Csf cisterns

CSF cisterns anatomy and their related disorders

1. MD Neurology Tanta University By Wafik Bahnasy

2. How does the blood reach the ventricles in SAH What is the 6 th ventricle? The name of 4 th ventricle, central canal junction and where is its level?

3. ♣ During reading brain CT or MRI films, our eyes are usually attracted to the brain parenchyma while , inspite of its great importance, the CSF cisterns do not gain the same degree of attention. ♣ Cistern is Latin word means box. Brain Cisterns

4. ♣ The brain and spinal cord are covered by 3 layers; the dura (2 layers), the arachnoid and the pia maters. (1) The dura mater (tough mother): falx cerebri vessels, falx cerebelli, tentorium cerebelli and diaphragma sella. (2) Arachnoid: spidery & holds the blood vessels. (3) Pia mater: delicate mother. The Meninges

5. ♣ The subarachnoid space is the anatomic space between the arachnoid and pia maters. It is a narrow space containing CSF as well as vascular and nervous elements. The Meninges

6. ♣ The subarachnoid cisterns are discrete named spaces within the subarachnoid space where the pia mater and arachnoid membrane are not in close approximation. ♣ The cisterns may have vessels and/or cranial nerves passing through them. ♣ Loss of one or more of the cisterns is a sign of increased intracranial pressure. Loss of symmetry of one or more of the cisterns may be a sign of midline shift. Brain Cisterns

7. ◘ The adult have 150 cc of CSF. ◘ The CSF is formed in the lateral ventricle in a rate of 0.5 – 1 cc /minute. CSF Circulation

8. Liliequist Classification According to Ventricular Communication

9. Brain Cisterns

10. Non-Communicating Ventral Cisterns Dorsal Cisterns Median “unpaired” Paramedian “paired” Pre-Medullary Pre-Pontine Inter- peduncular Chiasmatic CP Angle Crural Carotid Sylvian Median “unpaired” Paramedian “paired” Peri-Callosal Quadri-geminal Supra-Cerebellar Ambient Retro-Thalamic Cisterna Magna Lamina Terminalis Communicating

11. Anterior Carotid Chiasmatic Lamina Terminalis Olfactory Crural Ambient Quadri-geminall Velum Interpositum Peri-Callosal Hemispheric Posterior Lateral Superior Sylvian Supra-Tentorial Cisterns

12. Anterior Inferior CPA Cisterna Magna Superior Cerebellar Superior CPA Vermin Hemispheric Posterior Lateral Superior Inter- peduncular Pre-Medullary Pre-Pontine Ambient Infra -Tentorial Cisterns

13. Brain Cisterns

14. Brain Cisterns

15. Brain Cisterns

16. Posterior Fossa Cisterns

17. ◘ Location: - Surrounding the medulla. - Continous posteriorly with the cisterna magna. ◘ Contents: - Vertebral arteries. - PICA. - Anterior spinal artery. - Posterior spinal arteries. - Premedullary vein. - Cr N 12. Medullary Cistern

18. Medullary Cistern

19. Axial Section at Foramen Magnum

20. Arnold Chiari Malformation

21. Medullary Cistern

22. ◘ Location: - Between the pons and the clivus . - Has a central portion and two lateral recesses between the pons and cerebellum. - Continuous above with the interpeduncular cistern. - Receives CSF from lateral apertures of 4th ventricle ( Luschka ). Pontine (pre-pontine) Cistern

23. ◘ Contents (in descending fashion): - Cr N 5. - The superior cerebellar artery (SCA). - Cr Ns 4, 8 & 7. - A loop of the AICA. - PICA and Cr Ns 9, 10 & 11 in close relation to it. - Cr N 12. - The basilar artery. Pontine Cistern

24. Pontine Cistern

25. Pontine Cistern

26. Pre-pontine Arachnoid Cyst

27. ◘ Location: - Lies behind the medulla and below the cerebellar hemispheres. - Continous with 4 th ventricle through median aperture of Magendie . ◘ Contents: - Its lateral part contains the vertebral artery and its PICA branch. Cerebello -medullary Cistern “Cisterna Magna”

28. Mega Cisterna Magna

29. ◘ Location: - Lies below the vermis and between the cerebellar tonsils. - Connects the 4 th ventricle and cisterna magna. ◘ Contents: - PICA and falax cerebelli. Vallecula Vallecula Cerebelli

30. ◘ Agenesis or hypoplasia of the cerebellar vermis . ◘ Cystic dilatation of the 4 th ventricle. ◘ Enlargement of the posterior fossa with high level tentorium. ◘ Hydrocephalus. Dandy Walker Malformation

31. ◘ Location: - Between the tentorium cerebelli and superior vermis. ◘ Contents: - Superior cerebellar artery. - Superior vermian vein Superior Cerebellar Cistern

32. Superior Cerebellar Cistern Arachnoid Cyst

33. ◘ Location: - Triangular subarachnoid space lies between the anterior surface of the cerebellum and the lateral surface of the pons. ◘ Contents: - AICA. - Cr N 7 & 8. Superior CP Angle Cistern

34. ◘ Also called lateral cerebello -medullary cistern. ◘ Contents: - Cr N 9 & 10. Inferior CP Angle Cistern

35. ◘ Schwanoma ◘ Arachnoid Cyst ◘ Meningioma ◘ Epidermoid ◘ Metastasis ◘ Paraganglioma Common CP Angle Tumors

36. Inferior CP angle arachnoid cyst Superior CP angle acoustic neuroma

37. Peri-mesencephalic Cisterns

38. Inter- peduncular Cistern Quadrigeminal Cistern Peri-Mesencephalic Cisterns

39. Peri-Mesencephalic Cisterns

40. ◘ Location: - Between the cerebral peduncles. - Continuous below with the pontine cistern, laterally with the ambient cisterns, and superiorly with the suprasellar cistern. ◘ Contents: - Basilar tip. - PCA. - SCA. - Inter- peduncular vein. - Cr N 3. Inter-peduncular Cistern

41. Inter-peduncular Cistern

42. ◘ is a short trunk formed by the union of the two internal cerebral veins and basal veins of Rosenthal. ◘ It lies in the quadrigeminal cistern. It curves backward and upward around the posterior border of the splenium of the corpus callosum to drain into the confluence of the inferior sagittal sinus and the anterior extremity of the straight sinus. Quadrigeminal “Vein of Galen” Cistern

43. ◘ Contents: - Vein of Galen. - Precentral vein. - P3 of PCA. Quadrigeminal “Vein of Galen” Cistern

44. Precentral Vein

45. Vein of Galen Aneurysm

46. Quadrigeminal Cistern Epidermoid Cyst

47. ◘ Location: - Between the midbrain cerebral peduncles medially and uncus of the temporal lobe laterally. ◘ Contents: - P2 segment of PCA. - Superior cerebellar artery. - Anterior choroidal artery. - Basal vein of Rosenthel . Crural Cisterns

48. ◘ Location: - Extends around both sides of midbrain between the interpeduncular cistern anteriorly and the qudrigeminal cistern posteriorly. ◘ Contents: - P2 segment of PCA. - Superior cerebellar artery. - Anterior choroidal artery. - Lateral mesencephalic vein. - Basal vein of Rosenthel . - Cr N 4. Ambient Cisterns

49. Trochlear Nerve

50. Trochlear Nerve Schwanoma

51. Posterior Cerebral Artery

52. ◘ Paired, paramedian veins which originate on the medial surface of the temporal lobe and run posteriorly and medially. It passes lateral to the midbrain through the ambient cistern to drain into the vein of Galen. Basal vein of Rosenthel

53. Basal vein of Rosenthel

54. ◘ Usually venous in origin due to anomalies in the basal vein of Rosenthel or great vein of Galen in which they may be partially or completely absent with direct drainage of the cerebral veins to the brain sinuses. Peri-Mesencephalic SAH

55. Supra- tentorial Cisterns

56. Supra- Sellar / Chiasmatic Cistern ◘ Location: - Lies superior to the sellar diaphragm. - Continuous posteriorly with the interpeduncular cistern and laterally with the sylvian cistern. ◘ Contents: - It contains the anterior part of the circle of Willis and the optic nerve as it passes to the chiasm. - Pituitary Infundibulum.

57. ◘ Chiasmatic cistern is the part of suprasellar cistern that is anterior to the optic nerve. ◘ Part of the subarachnoid space goes through the infundibular orifice and forms a small cavity above the pituitary gland. Supra- Sellar / Chiasmatic Cistern

58. Supra- Sellar Arachnoid Cyst

59. ◘ Location: - Lateral to the sella . - Inferior to the anterior clinoid process. - Superior to the cavernous sinus. ◘ Contents: - Internal carotid artery (C7). - Origin of ACA, MCA, AchA and PcomA . Carotid Cisterns

60. ◘ Location: - Between the carotid cistern and sylvian fissure. ◘ Contents: - MCA. - Superficial and deep sylvian veins. Sylvian Cisterns

61. Sylvian Cisterns

62. ♣ It is an arachnoid membrane located between the interpeduncular cistern posteriorly, the infundibulum anteriorly, the carotid cisterns antero -laterally, and the chiasmatic cistern antero -medially. Liliequist Membrane

63. ◘ Lower attachment: Dorsum sellae. ◘ Upper attachment: Mammillary body. ◘ Lateral attachment: - Arachnoid sheath surrounding the oculomotor nerve and the mesial surface of the temporal lobe above the tentorial edge. - The membrane has a free edge between the optic tract and the temporal uncus . Liliequist Membrane

64. D = diencephalic segment, M = mesencephalic segment, S = sellar segment. Liliequist Membrane

65. The lateral border of the Liliequist membrane is directly attached to the oculomotor nerves bilaterally. Liliequist Membrane

66. ◘ Diencephalic segment: - Separates the interpeduncular cistern from the chiasmatic cistern. ◘ Mesencephalic segment: - Separates the interpeduncular cistern from the prepontine cistern Liliequist Membrane Segments

67. 3 rd Ventriculostomy

68. Third Ventricle Anatomy

69. ◘ The supra-optic recess, above the optic chiasma. ◘ the infundibular recess, above the pituitary stalk. ◘ The pineal and suprapineal recesses. Third Ventricle Recesses

70. ♣ In endoscopic 3 rd ventriculostomy , a small perforation is made in the thinned floor of the 3 rd ventricle, allowing movement of CSF out of the blocked ventricular system and into the interpenducular cistern. Third Ventriculostomy

71. ◘ Location: - Above the corpus callosum and between the cingulate gyri. - Continuous posteriorly with the quadrigeminal cistern. ◘ Contents: - The pericallosal artery Pericallosal Cistern

72. Interhemispheric Dermoid Cyst

73. ◘ Location: - It is the superior extension of suprasellar and chiasmatic cisterns that extend to the superior surface of corpus callosum as the pericallosal cistern. - It lies anterior to the lamina terminalis , inferior to the rostrum of the corpus callosum and superior to the optic chiasma ◘ Contents: - ACA. - A Com A. Cistern of Lamina Terminalis Lamina Terminalis Cistern

74. A Com Aneurysm in the Lamina Terminalis Cistern

75. ◘ Location: - The velum interpositum is a small membrane containing a potential space just above and anterior to the pineal gland which can become enlarged to form a cavum velum interpositum . Vellum Interpositum Cistern

76. ◘ Extensions: - Closed anterior end: behind the interventricular foramen. - Open posterior end: Continuous with the quadrigeminal cistern. ◘ Contents: - Internal cerebral vein. Vellum Interpositum Cistern

77. ◘ Location: - Lateral extension of the ambient cistern posterior to the thalamic pulvinar. ◘ Contents: - Lateral posterior choroidal artery Retro-Thalamic Cisterns

78. ◘ Lies between the leaflets of the septum pellucidum and sometimes called the 5 th ventricle. ◘ The 5 th and 6 th ventricles are actually subarachnoid cisterns and not in direct communication with the ventricular system. Cavum Septum Pellucidum

79. ◘ Sometimes called 6 th ventricle. ◘ It is the posterior extension of the cavum septum pellucidum and commonly coexist together. ◘ Lies posterior to the anterior columns of the fornix and inferior to the splenium of the corpus callosum. Cavum Vergae Cavum Septum Pellucidum Cavum Vergae

80. ◘ It is a normal variant where there is a dilated velum interpositum CSF space larger than 1 cm in axial transverse measurement. Cavum Veli Interpositi

81. Arachnoid Cyst of the Velum Interpositum

82. CSF Cisterns Connections

83. ◘ The obex is the point at which the 4 th ventricle narrow to become the central canal of the spinal cord. ◘ Located at the level of the foramen magnum. ◘ Neurosurgical intervention in syringomyelia and syringobulbia involve plugging of the obex to prvent CSF transmission to the central canal of the spinal cord. The Obex

84. CSF Circulation

85. ♣ Sudden rise of intra- cisternal pressure in acute SAH results in blood reflux to the ventricles through the 4 th ventricle foramina. ♣ The interface between the quadrigeminal cistern and the 3 rd ventricle, and between the ambient cistern and lateral ventricle, may be part of the compensatory CSF pathways from cisterns to ventricles in pathological conditions. Reversed CSF Circulation in SHA

86. Subarachnoid Hemorrhage From Cisterns Point of View

87. Lamina Terminalis Cistern Sylvian Cistern Interpeduncular Cistern Pentagonal Cisterns