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Subarachnoid cisterns and their contents are described briefly in the light of
observations made during microsurgicalexplorations. The concept of intracranial sur-
gery in terms of moving from one cistern to another is presented here with particular
emphasis on the cisterns in surgical approaches to intracranial vessels and nerves for
the treatment of aneurysms, arteriovenous malformations, and for surgery of basal
tumors.
T
Anatomical Observations
sions of subarachnoid space situated
This summary of observations is based on
between the arachnoid membrane of the
approximately 1500 intracranial operations
brain and its pial surface. They are filled with
performed by one of us (MGY) under the
cerebrospinal fluid and traversed by fibers
microscope (Figs. 1-3). We stress the concept
and trabeculae which connect the two bound-
of performing intracranial operations by
ing membranes. The major intracranial
moving from one cistern to another. Par-
nerves and blood vessels ensheathed in
ticular attention is paid to cisterns in surgical
arachnoidal fibers pass through these com-
approaches to intracranial aneurysms, e
partments.
vascular malformations and basal tumors,
The first definitive work on the anatomy of
such as craniopharyngiomas, meningiomas,
subarachnoid cisterns was done by Key and
acoustic neuromas) epidermoids, and chor-
Retzius 1 100 years ago. There was no notable
domas/chondromas.
study on this subject until the monograph by
neuroradiologist Liliequist in 19597 Later
studies on this subject were done by
Leighton,~ and Wilson?
Cisterna Cerebellomedullaris Lateralis
Some authors have described cisterns for
each individual nerve and artery but for prac- The cisterna cerebellomedullaris ventro-
tical purposes the description is confined to lateralis contains
cisterns of interest to neurosurgeons. The 1. the vertebral artery and origin of
usual contents of each cistern are described. posterior inferior cerebellar artery;
FIG. 1. Artist's concept of the subarachnoid cisterns at the base of the brain. Left." Relation of cranial
nerves to cisterns, Right: Relation of arteries to cisterns. The cranial nerves are designated by Roman
numerals. 1 = Olfactory cistern; 2 = Callosal cistern; 3 = Chiasmatic cistern with I and II nerves;
4 = Carotid cistern; 5 = Sylvian cistern; 6 = Crural cistern; 7 = Interpeduncular cisterns with III
nerves; 8 = Ambient cisterns with IV nerves; 9 = Prepontine cistern with VI nerves; 10 = Cerebellopon-
tine cistern on each side with VII and VIII nerves; 11 = Lateral cerebellomedullary cistern on each side
with IX, X, XI and XII nerves; 12 = Cervical subarachnoid space; 13 = Cisterna cerebellomedullaris.
Cisterna Chiasmatis
The cisterna chiasmatis contains
1. the anterior aspect of the optic chiasma
and optic nerves;
2. the hypophyseal stalk;
3. the origin of the anterior cerebral
arteries; and
4. the anterior communicating vein.
Carotid Cistern
The carotid cistern contains
1. the internal carotid artery;
FI~. 2. Cisterns encountered in surgery of 2. the origin of the anterior choroid artery;
cerebellopontine angle tumors. 1 = cisterna am- and
biens and quadrigemina; 2 = cerebellopontine 3. the origin o f the posterior com-
angle cistern; 3 = lateral cerebellomedullary municating artery.
cistern with choroid plexus; 4 = fourth ventricle; 5
= hemispherical cistern (cerebellar); 6 = superior
vermian cistern; 7 = cisterna magna; 8 = cervi- Sylvian Cistern
cal subarachnoid space, spca = superior cerebellar The Sylvian cistern contains
artery; aica = anterior inferior cerebellar artery;
~ ica = posterior inferior cerebellar artery; B =
asilar artery; V = vertebral artery; Vp = petrosal
1. the middle cerebral artery;
2. middle cerebral (Sylvian) veins;
vein; mV = medullary vein; F1 = foramen of 3. fronto-orbital veins; and
Luschka; PI = choroid plexus. The cranial nerves 4. collaterals to the vein of Rosenthal.
are designated by Roman numerals. Solid black
lines represent the definite extent of subarachnoid
space. Dotted lines represent the probable extent Cisterna Lamina Terminalis
of subarachnoid space. The cisterna lamina terminalis contains
1. anterior cerebral arteries; the A-I seg-
ment and the proximal part of the A-2
segment;
2. the anterior communicating artery;
3. Heubner's artery;
4. the hypothalamic arteries;
5. the origin of the fronto-orbital arteries;
6. the venous system of the lamina ter-
minalis.
Quadrigeminal Cistern
The quadrigeminal cistern contains
1. the vein of Galen;
2. the posterior pericallosal arteries;
3. the third portion of the superior cere-
bellar arteries;
4. perforating branches of the posterior
Fro. 3. Subarachnoid cisterns of the anterior cerebral and the superior cerebellar arteries;
fossa. Note the thickened fibers over the A~ and M1 and
segments. 1 = medial basal part of Sylvian cistern; 5. the third portion of the posterior cere-
2 = olfactory cistern; 3 = carotid cistern; 4 = bral arteries. The two arteries approach each
lateral upper part of the interpeduncular cistern; 5
= crural cistern; 6 = chiasmatic cistern; 7 = other and then continue posteriorly beneath
cistern of lamina terminalis; 8 = callosal cistern. the splenium corporis callosi to the apex of
and tougher where the arteries pass through 2. Leighton RS: Neuroradiologic Anatomy -- A
the trabeculated wall from one cisternal com- Stereoscopic Atlas. Baltimore: Williams &
partment to another. At these positions of Wilkins, 1971
thickened arachnoid, such as over A1 and M1 3. Liliequist B: The suharachnoid cisterns. An
segments (see Fig. 3), the arachnoid cannot be anatomic and roentgenologic study. Acta
Radiol [Soppl] 185:1-108, 1959
safely opened and eliminated simply by 4. Wilson McC: The Anatomic Foundations of
spreading with a forceps, but must be cut with Neuroradioiogy of the Brain, ed 2. Boston: Lit-
scissors or microknives. tle Brown, 1972
Increased knowledge of the construction of 5. Ya~argil MG, Fox JL: The microsurgical ap-
the basal cisterns and arachnoidal fibers and proach to acoustic neuromas. Sorg Neurol
their variations will greatly assist neuro- 2:393-398, 1974
surgeons in avoiding any trauma to the basal 6. Ya~argil MG, Fox JL, Ray MW: The operative
nerves, brain tissues, or vessels during dissec- approach to aneurysms of the anterior com-
tion. municating artery, in Krayenbfihl H (eel): Ad-
vances and Technical Standards in Neuro-
surgery, vol 2. New York: Springer-Verlag,
1975, pp 113-170
References
1. Key EAH, Retzius MG: Studien in der Address reprint requests to: M. Gazi Ya~argil,
Anatomie des Nervensystems und des M.D., Kantonsspital Zfirich, Neurochirurgische
Bindegewebes. Stockholm: Samson & Wallin, Universit~tsklinik, R~imistrasse 100, 8006 Zfirich,
1875 Switzerland.