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Subarachnoid cisterns

Subarachnoid cisterns are enlarged, fluid-filled compartments within the subarachnoid space of the brain and spinal cord, formed by the separation of the arachnoid mater from the pia mater due to the irregular contours of the brain's surface.^[1] These cisterns contain cerebrospinal fluid (CSF), which cushions the central nervous system, along with major arteries, veins, and cranial nerves that traverse them.^[1] They play a critical role in the circulation of CSF, produced at a rate of approximately 0.3 mL per minute with a total volume of about 150 mL in the subarachnoid space, facilitating nutrient delivery, waste removal, and pressure equalization within the intracranial cavity.^[1] The subarachnoid space, including its cisterns, is bounded by the arachnoid mater superiorly and the pia mater inferiorly, with delicate connective tissue trabeculae bridging the gap to provide structural support for neurovascular elements.^[1] Key cisterns include the cisterna magna (cerebellomedullary cistern), the largest at the posterior cranial fossa between the cerebellum and medulla oblongata; the pontine cistern anterior to the pons; the interpeduncular cistern at the base of the midbrain between the cerebral peduncles; the suprasellar cistern surrounding the optic chiasm and pituitary infundibulum; the Sylvian cistern (cisternal operculum) lateral to the brainstem along the Sylvian fissure; the cistern of the lamina terminalis anterior to the third ventricle; the superior cistern (quadrigeminal cistern) posterolateral to the midbrain; the cerebellopontine angle cistern at the lateral junction of the pons and cerebellum; and the lumbar cistern in the lower spinal canal.^[1] These structures interconnect via narrow channels, allowing free CSF flow while compartmentalizing vascular and neural pathways.^[1] Clinically, subarachnoid cisterns are significant in neuroimaging and pathology, as they are common sites for blood accumulation in subarachnoid hemorrhage (SAH), often visualized on non-contrast CT scans as hyperdense material leading to symptoms like thunderclap headache and requiring urgent intervention.^[1] They also relate to conditions such as hydrocephalus, where CSF obstruction alters cistern distension, and papilledema from elevated intracranial pressure, which transmits via the optic nerve sheath within the subarachnoid space.^[1] Understanding cistern anatomy aids in neurosurgical approaches, such as for aneurysm clipping or tumor resection, where preservation of these spaces prevents complications like vasospasm or ischemia.

Anatomy

General structure

Subarachnoid cisterns are defined as enlarged compartments within the subarachnoid space, where the arachnoid mater and pia mater separate more widely than in surrounding areas, creating pockets filled with cerebrospinal fluid (CSF). These cisterns form part of the broader subarachnoid space, which lies between the arachnoid and pia mater layers of the meninges surrounding the brain and spinal cord.^[1] The composition of subarachnoid cisterns includes boundaries formed by delicate arachnoid trabeculae—thin connective tissue strands that span the space—along with the pia mater adhering closely to underlying brain structures and the arachnoid mater forming the outer limit. These spaces are filled with CSF and accommodate major cerebral blood vessels, providing a cushioning environment. Histologically, the walls of some cisterns feature arachnoid granulations, which are protrusions of arachnoid cells into the dural venous sinuses facilitating CSF absorption.^[1] Subarachnoid cisterns develop during early embryonic stages through the differentiation and separation of meningeal layers derived from the primary meninx. By embryonic stage 14 (approximately 33 days post-fertilization), irregular cavities emerge as primordia of the subarachnoid space, initially on the ventral surface of the spinal cord and expanding around the brain following neural tube closure during the third and fourth weeks of embryonic development (approximately days 21-28 post-fertilization). Subarachnoid spaces become evident around day 32, with CSF circulation beginning around day 41, and the cisterns coalescing into distinct enlarged pockets by stages 19–23 (46–56 days), influenced by the irregular contours of the brainstem, cerebellum, and base of the brain.^[1]^[2]^[3] Spatially, subarachnoid cisterns are primarily located at the base of the brain, encircling the brainstem and cerebellum while surrounding major blood vessels such as the circle of Willis. They interconnect through continuous subarachnoid pathways, allowing communication across the cranial and spinal regions and contributing to the overall distribution of CSF.^[1]

Individual cisterns

The cisterna magna (cerebellomedullary cistern), represents the largest subarachnoid cistern and is situated in the midline posterior to the medulla oblongata, beneath the cerebellum and above the foramen magnum.^[1] It is bounded anteriorly by the medulla, posteriorly by the cerebellar tonsils and vermis, laterally by the cerebellar hemispheres, and inferiorly by the occipital bone near the foramen magnum.^[4] This cistern contains the vertebral arteries, the posterior inferior cerebellar artery (PICA) in its third through fifth segments, the glossopharyngeal nerve (CN IX), vagus nerve (CN X), accessory nerve (CN XI), hypoglossal nerve (CN XII), inferior vermian vein, and medial posterior medullary vein.^[5] It receives cerebrospinal fluid (CSF) from the fourth ventricle via the foramen of Magendie and communicates superiorly with the superior cerebellar cistern.^[5] The pontine cistern lies anterior to the pons at the pontocerebellar angle, encasing the ventral aspect of the brainstem.^[5] Its boundaries include the clivus anteriorly, the pons posteriorly, the interpeduncular cistern superiorly, and the premedullary cistern inferiorly, with a superior limit formed by the superior cerebellar membrane separating it from the ambient cistern.^[4] Contents of this cistern encompass the basilar artery and its plexus, the anterior inferior cerebellar artery (AICA), superior cerebellar artery, abducens nerve (CN VI), facial nerve (CN VII), vestibulocochlear nerve (CN VIII), and portions of cranial nerves IV, IX, X, XI, and XII, along with the superior petrosal vein.^[5] It receives CSF from the lateral apertures (foramina of Luschka) of the fourth ventricle.^[1] The cerebellopontine angle cistern is located at the lateral angle between the pons and cerebellum.^[1] It contains the trigeminal nerve (CN V), facial nerve (CN VII), vestibulocochlear nerve (CN VIII), and anterior inferior cerebellar artery.^[1] The interpeduncular cistern occupies the interpeduncular fossa, a conical space anterior to the midbrain within the tentorial notch.^[5] It is bounded anteriorly by the sella turcica, pituitary stalk, and optic chiasm; its roof consists of the inferior mesencephalon, lower diencephalon, and mammillary bodies; the floor is formed by the medial and lateral pontomesencephalic membranes; and laterally it connects to the ambient cisterns, with Liliequist's membrane separating it posteriorly from the chiasmatic cistern.^[5] Key contents include the bifurcation of the basilar artery, peduncular segments of the posterior cerebral artery (PCA) and superior cerebellar artery (SCA), thalamogeniculate arteries, medial and lateral posterior choroidal arteries, basal vein of Rosenthal, and oculomotor nerve (CN III).^[1] This cistern serves as a convergence point for supratentorial and infratentorial subarachnoid spaces.^[5] The chiasmatic cistern, located in the midline superior to the sella turcica, surrounds the anterior aspect of the optic chiasm between the uncus of the temporal lobes and beneath the hypothalamus.^[5] Its boundaries feature communication superiorly with the cistern of the lamina terminalis, anterolaterally with the Sylvian cistern, and posteriorly with the interpeduncular cistern via the Liliequist membrane.^[5] It contains the optic nerves (CN II), optic chiasm, hypophyseal stalk, perforating branches of the internal carotid artery, superior hypophyseal artery, infundibular artery, and optic venous plexus.^[1] The cistern of the lamina terminalis is positioned in the midline of the basal telencephalon, anterior to the lamina terminalis and third ventricle, presenting a tent-shaped configuration above the optic chiasm.^[5] It is bordered laterally by the medial surface of the posterior gyrus rectus and septal area, anteriorly by the pia and arachnoid mater in front of the anterior communicating arteries, inferiorly by the optic chiasm, and posteriorly by the lamina terminalis itself.^[5] Contents comprise the A1 and proximal A2 segments of the anterior cerebral artery (ACA), anterior communicating artery (ACoA), recurrent artery of Heubner, hypothalamic arteries, origin of orbitofrontal arteries, and veins of the lamina terminalis.^[1] This cistern interconnects the chiasmatic and pericallosal cisterns.^[5] The ambient cistern extends along the lateral aspect of the brainstem, encompassing both supratentorial and infratentorial portions within the tentorial notch, posterolateral to the midbrain.^[1] It is divided by the superior cerebellar membrane into a superior compartment (posterior cerebellar ambient cistern) and an inferior compartment (superior cerebellar ambient cistern), bounded anteriorly by the crural cistern, posteriorly by the quadrigeminal cistern, and medially by the interpeduncular cistern, with lateral extensions connecting to the interpeduncular cistern.^[4] The superior compartment houses the PCA (third part), medial and lateral posterior choroidal arteries, perforating branches to the brainstem, and basal vein of Rosenthal, while the inferior compartment includes the SCA and trochlear nerve (CN IV).^[5] The quadrigeminal cistern arises as a medial extension of the ambient cistern, positioned posterior to the midbrain around the pineal gland and above the colliculi.^[4] Its boundaries are anteriorly the dorsal mesencephalon, quadrigeminal plate, and pineal gland; posteriorly the vermis; superiorly the splenium of the corpus callosum; and inferiorly the collicular bodies and lingula of the cerebellum.^[5] This cistern contains the PCA and its perforating branches, posterior pericallosal arteries, third part of the SCA, medial and lateral posterior choroidal arteries, great cerebral vein of Galen, basal vein of Rosenthal, internal cerebral veins, atrial veins, posterior pericallosal veins, vein of the cerebellomesencephalic fissure, and trochlear nerve (CN IV).^[5] The Sylvian cistern, also referred to as the lateral or insular cistern, occupies the lateral sulcus (Sylvian fissure), serving as a transition between basal cisterns and the hemispheric subarachnoid space in a T-shaped configuration between the temporal and frontal lobes.^[1] It is bounded superiorly by the inferior frontal gyrus and opercular cortex, inferiorly by the superior temporal gyrus, medially by the insula, and compartmentalized into anterior (lateral to the middle cerebral artery origins up to the limen insula) and posterior (behind the limen insula) portions.^[4] Contents include the middle cerebral artery (MCA) branches such as M1-M4 segments, lenticulostriate arteries, anterior temporal artery, temporopolar artery, middle cerebral vein, superficial Sylvian veins, and deep Sylvian veins.^[5] The lumbar cistern is located in the lower lumbar spinal canal, extending from the conus medullaris (L1-L2 level) to the second sacral vertebra (S2).^[1] It contains the filum terminale and the cauda equina nerve roots and is the site for lumbar puncture to access CSF.^[1] Among the subarachnoid cisterns, the cisterna magna is the largest, with volumes varying by individual but generally accommodating significant CSF reservoirs, while others like the interpeduncular and chiasmatic cisterns are smaller and more confined.^[1] These cisterns interconnect extensively to facilitate CSF circulation, such as the cisterna magna linking to the pontine cistern via the premedullary space, the ambient cistern communicating with the quadrigeminal and interpeduncular cisterns through arachnoid membranes, and the chiasmatic cistern connecting to the Sylvian cistern anterolaterally, often via foramina like the foramen magnum for overall subarachnoid continuity.^[5]

Physiology

Cerebrospinal fluid circulation

Cerebrospinal fluid (CSF) is primarily produced by the choroid plexus within the lateral, third, and fourth ventricles at a rate of approximately 0.3–0.4 mL per minute, resulting in a daily production of about 500 mL.^[6] The majority of this CSF enters the subarachnoid space from the fourth ventricle through the foramina of Luschka (lateral apertures) and the foramen of Magendie (median aperture), marking the transition from the ventricular system to the extracerebral CSF pathways.^[7] Once in the subarachnoid space, CSF flows into the cisterna magna, the largest basal cistern, which serves as the primary reservoir immediately following ventricular outflow. From there, the fluid ascends through the pontine cistern and ambient cistern along the brainstem, continuing over the cerebral hemispheres via the subarachnoid space before reabsorption primarily occurs through arachnoid granulations into the superior sagittal sinus.^[8] Specific cisterns contribute to this pathway as key junctions; for instance, the interpeduncular cistern and chiasmatic cistern facilitate basal CSF flow by connecting infratentorial and supratentorial compartments, ensuring unimpeded circulation around the midbrain and optic chiasm.^[9] The total CSF volume in adults is approximately 150 mL, with the cranial subarachnoid space, including the cisterns, containing about 50 mL, while the ventricles hold around 30 mL and the spinal subarachnoid space the remainder.^[10] Normal intracranial pressure (ICP) ranges from 7 to 15 mmHg, with cisternal compliance playing a critical role in buffering volume changes to maintain this equilibrium.^[11] CSF circulation is regulated by pulsatile flow driven by arterial pulsations from cardiac cycles and pressure variations from respiratory cycles, with the subarachnoid cisterns functioning as compliant cushions that accommodate these oscillations and prevent pressure spikes.^[12]

Protective and supportive roles

The subarachnoid cisterns, as enlargements of the subarachnoid space filled with cerebrospinal fluid (CSF), serve essential protective functions by acting as mechanical shock absorbers during head trauma. When external forces impact the skull, the CSF within these cisterns displaces dynamically, distributing mechanical stress and buffering the brain from direct contact with bony structures. This displacement mechanism helps mitigate acceleration-deceleration injuries, preserving the integrity of delicate neural tissues.^[13] A primary supportive role of the cisterns involves providing buoyancy to the brain through the surrounding CSF, which reduces the organ's effective weight by approximately 95%—from about 1,500 grams to roughly 50 grams. This buoyancy prevents gravitational sagging of the brain within the cranial cavity, thereby avoiding compression of cerebral blood vessels and cranial nerves against the skull base. Without this support, the full weight of the brain could lead to vascular distortion and impaired neural function even under normal physiological conditions.^[14]^[15] The cisterns also contribute to vascular protection by accommodating major arterial and venous structures without constraint, such as the circle of Willis housed within the basal cisterns. This spatial arrangement allows these critical vessels to pulsate freely, reducing the likelihood of extrinsic compression and ensuring stable cerebral blood flow. In the ambient and interpeduncular cisterns, for instance, branches of the posterior cerebral arteries traverse unhindered, supporting overall hemodynamic stability.^[16]^[17] Beyond mechanical and vascular roles, the CSF in cisterns enables limited nutrient diffusion and metabolite exchange with adjacent brain parenchyma, particularly in regions like the brainstem and cerebellum bordering the pontine and quadrigeminal cisterns. This process supplies essential ions, glucose, and vitamins while facilitating the removal of metabolic byproducts, though it is secondary to blood-brain barrier transport. Additionally, CSF circulation through the cisterns promotes thermal homeostasis by dissipating heat acquired from neural activity, maintaining a consistent brain temperature gradient and preventing localized overheating.^[18]^[19]^[20]

Clinical significance

Pathological conditions

Subarachnoid hemorrhage (SAH) represents the most common pathological condition directly involving the subarachnoid cisterns, characterized by the accumulation of blood within the subarachnoid space, including the basal and ambient cisterns. Approximately 85% of nontraumatic SAH cases arise from the rupture of intracranial aneurysms, with common sites including the anterior communicating artery, which often leads to blood filling the chiasmatic (suprasellar) cistern and extending to adjacent basal cisterns. This rupture triggers a sudden influx of blood that irritates the meninges and obstructs cerebrospinal fluid (CSF) pathways, resulting in symptoms such as thunderclap headache, described as the "worst headache of my life," accompanied by nausea, vomiting, and potential loss of consciousness. Complications frequently include cerebral vasospasm, occurring in up to 60% of cases radiographically and leading to delayed cerebral ischemia, as well as acute hydrocephalus in about 30% of patients due to impaired CSF resorption from blood products and inflammation within the cisterns.^[21]^[22]^[21] Infections, particularly bacterial and tuberculous meningitis, can lead to pathological accumulation of pus or exudates in the subarachnoid cisterns, disrupting CSF circulation and causing significant morbidity. In bacterial meningitis, such as that caused by methicillin-resistant Staphylococcus aureus (MRSA), pus forms loculated collections within the subarachnoid space, including the basal cisterns, leading to restricted diffusion on imaging and impaired CSF flow that exacerbates intracranial pressure. Tuberculous meningitis preferentially involves the basal cisterns, with thick gelatinous exudates accumulating in the interpeduncular, ambient, and chiasmatic cisterns, resulting from the spread of Mycobacterium tuberculosis via hematogenous dissemination; this basal predominance stems from the organism's affinity for the rich vascularity and lymphatic drainage in these regions. These infectious processes provoke intense meningeal inflammation, cranial nerve involvement, and secondary vascular complications like arteritis, further compromising cisternal function.^[23]^[24]^[25] Traumatic subarachnoid hemorrhage (TSAH) occurs in 33–60% of moderate to severe traumatic brain injuries, with blood accumulating primarily in the cisterns and sulci due to direct vascular disruption from shear forces or contusions. These areas are vulnerable in deceleration injuries common in road traffic accidents or falls, leading to rapid increases in intracranial pressure (ICP) through mass effect and CSF outflow obstruction. The presence of cisternal blood in TSAH correlates with higher ICP levels, potentially exceeding 20 mm Hg, which triggers compensatory mechanisms like elevated mean arterial pressure but also risks secondary brain ischemia and herniation if unchecked.^[26]^[26]^[27] Tumors adjacent to the subarachnoid cisterns can cause compression and distortion of these spaces, leading to neurological deficits through mass effect on enclosed structures. For instance, acoustic neuromas (vestibular schwannomas) arising in the cerebellopontine angle cistern—often considered part of the pontine cistern—grow to compress the cistern, affecting cranial nerves VII and VIII primarily, resulting in progressive hearing loss in over 90% of cases, balance disturbances (common due to vestibular involvement), and facial weakness in 15-30% of cases (more frequent with larger tumors) due to direct nerve compression and ischemia. Larger tumors may extend to involve the trigeminal nerve (CN V), causing facial numbness or pain, while the overall cisternal narrowing impairs local CSF dynamics and contributes to headaches from elevated local pressure.^[28]^[29]^[28] Obstructive hydrocephalus involving the subarachnoid cisterns arises when pathological processes block CSF pathways at key transition points, such as the foramen magnum, leading to upstream ventricular dilation and cistern effacement. Compression or adhesions at the foramen magnum, often from Chiari malformations, tumors, or post-infectious scarring, prevent CSF egress from the fourth ventricle into the spinal subarachnoid space, resulting in acute pressure buildup that manifests as headaches, nausea, and altered mental status. In severe cases, this cisternal obstruction at the cranio-cervical junction can cause tonsillar herniation, emphasizing the cisterns' critical role in maintaining CSF pressure equilibrium.^[30]^[30]

Diagnostic and therapeutic approaches

Diagnostic imaging plays a crucial role in evaluating subarachnoid cisterns, particularly in detecting pathologies such as subarachnoid hemorrhage (SAH). Non-contrast computed tomography (CT) is the initial modality of choice for acute SAH, where hyperdense blood appears within the cisterns, offering high sensitivity in the first 24 hours post-ictus.^[21] For chronic or subacute conditions, magnetic resonance imaging (MRI) with fluid-attenuated inversion recovery (FLAIR) sequences suppresses cerebrospinal fluid (CSF) signal, enhancing visualization of blood products or other abnormalities in the cisterns.^[31] Cisternography, involving intrathecal contrast administration followed by CT or MRI, is employed to identify CSF leaks originating from the cisterns, providing detailed mapping of leakage sites.^[5] Lumbar puncture enables direct CSF sampling from the subarachnoid space, which communicates with the cisterns, allowing assessment of infections, hemorrhages, or other cistern-involved processes through analysis of pressure, cell count, and protein levels.^[32] However, it is contraindicated in cases of suspected raised intracranial pressure (ICP) due to the risk of herniation, necessitating prior imaging to exclude mass lesions.^[33] Surgical interventions for cistern-related pathologies often target underlying causes like aneurysms in the basal cisterns. Microsurgical clipping involves direct access to the aneurysm via craniotomy, securing the vessel neck to prevent rebleeding into the cisterns, while endovascular coiling deploys coils through catheter navigation to occlude the aneurysm sac, both approaches aimed at securing ruptured lesions.^[34] External ventriculostomy drains CSF from the ventricles into the subarachnoid space, including cisterns, to manage hydrocephalus secondary to cistern obstruction or blood accumulation.^[35] Endoscopic techniques, such as third ventriculostomy, create a stoma in the floor of the third ventricle near the interpeduncular cistern, bypassing obstructions to restore CSF flow into the basal cisterns for treating obstructive hydrocephalus.^[36] Monitoring of ICP in trauma patients may involve subarachnoid bolt probes inserted into the cisterns to provide continuous pressure readings, guiding therapeutic interventions to prevent secondary brain injury.^[37] In neonates, cranial ultrasound assesses the cisterna magna for effacement or dilation, aiding in the evaluation of raised ICP or hydrocephalus without ionizing radiation.^[38]

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