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1 ( Microsurgical natomy and Surgical Procedures for the Tentorial Incisura Jun C. Takahashi, M.D. 1 and Susumu Miyamoto, M.D. 1 1 Department of Neurosurgery, Graduate School of Medicine, Kyoto University The tentorial incisura can be defined as the space surrounded by the free edge of the cerebellar tentorium. It provides the only communication between the supratentorial and infratentorial spaces, and contains many vital structures such as the components comprising the circle of Willis, cranial nerves, and deep venous systems. Surgery of the tentorial incisura requires correct knowledge of the normal anatomy, and furthermore, variations of the deep venous system should also be well recognized. Received May 23, 2012 accepted June 26, 2012 Key words tentorial incisula, microsurgical anatomy Jpn J Neurosurg Tokyo , 2012 tentorial incisura tentorial edge middle incisural space tentorial apex 3 anterior middle posterior incisural space Fig parahippocampal gyruspulvinar splenium Fig. 1 basilar artery posterior cerebral artery PC superior cerebellar artery SC 1 SC Fig. 2 quadrigeminal segment ambient segment dural canal tentorial segment 2 SC middle incisural space ( ddress reprint requests to Jun C. Takahashi, M.D., Department of Neurosurgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara cho, Sakyo ku, Kyoto shi, Kyoto , Japan

P-com a. Uncus of parahippocampal gyrus Optic tract geniculate body Cr. nterior Cr. SC Middle Cr.

1 natomy of the tentorial incisura The tentorial incisura can be divided into three spaces according to the relationship to the midbrain.

5 mm SC 1 2 middle incisural space SC Fig. 2 interpeduncular cistern SC SC Fig. 3 Superior petrosal vein Pulvinar of thalamus Sup.colliculi Inf.colliculi mesencephalic v.

2 P-com a. Uncus of parahippocampal gyrus Optic tract geniculate body Cr. nterior Cr. SC Middle Cr. SC Medial SC Posterior Cerebellum Tentorium geniculate body Pulvinar of thalamus Parahippocampal gyrus Pineal body Splenium of corpus callosum Fig. 1 natomy of the tentorial incisura The tentorial incisura can be divided into three spaces according to the relationship to the midbrain. Structures which constitute the roof of the tentorial incisura. 2 rostral trunk caudal trunk posterior incisural space SC 1 Sitting position Fig mm SC 1 2 middle incisural space SC Fig. 2 interpeduncular cistern SC SC Fig. 3 Superior petrosal vein Pulvinar of thalamus Sup.colliculi Inf.colliculi mesencephalic v. To Pineal body Medial geniculate body To basal v. PC Cr. SC Loop of SC mesencephalic sulcus Fig. 2 natomical relationship of the tentorium, trochlear nerve, and major vessels around the brain stem ambient cistern SC Fig. 4 Fig. 5 middle incisural space spinal drainage transverse sinus temporobasal vein sphenopetro- Jpn J Neurosurg VOL. 21 NO

petrous meningioma Skin incision and craniotomy Operative field after the tumor resection C Opening

T inferior surface of the tentorium, superior petrosal vein C D Ce CT RT Fig.

edge and the arachnoid membrane of the ambient cistern Opening the cistern exposes the trochlear nerve

rrow SC, arrowhead trochlear nerve, asterisk lateral surface of the midbrain, Ce cerebellum, RT

ambient cistern を開放すると滑車神経お流入せず側頭葉下面を走行する破格が中頭蓋底に癒着この時点で滑よび SC の一部が観察される Fig.

3 T T C Ⅲ Ⅳ Ⅴ Ⅷ SC Fig. 3 The trochlear nerve and the SC exposed by the right suboccipital approach for the resection of a petrous meningioma Skin incision and craniotomy Operative field after the tumor resection C Opening the ambient cistern exposes the trochlear nerve and SC running in the middle incisural space. T inferior surface of the tentorium, superior petrosal vein C D Ce CT RT Fig. 4 Intraoperative photographs of the right subtemporal approach for an ST SC anastomosis Tentorial free edge and the arachnoid membrane of the ambient cistern Opening the cistern exposes the trochlear nerve and SC. C Incision of the tentorium D Reflection of the tentorium provides an excellent view of the SC. rrow SC, arrowhead trochlear nerve, asterisk lateral surface of the midbrain, Ce cerebellum, RT rostral trunk, CT caudal trunk sal vein superficial sylvian vein が sphenoparietal sinus に膜を切開して ambient cistern を開放すると滑車神経お流入せず側頭葉下面を走行する破格が中頭蓋底に癒着この時点で滑よび SC の一部が観察される Fig. 4 していることがあり硬膜から慎重に / 離する Sinus 車神経はテント縁に隠れて見えないことも多いテント流入部よりかなり手前で硬膜内に移行している場合に縁を切開飜転すると middle incisural space における両は静脈の両側で硬膜を短冊状に切開して硬膜ごと頭蓋者の全走行が確認できる Fig. 4C D くも底から分離するテント自由縁に至り Fig 脳外誌 21 巻 9 号テント切開飜転の際には硬膜貫通部での滑車神経損 2012 年 9 月

② P Ce SS SS TS ① D C LMV T T PC SC Ⅳ mbient cistern Fig.

Ligation and cutting of the superior petrosal sinus white line. C Tentorial incision black arrowhead.

D PC on the lateral surface of the midbrain superior petrosal sinus, SS sigmoid sinus, TS transverse sinus, P petrous bone, Ce cerebellum, T tentorium, LMV lateral mesencephalic vein draining to the

からの硬膜枝 artery of Davidoff and Schechter と異なり無名であるが不用意なテント飜転 sulcus 前端まで P4 cortical segment Calcarine sulcus 前端以後の皮質表面 Pterional approach で内頚動脈後方の Liliequist s men- で SC からの引き抜け損傷を起こさないよう注意が必 brane

4 ② P Ce SS SS TS ① D C LMV T T PC SC Ⅳ mbient cistern Fig. 5 Intraoperative photographs of the right posterior petrosal approach for an ST PC anastomosis Craniotomy, petrosectomy, and the dural opening line white arrows. Ligation and cutting of the superior petrosal sinus white line. C Tentorial incision black arrowhead. The transverse sigmoid junction and the draining point of the vein of Labbé can be elevated by the retraction of the temporal lobe blue arrow indicates the direction of the elevation. D PC on the lateral surface of the midbrain superior petrosal sinus, SS sigmoid sinus, TS transverse sinus, P petrous bone, Ce cerebellum, T tentorium, LMV lateral mesencephalic vein draining to the independently, PC posterior cerebral artery, SC superior cerebellar artery, asterisk lateral surface of the midbrain 傷に注意が必要であるまた SC の rostral trunk から自由縁近くのテント下面に向かう dural branch が存在する 16 ことがある PC からの硬膜枝 artery of Davidoff and Schechter と異なり無名であるが不用意なテント飜転 sulcus 前端まで P4 cortical segment Calcarine sulcus 前端以後の皮質表面 Pterional approach で内頚動脈後方の Liliequist s men- で SC からの引き抜け損傷を起こさないよう注意が必 brane を切開して脚間槽を開放すると P1 が確認される要である脚間槽内の P1 からは後有孔質に向かう thalamoperforating arteries 脳幹への circumflex branches が起始する 2 PC Subtemporal approach により P1 および P2 に到達で 10 PC は 5 つの segment に分けられるきる PC は SC より上方に位置し遠位部ほど高位と P1 precommunicating segment 先端部から P なるため P2 の露出は容易であるが P2P を見るには側 com a. との合流部まで頭葉の強い圧排挙上を要し P2P 後半部になるとこの P2 crural segment P com a. との合流部から大脳脚後縁まで crural cistern 内 approach では露出不可能であるや P1 の unclippable aneurysm に対して母血管閉塞を行う際に PC への P2P ambient segment 大脳脚後縁から中脳後縁まで血行再建術 ST PC anastomosis などを要することがあるが12 P2 前半部は低位で捉えやすいものの大 ambient cistern 内 P3 quadrigeminal segment 中脳後縁から calcarine 脳脚を周回しながら先端部に向かって深くなってい Jpn J Neurosurg VOL. 21 NO

Straight sinus V. Of Galen Internal cerebral v. Pulvinar of thalamus asal v. mesencephalic v. CS Transverse pontine v. mesencephalic v. Pontotrigeminal v. SS pontine v. V. of great horizontal fissure Fig.

and the infratentorial venous systems in the case of Galenic obstruction. Fig.

5 Straight sinus V. Of Galen Internal cerebral v. Pulvinar of thalamus asal v. mesencephalic v. CS Transverse pontine v. mesencephalic v. Pontotrigeminal v. SS pontine v. V. of great horizontal fissure Fig. 6 natomical relationship of the basal vein, lateral mesencephalic vein and superior petrosal vein The lateral mesencephalic vein can operate as a main collateral pathway between the supratentorial and the infratentorial venous systems in the case of Galenic obstruction. Fig. 7 Veins of the cerebellar hemisphere and the brain stem which constitute the superior petrosal vein complex P2 P2P P2 peduncular perforating artery thalamogeniculate artery safcrifice SC subtemporal approach PC posterior petrosal approach Fig cosmetic mastoidectomy sigmoid sinus sinus retrolabyrinthine posterior petrosectomy Superior petrosal sinus Presigmoid dura Fig. 5 subtemporal approach ambient cistern vein of Labbe transverse sigmoid junction Labbe Fig. 5C petrosectomy P2 Fig. 5D P2 PC recipient 3 asal vein of Rosenthal Fig. 6 nterior incisural space deep sylvian vein anterior cerebral vein PC 16 mm 15 approach occipital transtentorial approach infratentorial supracerebellar approach asal vein internal cerebral vein vein of Galen tentorial sinus variation 11 4 mesencephalic vein Fig. 6 basal vein superior petrosal vein Galen Galenic system 3 4 mesencephalic vein Fig. 2 SC lateral mesencephalic sulcus 5 Superior petrosal vein Fig

1 mesencephalic vein pontotrigeminal vein 2 Vein of cerebellopontine fissure vein of great horizontal fissure 3 Transverse pontine vein 4 pontine vein vein of middle cerebellar peduncle Cadaver

6 1 mesencephalic vein pontotrigeminal vein 2 Vein of cerebellopontine fissure vein of great horizontal fissure 3 Transverse pontine vein 4 pontine vein vein of middle cerebellar peduncle Cadaver Matsushima medial group 64.7 intermediate group 8.8 lateral group 26.5 Medial group Meckel s cave anterior petrosal approach posterior petrosal approach Tanriover Fig. 8 Type 19 Type Meckel 72 Type9 nterior petrosal approach Type Type Meckel cave Type prepontine cistern 14 Koerbel 5 retrosigmoid approach major complication shunt Type V1 V2 V3 splitting Type nterior petrosal approach Type splitting Posterior petrosal approach Fig. 8 Three patterns of the C drainage and the splitting point of the in anterior and posterior petrosal approaches 1.3 mm cadaver lateral mesencephalic vein superior petrosal vein 4 6 Medial tentorial artery Fig. 9 Meningopypophyseal trunk marginal tentorial artery artery of ernasconi Cassinari 1 segment 2 Cavernous sinus Falx posterior attachment 0.53 mm 8 1.5T MR tentorial dural VF petroclival meningioma feeder Fig. 9 C Jpn J Neurosurg VOL. 21 NO

Inferior clival branch Hypophyseal branch IC MHT tentorial artery Medial tentorial artery TS C Fig.

The dilated medial tentorial artery white arrow feeding the tentorial dural VF orden typeⅢ, Cognard typeⅣ. C The dilated medial tentorial artery black arrow feeding a large petroclival meningioma.

infratentorial supracerebellar approaches to the posterior and middle incisural space a cadaveric study. J Neurosurg 97 922 928, 2002.

cta Neurochir 144 1323 1327, 2002. 3 rdeshiri, rdeshiri, Tonn JC, Winkler P Microsurgical anatomy of the lateral mesencephalic vein and its meaning for the deep venous outflow of the brain.

7 Inferior clival branch Hypophyseal branch IC MHT tentorial artery Medial tentorial artery TS C Fig. 9 The medial tentorial artery natomical relationship of the medial tentorial artery and the surrounding structures. The dilated medial tentorial artery white arrow feeding the tentorial dural VF orden typeⅢ, Cognard typeⅣ. C The dilated medial tentorial artery black arrow feeding a large petroclival meningioma. MHT meningohypophyseal trunk おわりにテント切痕部の解剖と手術について解説した脳組織の損傷回避静脈灌流障害の回避のためには正常解剖とバリエーションを熟知する必要がある本稿がテント切痕部の理解に少しでも役立てば幸いである文献 1 mmirati M, ernardo, Musumeci, ricolo Comparison of different infratentorial supracerebellar approaches to the posterior and middle incisural space a cadaveric study. J Neurosurg , mmirati M, Musumeci, ernardo, ricolo The Microsurgical natomy of the Cisternal Segment of the Trochlear Nerve, as Seen Through Different Neurosurgical Operative Windows. cta Neurochir , rdeshiri, rdeshiri, Tonn JC, Winkler P Microsurgical anatomy of the lateral mesencephalic vein and its meaning for the deep venous outflow of the brain. Neurosurg Rev , Ebner FH, Roser F, Shiozawa T, Ruetschlin S, Kirschniak, Koerbel, Tatagiba M Petrosal vein occlusion in cerebello pontine angle tumour surgery n anatomical study of alternative draining pathways. Eur J Surg Oncol 脳外誌 21 巻 9 号 , Koerbel, Gharabaghi, Safavi bbasi S, Samii, Ebner FH, Samii M, Tatagiba M Venous complications following petrosal vein sectioning in surgery of petrous apex meningiomas. Eur J Surg Oncol , Matsushima T, Rhoton L Jr., De Oliveira E, Peace D Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg , Ono M, Ono M, Rhoton L Jr., arry M Microsurgical anatomy of the region of the tentorial incisura. J Neurosurg , Peltier J, Fichten, Havet E, Foulon P, Page C, Le Gars D Microsurgical anatomy of the medial tentorial artery. Surg Radiol nat , Rhoton L Jr. Tentorial incisula. Neurosurgery 47 3 Suppl S , Rhoton L Jr. The supratentorial arteries. Neurosurgery 51 4 Suppl S53 120, Suzuki Y, Ikeda H, Shimadu M, Ikeda Y, Matsumoto K Variations of the basal vein Identification using three dimensional CT angiography. m J Neuroradiol , Takahashi JC, Murao K, Iihara K, Nonaka Y, Taki J, Nagata I, Miyamoto S Successful blind alley formation with bypass surgery for a partially thrombosed giant basilar artery tip aneurysm refractory to upper basilar artery obliteration. Case report. J Neurosurg , (橋淳宮本享舟木健史飯原弘二複雑な椎骨 2012 年 9 月

8 pp Tanriover N, be H, Rhoton L Jr., Kawashima M, Sanus GZ, kar Z Microsurgical anatomy of the superior petrosal venous complex new classifications and implications for subtemporal transtentorial and retrosigmoid suprameatal approaches. J Neurosurg , Tubbs RS, Loukas M, Louis RG, Shoja MM, skew CS, Phantana ngkool, Salter G, Oakes WJ Surgical anatomy and landmarks for the basal vein of Rosenthal. J Neurosurg , Weil G, MacLaughlin N, Denis D, ojanowski MW Tentorial branch of the superior cerebellar artery. Surg Neurol Int 2 71, ( Jpn J Neurosurg VOL. 21 NO

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Kittipong 1. Aoki R, Srivatanakul K, Hirayama A, A vein of the foramen caecum observed on angiography, Eur J Ana 21(4): 305-307, 2017 2. Hui Han & Wei Tao & Ming Zhang, The dural entrance of cerebral bridging veins