The microsurgical anatomy of the cisternal segment of the trochlear nerve, as seen through different neurosurgical operative windows.
OBJECTIVE
To describe the anatomy of the cisternal segment of the trochlear nerve as seen through different neurosurgical approaches.


METHODS
The cisternal course of ten trochlear nerves was observed in five cadaveric embalmed heads, through the view afforded by the median infratentorial-supracerebellar, the extreme-lateral infratentorial-supracerebellar, and the combined presigmoid-subtemporal transtentorial approaches. The relationships of the trochlear nerve with the surrounding neuro-vascular structures were analyzed.


RESULTS
We identified 3 segments of the cisternal trochlear nerve: quadrigeminal, ambient and tentorial. The median infratentorial-supracerebellar approach allowed exposure of the quadrigeminal segment, including the origin of the nerve. The extreme-lateral supracerebellar and the combined presigmoid-subtemporal transtentorial approaches provided visualization of the ambient and tentorial segments of the nerve. The tentorial segment runs in a dural canal contained in the free edge of the tentorium, surrounded by its own arachnoidal sleeve.


CONCLUSIONS
The trochlear nerve is a very delicate structure that can be easily injured during approaches to the tentorial incisura. Accurate knowledge of its anatomy as seen through different operative windows is helpful in maintaining its integrity during surgery.
Ammirati
M
M
Division of Neurosurgery, Albert Einstein Medical Center, Jefferson Health System, Klein Professional Building, Suite 501, 5401 Old York Road, Philadelphia, PA 19141, USA.
Musumeci
A
A
Bernardo
A
A
Bricolo
A
A
D001927:Brain Diseases / Q000473:pathology* / Q000601:surgery*; D002946:Cisterna Magna / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications; D008866:Microsurgery / Q000009:adverse effects*; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D014321:Trochlear Nerve / Q000473:pathology* / Q000601:surgery*; D020432:Trochlear Nerve Diseases / Q000473:pathology* / Q000517:prevention & control* / Q000601:surgery; D061247:Trochlear Nerve Injuries