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Cisterns 360°

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Cisterns 360°

  1. 1. Cisterns 360° 7-5-2016 12.24 pm
  2. 2. Great teachers – All this is their work . I am just the reader of their books . Prof. Paolo castelnuovo Prof. Aldo Stamm Prof. Mario Sanna Prof. Magnan
  3. 3. For Other powerpoint presentatioins of “ Skull base 360° ” I will update continuosly with date tag at the end as I am getting more & more information click www.skullbase360.in - you have to login to slideshare.net with Facebook account for downloading.
  4. 4. Oculomotor cistern
  5. 5. Oculomotor cistern Cranial nerve III enters the roof included in its own cistern (oculomotor cistern). Oculomotor cistern goes upto anterior clinoid tip
  6. 6. LT lamina terminalis cistern= Suprachiasmatic cistern
  7. 7. LT lamina terminalis cistern – The lamina terminalis cistern is situated above the optic chiasm (Martins etal. 2011 ) . Within this cistern, A1 and A2, as well as the anterior communicating artery and the first part of the recurrent artery of Heubner, are evident.
  8. 8. The space between a & oc is Lamina terminalis Neuroendoscopic view of the third ventricle floor-----Infundibular recess (i), optic chiasm (oc) and a prominent anterior commissure (a) are seen anterior to the opaque and narrow tuber cinereum (t). B Neuroendoscopic view of the third ventricle floor in another myelomeningocele patient. A non-transparent tuber cinereum (t) and a dilated infundibular recess (i) are seen anterior to the mamillary bodies (m). Note to the vascular structure of the third ventricle floor. cNeuroendoscopic view showing a steep third ventricle floor in a myelomeningocele patient. A narrow tuber cinereum (t) is visible just anterior to the mamillary bodies (m). dNeuroendoscopic view through a very narrow prepontine cistern. Note the close proximity of the basillary artery (ba) and clivus (cl)
  9. 9. Endoscopic third ventricle from posteriorly -- a. Infundibular recess b. tuber cinereum c. mammillary bodies left posterior communicating artery (a), mammillary body (b), and right posterior hypoplasic communicating artery (c) --- measurement performed between the posterior communicating arteries using Geogebra software (a-b = 11.3 mm),
  10. 10. Endoscopic third ventricle from posteriorly -- a. Infundibular recess b. tuber cinereum c. mammillary bodies From front – through lamina terminalis
  11. 11. In the descriptive analysis of the 20 specimens, the PCoAs distance was 9 to 18.9 mm, mean of 12.5 mm, median of 12.2 mm, standard deviation of 2.3 mm.
  12. 12. Optic chiasma – infundibulum – Mamillary bodies
  13. 13. Chiasmatic cistern
  14. 14. The AcomA complex is usually above the optic chiasm (70 % of cases) (Rhoton 2003 ) . The AcomA is similar to the textbook description in three- fourths of cases. In about 10 % of cases, it can be hypoplastic or even duplicated and triplicated (Lang 1995 ) . • 1. Supra-chiasmatic cistern = LT lamina terminalis cistern • 2. Chiasmatic cistern • 3. Sub -chiasmatic cistern
  15. 15. Chiasmatic cistern
  16. 16. 1. The transplanum route may also facilitate exposing the anterior incisural space. On the center of this space the chiasm helps separate the two major cisternal compartments. Below the chiasm is the chiasmatic cistern, and above it is the center of the lamina terminalis cistern. 2. The pituitary stalk and superior hypophyseal arteries are located into the chiasmatic cistern.
  17. 17. Below the OT & A1 you will see PComA Endoscopic view of the anterior part of the Left Suprasellar area [ = Sub- Chiasmatic Cisttern ] . A1 first segment of the anterior cerebral artery, AChA anterior choroidal artery, GR gyrus rectus, ICA internal carotid artery, OC optic chiasm, ON optic nerve, OT optic tract, PCoA posterior communicating artery, PG pituitary gland, PitS pituitary stalk, MB midbrain, U uncus
  18. 18. Chiasmatic cistern – The chiasmatic cistern is located in front of the optic chiasm and above the sella turcica. In the lateral border of the chiasmatic cistern the first part of the ICAi is visible. lt ICA SEEN ON LT SIDE.. A HOLE IN THE ARACHNOID.. THE STALK JUST BEHIND IT.. THE DIAPHRAGM SEEN IN 5/6 O CLOCK POSITION..
  19. 19. CSF rhinorrhoea case Closed with hadad flap lt ICA SEEN ON LT SIDE.. A HOLE IN THE ARACHNOID.. THE STALK JUST BEHIND IT.. THE DIAPHRAGM SEEN IN 5/6 O CLOCK POSITION..
  20. 20. Sub-chiasmatic cistern = Supra sellar area = Supr-sellar cistern
  21. 21. Observe here the Pcom (here labelled as ACoP in some language ) is parallel to 3rd nerve in infrachiasmatic cistern . Excellent photo . Other points to note 1. 3rd nerve sandwitched between posterior cerebral artery & superior cerebellar artery . 2. On the left side 2 superior cerebellar arteries present from the origin itself. 3. Diameter of Pcom varies on two sides. 4. Infra-chiasmastic cistern is nothing but suprasellar area Lillequit’s membrane
  22. 22. Within the medial part of the carotid cistern a tremendous arterial network given by the superior hypophyseal arteries, the infundibular arteries and perforating branches from the internal carotid artery is visible. The superior hypophyseal arteries and infundibular arteries (from the posterior communicating artery) form a complex network around the pituitary stalk, named circuminfundibular plexus (Rhoton 2003 ) . This plexus gives rise to descending (for the anterior lobe of PG) and ascending (for tuber cinereum, median eminence and inferior surface of optic chiasm) branches (Rhoton 2003 ) . CP circuminfundibular plexus, ICAi intracranial portion of the internal carotid artery, OT optic tract, PCP posterior clinoid process, PG pituitary gland, PS pituitary stalk, SHA superior hypophyseal artery, black arrow indicates the direction of the view (as seen in the bigger picture)
  23. 23. Retrosellar
  24. 24. Interpeduncular cistern [= basal cistern ]
  25. 25. Interpeduncular cistern
  26. 26. Interpeduncular cistern IR = infundibulum
  27. 27. Endoscope-assisted microsurgery [ 45° endoscope in a corridor between the carotid artery and the oculomotor nerve ]-- Fig. 4.12 Intradural exposure; right approach; microsurgical (a) and endoscopic (b–d) views. AchA anterior choroidal artery, BA basilar artery, C clivus, FL frontal lobe, ICA internal carotid artery, III oculomotor nerve, ON optic nerve, P1 first segment of the posterior cerebral artery, P2 second segment of the posterior cerebral artery, PC posterior clinoid, PCA posterior cerebral artery, PcoA posterior communicating artery, SCA superior cerebellar artery, TE tentorial edge, TL temporal lobe, Tu thalamoperforating artery; green dotted triangle area for entry of the endoscope into the interpeduncular fossa
  28. 28. Cadaveric dissection image demonstrating the close anatomical relationship of the posterior clinoid (PC) with both the intracranial carotid artery (ICCA) and the posterior genu of the intracavernous carotid artery (P. CCA). AL, anterior lobe of the pituitary gland; PL, posterior lobe of the pituitary gland; BA, basilar artery. green dotted triangle area for entry of the endoscope into the interpeduncular fossa
  29. 29. Posteior clinoid can be approached in optico-carotid triangle [ 3mm ] OR lateral carotid triangle
  30. 30. Posteior clinoid can be approached in optico-carotid triangle [ 3mm ] OR lateral carotid triangle
  31. 31. Pcom is seen in optico-carotid triangle – can be injured in cisternostomy while cutting lillequet membrane
  32. 32. Interpeduncular cistern -- Removal of the upper clivus (dorsum sella and posterior clinoids) provides an excellent view of the interpeduncular cistern Once the gland has been completely dissected from the surrounding dura, the pituitary aperture or diaphragm should be transected along with the superior intercavernous sinus. This allows the transposition of the gland into the suprasellar space, between the optic nerves. This maneuver exposes the dorsum sella and posterior clinoids that can now be safely removed. An osteotomy between the dorsum sella and the posterior clinoids is advised to avoid excessive traction while removing the clinoid, which can be risky for the third nerve and carotid artery.
  33. 33. Right supraorbital approach (30 optic). Window between cn II and ICA: 1 left PCoA, 2 left P2, 3 left cn III, 4 left P1, 5 left SCA, 6 BA, 7 doubled right SCA, 8 right cn III, 9 right P1, 10 mammillary bodies, 11 tuber cinereum, 12 right PCoA, 13 right M1.* sucker
  34. 34. Mammillary bodies Without removing the DS , Subchiasmatic view downwards After removing the DS & midclivus
  35. 35. ENDOSCOPIC ENDONASAL PITUITARY TRANSPOSITION FOR A TRANSDORSUM SELLAE APPROACH TO THE INTERPEDUNCULAR CISTERN http://www.ncbi.nlm.nih.gov/pubmed/1842496 8 - get paper at www.sci-hub.io
  36. 36. I think we can reach the prepontine area/ interpedincular cistern by retrolabyrinthine approach [ presigmoid ] without doing 1. posterior clinoidectomy in pterional approach 2. Pituitary transposition in anterior skull base
  37. 37. From paper http://www.ncbi.nlm.nih.gov/pubmed/18424968 - get paper at www.sci-hub.io
  38. 38. posterior clinoidectomy by middle cranial fossa approach needs lot of training – see in this cisternostomy video https://www.youtube.com/watch?v=vNaEFMrdgfw . I think we can reach the prepontine area without doing posterior clinoidectomy by retrolabyrinthine approach [ presigmoid ] which is easier than posterior clinoidectomy to learn . we can do endoscopic retrolabyrinthine [ endoscoopic presigmoid ] approach to reach prepontine – to understand retrolabyrinthine [ = presigmoid ] approach click http://www.slideshare.net/muralichandnallamothu/cp- angle-360 Retrolabyrinthine Subtemporal Transapical Approach Retrolabyrinthine Subtemporal Transtentorial Approach
  39. 39. cisternostomy in head injury video – by Dr. Iype Cherian - click https://www.youtube.com/watch?v =vNaEFMrdgfw and https://youtu.be/NLTm8-rHzAA
  40. 40. For Other powerpoint presentatioins of “ Skull base 360° ” I will update continuosly with date tag at the end as I am getting more & more information click www.skullbase360.in - you have to login to slideshare.net with Facebook account for downloading.

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