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Anatomy and Radiology of the Anterior Inferior Cerebellar Artery

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Anatomy and Radiology of the Anterior Inferior Cerebellar Artery Anatomy and Radiology of the Anterior Inferior Cerebellar Artery INIS-mf —10469 J.J. Heimans Vrije Universiteit te Amsterdam ANATOMY AND RADIOLOGY OF THE ANTERIOR INFERIOR CEREBELLAR ARTERY Academisch proefschrift ter verkrijging van de graad van doctor in de geneeskunde aan de Vrije Universiteit te Amsterdam, op gezag van de rector magnificus dr. P.J.D. Drenth, hoogleraar in de faculteit der sociale wetenschappen, in het openbaar te verdedigen op vrijdag 30 september 1983 te 13.30 uur in het hoofdgebouw der universiteit, De Boelelaan 1105 door JAN JACOB HEIMANS geboren te 's-Gravenhage AMSTERDAM 1983 Promotor : Prof. dr. J. Valk Copromotor : Prof. dr. A.H.M. Lohman Referent : Prof. dr. J.H.A. van der Drift STELLINGEN 1. Bij een aangetoonde brughoektumor dient pre-operatief een verte- bralisangiografie verricht te worden. 2. Een acusticusneurinoom wordt vaak mede gevasculariseerd door takken van de arteria carotis externa. Pre-operatieve carotis externa angiografie aan de zijde van de tumor verdient daarom aanbeveling. 3. In de meeste gevallen waarin er een sterk ontwikkelde caudomediale tak van de arteria cerebelli anterior inferior bestaat is de arteria cerebelli posterior inferior afwezig. 4. De arteria auditiva interna, gedefinieerd als een arterie die uitsluitend het binnenoor vasculariseert, ontspringt nooit direkt aan de arteria basilaris. 5. Het laterale medulla oblongata syndroom (of syndroom van Wallen- berg) treedt vrijwel altijd op als gevolg van een afsluiting van de arteria vertebralis en niet van de arteria cerebelli posterior inferior. 6. Geslachtsgebonden overerving kan zowel bij het hypertrofische type als bij het axonale type van het syndroom van Charcot-Marie-Tooth (Hereditary Motor and Sensory Neuropathy, type I en II) voorko- men. 7. Bij patiënten die na een schedeltrauma worden beademd dient terughoudendheid betracht te worden met het gebruik van Etomi- date. 8. Het toedienen van een aldose-reductase-remmer aan patiënten met een diabetische polyneuropathie is een rationele behandeling en de waarde van deze therapie voor de praktijk dient verder onderzocht te worden. 9. Er is tot nu toe onvoldoende onderzoek gedaan naar het effect van combinatie chemotherapie op het cervixcarcinoom stadium III en IV. 10. Cursorisch onderwijs in de neuroanatomie en daarbij aansluitend in de neuroradiologie moet een verplicht onderdeel gaan vormen van de opleiding tot neuroloog. 11. Een onderschildering in ei- of caseïnetempera biedt grote voordelen, mits daarna in een glacerende olieverftechniek wordt gewerkt. 12. Een medische faculteit die zich moet gaan toeleggen op onderzoek in de zogenaamde eerstelijns gezondheidszorg is in dezelfde positie als een symfonieorkest waar alleen nog het slagwerk mag worden bespeeld. "What's the good of Mercator's North Poles and Equators, Tropics, Zones and Meridian Lines?" So the Bellman would cry: and the crew would reply, "They are merely conventional signs!" LEWIS CAROLL from: The Hunting of the Snark. VOOR HESTER WOORD VAN DANK Dit proefschrift is dankzij de hulp van velen tot stand gekomen en ik realiseer mij achieraf pas goed, hoe gemakkelijk ik — als gast — toegang had tot de afdeling Anatomie en de afdeling Neuroiadiologie. Mijn promotoi, prof. dr. J. Valk, ben ik dankbaar voor zijn creatieve en inspirerende inzet. Zijn optimisme heeft mij vaak gesteund op momenten, dat ik meende vastgelopen te zijn. De angiografieën werden door hem en door F.C. Crezée (als neuroradioloog verbonden aan de Valeriuskliniek) vervaardigd. Zonder de hulp van mijn copromotor, prof. dr. A.H.M. Lohman, was dit proefschrift nooit voltooid. Hem ben ik dankbaar voor de vele uren, die hij heeft geïnvesteerd in het kritisch doornemen van het manuscript, waarbij hij voor geringe details aandacht had, zonder de grote lijnen uit het oog te verliezen. Prof. dr. J.H.A. van der Drift maakte vele nuttige kanttekeningen en heeft mij vanaf het begin van het onderzoek gestimuleerd. De medewerkers van de afdeling Anatomie, met name de heren C. van der Hout, D. de Jong, J.F. Olijhoek, F. ter Riet en S.H. Speelman, dank ik voor hun enthousiaste hulp en voor het geduld dat ze hebben gehad tijdens het tot stand komen van het anatomische deel van de studie. Dirk de Jong was bovendien op vakkundige wijze behulpzaam bij het afwer- ken van de illustraties, wat hij snel en met een door niets te beïnvloeden opgewektheid deed. Alle medewerkers van de afdeling Neuroradiologie ben ik dankbaar voor hun steun en medewerking. Annemieke Bredius heeft mij bij het verzamelen en selecteren van de vele röntgenfoto's en patiëntengegevens geweldig bijgestaan en was steeds meer in staat om orde te scheppen in de chaos, die door mij werd aangericht. Els van Deventer dank ik voor haar hulp bij het verzamelen van de literatuur, die voor een groot deel niet binnen handbereik lag. I am indebted to Melanie Stiaszny for her dedicated help in reviewing the manuscript. Els Zijlstra dank ik voor het snelle en nauwgezette uittypen van het manuscript. De patiëntengegevens waren afkomstig van de afdeling Neurologie van de Valeriuskliniek en van de afdeling Neurochirurgie van het AZVU en konden snel worden verzameld dankzij de adequate hulp van de mede- werkers van deze afdelingen. De medewerkers van de Audiovisuele Dienst van het AZVU, met name Leo Cremers en Co van Ederen, dank ik voor hun vakkundige hulp. De stafleden en assistenten van de afdeling Neurologie en de medewerkers van de neurologische polikliniek van het AZVU ben ik dankbaar voor hun bemoedigende belangstelling. Al diegenen, die hebben bijgedragen tot mijn opleiding tot arts en neuroloog, en dat zijn niet in de laatste plaats mijn ouders geweest, wil ik hierbij mijn dank betuigen. Tot slot wil ik Diny bedanken voor haar voortdurende steun tijdens alle fasen van het tot stand komen van deze studie en Hester, voor wie dit boek is en die later de plaatjes mag kleuren, voor haar stimulerende aanwezigheid tijdens de laatste fase van het ontstaan van dit proefschrift. CONTENTS CHAPTER 1. INTRODUCTION 1 CHAPTER 2. ANATOMY 3 Review of the literature 3 General description of the arteries of the posterior cranial fossa 3 Detailed description of the anterior inferior cerebellar artery 6 Origin 6 Multiplication of the AICA 7 Absence of the AICA 8 The course of the AICA in relation to the abducens nerve 8 Relation of the AICA with the facial and vestibulo- cochlear nerves and the internal auditory meatus 9 Branches of the AICA 10 Variations of the AICA 13 Areas of supply 13 Anastomoses between the AICA and other cerebellar arteries 14 Injection study of the vertebrobasilar arteries 15 Materials and methods 15 Results 16 Discussion 30 CHAPTER 3. RADIOLOGY 35 Review of the literature 35 Visualization of the vertebrobasilar system 35 Subtraction 36 The AICA in vertebral angiography 37 Projection 41 The AICA in posterior fossa tumours — general aspects 42 The AICA in cerebellopontine angle tumours 43 The AICA in cerebellar tumours 47 The AICA in brain stem tumours 48 The AICA in vertebrobasilar ischemic lesions 48 Analysis of normal and abnormal angiograms 51 Materials and methods 51 Results 54 The AICA in 100 normal vertebral angiograms 54 The AICA in cerebellopontine angle tumours 58 The AICA in cerebellar tumours 59 The AICA in brain stem tumours 59 The AICA in ischemic lesions 60 Illustrations 61 Discussion 95 CHAPTER 4. SUMMARY 101 SAMENVATTING 104 REFERENCES 107 ABBREVIATIONS 115 CHAPTER 1 INTRODUCTION The anterior inferior cerebellar artery (AICA) is one of the major bran- ches of the basilar artery and supplies part of the pons, the upper medulla and the cerebellar hemisphere. The artery can be visualized by means of vertebral angiography. This technique of examination was carried out for the first time in 1933 by Moniz et al. During the decades that followed angiographic techniques improved considerably with the result that more details of the angio-architecture of the posterior cranial fossa could be demonstrated. Satisfactory visualiza- tion of the AICA and its branches depends greatly on the use of subtraction, and this is the reason why detailed reports on the angio- graphic appearance of the artery were for the greater part published after 1965 when subtraction techniques were more consistently used (Taka- hashi et al. 1968, 1974; Gerald et al, 1973). The angiographic appearance of the various segments of the AICA in the lateral projection, both in the normal situation and in the presence of tumours, has been studied by Naidich et al (1976). The primary aim was to recognize and denominate the separate branches, loops and segments of the AICA in order to locate tumours on the basis of displacements of portions of the artery. The large variability of the AICA, as regards course, calibre and distribution, was not emphasized. Since the introduction of computed tomography (CT) the localizing role of vertebral angiography is of less importance. However, in cases in which operation on posterior fossa tumours is considered, angiography offers essential information by revealing both the vascularization of the tumour and the relationship of the tumour and major arteries, thus reducing the chance of damage to the AICA which may occur during cerebellopontine angle surgery. Such damage may result in lateral pontine infarction. During the last years several reports have been published on extra- intracranial bypass operations in patients suffering from occlusive disease in the vertebrobasilar system (Khodadad et al, 1977; Sundt et al, 1978; Ausman et al, 1979, 1981). Also in these cases thorough knowledge of the variations in the course and distribution of the posterior fossa arteries is of great practical importance. The aim of the present study is to describe the variations of the AICA and to identify its types of appearance in normal angiograms as well as in angiograms of patients suffering from posterior fossa tumours or from ischemic lesions in the vertebro-basilar territory. For this purpose a study of 20 normal specimens was undertaken.
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