RHOTON CRANIAL ANATOMY & SURGICAL APPROACHES

DESCRIPTION

CranialAnatomy and Surgical Approaches is the masterwork of the legendaryneurosurgeon Albert L. Rhoton, Jr.a distillation of 40 years of work to, inthe authors words, make the delicate, fateful, and awesome procedures ofneurosurgery more gentle, accurate, and safe. This definitive text on themicrosurgical anatomy of the brain remains an essential tool for the educationand enrichment of neurosurgeons at any level of experience. The hardboundcollection of this complete classic work contains more than 2,000 high-qualityimages. 

• Covers every aspect of cranial surgery: general operative techniques, the supratentorial cranial compartment, and the posterior fossa 

• Details the safest approaches to brain surgery, including micro-operative techniques and instrument selection; microsurgical anatomy and approaches to the supratentorial area and anterior cranial base; anatomy and approaches to the posterior cranial fossa and posterior cranial base; and supra- and infratentorial areas 

• Illustrates surgical approaches using a combination of clearly written text and detailed photographs and illustrations, which highlight the key features of each procedure 

• Features outstanding cadaveric anatomic photographs that highlight relevant anatomy and anatomical variations 
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TABLE OF CONTENTS

PART 1:Operative Techniques and Instrumentation for Neurosurgery

1.Operative Techniques and Instrumentation for Neurosurgery

GENERAL CONSIDERATIONS

HEAD FIXATION DEVICES

INSTRUMENT SELECTION

Bayonet Forceps

Bipolar Coagulation

Scissors

Dissectors

Needles, Sutures, and Needle-holders

Suction Tubes

Brain Retractors

Drills

Bone Curettes

Cup Forceps

OPERATING MICROSCOPE

ULTRASONIC AND LASER DISSECTION

Ultrasonic Aspirators

Laser Microsurgery

REFERENCES

PART 2: TheSupratentorial Cranial Space: Microsurgical Anatomy and Surgical Approaches

1. The Cerebrum

THE HEMISPHERES

Hemispheric Surfaces

Boundariesand Surfaces of the Lobes

Sulci and Gyri

SYLVIAN FISSURE

Anterior Perforated Substance

Insula

SULCI AND GYRI

Central Sulcus

Lateral Convexity

Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Medial Hemispheric Surface

Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Basal Surface

Frontal Lobe

Temporal and Occipital Lobes

CENTRAL CORE

WHITE MATTER

Association Fibers

Uncinate Fasciculus

Cingulum

Superior Longitudinal Fasciculus

Projection Fibers

Commissural Fibers

Corpus Callosum

Anterior Commissure

Fornix

Septum Pellucidum

GRAY MATTERIN THE CENTRAL CORE

Caudate Nucleus

Lentiform Nucleus

Thalamus

DISCUSSION

Temporal Lobectomy and Amygdalohippocampectomy

REFERENCES

2. The Supratentorial Arteries

SUPRACLINOIDALPORTION OF THE INTERNAL CAROTID ARTERY

Segments ofthe Internal Carotid Artery

Segments ofthe C4

C4 Perforating Branches

Ophthalmic Segment

Communicating Segment

Choroidal Segment

Superior Hypophyseal and Infundibular Arteries

OPHTHALMIC ARTERY

POSTERIOR COMMUNICATING ARTERY

PComA Branches

ANTERIOR CHOROIDAL ARTERY

Course

Segments

Branches

Clinical Features

MIDDLE CEREBRAL ARTERY

Segments

Perforating Branches

Cortical Distribution

Branching Pattern

Stem Arteries

Cortical Arteries

Early Branches

Anomalies

MCABranches for Extracranial-Intracranial Bypass

Discussion

ANTERIOR CEREBRAL ARTERY

Segments

A1 Segmentand the Anterior Communicating Arteries

Recurrent Artery

Basal Perforating Branches

Distal Part

The PericallosalArtery

The CallosomarginalArtery

Distal ACA Branches

Basal Perforating Branches

Cortical Branches

Convexity Branches

Callosal Branches

Anomalies

ANTERIOR PERFORATING ARTERIES

Choroidal Segmentof the C4

Anterior Choroidal Artery

Middle Cerebral Artery

Anterior Cerebral Artery

Discussion

THEPOSTERIOR PART OF THE CIRCLE OF WILLIS

THE POSTERIOR CEREBRAL ARTERY

PCA Segments

P1 Segment

P2 Segment

P3 Segment

P4 Segment

PCA Branches

Perforating Branches

Thalamoperforating Arteries

Peduncular Perforating Arteries

Circumflex Branches

Thalamogeniculate Arteries

Ventricular and Choroid Plexus Branches

Cortical Branches

Inferior Temporal Arteries

Hippocampal Arteries

Anterior Temporal Artery

Middle Temporal Artery

Posterior Temporal Artery

Common Temporal Artery

Parieto-occipital Artery

Calcarine Artery

Splenial Artery

Lateral Convexity Branches

IIIrd and IVthCranial Nerves

Discussion

REFERENCES

3. Aneurysms

ANEURYSM SITES

Internal CarotidArtery Aneurysms

Carotid-Ophthalmic Aneurysms

Carotid-Superior Hypophyseal Aneurysms

Carotid-Posterior Communicating Aneurysms

Carotid-Anterior Choroidal Aneurysms

Carotid BifurcationAneurysms

Middle Cerebral Artery Aneurysms

Anterior Communicating Aneurysms

Pericallosal Aneurysms

Vertebral and Basilar Artery Aneurysms

Basilar Apex Aneurysms

Basilar Trunk Aneurysms

ANATOMIC PRINCIPLES DIRECTING SURGERY

OPERATIVE APPROACHES

REFERENCES

4. The Cerebral Veins

THE SUPERFICIAL VEINS

Drainage Groups

Superior Sagittal Group

Sphenoidal Group

Tentorial Group

Falcine Group

Dural Sinusesand Veins

SuperiorSagittal Sinus and Venous Lacunae

Inferior Sagittal Sinus

Straight Sinus

Transverse Sinus

Tentorial Sinuses

Cavernous Sinus

Superior Petrosal Sinus

Sphenoparietal, Sphenobasal, and Sphenopetrosal Sinuses

Anastomotic Veins

Vein of Trolard

Vein ofLabbé

Superficial Sylvian Vein

Cortical Veins

Frontal Lobe

Parietal Lobe

Temporal Lobe

Occipital Lobe

Meningeal Veins

THE DEEP VEINS

VENTRICULAR GROUP

Neural Relationships

Choroid Plexusand Choroidal Fissure

Velum Interpositum

Ventricular Veins

Frontal Horn

Body of the Lateral Ventricle

Atrium and Occipital Horn

Temporal Horn

Choroidal Veins

Internal Cerebral Veins

CISTERNAL GROUP

Anterior Incisural Region

Middle IncisuralSpace

Posterior Incisural Region

DISCUSSION AND OPERATIVE APPROACHES

REFERENCES

5. The Lateral and Third Ventricles

LATERAL VENTRICLE

Neural Relationships

Thalamus

Caudate Nucleus

Fornix

Corpus Callosum

Septum Pellucidum

Internal Capsule

Lateral Ventricular Walls

Body

Atrium and Occipital Horn

Temporal Horn

Choroidal Fissureand Choroid Plexus

THIRD VENTRICLE

Neural Relationships

Roof

Floor

Anterior Wall

Posterior Wall

Lateral Wall

Tentorial Incisura

ARTERIAL RELATIONSHIPS

Choroidal Arteries

Internal CarotidArtery

Posterior Communicating Artery

AnteriorCerebral and Anterior Communicating Arteries

Middle Cerebral Artery

Posterior Cerebral Artery

Superior Cerebellar Artery

VENOUS RELATIONSHIPS

Choroidal Veins

InternalCerebral, Basal, and Great Veins

SURGICALCONSIDERATIONS

CraniotomyPlacement

NeuralIncisions

ArterialConsiderations

VenousConsiderations

TumorRemoval

OPERATIVEAPPROACHES

AnteriorApproaches

AnteriorTranscortical Approach

AnteriorFrontal Approach

PosteriorApproaches

PosteriorTranscortical Approach

PosteriorTranscallosal Approach

OccipitalApproach

InfratentorialSupracerebellar Approach

LateralApproaches

Frontotemporal(Pterional) and Posterior Frontotemporal Exposures

Transtemporaland Subtemporal Approaches

SELECTIONOF OPERATIVE APPROACHES

REFERENCES

6. TheAnterior and Middle Cranial Base

OVERVIEW

ANTERIORCRANIAL BASE

EndocranialSurface

ExocranialSurface

MIDDLECRANIAL BASE

EndocranialSurface

ExocranialSurface

POSTERIORCRANIAL BASE

DISCUSSION

REFERENCES

7. TheOrbit

OVERVIEW

OSSEOUSRELATIONSHIPS

PERIORBITA,DURA, AND ANNULAR TENDON

NEURALRELATIONSHIPS

Optic Nerve

Oculomotor,Trochlear, and Abducens Nerves

TrigeminalNerve

CiliaryGanglion

SympatheticFibers

VidianNerve and Pterygopalatine Ganglion

ARTERIALRELATIONSHIPS

InternalCarotid Artery

OphthalmicArtery

VENOUSRELATIONSHIPS

MUSCULARAND TENDINOUS RELATIONSHIPS

SURGICALCONSIDERATIONS

OrbitofrontalCraniotomy

The MedialOrbitofrontal Approach

The CentralOrbitofrontal Approach

The LateralOrbitofrontal Approach

LateralWall Approach (Sphenozygomatic Approach)

TransmaxillaryApproach

MedialOrbital and Transethmoidal Approaches

REFERENCES

8. TheSellar Region

SUBCRANIALRELATIONSHIPS

NasalCavity

SphenoidBone

SphenoidSinus

DiaphragmaSellae

PituitaryGland

PituitaryGland and Carotid Artery

IntercavernousVenous Connections

CavernousSinus

SUPRASELLARAND THIRD VENTRICULAR REGION

Ventricularand Cisternal Relationships

CranialNerves

OpticChiasm

OculomotorNerve

TrochlearNerve

AbducensNerve

TrigeminalNerve

ArterialRelationships

VenousRelationships

DISCUSSIONAND OPERATIVE APPROACHES

SublabialTranssphenoidal Approach

TransseptalApproach

EndonasalApproach

Managementof Sphenoid Sinus and Sella

SubfrontalExposure of the Suprasellar Region

REFERENCES

9. TheCavernous Sinus, the Cavernous Venous Plexus, and the Carotid Collar

THE SINUS

OSSEOUSRELATIONSHIPS

Anteriorand Middle Clinoid Processes

Optic Strut

DURALRELATIONSHIPS

CarotidCollar

NEURALRELATIONSHIPS

CAVERNOUSSINUS AND MIDDLE FOSSA TRIANGLES

CavernousSinus Triangles

OculomotorTriangle

SupratrochlearTriangle

InfratrochlearTriangle (Parkinsons Triangle)

MiddleFossa Triangles

AnterolateralMiddle Fossa Triangle

PosterolateralMiddle Fossa Triangle (Glasscocks Triangle)

PosteromedialMiddle Fossa Triangle (Kawases Triangle)

ParaclinoidTriangles

InferomedialParaclival Triangle

ARTERIALRELATIONSHIPS

OphthalmicArtery

IntracavernousBranches

VENOUSRELATIONSHIPS

IntercavernousSinus

ClinoidVenous Space

DISCUSSION

OperativeConsiderations

REFERENCES

PART 3: ThePosterior Cranial Fossa: Microsurgical Anatomy and Surgical Approaches

1.Cerebellum and Fourth Ventricle

CEREBELLARSURFACES

Tentorial surface

Suboccipital surface

Petrosal surface

THE FOURTHVENTRICLE AND THE CEREBELLAR-BRAINSTEM FISSURES

Fourthventricle

Upperventricular roof and the cerebellomesencephalic fissure

Lower roofand cerebellomedullary fissure

LATERALRECESS AND CEREBELLOPONTINE FISSURE

CHOROIDPLEXUS

BRAINSTEMAND FLOOR

Brainstem

Floor

VASCULARRELATIONSHIPS

DISCUSSION

Effects ofneural injury

Telovelarapproach to fourth ventricle

REFERENCES

2. TheCerebellar Arteries

THESUPERIOR CEREBELLAR ARTERY

Overview

Segments

Anteriorpontomesencephalic segment

Lateralpontomesencephalic segment

Cerebellomesencephalicsegment

Corticalsegment

Origin

Bifurcation

Branches

Precerebellarbranches

Corticalarteries

Hemisphericarteries

Vermianarteries

Marginalbranch

Relationshipto the cranial nerves

Oculomotornerve

Trochlearnerve

Trigeminalnerve

Relationshipto the tentorium cerebelli

DISCUSSION

Operativeexposure

ANTEROINFERIORCEREBELLAR ARTERY

Overview

Segments

Anteriorpontine segment

Lateralpontine segment

Flocculopeduncularsegment

Corticalsegment

Origin

Bifurcation

Nerve-relatedbranches

Premeatalsegment

Meatalsegment

Subarcuateloop

Postmeatalsegment

Branches ofnerve-related AICAs

Labyrinthine(internal auditory) arteries

Recurrentperforating arteries

Subarcuateartery

Cerebellosubarcuateartery

Corticalbranches

DISCUSSION

Operativeexposure

POSTEROINFERIORCEREBELLAR ARTERY

Overview

Segments

Anteriormedullary segment

Lateralmedullary segment

Tonsillomedullarysegment

Telovelotonsillarsegment

Corticalsegment

The PICAorigin and the vertebral artery

Bifurcation

Branches

Perforatingarteries

Choroidalarteries

Corticalarteries

Hemisphericbranches

Vermianarteries

Tonsillarbranches

Relationshipto the cranial nerves

Hypoglossalrootlets

Glossopharyngeal,vagus, and accessory nerves

Facial andvestibulocochlear nerves

DISCUSSION

Occlusion

Operativeexposure

REFERENCES

3. ThePosterior Fossa Veins

THEPOSTERIOR FOSSA VEINS

Superficialveins

Deep veins

Veins ofthe brainstem

Bridgingveins and major draining groups

SUPERFICIAL VEINS

Tentorial surface

Superior vermian veins

Superior hemispheric veins

Suboccipital surface

Inferior vermian veins

Inferior hemispheric veins

Retrotonsillar veins

Medial and lateral tonsillar veins

Petrosal surface

Anterior hemispheric veins

DEEP VEINS

Cerebellomesencephalicfissure

Vein of thesuperior cerebellar peduncle

Vein of thecerebellomesencephalic fissure

Pontotrigeminalvein

Tectalveins

Cerebellomedullaryfissure

Vein of thecerebellomedullary fissure

Vein of theinferior cerebellar peduncle

Supratonsillarveins

Choroidalveins

Cerebellopontinefissure

Vein of thecerebellopontine fissure

Vein of themiddle cerebellar peduncle

VEINS OFTHE BRAINSTEM

Longitudinalveins

Median anterior medullary vein

Lateral anterior pontomesencephalicvein

Lateral anterior medullary vein (preolivary vein)

Lateralmesencephalic vein

Lateralmedullary and retro-olivary veins

Transverselyoriented veins

Posteriorcommunicating vein

Vein of thepontomesencephalic sulcus

Transversepontine veins

Vein of thepontomedullary sulcus

Transversemedullary veins

MAJORDRAINING GROUPS

Galenicdraining group

Tentorialdraining group

Petrosaldraining group

Otherbridging veins

DISCUSSION

REFERENCES

4. TheCerebellopontine Angle and Posterior Fossa Cranial Nerves by the RetrosigmoidApproach

UPPERNEUROVASCULAR COMPLEX

Trigeminalroot anatomy

Anatomy ofvascular compression in the upper neurovascular complex

Venousrelationships

Suprameatalextension of the retrosigmoid approach

MIDDLENEUROVASCULAR COMPLEX

Anatomy ofacoustic neuromas

Meatalrelationships

Brainstemrelationships

Summary:Anatomy of acoustic neuromas

Anatomy ofvascular compression in the middle neurovascular complex

Cochlearand vestibular nerve compression syndromes

Geniculateneuralgia

LOWERNEUROVASCULAR COMPLEX

Neuralrelationships

Anatomy ofglossopharyngeal neuralgia

Vascularrelationships

Vascularcompression in the lower neurovascular complex

Tumorsinvolving multiple neurovascular complexes

REFERENCES

5.Tentorial Incisura

ANATOMY OFTHE TENTORIUM

TENTORIALINCISURA

ANTERIORINCISURAL SPACE

Neuralrelationships

Cisternalrelationships

Ventricularrelationships

Cranialnerves

Arterialrelationships

Venousrelationships

MIDDLEINCISURAL SPACE

Neuralrelationships

Cisternalrelationships

Ventricularrelationships

Cranialnerves

Arterialrelationships

Venousrelationships

POSTERIORINCISURAL SPACE

Neuralrelationships

Cisternalrelationships

Ventricularrelationships

Arterialrelationships

Venousrelationships

Tentorialarteries

DISCUSSION

Tentorialherniation

Pathologyand operative approaches

Anteriorincisural space

Middleincisural space

Posteriorincisural space

Comparisonof occipital transtentorial and infratentorial supracerebellar approaches

REFERENCES

6. TheForamen Magnum

THE FORAMENMAGNUM

Osseousrelationships

Occipitalbone

The atlas

The axis

Theatlantoaxial joints

Theatlanto-occipital joints

Axis andoccipital bone

Muscularrelationships

Neuralrelationships

Spinal cord

Dentateligament

Brainstem

Cerebellum

Cranialnerves

Cervicalnerve roots

Arterialrelationships

Vertebralartery

Posteriorspinal artery

Posteroinferiorcerebellar artery

Anteriorspinal artery

Meningealarteries

Venousrelationships

Extraduralgroups

Duralvenous sinuses

Intradural(neural) veins

DISCUSSION

Herniations

Tumors

Surgicalapproaches

Posteriorapproaches

Anterioroperative approaches

Transoralapproaches

Transmaxillaryapproach

Transsphenoidalapproach

Transcervicalapproach

Transcranial-transbasalapproach

Extendedfrontal approach

Selectionof operative approach

REFERENCES

7. TheFar-lateral Approach and Its Transcondylar, Supracondylar, and ParacondylarExtensions

STAGES OFAPPROACH

Muscularstage

Musculardissection

Vascularstructures

Osseousstructures

Neuralstructures

Extraduralstage

Intraduralstage

DISCUSSION

REFERENCES

8. TheTemporal Bone and Transtemporal Approaches

THETEMPORAL BONE AND TRANSTEMPORAL APPROACHES

Lateralsurface

Thetympanic part

Thesquamous part

The mastoidpart

The petrouspart

Petroclivalregion

Theinferior petroclival space

The middlepetroclival space

Thesuperior petroclival space

Adjacentstructures

Infratemporalfossa

Parapharyngealspace

Pterygopalatinefossa

Arterialrelationships

Commoncarotid artery

Externalcarotid artery

Vertebralartery

Venousrelationships

SURGICALAPPROACHES

Middlefossa approach

Subtemporalanterior transpetrosal approach

Translabyrinthineapproach

Transcochlearapproach

Combinedsupra- and infratentorial presigmoid approach

Subtemporalpreauricular infratemporal fossa approach

Postauriculartranstemporal approach

DISCUSSION

REFERENCES

9. JugularForamen

OSSEOUSRELATIONSHIPS

ADJACENTBONY STRUCTURES

Duralarchitecture

Neuralrelationships

Accessorynerve

Hypoglossalnerve

ARTERIALRELATIONSHIPS

Internalcarotid artery

Externalcarotid artery

Vertebralartery

VENOUSRELATIONSHIPS

Sigmoid sinusand jugular bulb

Inferiorpetrosal sinus and venous confluens

Bridging veins

MUSCULAR RELATIONSHIPS

SURGICAL APPROACHES

Postauricular transtemporalapproach

Retrosigmoid approach

Far-lateral approach

Preauricular subtemporal-infratemporalapproach

DISCUSSION

Pathologies

Selection ofsurgical approach

Lateral approach

Posterior approach

Anterior approach

REFERENCES

10. The Posterior Fossa Cisterns

INTERPEDUNCULAR CISTERN AND LILIEQUISTS MEMBRANE

PREPONTINE CISTERN

CEREBELLOPONTINE CISTERN

PREMEDULLARY CISTERN

CEREBELLOMEDULLARY CISTERN

CISTERNA MAGNA

QUADRIGEMINAL CISTERN

SUPERIOR CEREBELLAR CISTERN

DISCUSSION

REFERENCES

Subject Index