1. Cisterns 360°
7-5-2016
12.24 pm

2. Great teachers – All this is their work .
I am just the reader of their books .
Prof. Paolo castelnuovo
Prof. Aldo Stamm Prof. Mario Sanna
Prof. Magnan

3. For Other powerpoint presentatioins
of
“ Skull base 360° ”
I will update continuosly with date tag at the end as I am
getting more & more information
click
www.skullbase360.in
- you have to login to slideshare.net with Facebook
account for downloading.

4. Oculomotor cistern

5. Oculomotor cistern
Cranial nerve III enters the roof included in its own cistern
(oculomotor cistern).
Oculomotor cistern goes upto
anterior clinoid tip

6. LT lamina terminalis cistern=
Suprachiasmatic cistern

8. LT lamina terminalis cistern –
The lamina terminalis cistern is situated above the optic chiasm (Martins etal.
2011 ) . Within this cistern, A1 and A2, as well as the anterior communicating
artery and the first part of the recurrent artery of Heubner, are evident.

12. The space between a & oc is Lamina terminalis
Neuroendoscopic view of the third ventricle floor-----Infundibular recess (i), optic chiasm (oc)
and a prominent anterior commissure (a) are seen anterior to the opaque and narrow tuber cinereum (t). B
Neuroendoscopic view of the third ventricle floor in another myelomeningocele patient. A non-transparent
tuber cinereum (t) and a dilated infundibular recess (i) are seen anterior to the mamillary bodies (m). Note to
the vascular structure of the third ventricle floor. cNeuroendoscopic view showing a steep third ventricle
floor in a myelomeningocele patient. A narrow tuber cinereum (t) is visible just anterior to the mamillary
bodies (m). dNeuroendoscopic view through a very narrow prepontine cistern. Note the close proximity of
the basillary artery (ba) and clivus (cl)

13. Endoscopic third ventricle from
posteriorly -- a. Infundibular
recess b. tuber cinereum c.
mammillary bodies
left posterior communicating artery (a),
mammillary body (b), and right posterior
hypoplasic communicating artery (c) ---
measurement performed between the
posterior communicating arteries using
Geogebra software (a-b = 11.3 mm),

14. Endoscopic third
ventricle from
posteriorly --
a. Infundibular recess b.
tuber cinereum c.
mammillary bodies
From front – through
lamina terminalis

15. In the descriptive analysis of the 20 specimens, the PCoAs
distance was 9 to 18.9 mm, mean of 12.5 mm, median of 12.2
mm, standard deviation of 2.3 mm.

16. Optic chiasma – infundibulum – Mamillary
bodies

17. Chiasmatic cistern

18. The AcomA complex is usually above the optic chiasm (70 % of cases)
(Rhoton 2003 ) . The AcomA is similar to the textbook description in three-
fourths of cases. In about 10 % of cases, it can be hypoplastic or even
duplicated and triplicated (Lang 1995 ) .
• 1. Supra-chiasmatic
cistern = LT lamina
terminalis cistern
• 2. Chiasmatic cistern
• 3. Sub -chiasmatic
cistern

19. Chiasmatic cistern

20. 1. The transplanum route may also facilitate exposing the
anterior incisural space. On the center of this space the chiasm
helps separate the two major cisternal compartments. Below the
chiasm is the chiasmatic cistern, and above it is the center of the
lamina terminalis cistern.
2. The pituitary stalk and superior hypophyseal arteries are
located into the chiasmatic cistern.

21. Below the OT & A1 you will see PComA
Endoscopic view of the anterior part of the Left Suprasellar area [ = Sub-
Chiasmatic Cisttern ] . A1 first segment of the anterior cerebral artery, AChA
anterior choroidal artery, GR gyrus rectus, ICA internal carotid artery, OC optic chiasm,
ON optic nerve, OT optic tract, PCoA posterior communicating artery, PG pituitary
gland, PitS pituitary stalk, MB midbrain, U uncus

22. Chiasmatic cistern –
The chiasmatic cistern is located in front of the
optic chiasm and above the sella turcica. In the lateral border of the
chiasmatic cistern the first part of the ICAi is visible.
lt ICA SEEN ON LT SIDE.. A HOLE IN THE ARACHNOID..
THE STALK JUST BEHIND IT.. THE DIAPHRAGM SEEN IN
5/6 O CLOCK POSITION..

23. CSF rhinorrhoea case
Closed with hadad flap
lt ICA SEEN ON LT SIDE.. A HOLE IN THE ARACHNOID..
THE STALK JUST BEHIND IT.. THE DIAPHRAGM SEEN IN
5/6 O CLOCK POSITION..

24. Sub-chiasmatic cistern = Supra
sellar area = Supr-sellar cistern

27. Observe here the Pcom (here labelled as ACoP in some language ) is parallel
to 3rd nerve in infrachiasmatic cistern . Excellent photo .
Other points to note 1. 3rd nerve sandwitched between posterior cerebral
artery & superior cerebellar artery . 2. On the left side 2 superior cerebellar
arteries present from the origin itself. 3. Diameter of Pcom varies on two
sides. 4. Infra-chiasmastic cistern is nothing but suprasellar area
Lillequit’s membrane

28. Within the medial part of the carotid cistern a tremendous arterial network given by the
superior hypophyseal arteries, the infundibular arteries and perforating branches from the
internal carotid artery is visible. The superior hypophyseal arteries and infundibular arteries
(from the posterior communicating artery) form a complex network around the pituitary stalk,
named circuminfundibular plexus (Rhoton 2003 ) . This plexus gives rise to descending (for the
anterior lobe of PG) and ascending (for tuber cinereum, median eminence and inferior surface
of optic chiasm) branches (Rhoton 2003 ) .
CP circuminfundibular plexus, ICAi intracranial
portion of the internal carotid artery, OT optic
tract, PCP posterior clinoid process, PG pituitary
gland, PS pituitary stalk, SHA superior
hypophyseal artery, black arrow indicates the
direction of the view (as seen in the bigger
picture)

29. Retrosellar

32. Interpeduncular cistern [= basal
cistern ]

33. Interpeduncular cistern

34. Interpeduncular cistern
IR = infundibulum

35. Endoscope-assisted microsurgery [ 45° endoscope in a corridor
between the carotid artery and the oculomotor nerve ]-- Fig. 4.12
Intradural exposure; right approach; microsurgical (a) and endoscopic (b–d) views. AchA
anterior choroidal artery, BA basilar artery, C clivus, FL frontal lobe, ICA internal carotid artery, III
oculomotor nerve, ON optic nerve, P1 first segment of the posterior cerebral artery, P2 second
segment of the posterior cerebral artery, PC posterior clinoid, PCA posterior cerebral artery, PcoA
posterior communicating artery, SCA superior cerebellar artery, TE tentorial edge, TL temporal
lobe, Tu thalamoperforating artery; green dotted triangle area for entry of
the endoscope into the interpeduncular fossa

36. Cadaveric dissection image demonstrating the close anatomical relationship
of the posterior clinoid (PC) with both the intracranial carotid artery (ICCA)
and the posterior genu of the intracavernous carotid artery (P. CCA). AL,
anterior lobe of the pituitary gland; PL, posterior lobe of the pituitary gland;
BA, basilar artery.
green dotted triangle area for entry
of the endoscope into the interpeduncular fossa

37. Posteior clinoid can be approached in optico-carotid
triangle [ 3mm ] OR lateral carotid triangle

38. Posteior clinoid can be approached in optico-carotid triangle [
3mm ] OR lateral carotid triangle

39. Pcom is seen in optico-carotid triangle – can be injured
in cisternostomy while cutting lillequet membrane

40. Interpeduncular cistern -- Removal of the upper clivus (dorsum sella and
posterior clinoids) provides an excellent view of the interpeduncular cistern
Once the gland has been completely dissected from
the surrounding dura, the pituitary aperture or
diaphragm should be transected along with the
superior intercavernous sinus. This allows the
transposition of the gland into the suprasellar space,
between the optic nerves. This maneuver exposes the
dorsum sella and posterior clinoids that can now be
safely removed. An osteotomy between the dorsum
sella and the posterior clinoids is advised to avoid
excessive traction while removing the clinoid, which
can be risky for the third nerve and carotid artery.

41. Right supraorbital approach (30 optic).
Window between cn II and ICA: 1 left
PCoA, 2 left P2, 3 left cn III, 4 left P1, 5
left SCA, 6 BA, 7 doubled right SCA, 8
right cn III, 9 right P1, 10 mammillary
bodies, 11 tuber cinereum, 12 right
PCoA, 13 right M1.* sucker

42. Mammillary bodies
Without removing the DS ,
Subchiasmatic view downwards
After removing the DS &
midclivus

43. ENDOSCOPIC ENDONASAL PITUITARY
TRANSPOSITION FOR A TRANSDORSUM SELLAE
APPROACH TO THE INTERPEDUNCULAR CISTERN
http://www.ncbi.nlm.nih.gov/pubmed/1842496
8 - get paper at www.sci-hub.io

48. I think we can reach the prepontine area/
interpedincular cistern by retrolabyrinthine
approach [ presigmoid ] without doing
1. posterior clinoidectomy in pterional
approach
2. Pituitary transposition in anterior skull base

49. From paper http://www.ncbi.nlm.nih.gov/pubmed/18424968 - get
paper at www.sci-hub.io

50. posterior clinoidectomy by middle cranial fossa approach needs lot of training – see
in this cisternostomy video https://www.youtube.com/watch?v=vNaEFMrdgfw . I
think we can reach the prepontine area without doing posterior clinoidectomy by
retrolabyrinthine approach [ presigmoid ] which is easier than posterior
clinoidectomy to learn . we can do endoscopic retrolabyrinthine [ endoscoopic
presigmoid ] approach to reach prepontine – to understand retrolabyrinthine [ =
presigmoid ] approach click http://www.slideshare.net/muralichandnallamothu/cp-
angle-360
Retrolabyrinthine Subtemporal
Transapical Approach
Retrolabyrinthine Subtemporal
Transtentorial Approach

51. cisternostomy in head injury video –
by Dr. Iype Cherian - click
https://www.youtube.com/watch?v
=vNaEFMrdgfw
and
https://youtu.be/NLTm8-rHzAA

52. For Other powerpoint presentatioins
of
“ Skull base 360° ”
I will update continuosly with date tag at the end as I am
getting more & more information
click
www.skullbase360.in
- you have to login to slideshare.net with Facebook
account for downloading.