual blood
supply formed by the medial tentorial and the basal tentorial arteries. Meningiomas of the tentorium cerebelli and
petroclival meningiomas are fed by the MHT [38] (Fig. 10).
Preoperative embolization for these meningiomas can
reduce surgical blood loss, shorten operating time and
reduce the risk of damage to surrounding structures [5, 13].
Embolization is performed with 250500 m polyvinyl
alcohol particles [13].
The MTA is a complex artery, which participates in the
blood supply of the tentorium cerebelli. Its origin, course
and relationships are very deep and justify thorough anatomical dissections. Its proximal segment is surrounded by
the cavernous sinus. Equally, its distal segment is hidden in
the free margin of the tentorium cerebelli. The MTA plays
an important role in the supply of the tentorium meningiomas and in the aVerences of tentorial dural AVM. Its tiny

Fig. 9 Lateral angiogram of a left ICA showing an enlarged

rectilinear MTA (arrows) in a case of dural arteriovenous Wstula of the
tentorium cerebelli

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Fig. 10 Frontal T1 gadolinium-enhanced MR imaging showing a

meningioma located on the free edge of the tentorium cerebelli
supplied by the MTA

caliber contrasts with a localization in greater hemodynamic stress under the distal dural ring leading to various
vascular diseases.

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