Surg Radiol Anat (2010) 32:919925

DOI 10.1007/s00276-010-0655-z

ORIGINAL ARTICLE

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

AbstractObjective In the current literature, there is a lack ofdetailed map of the origin, course and relationships of themedial tentorial artery (MTA) of BernasconiCassinarioften implicated in various diseases such as dural arteriove-nous Wstulas of the cranial base, stenotic lesions of the ICA,saccular infraclinoid intracavernous aneurysms and tento-rial meningiomas.Methods Using a colored silicone mix preparation, tencranial bases were examined using 3 to 40 magniWca-tion of the surgical microscope.Results The MTA arose as a single branch in 95% ofcases from the MHT at the level of the C4 segment of theinternal carotid artery. The average length of the MTA was21.7 mm (range 20.023.4 mm). The average diameter ofthe MTA was 0.53 mm (range 0.490.60 mm).The MTApassed just below the lower dural ring detached from thelower margin of the anterior clinoid process. During itscourse, the MTA drop over the intracavernous segment ofthe abducens nerve twisted at its exit from the Dorelloscanal and overlay the trochlear into the thickness of the freemargin of the tentorium cerebelli. Vascular relationships ofthe MTA were venous trabeculation of the cavernous sinus,basilar plexus and branches of the inferolateral trunk. TheMTA sent two terminal branches: one medial rectilinear,which pursued the initial dorsal course, and the other

shorter with a lateral course, which disappeared into thelateral wall of the cavernous sinus. The medial branch of theMTA curved laterally, ramifying within the free edge ofthe tentorium cerebelli and anastomosing along the base ofthe dorsal part of the falx.Conclusion The implications of these anatomic Wndings forsurgery 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, themedial tentorial artery (MTA), also called marginal tentorialartery in other nomenclatures, arises from the intracavernouspart of the internal carotid artery (ICA). It contributes to thesupply of the medial portion of the tentorium cerebelli. Itplays a well-known role in the vascularization of tentorial orpetroclival meningiomas. Moreover, it can be enlarged indural arteriovenous Wstulas of the cranial base, stenotic lesionsof the ICA such as Moyamoya disease and may be the site offormation of saccular infraclinoid intracavernous aneurysms[2, 5, 10, 13, 14, 18, 24, 27, 30, 38]. To improve our under-standing of this important vessel, we have performed a cadav-eric microsurgical anatomical study of the MTA.

Materials and methods

Ten cranial bases of both sexes were examined using 3 to 40 magniWcation of the surgical microscope (Carl ZeissInc., Gttigen, Germany). Saline irrigation was then used to

J. Peltier E. Havet P. Foulon C. Page D. Le GarsLaboratoire dAnatomie et dOrganogense, Universit de Picardie Jules Verne, Amiens, France

J. Peltier (&) A. Fichten D. Le GarsService de Neurochirurgie, Centre Hospitalier Universitaire dAmiens Nord, Place Victor Pauchet, 80054 Amiens Cedex 1, Francee-mail: peltier.johann@chu-amiens.fr123

920 Surg Radiol Anat (2010) 32:919925wash out residual luminal clots. In one half, the internalcarotid arteries and internal jugular veins were dissected,cannulated and perfused with colored silicon on freshcadavers (Latex, Fouche Chimie Service, Marseille); in theother half, arterial injection was given on formalin-Wxednormal adult human brains.

Results

Origin

The MTA arose as a single branch in 95% of cases from theMHT. The average length of the MTA was 21.7 mm (range20.023.4 mm). The average diameter of the MTA was0.53 mm (range 0.490.60 mm).

Course

The MTA passed just below the lower dural ring detachedfrom the lower margin of the anterior clinoid process alsocalled carotidooculomotor membrane, and had a horizontalcourse toward the free margin of the tentorium cerebelli. Itdraped over the intracavernous segment of the abducensnerve and over the posterior clinoid process (Fig. 1).

Ending

The MTA sent two terminal branches: one medial long rec-tilinear branch which pursued the initial dorsal course; theother was shorter with a lateral course, which narrowed todisappear in the lateral wall of the cavernous sinus.

Relationships

The ILT was the main vascular relationship of the MTA.The ILT gave rise to a superior branch supplying the roof ofthe cavernous sinus, and a lateral branch for the foramenrotundum. More laterally, a branch supplied the gasserianganglion 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 abducensnerve. The most lateral branch supplied the medial portionof the abducens nerve, whereas the most ventral branchsupplied the anterior segment of the abducens nerve in thevicinity of the superior orbital Wssure (Fig. 3).

Both proximal segments of the dorsal clival artery andthe MTA had a parallel course. The MTA draped over theabducens nerve, which twisted at its exit from the Dorelloscanal (or petroclival conXuence) (Fig. 4). The MHT canhave a candelabra-like pattern with three to Wve branches(inferior and superior hypophyseal arteries medially, MTAlaterally, and medial and lateral dorsal clival arteries dor-sally). More ventrally, the falciform ligament covered theWrst few millimeters of the optic nerve, and the III, IV andVI nerves converged into the superior orbital Wssure(Fig. 5). The MTA was cushioned into the thickness of thefree margin of the tentorium cerebelli (Fig. 6).The peelingof the free margin of the tentorium cerebelli showed theMTA.

The MHT gave oV the inferior hypophyseal artery,which passed over the clinoid venous space characterizedby the conXuence of diploic veins of the orbital roof closeto the dural collar. The medial long branch of the MTAcurved 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 anteriorchoroidal artery; 5 superior cerebellar artery; 6 basilar artery; 7 abdu-cens nerve; 8 C4 segment of the ICA; 9 lateral branch of the ILT;10 MTA; 11 posterior clinoid process; 12 free margin of the tentoriumcerebelli; 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 oculomotornerve; 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 perforatingbranches of the basilar artery; 13 optic groove123

Surg Radiol Anat (2010) 32:919925 921and anastomosing along the base of the dorsal part of thefalx. The oculomotor nerve crossed the anterior incisuralspace between the posterior cerebral artery and the superiorcerebellar artery and entered the roof of the cavernous sinusthrough the oculomotor trigone. The abducens nerveascended from deep within the infratentorial part of theanterior incisural space to pierce the dura covering the cli-vus and passed below the petrosphenoid ligament at thelevel of the petroclival conXuent to enter the cavernoussinus. The trochlear nerve had a long course within the ten-torial incisura and was very intimately related to the freeedge. It ran for a short distance in the petroclinoid fold andentered the lateral wall of the cavernous sinus (Fig. 7).

Variations

In 5% of the specimens, the MTA unusually arose from theILT. During its course, the MTA overlay the trochlearnerve. Medial and lateral dorsal clival arteries originatingfrom the MHT merged into the posterior intercavernousvenous sinus and basilar venous plexus (Fig. 8).

Discussion

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

Fig. 3 Lateral view of the intracavernous ICA after opening of thedura; 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 ofboth abducens and trochlear nerves; 8 abducens nerve; 9 ventral branchof the ILT; 10 roof of the cavernous sinus; 11 carotid collar; 12 poster-ior clinoid process

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

Fig. 5 Superior view of the suprasellar region. 1 MHT; 2 dorsal men-ingeal 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 seg-ment 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 trigeminalnerve; 17 oculomotor nerve; 18 trochlear nerve

Fig. 6 Superomedial view of the cavernous sinus and the tentorialincisura. 1 tentorial edge; 2 MTA; 3 oculomotor nerve; 4 dorsumsellae; 5 C5 segment of the ICA; 6 optic nerve; 7 pituitary stalk; 8trochlear nerve; 9 basilar artery; 10 lateral wall of the cavernous sinus123

922 Surg Radiol Anat (2010) 32:919925cases [26]. In only 3% of the cases, the MTA arises directlyin the intracavernous ICA. The MTA supplies the trans-dural segments of the oculomotor nerve and the trochlearnerve, the roof of the cavernous sinus, the medial third ofthe tentorium and the posterior attachment of the falx cere-bri to reach the straight sinus and the torcular [15, 20].

The MTA can have an anastomosis with the contralateralmedial tentorial artery creating an arcade. Anastomosiswith the lateral tentorial artery, petrosal branch and poster-ior division of the middle meningeal artery, dorsal menin-

geal artery and inferolateral trunk of the ICA are alsopossible. These arcades anastomoses across the midline[31].

The intracavernous segment of the ICA gives rise tobranches, which supply the walls and enclosed structures ofsella, cavernous sinus and tentorium. Lasjaunias classiWca-tion divides the ICA into seven segments: 1, cervical seg-ment; 2, initial ascending intrapetrous segment; 3, distalhorizontal intrapetrous segment; 4, segment ascending inthe sphenoid Wssure and through the cavernous sinus; 5,horizontal segment of the carotid Wssure; 6, clinoid segmentand 7, terminal segment [16]. These branches can bedivided on the basis of the embryology into two groups: adorsomedial group (remnants of the trigeminal artery) and alateral group (which are the remnants of the primitive dor-sal ophthalmic artery). The dorsomedial group includes theinferior hypophyseal artery, the medial clival artery, thedorsal meningeal artery, the medial tentorial artery (MTA)and the Mc Connells capsular arteries [20]. The inferolat-eral trunk (ILT) belongs to the lateral group. The ILT has acommon origin with the MHT in 8% of the specimens [26].

The meningohypophyseal trunk (MHT), which is thelargest branch of the intracavernous ICA, arises lateral tothe dorsum sellae often at an acute angle, at or just proxi-mal to the apex of the Wrst curve of the intracavernous ICA.It takes origin from the superomedial part of the medialloop of the ICA (C3 segment) in the posterosuperior area ofthe cavernous sinus [9, 26]. It has the same caliber as theophthalmic artery. In its modal form, it trifurcates and givesrise to the MTA, the inferior hypophyseal artery, medialclival artery and dorsal meningeal arteries [19, 23, 30, 40].The origin of the meningohypophyseal trunk can beexposed through Parkinsons triangle, located in the lateralview between the trochlear and ophthalmic nerves, exceptwhen the ICA is elongated and tortuous, causing the poster-ior bend to rise above the trochlear nerve [8, 28, 29]. TheMHT can be absent [34].

The ILT arises from the C4 portion of the siphon andbends over the abducens nerve. It usually gives rise to threebranches: a superior branch supplying the cavernous roofand the III and IV nerves and anastomosing with the super-Wcial recurrent ophthalmic system; a ventral branch thatdivides into a medial ramus toward the superior orbitalWssure and a lateral ramus, extending toward the foramenrotundum and anastomosing with the deep recurrent oph-thalmic artery; and a dorsal branch that also subdivides intoa medial branch to the VI nerve and the medial third of thegasserian ganglion, and a lateral branch for the lateral andmiddle thirds of the gasserian ganglion, passing through theforamen ovale and anastomosing with the accessory menin-geal artery or the middle meningeal artery at the level of theforamen spinosum. The ILT is visualized in only 11% ofICA carotidograms [16, 17, 31].

Fig. 7 Superolateral view of the cavernous sinus after opening of thelateral wall. 1 optic nerve; 2 oculomotor nerve; 3 medial branch of theILT; 4 C4 segment of the ICA; 5 abducens nerve; 6 lateral branch ofthe ILT; 7 venous trabeculations of the cavernous sinus; 8 trunk of theMTA; 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 lateralwall of the cavernous sinus

Fig. 8 Posterior view of the cavernous sinus. 1 ILT; 2 C4 segment ofthe 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 dorsalmeningeal artery; 10 venous trabeculations of the cavernous sinus;11 posterior clinoid process; 12 tentorial edge; 13 temporal fossa; 14 C5segment of the ICA; 15 venous trabeculations of the basilar plexus123

Surg Radiol Anat (2010) 32:919925 923Finally, there is a rich arterial anastomotic networkbetween the left and right ICA and between the externalcarotid artery and ICA, especially on the clivus and thedorsum sellae explaining the important arterial bloodsupply of pathologic lesions arising here. These anastomosesform the rete mirabileof the clivus [40].

The second source of the tentorial arteries is from thesuperior cerebellar artery in 28% of cases. These branchescan be encountered when the tentorium is sectionedthrough a subtemporal approach [22, 28]. The third sourceof the tentorial arteries is the proximal part of the posteriorcerebral artery, which arises as a long circumXex artery thatcourses around the mesencephalon to enter the tentoriumnear the apex [22, 29, 41]. These various arteries andvenous sinuses may be encountered in sectioning the tento-rium to alleviate pressure on the brain stem caused by largeincisural lesions that cannot be removed, such as giantmeningiomas [6, 28].

It is very important to be familiar with the detailed anat-omy of the blood supply of the oculomotor nerve and troch-lear nerve. Their distal segments are supplied by a branch ofthe MTA, which runs on the nerves inferior surface in87.5% of cases for the oculomotor nerve and in 67% ofcases for the trochlear nerve, respectively [1]. Thesebranches that arise from the MTA run with the trochlearnerve to the superior orbital Wssure [4]. Ischemic injuryprobably accounts for the majority of permanent cranialnerve deWcits [4, 9, 33]. The Wrst branch of the gasserianganglion (ophthalmic nerve V1) is constantly supplied bythe ILT. The abducens nerve is also supplied by the ILT thatcrosses it or eventually by branches of the MTA [40].Embolization of MHT or inferolateral trunk for tumordevascularization carries a risk of ischemic injury to the cra-nial nerve [12, 30]. Using particular larger than 150 m hasbeen suggested as a strategy to protect the small vasa vaso-rum, minimizing the risk of cranial nerve ischemia [18].

When visible during normal angiography, the MTAranges in length from 5 to 35 mm. A pathological lesion isconsidered when the MTA can be followed, in the angio-gram, for a distance longer than 40 mm [29, 32, 35, 37].This long and serpiginous aspect with an anterosuperiorconcavity can be seen in cerebral AVM, gliomas with ten-torial invasion, trigeminal schwannomas and also in thenormal patient [3, 7, 11, 28].

Progressive occlusion and kinking of ICA siphonsrelated to moyamoya disease can lead to the developmentof a meningeal contribution with a bulky and tortuous MTA[24, 36]. The presence of embryonic arteries associatedwith moyamoya disease has been previously reported usu-ally with the trigeminal artery, but unusually with the MTA[14, 24].

Tentorial dural AVM are relatively rare, accounting for0.81.9% of dural intracranial AVM [2, 25]. More than

80% of patients with these AVM presented with aggressiveclinical features, such as intracranial hemorrhage and morerarely trigeminal neuralgia related to ectatic petrosal orleptomeningeal reXux veins with a remarkable varix com-pressing the root entry zone [27]. Carotid angiogramusually demonstrates the AVM fed by the MTA (Fig. 9)and by branches of the middle meningeal artery withvenous drainage through the petrosal vein, pontine and par-amesencephalic veins and into the superior petrosal sinus[25, 27, 39]. These tentorial dural AVM are actually treatedwith a combination of endovascular surgery and radiosur-gery, which provide symptom relief and durable response[2, 21, 27].

Infraclinoid intracavernous internal carotid artery aneu-rysms are a rare entity. They carry a low risk of subarachnoidhemorrhage. Hemodynamically, there are multiple potentialsites of incidental aneurysms formation in this region, such asthe superior hypophyseal artery or the MTA [10].

The tentorium cerebelli has a characteristic dual bloodsupply formed by the medial tentorial and the basal tento-rial arteries. Meningiomas of the tentorium cerebelli andpetroclival meningiomas are fed by the MHT [38] (Fig. 10).Preoperative embolization for these meningiomas canreduce surgical blood loss, shorten operating time andreduce the risk of damage to surrounding structures [5, 13].Embolization is performed with 250500 m polyvinylalcohol particles [13].

The MTA is a complex artery, which participates in theblood supply of the tentorium cerebelli. Its origin, courseand relationships are very deep and justify thorough ana-tomical dissections. Its proximal segment is surrounded bythe cavernous sinus. Equally, its distal segment is hidden inthe free margin of the tentorium cerebelli. The MTA playsan important role in the supply of the tentorium meningio-mas and in the aVerences of tentorial dural AVM. Its tiny

Fig. 9 Lateral angiogram of a left ICA showing an enlargedrectilinear MTA (arrows) in a case of dural arteriovenous Wstula of thetentorium cerebelli123

924 Surg Radiol Anat (2010) 32:919925caliber contrasts with a localization in greater hemody-namic stress under the distal dural ring leading to variousvascular diseases.

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Microsurgical anatomy of the medial tentorial artery of Bernasconi-CassinariAbstractIntroductionMaterials and methodsResultsOriginCourseEndingRelationshipsVariations

DiscussionReferences

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