Tentorium Incisura

CHAPTER 5
Tentorial Incisura
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Key words: Anatomic study, Anatomy, Circle of Willis, Incisura, Midbrain, Neurovascular, Tentorium
T
he tentorial incisura provides the only communication
between the supratentorial and infratentorial spaces
(17) (Fig. 5.1). The area between the upper brainstem
and the incisural edges is divided into the anterior, middle,
and posterior incisural spaces (Fig. 5.2). The anterior incisural
space is located anterior to the brainstem and extends upward
around the optic chiasm to the subcallosal area; the middle
incisural space is located lateral to the brainstem and is inti-
mately related to the hippocampal formation in the medial
part of the temporal lobe; and the posterior incisural space is
located posterior to the midbrain and corresponds to the region
of the pineal gland and vein of Galen. The arterial relationships
in the anterior incisural space and the venous relationships in the
posterior incisural space are extremely complex, since the ante-
rior incisural space contains all of the components of the circle of
Willis and the bifurcation of the internal carotid and basilar
arteries, and the posterior incisural space contains the conver-
gence of the internal cerebral and basal veins and many of their
tributaries on the vein of Galen. The incisura is intimately related
to the depths of the cerebrumand cerebellum, the first six cranial
nerves, and the upper brainstem. Some part of the incisura is
commonly exposed during the operations for aneurysms, deep
tumors and arteriovenous malformations, trigeminal neuralgia,
and epilepsy. Much attention has been focused on the distortions
of this anatomy by herniation of the brain through the incisural
space.
ANATOMY OF THE TENTORIUM
The tentorium covers the cerebellum, supports the cere-
brum, and forms a collar around the brainstem (Figs. 5.2 and
5.3). The tentorium slopes downward from its apex, located at
the posterior edge of the incisura, to its attachment to the
temporal, occipital, and sphenoid bones. All of the tentorial
margins, except the free edges bordering the incisura, are
rigidly attached to the cranium. The anterior border is at-
tached to the petrous ridge and divides to enclose the superior
petrosal sinus. The lateral and posterior borders, which divide
to enclose the transverse sinus and the torcula, are attached to
the inner surface of the occipital and temporal bones along the
internal occipital protuberance and to the edges of the shallow
osseous groove for the transverse sinus.
The anterior end of each free edge is attached to the petrous
apex and the anterior and posterior clinoid processes (Figs.
5.15.3). The attachment to the petrous apex and the clinoid
processes forms three dural folds: the anterior and posterior
petroclinoid folds and the interclinoid fold. Between these
folds is located the oculomotor trigone, a shallow depressed
area over the posterior part of the roof of the cavernous sinus,
through which the oculomotor and trochlear nerves enter the
sinus. The posterior petroclinoid fold extends from the pe-
trous apex to the posterior clinoid process; the anterior pet-
roclinoid fold extends from the petrous apex to the anterior
clinoid process; and the interclinoid fold covers the ligament
extending from the anterior to the posterior clinoid process.
The oculomotor nerve penetrates the dura in the central part
of this triangle, the oculomotor triangle, and the trochlear
nerve enters the dura at the posterolateral edge of this trian-
gle. The petrosphenoid ligament passes between the leaves
of the posterior petroclinoid fold from the petrous apex to
the lateral border of the dorsum sellae, just below the
posterior clinoid process. The abducens nerve passes below
the petrosphenoid ligament to enter the cavernous sinus.
The dura forming the roof of the oculomotor trigones ex-
tends medially across the sella to form the diaphragma
sellae, which covers the pituitary gland and contains an
opening for the infundibulum.
Anterolateral to the diaphragma are two orifices: a bone
orifice, the optic canal (through which the optic nerve enters
the orbit), and a dural orifice through which the internal
carotid artery exits the cavernous sinus (Fig. 5.3). From the
anterior part of the free edge, the dura mater slopes steeply
downward to form the lateral wall of the cavernous sinus and
to cover the middle cranial fossa. Plaut reported that the
attachment of the anterior end of the free edge to the petrous
apex may be situated as much as 10 mm lateral and 8 mm
below the level of the clinoid processes and that the low
position of the free edge may facilitate descending tentorial
herniations (20).
The falx cerebri fuses into the dorsal surface of the tento-
rium in the midline behind the apex (Fig. 5.1). The straight
sinus, which is enclosed in the falcotentorial junction, begins
at the tentorial apex, where it receives the vein of Galen and
the inferior sagittal sinus, and terminates in the torcular.
S131 Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
TENTORIAL INCISURA
The incisura is roughly triangular and has its anterior edge or
base on the dorsum sellae and its apex dorsal to the midbrain,
just posterior to the pineal gland (Fig. 5.2). The incisura, when
viewed from above after removal of the cerebral hemispheres, is
filled by the midbrain, pons, and cerebellum, and the free edges
skirt the cerebral peduncles, either touching or being separated
from them by a variable distance (Fig. 5.2). The amount of
cerebellar cortex visible between the midbrain and the free edge
varies from none when the free edge hugs the tectum to a large
amount when the incisura extends far posteriorly. When viewed
from below after removal of the cerebellum, the incisura is filled
by the midbrain and the uncus and parahippocampal gyrus (Fig.
5.4). The amount of parahippocampal gyrus visible from below
varies from none when the free edge hugs the tectum to a large
amount when the incisura is very wide. The width of the inci-
sura varies from 26 to 35 mm (average, 29.6 mm) and the
anteroposterior diameter varies from 46 to 75 mm (average, 52.0
mm) (17).
The area between the brainstem and the free edges is di-
vided into: an anterior incisural space located in front of the
brainstem; paired middle incisural spaces situated lateral to
the brainstem; and a posterior incisural space located be-
hind the brainstem (Figs. 5.15.4). The description of each
incisural space is divided into sections on neural, cisternal,
ventricular, cranial nerve, arterial, and venous relationships.
ANTERIOR INCISURAL SPACE
Neural relationships
The anterior incisural space is located anterior to the mid-
brain and pons. It extends inferiorly between the brainstem
and clivus and obliquely forward and upward around the
optic chiasm to the subcallosal area. It opens laterally into
the medial part of the Sylvian fissure, and posteriorly be-
tween the uncus and the brainstem into the middle incisural
space (Figs. 5.3 and 5.4).
The part of the anterior incisural space located below the
optic chiasm has posterolateral and posterior walls. The pos-
terolateral wall is formed by the bulbous prominence of the
anterior third of the uncus, which hangs over the anterior part
FIGURE 5.1. Tentorial incisura. A, the left cerebral
hemisphere has been removed. The tentorial incisura is
located between the tentorial edges and is the only site of
communication behind the supra and infratentorial spaces.
The tentorial apex is located at the junction of the vein of
Galen and the straight sinus. The tentorial edges slope
downward from the apex. The free edge passes along the side
of the brainstem and anteriorly blends into the dura covering
the petrous apex and the anterior and posterior clinoid
processes. The incisura, in relation to the midbrain, is divided
into anterior, middle, and posterior spaces. The anterior
incisural space extends above the optic chiasm to the lamina
terminalis and below the chiasm and third ventricular floor to
the interpeduncular fossa. The middle incisural space is
located between the midbrain and tentorial edge, opens
upward into the ambient and crural cisterns, and extends
inferiorly into the anterior part of the cerebellomesencephalic
fissure. The posterior incisural space, located between the
posterior midbrain and the tentorial apex, encompasses the
quadrigeminal cistern, which extends into the
cerebellomesencephalic fissure and along the outer surface of
the upper part of the fourth ventricular roof. The anterior
incisural space, located below the frontal horn, contains the
basilar bifurcation. The PCA and SCA arise in the anterior and
pass around the brainstem to reach the middle and posterior
incisural spaces. The branches of the PCA and SCA pass
through the lateral part of the posterior incisural space, and
the large venous structures converging on the vein of Galen
course in the medial part of the posterior incisural space. B, part of the left central hemisphere and all of the left thalamus
have been removed, while preserving the fornix and choroid plexus. The frontal horn and anterior part of the third ventricle
is located above the anterior incisural space. The middle incisural space is located medial to the temporal horn, between the
temporal lobe and midbrain. The posterior incisural space is located between the tentorial apex and posterior midbrain
surface. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Chor., choroid; CN, cranial
nerve; Front., frontal; Gyr., gyrus; Incis., incisural; Mid., middle; Parahippo., parahippocampal; Ped., peduncle; Plex., plexus;
Post., posterior; Temp., temporal; Tent., tentorial; V., vein; Vent., ventricle.
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Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
of the free edge above the oculomotor trigone (Fig. 5.2). The
posterior wall is formed by the pons and cerebral peduncles. The
infundibulumof the pituitary gland crosses the anterior incisural
space to reach the opening in the diaphragma sellae. The part of
the anterior incisural space situated above the optic chiasm is
limited superiorly by the rostrum of the corpus callosum, pos-
teriorly by the lamina terminalis, and laterally by the part of the
medial surfaces of the frontal lobes located below the rostrum.
The anterior incisural space opens laterally into the part of
the Sylvian fissure situated below the anterior perforated
substance (Fig. 5.4). The anterior limb of the internal capsule,
the head of the caudate nucleus, and the anterior part of the
FIGURE 5.2. Tentorial incisura,
superior views. A, the left
cerebrum, above the level of the
cerebral peduncle, has been
removed to expose the anterior,
middle, and posterior incisural
spaces. The thalamus, which forms
the floor of the body of the lateral
ventricle, sits directly above the
central part of the tentorial
incisura. The right lateral ventricle
and the lower wall of the sylvian
fissure have been preserved. The
left half of the tentorium, except
the edge, has been removed to
expose the tentorial cerebellar
surface. The frontal horn is
located above the anterior
incisural space. Structures located
in the anterior incisural space
below the frontal horn include the
optic nerves and chiasm, internal
carotid arteries, and the upper
part of the basilar artery and its
branches. The middle incisural
space, located between the
midbrain and tentorial edge,
opens upward into the crural and
ambient cisterns and downward
into the anterior part of the
cerebellomesencephalic fissure.
The posterior incisural space,
located between the midbrain and
the tentorial apex, includes the
area of the quadrigeminal cistern
and opens into the central part of
the cerebellomesencephalic
fissure. The atrium of the lateral
ventricle is situated lateral to the posterior incisural space. B, view of the tentorial incisura after removing the cerebrum. The
tentorial edges sweep along the lateral margin of the cerebral peduncle. The oculomotor nerve passes medial to the anterior
edge of the tentorium and enters the cavernous sinus by passing through a triangular patch of dura called the oculomotor
trigone. C, superior view of the tentorial incisura before removing the left temporal lobe. The crural cistern is located
between the cerebral peduncle and uncus. The ambient cistern opens upward between the midbrain and the medial surface
of the temporal lobe formed by the parahippocampal and dentate gyri. The thalamus and the genu of the internal capsule are
located above the central part of the tentorial incisura. D, enlarged view after removing the temporal lobe. The internal
capsule and the lentiform nucleus are located above the middle incisural space. The genu of the internal capsule abuts on the
lateral ventricular wall at the level of the foramen of Monro. A., artery; Ant., anterior; Cap., capsule; Car., carotid; Caud.,
caudate; Cist., cistern; CN, cranial nerve; For., foramen; Front., frontal; Incis., incisural; Int., internal; Lent., lentiform; Mid.,
middle; Nucl., nucleus; P.C.A., posterior cerebral artery; Ped., peduncle; Post., posterior; Quad., quadrigeminal; Tent.,
tentorial; Trig., trigone.
Tentorial Incisura S133
FIGURE 5.3. Stepwise dissection of the neural structures above the tentorial incisura. A, the coronal section of the right
hemisphere crosses vertically through the thalamus and lateral geniculate body and the transverse section crosses the cere-
bral peduncle. The right temporal horn has been opened to expose the hippocampus and amygdaloid nucleus. The floor of
the third ventricle is exposed in the midline. The coronal section of the left hemisphere crosses anterior to the thalamus near
the foramen of Monro and genu of the internal capsule. The anterior incisural space extends from the interpeduncular fossa,
around the chiasm, and into the suprachiasmatic area. B, the right thalamus has been removed while preserving the fornix,
which wraps around the thalamus to form the outer edge of the choroidal fissure situated between the thalamus and fornix.
The middle incisural space extends upward into the ambient and crural cisterns. The crural cistern is located between the
uncus and the cerebral peduncle. The ambient cistern in located between the parahippocampal and dentate gyri and the fim-
bria of the fornix laterally and the midbrain medially. The posterior part of the tentorial edge is exposed. The quadrigeminal
cistern is located in the posterior incisural space between the tentorial apex and the pineal. The atrium is located lateral to
the quadrigeminal cistern and posterior incisural space. C, enlarged view. The coronal section through the left hemisphere
has been extended backward to the level of the thalamus and posterior limb of the internal capsule. The left temporal horn is
S134 Rhoton
lentiform nucleus are located above the anterior perforated
substance (Fig. 5.2).
Cisternal relationships
The interpeduncular cistern, which sits in the posterior part
of the anterior incisural space between the cerebral peduncles
and the dorsum sellae, communicates laterally with the Syl-
vian cistern below the anterior perforated substance and an-
teriorly with the chiasmatic cistern located below the optic chi-
asm. The interpeduncular and chiasmatic cisterns are separated
by Liliequists membrane, an arachnoidal sheet extending from
the dorsum sellae to the anterior edge of the mammillary bodies
(14, 35, 36). The chiasmatic cistern communicates around the
optic chiasm with the cisterna laminae terminalis, which lies
anterior to the lamina terminalis.
Ventricular relationships
The anterior part of the third ventricle projects into the
anterior incisural space in the medial plane, dividing it into
supra and infra chiasmatic portions. The frontal horns of the
lateral ventricles are located above the anterior incisural space
(Figs. 5.15.3). The tip of the temporal horn is separated from
the uncal surface, forming the posterolateral wall of the ante-
rior incisural space, by the amygdaloid nucleus.
Cranial nerves
The optic and oculomotor nerves and the posterior part of
the olfactory tracts pass through the anterior incisural space.
Each olfactory tract runs posteriorly, and splits just above the
anterior clinoid process to form the medial and the lateral
olfactory striae, which course along the anterior margin of the
anterior perforated substance (Fig. 5.4).
The optic nerves and chiasm and the anterior part of the
optic tracts cross the anterior incisural space (Fig. 5.3). The
optic nerves emerge from the optic canal medial to the attach-
ment of the free edge to the anterior clinoid processes, and are
directed posteriorly, superiorly, and medially toward the op-
tic chiasm. The optic chiasm is usually located above the
diaphragma sellae, but it may be prefixed and lie over the
tuberculum sellae or postfixed and lie over the dorsum sellae.
From the chiasm, the optic tract continues in a posterolateral
direction around the cerebral peduncle to enter the middle
incisural space (Fig. 5.4). The oculomotor nerve emerges from
the midbrain on the medial surface of the cerebral peduncle.
It crosses the anterior incisural space between the posterior
cerebral artery (PCA) and the superior cerebellar artery (SCA)
and passes inferomedial to the uncus to enter the roof of the
cavernous sinus through the oculomotor trigone. The abdu-
cens nerve ascends from deep within the infratentorial part of
the anterior incisural space. It emerges from the pontomedul-
lary sulcus, ascends in the prepontine cistern to pierce the
dura covering the clivus, and passes below the petrosphenoid
ligament to enter the cavernous sinus.
Arterial relationships
The arterial relationships of the anterior incisural space are
complex because it contains all of the components of the circle
of Willis (4, 5, 7, 18, 19, 27, 37). The internal carotid artery
enters the anterior incisural space by passing along the medial
surface of the anterior clinoid process and bifurcates below
the anterior perforated substance (Figs. 5.5 and 5.6). The pos-
terior communicating artery arises from the posteromedial
aspect of the carotid artery and courses superomedial to the
oculomotor nerve to join the PCA in the anterior incisural
space. The anterior choroidal artery originates from the pos-
terior surface of the carotid artery 0.1 to 3.0 mm distal to the
origin of the posterior communicating artery and courses below
the optic tract before passing between the uncus and the cerebral
peduncle to enter the middle incisural space (3, 24).
The proximal part of the anterior cerebral artery also
courses in the anterior incisural space (Fig. 5.6). It arises below
the anterior perforated substance and courses anteromedially
above the optic chiasm, where it is joined to its mate from the
opposite side by the anterior communicating artery. It then
courses upward in front of the lamina terminalis. The middle
cerebral artery courses laterally from its origin below the
anterior perforated substance. The major bifurcation of the
middle cerebral artery is usually located in the lateral part of
the anterior incisural space.
The basilar artery ascends and gives rise to the PCA and
SCA in the posterior part of the anterior incisural space be-
exposed below the basal ganglia. The optic nerves, chiasm, and tracts, and the oculomotor nerves cross the anterior incisural
space. The middle incisural space extends into the ambient and crural cisterns, and the posterior incisural space, located in
front of the tentorial apex, contains the quadrigeminal cistern. D, the upper parts of the anterior and middle incisural spaces
have been exposed by removing the thalami on both sides. The tentorial edges extend forward from the apex, located at the
posterior margin of the pineal region, along the side of the midbrain to attach to the petrous ridge and clinoid processes. E,
the temporal lobe has been sectioned in a coronal plane and the third ventricular floor has been removed. The lateral wall of
the ambient cistern is formed by the parahippocampal and dentate gyri and the fimbria of the fornix. F, enlarged view. The
rounded medial edge of the parahippocampal gyrus, the site of the subiculum, which blends into the hippocampus, joins the
dentate gyri and fimbria to form the lateral wall of the ambient cistern. The fimbria arises on the hippocampal surface. A.,
artery; Amyg., amygdaloid; Ant., anterior; Cap., capsule; Car., carotid; Chor., choroid; Cist., cistern; CN, cranial nerve; Coll.,
colliculus; Dent., dentate; Front., frontal; Gen., geniculate; Gyr., gyrus; Incis., incisural; Int., internal; Lat., lateral; Lent., lenti-
form; Nucl., nucleus; Parahippo., parahippocampal; Ped., peduncle; Plex., plexus; Quad., quadrigeminal; Sulc., sulcus; Temp.,
temporal; Tent., tentorial; Vent., ventricle.
tween the posterior perforated substance and the clivus (Fig.
5.7). The position of the basilar tip and bifurcation varies from
as far caudal as 1.3 mm below the pontomesencephalic sulcus
to as far rostral as the mammillary bodies (17). The PCA
courses laterally around the cerebral peduncle, above the
oculomotor nerve. It exits the anterior and enters the middle
incisural space by coursing between the uncus and the cere-
bral peduncle. The SCA originates in the anterior incisural
space below the PCA and courses laterally below the oculo-
motor nerve (Fig. 5.7). The origin is usually just rostral to the
level of the free edge. It dips below the tentorium to reach the
superior surface of the cerebellum at the junction of the ante-
FIGURE 5.4. Neural relationships
above the tentorial incisura.
Stepwise dissection viewed from
below. A, the anterior incisural
space extends forward from the
interpeduncular fossa below the
floor of the third ventricle and
around the optic chiasm to the
lamina terminalis. The middle
incisural space extends upward
into the crural cistern located
between the uncus and cerebral
peduncle and the ambient cisterns
located between the lateral
midbrain and the temporal lobe.
The posterior incisural space is
located behind the midbrain and
includes the quadrigeminal cistern
and pineal region. The anterior
part of the tentorial edge has
grooved the uncus. B, the medial
edge of the parahippocampal
gyrus has been removed to expose
the roof of the ambient cistern
formed by the lower surface of
the thalamus and the geniculate
bodies. The optic tract extends
posteriorly in the roof of the
crural cistern and terminates in
the lateral geniculate body
located in the anterior part of the
roof of the ambient cisterns. The
dentate gyrus and the fimbria of
the fornix are located in the
lateral margin of the ambient
cistern above the
parahippocampal gyrus. C, the
part of the parahippocampal gyrus
below the temporal horn has been
removed while preserving the
fimbria of the fornix. The choroid
plexus in the temporal horn is
attached along the choroidal
fissure located between the
fimbria and the thalamus. D, all but the upper part of the left temporal lobe and fimbria has been removed. The optic tract
extends posteriorly through the crural cistern to the anterior part of the ambient cistern where it terminates in the lateral
geniculate body. The posterior incisural space between the midbrain and the tentorial apex borders the atrium laterally.
Amyg., amygdaloid; Ant., anterior; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Dent., dentate; Fiss., fissure; Gen.,
geniculate; Gyr., gyrus; Interped., interpeduncular; Lat., lateral; Med., medial; Nucl., nucleus; Olf., olfactory; Parahippo.,
parahippocampal; Ped., peduncle; Perf., perforated; Pit., pituitary; Plex., plexus; Quad., quadrigeminal; Subst., substance; Temp.,
temporal; Tent., tentorial; Tr., trunk.
S136 Rhoton
rior and middle incisural spaces. The structures in the walls of
the anterior incisural space receive perforating branches from
all of the above arteries.
Venous relationships
The main venous trunk related to the anterior incisural
space is the basal vein (Figs. 5.5 and 5.6) (16). It courses
through the anterior, middle, and posterior incisural spaces to
empty into the vein of Galen. It originates below the anterior
perforated substance, courses posterolaterally around the ce-
rebral peduncle, below the optic tract and medial to the un-
cus, to enter the middle incisural space.
MIDDLE INCISURAL SPACE
The middle incisural space is located lateral to the brain-
stem (Figs. 5.3 and 5.4). This narrow space extends upward
between the temporal lobe and the midbrain and down-
ward between the cerebellum and the upper brainstem. It has
medial and lateral walls and a roof. The medial wall, formed
by the lateral surface of the midbrain and upper pons, is divided
by the pontomesencephalic sulcus, which lies at the level of the
free edge. The surface of the midbrain facing the middle inci-
sural space is divided into a larger anterior part formed by the
FIGURE 5.5. Tentorial incisura. A,
view from below of the cisterns
bordering the tentorial incisura.
The middle incisural space opens
upward into the crural cistern
located between the uncus and
peduncle and the ambient cistern
located between the
parahippocampal gyrus and the
lateral surface of the brainstem.
The PCAs course through the
crural and ambient cisterns to
reach the posterior incisural
space, the site of the
quadrigeminal cistern. The basal
vein accompanies the PCA in the
upper part of the crural and
ambient cisterns and empties into
the vein of Galen in the
quadrigeminal cistern. The medial
posterior choroidal arteries course
around the brainstem on the
medial side of the PCAs with the
long circumflex perforating
branches. B, the medial part of
the right temporal lobe has been
removed to expose the temporal
horn. The fimbria of the fornix,
which arises on the upper surface
of the hippocampus and forms the
lower margin of the choroidal
fissure, has been preserved. The
thalamus, geniculate bodies, and
optic tract are in the roof of the
crural and ambient cisterns. C, the right PCA has been removed. The basal vein passes backward above the PCA and empties
into the vein of Galen with the internal cerebral and internal occipital veins. The lower surface of the thalamus, the
geniculate bodies, and the optic tract form the roof of the crural and ambient cisterns. The anterior choroidal artery passes
posteriorly above the uncus and through the choroidal fissure to supply the choroid plexus in the temporal horn. D, both
PCAs have been removed to expose the roof of the middle incisural space on both sides and the basal veins, which drain the
neural structures in the region. A., artery; Ant., anterior; Car., carotid; Cer., cerebral; Chor., choroid, choroidal; Cist., cistern;
CN, cranial nerve; Fiss., fissure; Gen., geniculate; Gyr., gyrus; Incis., incisural; Int., internal; Lat., lateral; Med., medial; Mid.,
middle; Occip., occipital; Parahippo., parahippocampal; P.C.A., posterior cerebral artery; Plex., plexus; Post., posterior;
Quad., quadrigeminal; Temp., temporal; V., vein.
cerebral peduncle and a smaller posterior part formed by the
tegmental surface. The optic tract forms a smooth white band at
the upper edge of the cerebral peduncle that stands in sharp
contrast to the vertically striated surface of the peduncle. The
peduncular and tegmental surfaces are separated by the lateral
mesencephalic sulcus, a vertical groove that extends from the
pulvinar above to the pontomesencephalic sulcus below.
The roof of the middle incisural space has a narrow anterior
part formed by the posterior part of the optic tract that is
flattened between the cerebral peduncle and the uncus, and a
wider posterior part formed by the inferior surface of the
thalamus (Fig. 5.4). The lateral geniculate body protrudes
from the lower surface of the thalamus just behind the uncus.
The medial geniculate body bulges into the roof posterome-
dial to the lateral geniculate body just behind the lateral
mesencephalic sulcus.
The lateral wall of the supratentorial part of the middle
incisural space is composed of the hippocampal formation on
the medial surface of the temporal lobe (Figs. 5.3 and 5.4). The
uncus and parahippocampal gyri, the most inferior structures
FIGURE 5.6. Superior views of
the anterior, middle, and posterior
incisural spaces. A and B are from
one specimen and C is from
another. A, the basal cisterns in
the region of the tentorial incisura
have been exposed by removing
the thalamus and all of the left
cerebral hemisphere except the
occipital and temporal lobes. The
roof of the temporal horn has
been removed. The structures
related to the anterior incisural
space, located between the
tuberculum sellae anteriorly, the
midbrain posteriorly, and the
anterior tentorial edge laterally,
includes the optic nerve and
chiasm, and the internal carotid,
basilar, superior cerebellar, and
PCAs. The anterior incisural space
opens posteriorly into the middle
incisural space, which extends
into the crural and ambient
cisterns. The crural cistern is located between the cerebral peduncle and the
uncus, and the ambient cistern is located between the lateral midbrain and
the medial surface of the temporal lobe. The ambient cistern opens posteriorly
into the posterior incisural space, which contains the quadrigeminal cistern.
The basal vein and the PCA and SCA pass around the midbrain in the middle
incisural space to reach the posterior incisural space and quadrigeminal
cistern. B, enlarged view. The preserved tentorial edge is exposed between the
basal vein and trochlear nerve. C, superior view of the middle and posterior
incisural space in another specimen. The basal vein courses through the crural
and ambient cisterns. The upper lip of the calcarine sulcus has been removed
but the lower lip of the sulcus has been preserved. The calcarine branch of
the PCA loops laterally into the calcarine sulcus, which extends so deeply
into the medial part of the hemisphere that it forms a prominence, the calcar
avis, in the lower part of the medial wall of the atrium. A., artery; A.C.A.,
anterior cerebral artery; Ant., anterior; Car., carotid; Calc., calcarine; Cer.,
cerebral; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Comm.,
communicating; Gyr., gyrus; Incis., incisural; Int., internal; Interped.,
interpeduncular; M.C.A., middle cerebral artery; Mid., middle; Parahippo.,
parahippocampal; P.C.A., posterior cerebral artery; Plex., plexus; Post.,
posterior; Quad., quadrigeminal; Sulc., sulcus; Temp., temporal; Tent.,
tentorial; V., vein.
S138 Rhoton
in this part of the lateral wall, form a curved border around
the middle incisural space. The uncus bulges medially at the
anterior end of the parahippocampal gyrus. The amygdaloid
nucleus is situated just lateral to the medial surface of the
uncus and just anterior to the tip of the temporal horn.
The uncus commonly prolapses into the incisura anteriorly
and has a groove along its undersurface marking the free edge
(Fig. 5.4). This groove usually disappears at the lateral margin
of the peduncle, because the free edge often hugs the pedun-
cle at this site, but it may reappear posterior to the peduncle
on the lower surface of the parahippocampal gyrus as the
space between the brainstem and the free edge increases. In
our specimens, these grooves were commonly present on the
uncus and adjacent part of the parahippocampal gyrus without
being observed on the posterior part of the parahippocampal
gyrus, but they were only rarely present posteriorly, and not
anteriorly (17). The distance from the most medial point of the
uncus to this groove varied from 2 to 8.6 mm (average, 4.4 mm).
Howell reported that these grooves may measure up to 15 mm
in length and lie as far as 10 mmfromthe medial tip of the uncus
(10). Klintworth (12, 13) noted unilateral uncal grooving in 88.4%
of brains and bilateral grooving in 80%.
Posterior to the uncus, the surface of the temporal lobe
facing the middle incisural space is formed by three longitu-
FIGURE 5.7. AD. Anterior and middle incisural space. A, the right temporal lobe has been elevated. The middle incisural
space, located between the lateral surface of the midbrain and the tentorial edge, opens upward into the ambient cistern
where the PCA and basal vein course. The internal carotid artery is exposed in front of the midbrain in the anterior incisural space.
B, enlarged view of the junction of the anterior and middle incisural space. The internal carotid artery, optic nerves, and basilar
bifurcation are located in the anterior incisural space. The oculomotor nerve passes forward between the PCA and SCA.
C, the inferior temporal and fusiform gyri have been removed to expose the lateral edge of the parahippocampal gyrus
above the middle incisural space. The opening into the temporal horn exposes the choroid plexus attached along the
choroidal fissure. The veins draining the roof of the temporal horn empty into the basal vein. D, the choroidal fissure
has been opened by detaching the choroid plexus from the fimbria of the fornix. Opening the fissure exposes the upper
part of the ambient cistern and the branches of the PCA and basal vein. A., artery; Ant., anterior; Bas., basilar; Br.,
branch; Car., carotid; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Comm., communicating; Coll., collicu-
lus; Fiss., fissure; Gen., geniculate; Gyr., gyrus; Inf., inferior; Lat., lateral; Med., medial; Mes., mesencephalic; Para-
hippo., parahippocampal; P.C.A., posterior cerebral artery; Ped., peduncle; Plex., plexus; Post., posterior; S.C.A., supe-
rior cerebellar artery; Sup., superior; Temp., temporal; Tent., tentorial; V., vein; Vent., ventricular.
dinal strips of neural tissue, one located above the other,
which are interlocked with the hippocampal formation to
make an important part of the limbic system (Figs. 5.3 and
5.4). The most inferior strip is formed by the rounded medial
edge of the parahippocampal gyrus; the middle strip is
formed by the dentate gyrus, a serrated or beaded strip of
gray matter located on the medial surface of the hippocampal
formation; and the superior strip is formed by the fimbria
of the fornix, a white band formed by the fibers emanating
from the hippocampal formation that are directed posteriorly
into the crus of the fornix.
The middle incisural space extends below the tentorium to
communicate with the anterior part of the cerebellomesence-
phalic fissure, located between the anterosuperior part of the
cerebellum and the lateral surface of the tegmentum.
The supratentorial part of the middle incisural space con-
tains the crural and ambient cisterns (Figs. 5.25.6). The crural
cistern, located between the cerebral peduncle and the uncus,
is a posterolateral extension of the interpeduncular cistern. The
crural cistern opens posteriorly into the ambient cistern, demar-
cated medially by the midbrain, above by the pulvinar, and
laterally by the parahippocampal and dentate gyri and fim-
bria of the fornix. The ambient cistern is continuous pos-
FIGURE 5.7. EH. E, anterior and middle incisural space, enlarged view. The opening through the choroidal fissure exposes
the basal vein and branches of the PCA in the upper part of the ambient cistern. The PCA gives off numerous branches to the
choroid plexus, including a large lateral posterior choroidal artery. F, the hippocampus and the medial part of the temporal
lobe, including the parahippocampal gyrus, have been removed to expose the upper part of the middle incisural space. The
PCA and basal vein course through the middle incisural space on the medial side of the parahippocampal gyrus, which has
been removed. The choroid plexus remains attached along the choroidal fissure located between the fimbria and the lower
surface of the thalamus. The inferior ventricular veins drain the roof of the temporal horn and empty into the basal vein. G,
the branches of the PCA have been removed to expose the basal vein, which originates below the anterior perforated sub-
stance and courses posteriorly through the middle incisural space to gain access to the posterior incisural space and the
quadrigeminal cistern. The pulvinar and lower surface of the thalamus, including the geniculate bodies, are in the upper mar-
gin of the exposure. H, the basal vein has been removed. This exposes the lateral aspect of the cerebral peduncle and the teg-
mental part of the midbrain, which are separated by the lateral mesencephalic sulcus. The medial and lateral geniculate bod-
ies protrude downward from the lower surface of the thalamus.
S140 Rhoton
teriorly with the quadrigeminal cistern, the major cistern in
the posterior incisural space. The ambient cistern extends
below the free edge into the part of the cerebellomesence-
phalic fissure located above the origin of the trigeminal nerve.
The temporal horn extends into the medial part of the
temporal lobe lateral to the middle incisural space and ends
approximately 3 cm from the temporal pole (Figs. 5.25.7). The
choroidal fissure, located between the fimbria of the fornix
and the lower surface of the thalamus, is the site of attach-
ment of the choroid plexus in the temporal horn. The paired
bodies of the lateral ventricles are located directly above the
central part of the incisura. They sit on and are separated from
the central part of the incisura by the thalamus.
Cranial nerves
The trochlear and trigeminal nerves are related to the middle
incisural space (Fig. 5.8). The trochlear nerve has the longest
course within the incisura of any nerve and is the cranial nerve
most intimately related to the free edge. The trochlear nerve arises
below the inferior colliculus in the posterior incisural space
and passes forward through the middle incisural space be-
tween the PCA and SCA. Its initial course around the mid-
brain is medial to the free edge in the space between the
tectum and cerebellum. It reaches the lower margin of the free
FIGURE 5.8. Anterior and middle subtemporal exposure of the anterior and adjacent part of the middle incisural space. A,
the craniotomy flap and dural opening exposes the temporal lobe and the floor of the middle cranial fossa. The insert shows
the site of the scalp incision. B, the temporal lobe has been elevated to expose the PCA and SCA in the anterior and middle
incisural space. The PCA passes above and the SCA below the oculomotor nerve. The SCA branches course with the trochlear
nerve around the side of the brainstem. C, the PCA has been depressed to expose the basilar artery. The anterior choroidal
artery arises in the anterior incisural space and passes between the cerebral peduncle and uncus to enter the crural cistern in
the middle incisural space. D, the tentorium has been divided behind the petrous ridge to expose the SCA and the trigeminal
and trochlear nerves in the region of the middle incisural space. The SCA sends branches above the trigeminal nerve and into
the anterior part of the cerebellomesencephalic fissure. The medial posterior choroidal artery also passes around the lateral
side of the brainstem. A., artery; Ant., anterior; Bas., basilar; Br., branch; Car., carotid; Chor., choroidal, CN, cranial nerve;
Comm., communicating; Fiss., fissure; M.C.A., middle cerebral artery; Med., medial; P.C.A., posterior cerebral artery; Ped.,
peduncle; Post., posterior; S.C.A., superior cerebellar artery; Temp., temporal; Tent., tentorial.
edge at the posterior edge of the cerebral peduncle. It pierces
the free edge in the posterior part of the oculomotor trigone
and runs for a short distance in the anterior petroclinoid fold
before entering the lateral wall of the cavernous sinus.
The trigeminal nerve courses in the infratentorial part of the
middle incisural compartment. It arises on the anterolateral
aspect of the mid pons and passes above the petrous apex to
enter Meckels cave (the arachnoidal and dural cavern) where
it separates into the three sensory divisions (6). The medial
edge of the posterior trigeminal root is observed just medial to
the tentorial edge if one looks fromstraight superior through the
incisura with the cerebrum removed, but it is hidden below
the free edge in the lateral view provided by the subtemporal
operative exposure.
The major arteries in the middle incisural space, the ante-
rior choroidal, PCA, and SCA, arise in the anterior incisural
space and reach the middle incisural space by coursing
around the brainstem parallel to the free edge (Figs. 5.55.8).
The anterior choroidal artery enters the superior part of the
middle incisural space below the optic tract and passes
through the choroidal fissure near the inferior choroidal point
to supply the choroid plexus in the temporal horn.
The PCA enters the middle incisural space between the
cerebral peduncle and uncus and passes straight posteriorly
between the tegmentum and subiculum (Figs. 5.6 and 5.8). It
gives off several cortical branches, which cross the free edge to
reach the inferior surface of the temporal and occipital lobes,
and the lateral posterior choroidal and thalamogeniculate ar-
teries, which course medial to the free edge. The lateral pos-
terior choroidal arteries, arising in the middle incisural space,
course superolaterally through the choroidal fissure and
around the pulvinar to reach the choroid plexus in the tem-
poral horn and atrium (Fig. 5.7). The medial posterior choroi-
dal artery arises from the proximal part of the PCA in the
anterior incisural space and courses parallel and medial to
the PCA through the middle incisural space to reach the
posterior incisural space (Fig. 5.5). The thalamogeniculate
branches arise below the pulvinar and pass upward through
the geniculate bodies to reach the thalamus and internal
capsule.
The SCA usually passes below the level of the free edge and
bifurcates into rostral and caudal trunks as it passes around
the lateral margin of the cerebral peduncle to enter the middle
incisural spaces (Figs. 5.7 and 5.8). It passes above the trigem-
inal nerve and enters the cerebellomesencephalic fissure in
the anterior part of the middle incisural space. The walls
of the supratentorial part of the middle incisural space are
supplied by the perforating branches of the anterior choroidal
and PCA, and the walls in the infratentorial part are supplied
by the SCA.
The venous relationships in the middle incisural space are
relatively simple (Figs. 5.55.7). The basal vein courses along
the upper part of the cerebral peduncle and below the pulv-
inar to reach the posterior incisural space. It may infrequently
terminate in a tentorial sinus in the free edge at this level.
POSTERIOR INCISURAL SPACE
The posterior incisural space lies posterior to the midbrain
and corresponds to the pineal region (Figs. 5.15.4) (33). It has
a roof, floor, and anterior and lateral walls, and extends
backward to the level of the tentorial apex. The quadrigeminal
plate is located at the center of the anterior wall. The anterior
wall rostral to the colliculi is formed by the pineal body. The
habenular commissure forms the upper half and the posterior
commissure forms the lower half of the attachment of the pineal
body to the posterior part of the third ventricle. The part of the
anterior wall below the colliculi is formed in the midline by the
lingula of the vermis and laterally by the superior cerebellar
peduncles as they ascend beside the lingula.
The roof of the posterior incisural space is formed by the
lower surface of the splenium, the terminal part of the crura of
the fornices, and the hippocampal commissure (Figs. 5.1 and
5.4). Each crus arises as a continuation of the fimbria, passes
around the posterior margin of the pulvinar, and blends into
the lower margin of the splenium. The hippocampal commis-
sure is an oblique band of fibers that courses below the
splenium between the medial margins of the crura. The floor
of the posterior incisural space is formed by the anterosuperior
part of the cerebellum and consists of the culmen of the vermis
in the midline and the quadrangular lobules of the hemispheres
laterally. The posterior incisural space extends inferiorly into the
cerebellomesencephalic fissure.
Each lateral wall is formed by the pulvinar, crus of the
fornix, and the medial surface of the cerebral hemisphere.
The anterior part of the lateral wall is formed by the part
of the pulvinar located just lateral to the pineal body. The
lateral wall, posterior to the pulvinar, is formed by the seg-
ment of the crus of the fornix that wraps around the posterior
margin of the pulvinar (Fig. 5.1). The posterior part of the
lateral walls is formed by the cortical areas located below
the splenium on the medial surface of the hemisphere. These
areas include the posterior part of the parahippocampal and
dentate gyri. The posterior part of the parahippocampal gyrus
usually extends medially above the posterior part of the free
edge and may have shallow grooves from the free edge on its
lower surface.
The quadrigeminal cistern, situated posterior to the quad-
rigeminal plate, is the major cistern in the posterior incisural
space (Figs. 5.15.4). The quadrigeminal cistern communicates
above with the posterior pericallosal cistern; inferiorly into
the cerebellomesencephalic fissure; inferolaterally into the
posterior part of the ambient cistern located between the
midbrain and the parahippocampal gyrus; and laterally into
the retrothalamic areas medial to where the crus of the fornix
wraps the posterior part of the pulvinar. The quadrigeminal
cistern may communicate with the velum interpositum, a
S142 Rhoton
space that extends forward into the roof of the third ventricle
between the splenium above and the pineal body below.
The posterior portion of the third ventricle and the cerebral
aqueduct are anterior and the atria and occipital horns of the
lateral ventricles are lateral to the posterior incisural space
(Figs. 5.25.4). The aqueduct passes ventral to the anterior
wall of the posterior incisural space. The atrium is separated
from the posterior incisural space by the crus of the fornix as
it passes posterior to the pulvinar and by the cortical gyri
located in the lateral wall of the posterior incisural space.
The trunks and branches of the PCA and SCA enter the
posterior incisural space from anteriorly (Figs. 5.5 and 5.6).
The PCA courses through the lateral part of the posterior
incisural space and bifurcates into the calcarine and parieto-
occipital arteries near where it crosses above the free edge.
The medial posterior choroidal arteries enter the posterior
incisural space from anteriorly, turn forward beside the pineal
body, and enter the velum interpositum to supply the choroid
plexus in the roof of the third ventricle and the body of the
lateral ventricle. The lateral posterior choroidal arteries that
arise in the posterior incisural space pass around the postero-
medial surface of the pulvinar and through the choroidal
fissure to supply the choroid plexus in the atrium, giving
branches to the thalamus along the way.
The SCA is coursing within the cerebellomesencephalic
fissure when it reaches the posterior incisural space. These
branches, upon exiting the cerebellomesencephalic fissure, are
anterior to the free edge, but they pass below the free edge to
supply the tentorial surface of the cerebellum (Fig. 5.2).
The perforating branches of the PCA and SCA, and the
medial posterior choroidal arteries supply the walls of the
posterior incisural space. The PCAs supply the structures
above the level of the lower margin of the superior colliculi
and the SCAs supply the structures below the upper margin
of the inferior colliculus.
The posterior incisural space has the most complex venous
relationships in the cranium, because the internal cerebral and
basal veins and many of their tributaries converge on the vein
of Galen within this area (Figs. 5.1, 5.5, and 5.6). The internal
cerebral veins exit the velum interpositum and the basal veins
exit the ambient cistern to reach the posterior incisural space,
where they join to form the vein of Galen. The vein of Galen
passes below the splenium to enter the straight sinus at the
tentorial apex. The junction of the vein of Galen with the
straight sinus varies from being nearly flat if the tentorial apex
is located below the splenium to forming a sharp angle if the
apex is located above the splenium, so that the vein of Galen
must turn sharply upward to reach the straight sinus at the
apex. The largest vein from the infratentorial part of the
posterior incisural space, the vein of the cerebellomesence-
phalic fissure, originates from the union of the paired veins of
the superior cerebellar peduncle.
Tentorial arteries
The tentorial arteries arise from three sources (8). The
first source, the cavernous segment of the carotid artery,
provides two arteries: the basal tentorial artery (the artery of
Bernasconi-Cassinari) from the meningohypophyseal trunk,
and the marginal tentorial artery from the artery from the
inferolateral trunk (also called the artery of the inferior cav-
ernous sinus). The basal tentorial artery arises from the me-
ningohypophyseal trunk and courses posterolaterally along
the medial part of the tentorial attachment to the petrous
ridge. The marginal tentorial artery arises from the inferolat-
eral trunk, passes laterally over the abducens nerve, then
superoposteriorly near the trochlear nerve to enter the tento-
rial edge. If this artery is absent, a branch from the meningo-
hypophyseal artery may replace it (8, 28, 32).
The second source of tentorial arteries is from the SCA. The
meningeal branch originates from the main or rostral trunk
near where the artery passes under the tentorium, and it
enters the free edge in the middle incisural space. In our
specimens, 28% of the SCAs gave rise to a tentorial branch,
and such a vessel may be encountered when the tentorium is
divided through a subtemporal approach (17).
The third source is the proximal part of the PCA. The
tentorial branch of the PCA arises as a long circumflex artery
that courses around the brainstem and below the free edge to
enter the tentorium near the apex (17, 37). This artery may
also give branches to the superior vermis and inferior
colliculi.
DISCUSSION
Tentorial herniation
Tentorial herniation is the most common and most impor-
tant form of brain herniation (10, 12, 15). In descending her-
niation caused by supratentorial mass lesions, the uncus and
parahippocampal gyri herniate downward through the inci-
sura, and in ascending herniation resulting from infratentorial
masses, the superior part of the cerebellum may herniate
upward through the incisura. These brain herniations may
cause combinations of direct effects caused by neural com-
pression and indirect effects caused by vascular compromise.
Symptoms may result from displacement, compression, and
stretching of the brainstem and cranial nerves, hemorrhage
and infarction caused by compression and tearing of arteries
and veins, increasing edema and intracranial pressure caused
by venous obstruction, hydrocephalus caused by obstruction
of the aqueduct and subarachnoid space at the incisura, and
strangulation of the prolapsed tissue.
The type of the tentorial herniation in each case depends on
the position and rate of expansion of the lesion and the size
and shape of the incisura. The signs appear early when struc-
tures are deformed rapidly, whereas advanced distortion may
occur before the appearance of signs if the herniation devel-
ops slowly. A wide space between the free edge and brain-
stem facilitates cerebral herniation since more tissue can her-
niate into the space (20). A low position of the anterior portion
of the free edge also facilitates descending herniation (20).
Descending herniations are divided into anterior, posterior,
and complete types. In the anterior type, the uncus herniates
into the interpeduncular and crural cisterns. This shift carries
the brainstem to the opposite side, thus increasing the space
between the free edge and the brainstem, and facilitating a
further shift of tissue through the aperture. Eventually, the
parahippocampal gyrus, from the splenium to the uncus, may
be forced through the opening and the incisura becomes
plugged with herniated temporal lobe, deformed hypothala-
mus, and compressed midbrain. The amygdaloid nucleus is
involved with the uncus in the herniated mass. Distortion and
compression of the midbrain reticular activating pathways
causes a decreased level of consciousness. Compression of the
ipsilateral cerebral peduncle causes contralateral pyramidal
signs and, if the lateral displacement of brainstem is severe,
the contralateral cerebral peduncle may be forced against the
free edge, thus producing a groove on the peduncle called a
Kernohans notch, with ipsilateral pyramidal signs (30). In the
terminal stage, deformation of the midbrain causes decere-
brate rigidity. Distortion and compression of the posterior
hypothalamus may cause cardiovascular, respiratory, and
thermoregulatory disturbances. The pituitary stalk may be
stretched and compressed against the dorsum sellae, causing
diabetes insipidus. The oculomotor nerve courses between the
medial border of the uncus and the posterior petroclinoidal
fold, and may be kinked or compressed here or between the
PCA and SCA, or it may be stretched as the hernia displaces
the midbrain posteriorly. Initially, the pupilloconstrictor fi-
bers, which are concentrated on the superior surface of the
nerve, are compressed. Later, somatic fibers to the extraocular
muscles are disturbed. In the early stages, irritation of the
pupilloconstrictor fibers may cause pupillary constriction, but
this usually gives way to a paralytic effect with pupillary
dilation as the hernia enlarges. The optic tract is displaced
medially and downward, but the resulting visual loss is often
masked by deepening coma. Compression of the uncus,
amygdaloid nucleus, parahippocampal gyrus, and hippocam-
pal formation against the free edge may cause memory, be-
havior, and personality changes. Residual scarring of the hip-
pocampal formation may cause seizures. The trochlear nerve
usually escapes involvement in such herniations, but caudal
displacement of the brainstem may result in a palsy of the
abducens nerve by stretching it in the subarachnoid space or
by strangling it in its course around the AICA.
Stretching or compression of the anterior choroidal and
PCA between the temporal lobe and the peduncle or obstruc-
tion of the PCA as it crosses the free edge may cause visual
field loss caused by ischemia of the optic tract, optic radiation,
or the lateral geniculate body; contralateral hemiplegia caused
by involvement of the cerebral peduncle and midbrain; or
changes in personality and behavior caused by damage to the
amygdaloid nucleus or hippocampal formation; unconscious-
ness and decerebrate rigidity caused by midbrain ischemia;
and contralateral sensory loss caused by ischemia of the ven-
tral thalamic nuclei. Brainstem hemorrhage frequently accom-
panies tentorial herniation.
In the posterior type of tentorial herniation, the posterior
portion of the parahippocampal and lingual gyri and the
isthmus of the cingular gyrus may shift through the incisura
into the quadrigeminal cistern and compress and displace the
dorsal half of the midbrain. Tectal compression may cause
vertical gaze disturbances. Compression and obstruction of
the aqueduct causes hydrocephalus and raises the intracranial
pressure. In the posterior type of herniation, the PCA or its
calcarine branch is pressed against the free edge and may be
obstructed, causing infarction of the occipital cortex and
hemianopsia. The basal vein may be compressed between the
midbrain and herniated temporal lobe, and the vein of Galen
may be obstructed as it curves around the splenium, thus
aggravating the venous congestion, edema, and intracranial
tension. The complete type of herniation yields a combination
of signs and symptoms observed with anterior and posterior
herniations.
Hemorrhage into the brainstem as a result of tearing of
arteries and veins without cerebral herniation may occur if the
incisura hugs the brainstem so tightly that it prevents cerebral
herniation while allowing axial displacement of the brainstem.
In ascending herniation attributable to a posterior fossa
mass lesion, the superior part of the cerebellar vermis and
hemispheres herniate upward through the incisura into the
quadrigeminal cistern. Cerebellar infarction may result from
compression of the branches of the SCA where they pass
under the free edge. The hernia may compress the great
cerebral vein against the splenium, which is fixed above by
the falx, thus increasing the venous congestion, edema, and
intracranial pressure.
Pathology and operative approaches
Most aneurysms, many pineal, sellar, parasellar, and third
ventricular tumors, and some anteriovenous malformations
are approached through the incisural spaces. The arteries in
the incisura have been subject to bypass procedures, and
many operations for trigeminal neuralgia are directed
through this area. In addition, structures bordering the area
have been ablated either at craniotomy or stereotactically for
the control of epilepsy. The selection of the best operative
approach for a given lesion of the incisura depends on the
space involved.
Anterior incisural space
Nearly 95% of saccular arterial aneurysms arise within the
anterior incisural space. The basic anatomy of the common
aneurysms has been reviewed elsewhere by Rhoton (23).
The aneurysms arising from the part of the circle of Willis
located anterior to Liliequists membrane, and from the inter-
nal carotid and middle cerebral artery are most commonly
approached through a frontotemporal (pterional) craniotomy
(35) (Fig. 5.9). Aneurysms located behind Liliequists mem-
brane at the basilar apex in the interpeduncular fossa may be
exposed through either a frontotemporal or subtemporal cra-
niotomy if they are located above the dorsum sellae (35, 36)
S144 Rhoton
FIGURE 5.9. AF. Exposure of the anterior incisural space through a frontotemporal craniotomy. A, the insert shows the site of the
craniotomy. The frontal and temporal lobes have been retracted to expose the optic and oculomotor nerves and the anterior and
middle cerebral and posterior communicating arteries. B, the opticocarotid triangle, located between the optic nerve and the
carotid and anterior cerebral arteries, has been opened with gentle retraction to expose the basilar apex and the ipsilateral oculo-
motor nerve passing forward between the PCA and SCA. C, the exposure has been directed medially above the optic chiasm to
expose the region of the anterior communicating artery. D, the frontal lobe has been elevated to expose the contralateral carotid
and anterior and middle cerebral arteries. E, the carotid artery has been elevated to expose the basilar artery apex through the
interval between the carotid artery and oculomotor nerve. The posterior clinoid process blocks access to the basilar artery. F, the
anterior clinoid process and the roof of the cavernous sinus have been removed to provide access to the posterior clinoid process.
The upper dural ring is located at the level of the upper margin of the anterior clinoid process. A., artery; A.C.A., anterior cerebral
artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; Clin., clinoid; CN, cranial nerve; Comm., communicating; Con-
tra., contralateral; Ipsi., ipsilateral; Lam., lamina; M.C.A., middle cerebral artery; P.C.A., posterior cerebral artery; Post., posterior;
S.C.A., superior cerebellar artery; Term., terminalis; V1., first ophthalmic branch, trigeminal nerve.
(Figs. 5.8 and 5.9). Those located below the dorsum or in the
prepontine cistern may require a pretemporal, anterior, or
mid subtemporal craniotomy with incision or retraction of the
tentorium (Fig. 5.7).
Incision and retraction of the tentorium are commonly re-
quired to gain access to lesions around the incisura. The
incision in the tentorium to expose the interpeduncular and
prepontine cisterns is usually located just posterior to the
point where the trochlear nerve enters the free edge. The free
edge may be retracted by means of sutures placed near to it,
but special care is required to avoid stretching and damaging
the trochlear nerve in its course inferomedial to and entering the
free edge near the posterior margin of the oculomotor trigone.
The tentorial arteries and venous sinuses may be encountered in
sectioning the tentorium (16). Sectioning of the tentorium has
been used to alleviate pressure on the brainstem caused by large
incisural lesions that cannot be removed (2).
Perforating arteries to the brainstem are at greatest risk in
approaches to the anterior incisural space, because they are
commonly stretched around lesions in this area. Hypoplastic
arterial segments in the circle of Willis should not be sacri-
ficed during the exposure because hypoplastic segments have
been found to have the same number and size of perforating
branches as arteries of a normal diameter (23).
Tumors arising in or extending into the anterior incisural
space include pituitary adenomas, craniopharyngiomas, clival
chordomas, meningiomas arising from the tuberculum sellae,
clivus, and medial part of the sphenoid ridge, gliomas of the
optic nerve and hypothalamus, some dermoid cysts and ter-
atomas, and neuromas of the oculomotor nerve. Tumors in
the anterior incisural space may be approached by the bifron-
tal, subfrontal, frontal-interhemispheric, frontotemporal, sub-
temporal, and transsphenoidal routes. Tumors located ante-
rior to Liliequists membrane between the optic chiasm and
the sellar floor are commonly operated on by the transsphe-
noidal or subfrontal route. The transsphenoidal approach is
preferred if the tumor extends upward out of an enlarged
sella turcica and is located above a pneumatized sphenoid
FIGURE 5.9. GJ. Exposure of the anterior incisural space through a frontotemporal craniotomy. G, the posterior clinoid
process has been removed to increase access to the upper portion of the basilar artery. H, the anterior part of the tentorial
edge has been removed to expose the upper margin of the posterior trigeminal root in Meckels cave and to provide
increased access to the upper anterior part of the posterior fossa. The trochlear nerve was preserved in opening the anterior
part of the tentorial edge. I, another dissection in which the anterior clinoid process and roof of the cavernous sinus were
removed to expose the posterior clinoid process in the interval between the carotid anteriorly and the oculomotor posteri-
orly. J, the posterior clinoid was removed to provide increased access to the upper part of the basilar artery.
S146 Rhoton
sinus. The subfrontal intracranial approach is reserved for
those tumors in the chiasmatic cistern that are not accessible
by the transsphenoidal route because they are located entirely
above the diaphragma sellae, or extend upward out of a
normal or small sella, or are located above a nonpneumatized
(conchal) type of sphenoid sinus. The subfrontal approach
permits exposure of the tumor within the anterior incisural
space by four routes: 1) the subchiasmatic approach between
the optic nerves and below the optic chiasm; 2) the opticoca-
rotid route directed between the optic nerve and carotid ar-
tery; 3) the lamina terminalis approach directed above the
optic chiasm through a thinned lamina terminalis; and 4) the
transfrontal-transsphenoidal approach obtained by entering
the sphenoid sinus and sella through the transfrontal craniot-
omy (22, 25, 26). The subchiasmatic approach is used if the
subchiasmatic opening is enlarged by the tumor. The optico-
carotid route is selected if parasellar extension of the tumor
widens the space between the carotid artery and the optic
nerve and the tumor cannot be reached by the subchiasmatic
approach. The lamina terminalis approach is selected if the
tumor has pushed the chiasm into a prefixed position and
extends into the third ventricle to stretch the lamina terminalis
so that the tumor is visible through it. The transfrontal-
transsphenoidal approach is selected if the tumor grows up-
ward out of the sella, the sphenoid sinus is pneumatized and
the tumor does not stretch the lamina terminalis or widen the
opticocarotid space, and a prefixed chiasm blocks the subchi-
asmatic exposure. A bifrontal craniotomy may be used if the
tumor extends forward in both anterior cranial fossae and
cannot be reached by a unilateral subfrontal exposure. A
frontal interhemispheric approach directed along the anterior
part of the falx is used for lesions restricted to the part of the
anterior interhemispheric space located just below the ros-
trum, especially if the tumor arises in the genu or rostrum of
and grows into the anterior incisural space.
The frontotemporal approach is used for a tumor arising
from the sphenoid ridge or anterior clinoid process, or if it
arises above the diaphragma and extends along the sphenoid
ridge or into the middle cranial fossa, or if the lesion is
accessible through the spaces between the optic nerve and
carotid artery or between the carotid artery and the oculomo-
tor nerve (Fig. 5.9). Some lesions may require that the above
approach be combined with resection of the cranial base if the
lesion involves the paranasal sinuses, nasal cavity, pharynx,
orbit, or cavernous sinus, and for those extending from the
anterior incisural space into the area behind the dorsum sella
or petrous apex, and those in which the lower opening pro-
vided by cranial base resection will yield a better angle of exposure
or reduce the need for brain retraction. These approaches include
the transcranial-transbasal, extended frontal, fronto-orbital, or-
bitozygomatic, transcavernous, preauricular-infratemporal, and
subtemporal anterior petrousectomy, some of which are dis-
cussed more fully in the chapters on the foramen magnum and
temporal bone.
Middle incisural space
Lesions in the middle incisural space include meningiomas
arising from Meckels cave, the anterior part of the free edge
and the petrous apex, gliomas of the temporal lobe and thal-
amus, anteriovenous malformations of the medial temporal
lobe, and neuromas of the trochlear and trigeminal nerves.
The infrequent aneurysms arising in the middle incisural
space are usually located on the PCA at the origin of its first
major cortical branch or on the SCA at its bifurcation into
rostral and caudal trunks. Bypass operations using vein and
arterial grafts have been applied to the trunks and branches of
the posterior cerebral and superior cerebellar branches in the
middle incisural space bordering the incisura. The middle
incisural space is exposed in performing amygdalohip-
pocampectomy and temporal lobectomy for epilepsy since
both the amygdalae and hippocampus extend medial to the
free edge. The trigeminal nerve is also frequently exposed in
the middle incisural space in the course of operations for
trigeminal neuralgia.
Approaches to the middle incisural space include the poste-
rior frontotemporal, subtemporal, temporal-transventricular,
and the lateral suboccipital routes (Figs. 5.7 and 5.8). The
subtemporal approach with elevation of the temporal lobe is
commonly used to expose lesions in the cisterns around the
incisura. Hemorrhage, venous infarction, and edema follow-
ing retraction of the temporal lobe during this approach are
minimized by placing the lower margin of the craniotomy and
dural exposure at the cranial base so as to reduce the need for
retraction, and by avoiding occlusion of the bridging veins,
especially the vein of Labbe. The tentorium is frequently
divided to increase the exposure or to decompress the brain-
stem when mass lesions are impacted in the incisura (2).
Resection of part of the parahippocampal gyrus may facilitate
exposure of the upper part of the middle incisural space (1). A
transventricular approach using a cortical incision in the non-
dominant inferior or middle temporal gyrus may be used if
the lesion involves the temporal horn, choroidal fissure, hip-
pocampal formation, or the upper part of the middle incisural
space (9). A cortical incision in the medial occipitotemporal
gyrus on the inferior surface of the temporal lobe has been
used to minimize visual and speech deficits in exposing the
temporal horn of the dominant hemisphere. After entering
the temporal horn, the choroidal fissure is opened to expose
the middle incisural space. The subtemporal craniectomy may
be combined with a suboccipital craniectomy with section of
the tentorium and transverse sinus to remove lesions in the
prepontine or cerebellopontine cisterns. The trochlear nerve is
the cranial nerve most frequently injured in the middle inci-
sural space. It can be injured in dividing the free edge and is
so thin and friable that it may rupture from gentle retraction
on the leaves formed by dividing the tentorium. The above
approaches may be combined with cranial base approaches
involving resection or mobilization of the orbital rim, zygo-
matic arch, floor of the middle fossa, or a portion of the
temporal bone as are accomplished in the orbitozygomatic
craniotomy, and the preauricular infratemporal or anterior
petrousectomy approaches.
The posterior trigeminal root is frequently exposed through
a lateral suboccipital craniectomy in the infratentorial part of
the middle incisural space for rhizotomy or microvascular
decompression operations. The exposure is directed along the
FIGURE 5.10. AF. Comparison of the midline and paramedian infratentorial supracerebellar and the occipital transtentorial
approaches to the quadrigeminal cistern and the posterior third ventricle. AD, views of the third ventricle and quadrigemi-
nal cistern. A, third ventricle from above. The body of the fornix separates the body of the lateral ventricle from the roof of
the third ventricle. The body of the fornix blends posteriorly into the crus of the fornix, which is situated above the posterior
part of the third ventricle. The choroidal fissure, the site of attachment of the choroid plexus, is situated between the fornix
and thalamus. B, the fornix was divided at the level of the columns, just behind the foramen of Monro, and reflected
S148 Rhoton
angle formed by the insertion of the tentorium to the petrous
ridge. The posterior root proximal to Meckels cave has also
been exposed through a subtemporal craniectomy combined
with incision of the tentorium (11). The posterior root may
also be exposed for rhizotomy within Meckels cave through
a subtemporal extradural approach.
Posterior incisural space
Lesions in the posterior incisural space include pineal tu-
mors; meningiomas arising at the falcotentorial junction and
from the tela choroidea of the velum interpositum and atrium;
gliomas of the splenium, pulvinar, quadrigeminal plate, and
cerebellum; aneurysms of the vein of Galen; and anterio-
venous malformations involving the medial occipital lobe and
upper cerebellum.
Lesions in the posterior incisural space may be approached
from above the tentorium along the medial surface of the
occipital lobe using an occipital transtentorial approach,
through the posterior part of the lateral ventricle using a
posterior transventricular approach, and through the corpus
callosum using a posterior interhemispheric transcallosal ap-
proach, or from below the tentorium through the supracer-
ebellar space using an infratentorial supracerebellar approach
(Figs. 5.10 and 5.11). The infratentorial supracerebellar and
occipital transtentorial approaches, which are most com-
monly selected for pineal region tumors, may be combined
with incision of the tentorium lateral to the straight sinus and
less commonly with division of the tentorium and transverse
sinus. A tentorial branch of the PCA or SCA may enter the
dura lateral to the straight sinus. Venous sinuses are more
commonly encountered in the posterior than in the anterior
parts of the tentorium. Part of the tentorium may be removed
in resecting tumors that arise from or invade it.
The infratentorial supracerebellar approach may be selected
for lesions in the pineal region located below the vein of Galen
and its major tributaries (29). The approach is best suited to
tumors in the midline that grow into the lower half of the
posterior incisural space, displacing the quadrigeminal plate
and apex of the tentorial cerebellar surface. The occipital
transtentorial approach is preferred for lesions centered at or
above the tentorial edge, especially if they are located above
the vein of Galen. The latter approach may also provide a
better angle of access for some lesions involving the ipsilateral
half of the cerebellomesencephalic fissure and posterior part
of the ambient cistern, although they may be located below
the level of the vein of Galen (21, 34) The posterior transcal-
losal approach, in which the splenium is divided, would be
used only if the lesion appears to arise in the splenium above
the vein of Galen and extends into the posterior incisural
space. The posterior transventricular approach provides ade-
quate exposure of the atrium and posterior portion of the
body of the lateral ventricle and would be the preferred
approach to a tumor involving the posterior incisural space if
the tumor extends into the pulvinar or involves the atrium
or the glomus of the choroid plexus. The preferable approach
to the ventricle is through the superior parietal lobule, al-
though on approach to the pineal region using a cortical
incision in the superior temporal gyrus and directed through
the atrium has been advocated (31).
Comparison of occipital transtentorial and
infratentorial supracerebellar approaches
In examining the posterior incisural space, we compared
the midline and paramedian variants of the infratentorial
supracerebellar approach and the occipital transtentorial ap-
proach (Figs. 5.10 and 5.11). The midline infratentorial suprac-
erebellar approach is directed steeply upward over the apex
of the vermis where the large complex of veins emptying into
the vein of Galen, and especially the vein of the cerebellomes-
encephalic fissure, blocks access to the pineal region. The venous
complex could be gently displaced to expose the lower part of
the splenium, the pineal, and the superior colliculus, but the
prominent vermian apex forming the posterior lip of the cerebel-
lomesencephalic fissure limits exposure below the level of the
superior colliculus. In the paramedian variant of the infratento-
rial supracerebellar approach, the retraction was advanced
above the hemisphere lateral to the vermis. This approach was
not as upwardly steep as the approach above the vermian apex
and provided access to the pineal region, the lower part of the
splenium, and gave greater access to the ipsilateral half of the
cerebellomesencephalic fissure. In addition, the approach could
be advanced along the lateral part of the cerebellar surface to
expose the posterior part of the ambient cistern. In the occipital
posteriorly to expose the posterior commissure, pineal, and adjacent part of the quadrigeminal cistern. C, the quadrigeminal
cistern is located behind the pineal and the colliculi and between the pulvinars. It extends into the cerebellomesencephalic
fissure. The trochlear nerves arise below the inferior colliculi. D, view similar to C, except that the vessels have been pre-
served. The internal cerebral and basal veins join the vein of Galen behind the pineal. The PCA and SCA exit the ambient cis-
tern to enter the lateral part of the quadrigeminal cistern. Both the infratentorial supracerebellar and occipital transtentorial
approaches are directed to this area. E and F, midline infratentorial supracerebellar approach. E, the venous complex empty-
ing into the vein of Galen blocks access to the pineal region. This complex includes the internal occipital, basal and internal
cerebral veins, and the vein of the cerebellomesencephalic fissure. A tentorial branch of the SCA crosses the exposure. F, the
vein of Galen has been retracted to expose the splenium. The vein of the cerebellomesencephalic fissure has been retracted
to expose the pineal. A., artery; Bridg., bridging; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Chor., choroidal; Cist.,
cistern; CN, cranial nerve; Coll., colliculus; Comm., communicating; Fiss., fissure; For., foramen; Inf., inferior; Int., internal;
Lat., lateral; Med., medial; Occip., occipital; P.C.A., posterior cerebral artery; Ped., peduncle; Plex., plexus; Post., posterior;
Quad., quadrigeminal; Sag., sagittal; S.C.A., superior cerebellar artery; Str., straight; Sup., superior; Temp., temporal; Tent.,
tentorial; Trans., transverse; V., vein; Ve., vermian; Vent., ventricle.
FIGURE 5.10. GL. G and H, midline infratentorial supracerebellar approach. G, the left basal and internal cerebral veins have
been elevated and the vein of the cerebellomesencephalic fissure, which is joined by a superior vermian vein, has been retracted to
the right to expose the superior colliculus, pineal, and splenium. H, the tela choroidea attached to the upper surface of the pineal
has been opened to expose the posterior part of the third ventricle. IL, paramedian variant of the infratentorial supracerebellar
approach. In this variant, the retraction of the tentorial surface is shifted off the vermis and tentorial apex to the paramedian part
of the hemisphere. This paramedian variant of the approach accesses the lateral part of the quadrigeminal cistern and the posterior
part of the ambient cistern and, in addition, provides a better view into the central and ipsilateral half of the cerebellomesence-
phalic fissure than the approach directed in the midline above the vermian apex. I, the retraction for the paramedian approach has
been shifted to the left of the vermis. J, the left internal cerebral and internal occipital veins have been retracted to expose the pos-
terior part of the splenium, the pineal and the superior and inferior colliculi, and the branches of the PCA and SCA exiting the
ambient cistern. K, enlarged view. The exposure has been shifted to where the PCA exits the ambient cistern. L, the paramedian
approach provides easier access to the superior and inferior colliculi and requires less retraction than is needed to expose these
structures in the approach directed in the midline above the apex of the tentorial cerebellar surface.
S150 Rhoton
FIGURE 5.10. MR. Occipital transtentorial approach. M, the occipital transtentorial is directed along the medial surface of
the occipital lobe below the lambdoid suture. This occipital lobe below the lambdoid suture is commonly free of bridging
veins to the superior sagittal sinus, making it a reasonable route for the occipital transtentorial approach. N, there are no
large bridging veins between the posterior 6 cm of the occipital lobe and superior sagittal sinus. The first vein encountered is
the internal occipital vein that passes from the anterior part of the medial occipital lobe to the vein of Galen. O, the vein of
Galen has been retracted to expose the splenium and pineal from above. P, the tentorium has been opened lateral to the
straight sinus, and the vein of Galen has been displaced to the left side to expose the pineal and the superior and inferior col-
liculi. Q, elevating the branches of the vein of Galen provides a satisfactory view into the quadrigeminal cistern, with a better
view into the cerebellomesencephalic fissure than can be achieved with the infratentorial supracerebellar approach directed
over the apex of the tentorial cerebellar surface. R, the exposure has been directed laterally along the side of the brainstem
to the ambient cistern where the lateral margin of the cerebral peduncle is exposed.
transtentorial approach, the occipital lobe was retracted and the
tentorium divided along the edge of the straight sinus. This
provided access to the splenium above the vein of Galen and,
with gentle retraction of the venous complex in the posterior
incisural space, the pineal and the upper part of the cerebel-
lomesencephalic fissure could be visualized. The approach pro-
vided wider access to the midline and ipsilateral half of the
cerebellomesencephalic fissure than did the midline infratento-
rial supracerebellar approach. In addition, it provided an excel-
lent route for reaching the posterior part of the ambient cistern
and even the lateral surface of the cerebral peduncle in the crural
cistern. The exposure of the lateral part of the contralateral half
FIGURE 5.11. Comparison of infratentorial supracerebellar, the occipital transtentorial, and the combined supra- and infrat-
entorial approaches. A, infratentorial supracerebellar approach. The approach has been directed between the lower surface
of the tentorium and the tentorial cerebellar surface. The large venous complex draining into the vein of Galen is in the cen-
tral part of the exposure and the PCA and SCA are exposed laterally. A large vein of the cerebellomesencephalic fissure
blocks access to the pineal and limits access to the cerebellomesencephalic fissure. This approach is selected for lesions
located in the midline below the vein of Galen and not extending deeply into the cerebellopontine fissure. The SCA
branches looping around the lip of the cerebellomesencephalic fissure may extend upward and limit access to the pineal
region. B, the vein of the cerebellomesencephalic fissure has to be divided to expose the pineal. The medial posterior
choroidal arteries are intertwined with the veins in the region. C, the occipital transtentorial approach has been
directed along the medial side of the right occipital lobe. The tentorium behind the quadrigeminal cistern has been
divided. The approach provides access to the splenium and the upper part of the cerebellomesencephalic fissure and has
been extended forward to the lateral surface of the cerebral peduncles. Both the superior and inferior colliculi can be
exposed and the arteries can be followed forward into the ipsilateral ambient cistern. In addition, the veins joining the
vein of Galen can be elevated to expose the pineal. The trochlear nerve is exposed just distal to its brainstem exit below
the inferior colliculus. D, combined supra and infratentorial exposure with the division of the transverse sinus and ten-
torium. Division of the transverse sinus, if it is small and well collateralized, provides an exposure that combines both
the supra- and infratentorial approaches. A., artery; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Chor., choroidal;
CN, cranial nerve; Coll., colliculus; Fiss., fissure; Inf., inferior; Int., internal; Med., medial; Occip., occipital; P.C.A., pos-
terior cerebral artery; Ped., peduncle; Post., posterior; S.C.A., superior cerebellar artery; Sup., superior; Temp., tempo-
ral; V., vein.
S152 Rhoton
of the quadrigeminal cistern was more limited than could be
achieved with the midline infratentorial supracerebellar ap-
proach. The supra and infratentorial approaches can be con-
verted into a combined approach by dividing the transverse
sinus in addition to the tentorium, if the sinus is small and is well
collateralized through the opposite side (Fig. 5.11).
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro-
logical Surgery, University of Florida Brain Institute, P.O. Box 100265,
100 S. Newell Drive, Building 59, L2100, Gainesville, FL 32610-0265.
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CHAPTER 5

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